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CTN Pharmacotherapy Trials and the CTP
Allan J. Cohen, MA, MFTBay Area Addiction, Research and
Treatment, Inc(BAART)
Pacific Region Node
CTN 10th Anniversary SymposiumApril 21, 2010
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Eyjafjallajokull
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Growth of the CTN CTP Network
2000: 52 CTP - 6 Nodes
2002: 91 CTP - 14 Nodes 2005: 123 CTP – 17 Nodes 2010: 187 CTP -16 Nodes
• Total - 206 CTP have participated
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Therapeutic Communities
OpioidTreatment Programs
Drug Free Intensive Outpatient
Short-term and Long-term Residential Care
Small Community Clinics
Large Urban Clinics
Hospital Based
University Based Programs
VA
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Community Treatment Programs
• Many ways to classify CTP but one characteristic frequently used:
• Medication-assisted treatment (methadone/harm reduction)
• Traditionally do not utilize medications
( psychosocial, “drug free”, abstinence)
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We address a broad array of addictions with a wide variety of treatment
interventions
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“Wild Things” Group Therapy
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Some very innovative treatment
approaches
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Staff of earliest
recorded CTP
Staff of earliest
recorded CTP
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Staff of earliest
recorded CTP
Staff of earliest
recorded CTP
Richard Drandoff
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Pharmacotherapy Trails in CTP
Ten Medications Trials
• Six = Suboxone ( CTN 0001, 0002, 0003, 0010, 0027, 0030)
• Two = Methlyphenidate (CTN 0028, 0029) • One = Nicotine Patches (CTN 0009)
• One = Buproprion (CTN 0046)
* CTN 0048 Cocaine Use Reduction using buprenorphine (CURB)
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Agonist Replacement for Opioid Dependence
• Methadone has been around 50+ years
• Treatment for heroin addiction in specialized treatment programs
• 1200 licensed OTP in the US with 260,000 MMT
• CTP and patients struggle with stigma
• There were few tools in the treatment box for opiate addiction: naltrexone – effective/poor acceptance LAAM - euthanized
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Cont’d
• In non-methadone settings clonidine was (and still is) frequently used together with symptomatic specific meds; results were poor
• Anticipating approval of buprenorphine for treatment of opioid dependence the CTN launched two early, pre-approval, trials comparing suboxone to clonidine for short-term detox in outpatient and inpatient settings
• Prior to the early CTN 0001,0002, 0003 trials CTP pragmatic knowledge/understanding of buprenorphine was negligible.
• Early studies and then later 0010, 0027, 0030 helped shape best-practices guidelines for buprenorphine. Help educated staff and community. Help create a viable treatment addition to the options for opiate addiction.
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“Detoxification is good for many things, getting off drugs is not one
of them”
(Walter Ling)
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Suboxone
CTN 0001, 0002, 0003, 0010, 0027, 0030
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CTN Studies with Suboxone• CTN 0001, 0002, 0003: short-term treatment
• CTN 0010: adolescent and young adult population
• CTN 0027: hepatic safety study (START)
• CTN 0030: specific to prescription opiates
Really the first opportunity for many CTP to gain some pragmatic experience with buprenorphine, also gave patients a similar benefit
First time buprenorphine used in adolescent/young adult population
For CTP the value of such opportunities with new treatments/technologies cannot be underestimated
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CTP Experience with Suboxone Trials
• Six CTN trials utilizing Suboxone• Variety of programs participated• Many had little or no experience with
suboxone• Some had little or no experience with
research• All had some medical staff• Ranged from brief (13 day) to longer (8
months) exposure to buprenorphine
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Cont’d
• Early buprenorphine/medications trials helped to confirm the CTN model: it was feasible to conduct medications trials in community-based treatment programs, retain scientific rigor maintaining fidelity
• Confirmed the value and utility of bi-directionality: pragmatic and hybrid protocols in real world settings
• Afforded an invaluable opportunity for exposure to a new treatment option and build a skill set to help optimize it’s use
• Driving change in treatment
• Developing tension can be seen: specialized treatment providers/private office-based treatment
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To date there have been 2,946 patients randomized in six medication
trials with suboxone
Of these 2,404 had opportunity to receive suboxone
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START at BAART
• Fairly typical of the programs participating in START
• Very busy Opioid Treatment Program: – 700+ MMT
• Well known and established in community (SF) 30 yrs
• Staffing included: physicians/extenders medical assistants, counselors, dispensary nurses, (research assistants)
• Began START 6/2006 – completed recruitment 10/09
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START at BAART
• We had turnover of research staff including physicians
• We “relocated” the entire clinic during the study!
• When START rolled out the majority of study participants were only interested in methadone
• By the end a significant number of new participants were hoping to receiving suboxone
• We have learned much and this will be of practical use
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Smoking• High prevalence of smoking behavior in SUD populations
• Only one completed study on smoking completed thus far (0009) MMT and Psychosocial CTP
Difficulty in recruitment/retention No difference at 3 and 6 mo follow-up Use of behavioral and nicotine replacement therapy
• Nevertheless, this was an important study in my opinion: First CTN trial for smoking
Included MMT and Psychosocial programs Pragmatic study which reflected realities of treatment
• New smoking medication trial (0046 - Winhusen) using buproprion for a specific subset of substance abusers
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Medication Assisted Treatmentis being more widely adopted partially
as a result of CTN research
CTP who had previously generally not used agonist replacement treatment began slowly
incorporating suboxone:
Betty Ford CenterMaryhaven
others
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CTP Issues
• CTP are very busy places• Not all CTP are staffed to participate in
medication research• Program “philosophy” may not always
embrace the use of medication-assisted treatment
• Critical to integrate research staff• Space• Priorities
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What is important to CTP
• Treatment accessibility that meets need/demand
• Treatment retention• Acceptance of treatment by patients• Reduction of stigma • Sustaining treatment programs in tough times
• Retaining staff including research staff *• Dissemination of new treatment/knowledge• Funding• Regulatory consistency
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What’s important to patients:
Quality of Life
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Positive Outcomes
Exposure to new knowledge and skills
Possible new treatment interventions/options
Increased Accessibility to Treatment
Funding
Collegial support/Mentoring
Community Education
Bi-directional: invested in the protocol and research
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Considerations for future medications research
The bi-directional opportunity the CTN affords is unique and should continue to shape research:
Co-occurring SUD and psychiatric disorders Co-occurring Alcohol Use Disorders* Adaptive/Sequential Models of Care** Stimulant abuse/dependence Chronic Pain and SUD Treatment Optimization Tapering/converting MMT to suboxone
-“crossover” Specific Populations – adolescents, aging, gender, prescription opioid dependence Longitudinal studies/longer follow-up
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Cost-effectiveness and Cost-benefit analyses are useful to inform providers in making decisions regarding adoption
of new treatment
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Adoption requires Sustainability
• Sustainability incorporates any number factors: Characteristics of medication is important to
adoption Cost-benefit Fit into program Consumer acceptance Timing Funding
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Researchers/InvestigatorsProviders
*Provider-researchers
(something more than treatment providers who allow researchers to conduct studies within their programs)
This is an outcome of CTN bi-directionality, providers who are actively engaged in
research work with research mentor/colleagues, who enjoy and are invested
in the research as they are in treatment
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Legacy of pharmacotherapy trials in CTP
• Medication-assisted treatment options are gaining wider acceptance among treatment providers and funding sources
• Buprenorphine has gained broader acceptance by providers and patients
• Benefits of participation easily justify the effort
• CTP make excellent locations for “pragmatic or hybrid model” clinical trials
• Combined medication assisted and behavioral treatment models offer powerful tools which can help drive change in treatment
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Research drives treatment
Treatment drives research
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Pharmacotherapy “Special Interest Group”
• Comprised largely of investigators and physicians, NIDA representatives and a few of us CTP folks
• Current Chair – Kathleen Brady, MD
• Discuss possible pharmacotherapy studies, medications in various stages of development and concept design for CTN protocols
• I have found participation very satisfying and a great learning experience
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Just a few personal thoughts…
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Walter Ling
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What a great ride!
• Ten years of bi-directional research • New Director of NIDA and NIH• 8 NIDA Blending Meetings• “All Hands Big Hug” and 9/11• Snipers – Pooks Hill
• Blizzards, Volcanoes• Made many friends• Lost some friends: Eileen Pencer, Len Handelsman,
Patrick McAuliffe
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Sepulveda VA HospitalCirca 1977
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It has been a great ten years, we look forward to the future…
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