By Steve Martino, PhD, Yale University
I read with great interest the National Advisory Council on Drug Abuse Workgroup Report, Adoption of NIDA's Evidence-Based Treatments in Real World Settings. In particular, I was curious about what the workgroup members had concluded about the Clinical Trials Network's (CTN) success in moving the results of its trials into the hands of community treatment programs, thereby serving as an entity for evidence-based practice dissemination. Indeed, this was one of the CTN's original primary aims. The workgroup concludes that the CTN "was not positioned to conduct system-level implementation research nor can it be repositioned or reorganized to do so, given its history, structure, and personnel (p. 10)".
There had been two potential avenues for the dissemination and implementation of evidence-based practices in the CTN – one hopeful and one hoped-for. The hopeful avenue began in 2001, in large part through the CTN's participation in the National Institute on Drug Abuse (NIDA) - Substance Abuse and Mental Health Services Administration (SAMHSA) Blending Initiative and its close involvement with the Center for Substance Abuse Treatment's (CSAT) Addiction Technology Transfer Centers (ATTC). The hoped-for avenue was that the CTN would provide a program network ripe for dissemination and implementation research—the desire of many of the participating investigators and program directors. What happened?
The sudden disappointment of a hope leaves a scar which the ultimate fulfillment of that hope never entirely removes. – Thomas Hardy
Developed in 2001 by NIDA and SAMHSA and directed by NIDA's Office of Science Policy and Communications, the Blending Initiative melded science and practice together to improve substance use disorder treatment (see Condon, Miner, Balmer, & Pintello ). Its primary goal was to accelerate the adoption and implementation of research findings from the CTN trials and other NIDA-funded treatment studies into community-based practice through the development of blending products and accompanying training programs. In brief, a systematic process was used for this purpose in which blending teams consisting of researchers, program providers, and ATTC technology transfer experts developed the products and executed associated strategic dissemination plans. Strategic plans involved making blending product materials widely available through the ATTCs, training regional trainers for some products, and launching interactive websites as resources for continued learning, technical assistance, and information exchange. The bulk of the work occurred largely through the ATTCs, in collaboration with the CTN's Research Utilization Committee, the latter functioning as the formal locus for blending product implementation activities solely within CTN-participating programs (see Martino et al., 2010).
To date, blending products based on interventions tested in the CTN have promoted the adoption of buprenorphine for illicit and prescribed opiate treatment, motivational incentives (also called contingency management), motivational interviewing, and program-based HIV rapid testing. Hence, in 14 years since the CNT began, only four blending products have materialized from the 32 CTN research protocols that have been completed, a relatively small return on the investment made in the CTN and relatively little to show for the transfer of research results from its trials to community program providers and their clients.
Adding salt to this wound is the lack of information about the degree to which these products are utilized across the country, or if those trained as trainers of the products continue to provide training and technical assistance in the field. Moreover, there is no data that demonstrates the blending products result in adoption of evidence-based practices or the faithful implementation of them in real-world settings. While some efforts are underway to address these shortcomings (e.g., our NIDA-funded trial testing the effectiveness of the blending product to support the implementation of motivational interviewing [R01 DA023230; PI: Martino]), there is no current evidence that blending products are being used or improving the transfer of evidence-based practices into community treatment programs.
Finally, funding for the Blending Initiative has been substantially reduced over the years, diminishing the resources and personnel now devoted to this effort and the ability to address the shortcomings noted above. Moreover, the responsibility for the Blending Initiative now resides within the CTN rather than directed by NIDA's Office of Science Policy and Communications and formally shared with SAMHSA/CSAT/ATTC. This shift has weakened the NIDA/CTN-SAMHSA/CSAT/ATTC partnership that was the hallmark of the Blending Initiative. These structural changes stands in contrast to the tenets of well-respected implementation models of evidence-based practice that the CTN had once largely embraced (e.g., Dean Fixsen and colleagues'  synthesis of the implementation research, Dwayne Simpson's  program-based technology transfer approach, and Everett Rogers'  diffusion of innovations theory).
He that lives upon hope will die fasting. – Benjamin Franklin
The CTN originally aimed to conduct pharmacological and behavioral treatment trials to determine the effectiveness of drug abuse interventions within diverse community treatment programs and patient populations. A large national network of community treatment programs arose, including an infrastructure for developing protocols in a bidirectional manner between community-based researchers and service providers. Participants in the CTN quickly saw the opportunities the network afforded for dissemination and implementation research trials. Access to multiple sites, diverse provider and client groups and organizational structures and processes, and existing collaborations with community program partners to facilitate research practices were just a few of the many attractive features.
In contrast to the Workgroup's recent conclusions about the CTN's current state of affairs, the CTN had been very well positioned to conduct system-level implementation research, and it missed its opportunity to do so. Several efforts were made to put forth proposals to study how best to train providers or identify and address organizational issue that might influence the rate and quality of evidence-based practice adoption. However, the NIDA CTN leadership clearly defined these types of studies as outside the scope of the CTN and told investigators to look for funding to support dissemination and implementation proposals elsewhere. Rather than moving the CTN in the direction of effectiveness to implementation science research (two steps forward), it began to use the network of programs to test the efficacy of new treatment options in addition to the effectiveness of already established ones (one step back). The potential for the CTN to systematically study processes and factors that could lead to the widespread use of evidence-based practices was lost.
Despite the strategic decision to exclude dissemination and implementation research in the CTN, hope springs eternal for dissemination and implementation research elsewhere in NIDA via its Health Services Research Branch. It is a relatively young discipline and ripe for the influx of early career scientists who might build and sustain the field (Stamatakis, Stirman, Melvin, & Brownson, in press). Most recently, NIDA issued a Request for Information seeking "comments from a broad range of stakeholders on the research and information needed to support the widespread use of evidence-based drug abuse treatment interventions and practices" (http://grants.nih.gov/grants/guide/notice-files/NOT-DA-13-014.html). Bridging the gap between research and practice was the original impetus to the formation of the CTN (cf. IOM, 1998). The CTN dropped this important ball of its mandate. We are now back to the future. Hopefully, this time NIDA will invest in an alternative structure to the CTN that establishes a research network where dissemination and implementation research is welcomed and will flourish.