Sara J. Becker, Ph.D. - US grants

DESCRIPTION (provided by applicant): Underutilization of evidence-based psychotherapy (EBP) by adolescent substance abusers (ASA) represents a significant problem for our field and for our nation's public health. Prior treatment dissemination research has made inroads toward increasing the supply of EBP offered in the community, but efforts have not considered whether parents of ASA will demand the services provided. The overall goal of this proposal is to support the candidate, Sara Becker, Ph.D., in developing an independent clinical research program focused on applying strategies from the field of services marketing to increase demand for EBP. This long-term goal will be achieved through conduct of a mentored research study as well as didactic coursework, seminars, workshops, hands-on training, and manuscript writing. Career development activities have been crafted to support four training goals: (1) developing expertise in services marketing theory and methods relevant to increasing client demand; (2) gaining expert knowledge of leading treatment dissemination models and strategies; (3) acquiring specialized training in qualitative analysis; and (4) building proficiency in survey methodology. Training will be accomplished with the unconditional institutional support of the Center for Alcohol and Addiction Studies at Brown University. An interdisciplinary team of mentors will be co-led by Dr. Anthony Spirito of Brown University, an expert in the delivery, evaluation, and dissemination of EBP for ASA, and Dr. Valarie Zeithaml of the University of North Carolina, an international pioneer in the field of services marketing. The proposed research plan contains three phases. First, qualitative research with ASA and their parents will be conducted to adapt a well-established conceptual model and quantitative measure of service quality for the evaluation of substance use services. Second, a web-based survey of parents of ASA will establish the psychometric properties of the refined measure and elucidate the service preferences of this population. The survey uses a multi-method, single-mode sampling strategy that integrates common approaches from both marketing and treatment research. Finally, a randomized, web-based trial will compare the effectiveness of targeted marketing messages versus standard clinical information in persuading parents of ASA to seek EBP. Targeted marketing messages will be developed using the feedback collected from parents in the first two phases, whereas standard clinical information will consist of descriptions of EBP from leading scientific organizations in the field. The effectiveness of the marketing messages will be evaluated using the measure of service quality that was adapted in the first two phases, as well as two measures of behavioral intentions. Taken together, this work will establish the relevance of services marketing theory and methodology to the dissemination of EBP for ASA. Results of the proposed research program have the potential to advance dissemination science by increasing the demand for EBP, which in turn, can increase service utilization and improve the health outcomes of ASA.

? DESCRIPTION (provided by applicant): Adolescents with substance use disorders (ASUD) in residential treatment have the most serious substance use disorders and the highest rates of psychological, motivational, behavioral, legal, environmental, and vocational problems. ASUD in residential treatment are also at extremely high risk of relapse, with follow-up studies suggesting that 60% of ASUD will relapse within the first 90 days of discharge. Parenting practices have been established as a key influence on adolescents' initiation and maintenance of substance use, as well as their substance use outcomes and likelihood of relapse. However, therapists who treat ASUD have reported a myriad of systemic barriers to engaging parents in treatment. Findings such as these deem ASUD in residential treatment a high priority population and argue for the value of easily accessible parenting interventions during this critical time. The proposed study evaluates one potential low cost, low intensity model for delivering parenting skills to parents preparing for their adolescent's discharge from residential substance use treatment. Specifically, this project involves adapting the delivery of a computerized parenting intervention (Parenting Wisely; PW) that has preliminary evidence of efficacy in improving parenting skills and reducing youth behavior problems. This study adapts the delivery of PW for a new population (parents of ASUD preparing for discharge) and new setting (residential treatment), and obtains initial data on its feasibility, acceptability, and effectiveness. First, an open trialwith 10 parents will adapt the delivery of PW to include moderate engagement strategies relevant to this population. Initial engagement strategies have been developed based on focus groups and interviews with 13 parents, 11 ASUD, and three staff members and include up to six sessions of individualized coaching that begin prior to discharge (incorporated into standing family appointment times) and the use of technology (e.g., text messaging and an online parent message board) to maintain contact between staff and parents post-discharge. Second, a randomized trial with 60 parents will compare an adapted PW plus treatment as usual (TAU) condition (PW+TAU) versus TAU only in a residential treatment center. Both treatment conditions will be delivered by Master's-level community clinicians. Use of a low-cost, low-intensity intervention paired with moderate engagement strategies represents a marked change from traditional treatment delivery methods, with potential for extending treatment gains after discharge. Innovative aspects of the current approach include its timing, use of novel engagement strategies, combination of in-person and computer-delivered content, and focus on putative mediators. The approach has the potential to advance public health by: addressing a high-needs population; targeting parenting practices (putative mediators of change) that have been shown to influence ASUD outcomes; working with parents during a critical treatment juncture; improving parental engagement and access to care, and increasing ease of dissemination and implementation.

Project Description Overdoses and deaths due to opioid use disorders (OUDs) have been declared a public health emergency in the United States, bringing to light an urgent need for highly effective OUD treatments. There are currently five FDA-approved medication formulations, which relative to placebo have demonstrated effectiveness in helping patients attain abstinence from opioids. Nonetheless, patients' opioid abstinence rates are sub-optimal: even when treated with the newest extended-release formulations only about 40% of patients maintain abstinence during the first 6-months of treatment. Contingency management (CM; i.e., motivational incentives for achieving pre-defined treatment goals) is one of the only behavioral interventions shown to improve patient abstinence from opioids when combined with FDA-approved pharmacotherapy. Unfortunately, however, uptake of CM in OUD treatment centers remains low. In response to the urgent need for evidence-based behavioral OUD treatments, we propose a large-scale type 3 hybrid trial comparing two comprehensive strategies to promote CM implementation as an adjunct to pharmacotherapy within OUD centers. The control condition is the staff training strategy used by the SAMHSA-funded network of Addiction Technology Transfer Centers (ATTC; i.e., didactic workshop + performance feedback + staff coaching). The experimental condition is the ATTC strategy enhanced by external leadership coaching (ELC; i.e., leadership coaching focused on sustainment planning) and pay-for-performance (P4P; i.e., monetary bonuses for achieving pre-defined implementation goals), which we refer to hereafter as E-ATTC. Elements of E-ATTC were informed by our team's prior NIH-funded work evaluating organization-level implementation strategies. Using a cluster randomized design, 30 OUD treatment centers across New England will be randomized to one of the two implementation conditions (ATTC vs. E-ATTC) over the 5 year project. At each OUD treatment center, data will be collected at multiple intervals from two CM staff (n=60), two organizational leaders (n=60), and 25 newly admitted patients (n=750). Additionally, 25 patient charts per center (n=750) will be randomly selected for review to examine sustainment. Data collection will use rigorous, replicable procedures including electronic medical record review, ratings of audio recordings by staff blind to condition, well-validated measures, and biological verification of abstinence. Specific Aims of the study are to experimentally compare the effect of the two conditions on implementation outcomes (Primary Aim) and on patient outcomes (Secondary Aim). An Exploratory Aim is to test whether two organization-level variables (i.e., implementation climate, leadership engagement) partially mediate the relationship between implementation condition and the key study outcomes. Achievement of the Study Aims will address critical public health needs by (a) informing how evidence-based practice is implemented in OUD treatment centers, (b) improving the outcomes of OUD patients on pharmacotherapy, and (c) advancing knowledge about why and how implementation strategies work.

PROJECT SUMMARY South Africa is at the epicenter of the global HIV pandemic with the largest country population of individuals living with HIV in the world. South Africa also has alarming rates of alcohol use, which pose a significant challenge to the HIV care cascade. Integrated alcohol-HIV care is the gold standard, but delivery of integrated care in South Africa is extremely rare. To promote treatment integration, the South Africa HIV ATTC (led by M- PIs Becker, Kuo, and Sibeko) was established in October 2017. The South Africa HIV ATTC is a national center, jointly funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the President?s Emergency Plan for AIDS Relief (PEPFAR), dedicated to providing training to health professionals and lay workers who serve patients with HIV, alcohol use, and other mental health problems. On an annual basis, the South Africa HIV ATTC is charged with training 1,000 individuals as a means of driving the uptake of evidence-based approaches to address alcohol-HIV throughout the country. Recognizing the detrimental effects of heavy alcohol use and alcohol use disorders on the HIV care cascade, and in response to a needs assessment of national stakeholders and policy-makers, the South Africa HIV ATTC is preparing to roll out a national training initiative on Screening, Brief Intervention, and Referral to Treatment (SBIRT) for risky alcohol use. Using a novel task sharing approach, the South Africa HIV ATTC will provide SBIRT training and ongoing consultation to over 900 health professionals and lay workers embedded within HIV treatment organizations over a three-year period. Rollout of this national initiative presents unparalleled opportunities to advance implementation science for integrated alcohol-HIV treatment in a global priority site. However, research and data collected by the South Africa HIV ATTC is severely restricted under the SAMSHA and PEPFAR funded streams. Indeed, the only data currently collected by the South Africa HIV ATTC is a brief SAMHSA-required form called the Government Performance and Reporting Act (GPRA) tool, which measures satisfaction of training attendees. Thus, the current study proposes to first codify and then conduct comprehensive evaluation of training effectiveness on a range of key implementation science constructs. Study activities will occur across three phases. First, we will develop a SBIRT train-the-trainer manual consisting of a coding system to measure training fidelity, which will greatly enhance the rigor of the proposed training rollout. Second, we will evaluate the effectiveness of the SBIRT train-the-trainer model on key implementation science outcomes measured at the trainer (e.g., fidelity, knowledge), provider (e.g., attitudes, self-efficacy, acceptability), and patient levels (e.g., proportion of patients who receive each component of SBIRT ? screening, brief intervention, and referral to treatment). Finally, we will examine the relationship among trainer-level, provider-level, and patient-level outcomes. Results of this study will advance knowledge of key implementation science questions, while promoting the integration of alcohol and HIV care, in a global priority setting.

Project Description Adolescents in residential substance use (SU) treatment have the most serious SU disorders and the highest rates of psychological, behavioral, legal, environmental, and vocational problems. Adolescents in residential SU treatment are also at high risk of relapse, with follow-up studies demonstrating that 60% of discharged adolescents relapse within 90 days. Parenting practices, including parental monitoring and parent-adolescent communication, have been established as key predictors of adolescent SU outcomes and likelihood of relapse, but parents are notoriously difficult to engage in adolescent SU treatment. Accordingly, there is a clear need for effective, accessible, and scalable interventions for parents of adolescents receiving residential SU treatment. Building upon our successful NIDA-funded R34, this study evaluates a technology-assisted parenting intervention called Parent SMART (Substance Misuse among Adolescents in Residential Treatment), which has evidence of high feasibility and acceptability, as well as preliminary evidence of effectiveness, as an adjunct to short-term residential treatment as usual (TAU). Parent SMART centers around an off-the-shelf computerized intervention, Parenting Wisely (PW), which has demonstrated robust evidence of improving parenting skills and reducing youth behavior problems in multiple clinical trials. We conducted extensive formative research with parents, adolescents, and residential staff to guide the development and delivery of two highly scalable enhancements: 1) access to a state-of-the-art mobile networking app; and 2) up to four telehealth coaching sessions to tailor PW content. Our networking app allows parents to submit questions to an SU expert and connect with other parents of adolescents in residential SU treatment in real-time, while reinforcing parenting skills via ?Tip of the Day!? push notifications. In our pilot trial, Parent SMART was highly feasible and acceptable, and demonstrated evidence of effectiveness in improving parental monitoring and communication, reducing days of adolescent binge drinking and all other drug use, and reducing school-related problems, among parents in short-term residential treatment. This R01 proposes a fully powered evaluation of Parent SMART. Adolescent-parent dyads (n = 220 dyads; 440 in total) will be randomized to receive either TAU only or Parent SMART + TAU. Multi-method follow-up assessments (i.e., self-report parent and adolescent measures, parent-adolescent in vivo interaction task, 8-panel urine screens) will be conducted 6-, 12-, and 24-weeks post-discharge, to examine parenting skills, adolescent SU, and adolescent problem behaviors. Exploratory analyses will test whether improvements in parenting skills partially mediate reductions in adolescent SU. The proposed research has the potential to advance the field by: serving a high-need, underserved population during a vital treatment juncture; targeting parenting practices (putative mediators) that have been shown to predict adolescent SU outcomes; addressing barriers to accessing continuing care; and testing a highly scalable intervention model informed by extensive formative research.