Emily Campbell, MPH CIHR Team in Substance Abuse Treatment Research Coordinator, Addictions Unit

1. Knowledge translation and implementation of frontline screening and early intervention for substance abuse: why are we moving slowly? Emily Campbell, MPH CIHR Team in Substance Abuse Treatment Research Coordinator, Addictions Unit McGill University Health Centre (MUHC) emily.campbell@muhc.mcgill.ca

2. CIHR Team in Substance Abuse Treatment Co-Investigators Collaborators Kathryn Gill, PhD (MUHC) Gail Gauthier, PhD (MUHC) DaraCharney, MD (MUHC) SpyridoulaXenocostas, MSc (CSSS de la Montagne (DLM)) Ann Macaulay, CM, MD (Participatory Research at McGill (PRAM)) Marlene Yuen, BA (CSSS DLM) Donald Desrosiers, RN (CSSS DLM) Anita Cugliandro, MA (CSSS DLM) Jon Salsberg, PhD(c) (PRAM) Jorge Palacios-Boix, MD (MUHC) Ronald Fraser, MD (MUHC) Juan C. Negrete, MD (MUHC) • Research Coordinator: Emily Campbell, MPH • Addiction Program Coordinator: AntonisParaherakis, MSc • Research Assistant: Katie Boodhoo, BSc • Focus Group Leader, Qualitative & Quantitative Data Analysts

3. Rationale for the CIHR Team Project New provincial action plans and mandates in addictions from the Quebec government Natural laboratory for studying the implementation of evidence-based interventions within multiple primary care sites Screening, early (brief) intervention and referral to treatment

4. Why screen in primary care settings? • misuse of alcohol and other drugs is prevalent in many clinical settings • substance use often linked to presenting symptoms (e.g. injuries, hypertension, family problems, depression) • given the setting, clinicians have a mandate to assess, and ask questions related to risky behaviour • stigma can be minimized in non-specialized settings • detection of those at risk is a form of early intervention and secondary prevention

5. Evidence-based screening & brief intervention • WHO Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and the ASSIST-linked brief interventions. http://www.who.int/substance_abuse/publications/media_assist/en/index.html

6. Integrated Knowledge Translation Those who must live with the results of the innovation must be involved in the design and execution of its implementation, to facilitate ownership and to decrease resistance . (Backer et al., 1995) Collaborative Partnership: Throughout the process of program implementation, the CIHR TEAM has used an integrated knowledge translation (iKT) strategy equal partners • build collaborative mechanisms for knowledge exchange • joint decision making between researchers, clinic supervisors, psychiatrists, addiction specialists and frontline clinicians • integrated approach with the insertion of an addictions specialist into the CSSS for 18 months

7. Project Overview at CSSS • Time 1 (2010): Pre-implementation data collection: 34 participants (clinicians/managers): focus groups, interviews, (explored knowledge, skills, attitudes, barriers, training needs); questionnaires, chart review • Training Program Implementation (2010-11): Addictions Program Coordinator on site to help train and support staff and program development • Time 2 (2011): Post-data collection: 34 participants • Time 3 (2013): InternalAddictions Specialist: Training, consultation, co-intervention and support, questionnaire

8. Portrait of Current Practice • Use of formal screening tools for alcohol/drugs is rare • resistance to using formal tools • Most clinicians do not feel adequately equipped to deal with clients with substance problems • inadequately equipped to deal with dual diagnosis • Competing priorities; clients often present in crisis • Lack of knowledge of evidence-based practices for substance abuse

9. Summary of Clinician Needs • Practical, up-to-date knowledge of substance abuse/addictions: case based, clinical practice • Intervening with co-morbid substance abuse and psychiatric problems • Motivational approaches; dealing with resistance • Supervision by an Addictions Specialist • New screening tool: simple, clear, quick, practical • Improved collaboration with external resources

10. Training Groups

11. Changes from Time 1 to Time 2 • Changes in attitudes: heightened awareness regarding addictions; increased comfort and openness in addressing substance abuse • Minimal change in actual interventions • Tool Use: little use of screening tools • Training group knowledge transfer was limited • Systematic screening and brief interventions not implemented (pre-screening implemented in 2012) • Full-time internal addictions worker: training/co-intervention

12. Lessons Learned • Didactic training methods (lectures, powerpoint presentations) are not preferred by frontline staff, material considered to be too complex/theoretical not able to retain or use information • Case presentations and discussion + ongoing case based supervision was the preferred method of learning and considered to be most useful • Follow-up supervision post training • Adoption time frame for new practices is much slower than expected

13. Slow Adoption Time Frame – Why? • Difficult to implement? • specialized training and on-going supervision required; lack of knowledge: many staff do not have the skills to appraise, apply and understand evidence-based practices • Organizational climate? • lack of time, lack of staff/turnover, lack of managerial support, competing priorities, lack of access to resources • Incompatibility with clinicians’ beliefs? • screening and brief interventions conflict with belief that substance abuse is difficult to treat, requires lengthy treatment; focus on client priorities

14. Thank you! Questions? Emily Campbell, MPH Research Coordinator, Addictions Unit McGill University Health Centre emily.campbell@muhc.mcgill.ca