BRINGING DRUG ABUSE TREATMENT FROM RESEARCH TO PRACTICE

Release Date: December 22, 1998

RFA:  DA-99-007

P.T.

National Institute on Drug Abuse

Letter of Intent Receipt Date:  March 29, 1999
Application Receipt Date:  April 29, 1999

PURPOSE

This Request for Applications (RFA) will support research to improve our
knowledge of how to move research-based drug abuse treatment interventions into
clinical practice.  Despite research on the effectiveness of a variety of
psychosocial, behavioral, and pharmacological treatment interventions, many of
these interventions are still not in widespread clinical use.  Not enough is
known about how drug abuse treatment providers decide which clinical
interventions to adopt or the nature of organizational adaptation needed to
integrate new treatments with existing clinical practice.  Practice research is
conceptualized as having three significant aspects:  Effective transfer of
knowledge, changing organizational behavior, and financing new treatments.

HEALTHY PEOPLE 2000

The Public Health Service (PHS) is committed to achieving the health promotion
and disease prevention objectives of "Healthy People 2000," a PHS-led national
activity for setting priority areas.  This RFA, Bringing Drug Abuse Treatment
From Research to Practice, is related to the priority area of alcohol and other
drugs.  Potential applicants may obtain a copy of "Healthy People 2000" (Full
Report:  Stock No. 017-001-00474-0 or Summary Report:  Stock No. 017-001-00473-1)
through the Superintendent of Documents, Government Printing Office, Washington,
DC 20402-9325 (telephone (202) 512-1800).

ELIGIBILITY REQUIREMENTS

Applications may be submitted by domestic and foreign for-profit and non-profit
organizations, public and private, such as universities, colleges, hospitals,
laboratories, units of state and local governments, and eligible agencies of the
federal government.  Racial/ethnic minority individuals, women, and persons with
disabilities are encouraged to apply as Principal Investigators.

MECHANISM OF SUPPORT

This RFA will use the National Institutes of Health (NIH) research project grant
(R01).  Responsibility for the planning, direction, and execution of the proposed
project will be solely that of the applicant. The total project period for an
application submitted in response to this RFA may not exceed five years.  The
anticipated award date is September 1999.

This RFA is a one-time solicitation.  Future unsolicited competing continuation
applications will compete with all investigator-initiated applications and be
reviewed according to the customary peer review procedures.

FUNDS AVAILABLE

It is anticipated that approximately $2.0 million will be available to support
research grants under this RFA.  This level of support is dependent upon the
receipt of a sufficient number and diversity of applications of high scientific
merit.  Because the nature and scope of the research proposed in response to this
RFA may vary, the size of an award will also vary.  However, it is anticipated
that up to eight new awards will be made under this announcement.

RESEARCH OBJECTIVES

Background

Two powerful influences, a transition to managed health care and a rapidly
developing base of scientific knowledge, have the potential to transform the
quality of drug abuse treatment in the United States.  The National Institute on
Drug Abuse (NIDA) has significant ongoing research programs to develop
efficacious and effective drug abuse treatment interventions.  However,
interventions tested in well-controlled experimental settings are not always
readily adopted and used by non-scientist practitioners.  There is a comparative
lack of research on the processes through which science-based interventions enter
clinical practice.

Traditional technology transfer approaches, including education, training, and
dissemination of information through journal articles, newsletters, technical
reports, monographs, conferences, and workshops, produce only limited change in
drug treatment programs and systems (Backer, 1995; Becker, 1970; Brown 1998). 
One study of the effectiveness of technology transfer randomized treatment
programs into four strategies in which only receiving journal publications was
one.  This strategy produced no change in the programs (Sorensen et al., 1988),
but other strategies involving more expensive interventions of face-to-face
communication were more successful.  Even among strategies that worked, up to 70%
of the programs showed no significant change.

Underutilized Treatment Interventions

The gap between research knowledge and treatment practice was identified as
leading to an underutilization of effective drug abuse interventions in the
recent Institute of Medicine Report, Bridging the Gap Between Practice and
Research (Lamb et al., 1998).  Underutilized or imperfectly used
pharmacotherapies include methadone, LAAM (levo-alpha-acetylmethadol), and
naltrexone.  Low methadone dosing levels have been reported (Ball & Ross, 1991;
D'Aunno et al., in press).  Naltrexone, a pure opioid antagonist, has had limited
use (Brahen et al., 1978).  LAAM, an effective long lasting agonist treatment for
opioid dependence, has not been widely adopted.  Nor have research-based
behavioral interventions, including community reinforcement with vouchers
(Higgins et al., 1994; Silverman et al., 1996), other contingency management
strategies, or many cognitive behavioral approaches.  Shorter treatment episodes
have resulted from managed care, but little is known about the effectiveness of
brief behavioral interventions in drug abuse treatment, primary care, or other
settings.

Reductions in the number and frequency of comprehensive or "wrap around" services
such as employment, psychological, legal, or family/social services have been
reported (Etheridge et al., 1995; D'Aunno et al., 1995) despite the need of drug
abuse patients for such services (Ball & Ross, 1991; McLellan et al., 1994;
Widman et al., 1997; Simpson et al., 1997).

Injecting drug abusers are at high risk for contracting HIV, and those with
HIV/AIDS have significant medical needs that often cannot be managed in drug
treatment programs (Selwyn, 1996).  The integration of primary care services with
drug abuse services requires systematic evaluation and study of how to transfer
such integrated models into delivery systems (Lamb et al., 1998). Organizational
barriers may prevent the integration of services, especially where there are co-
occurring mental health problems (Lamb et al., 1998). Developing research-based
strategies to facilitate integrated service delivery is important for all drug
abuse patients, but especially for adolescents in treatment and for drug abusing
women and their children (Grella, 1996; Rahdert, 1996).

Objectives and Scope

Translating interventions into clinical practice is conceptualized as having
three significant aspects:  Effective transfer of knowledge about drug abuse
treatment interventions, changing treatment organizations, and financing new
treatments.  How drug abuse treatment adapts to cost containment pressures and
to evolving technology depends upon how new treatment approaches are learned, how
treatment programs and systems are organized and managed in a rapidly changing
environment, the internal and external incentives to adopt new practices, and how
decisions are made to reimburse particular services or interventions in drug
abuse treatment.

This Request for Applications is intended to stimulate research on how clinical
treatment technology is adopted by treatment providers, on how interventions are
adapted to various treatment settings so that their effectiveness is maintained
or improved, and on the economics of introducing treatments into new drug abuse
treatment settings.

Studies to further our understanding of how to translate new research-based
interventions into clinical practice may include, but are not limited to research
on:

Transmission of knowledge

o  Research on technology transfer, knowledge dissemination, and education
approaches, including technical assistance models, intervention marketing
strategies, transportability of efficacious behavioral therapies to community-
based settings.

o  Research on training treatment providers, including identification of needs,
skills, and competencies for different providers, development of new clinical
skills, adherence to manualized therapies, adult learning models, and processes
for re-training needed to implement new interventions in the drug abuse treatment
program environment.

Organizational adaptation and change

o  Factors such as level of support, supervision, and communication within and
outside the treatment organization needed to effectively implement, integrate,
and maintain new interventions.

o  The role of oversight and monitoring (for example, Joint Commission on
Accreditation of Healthcare Organizations, National Committee for Quality
Assurance, or other organizational accreditation; performance monitoring by
managed care organizations or health maintenance organizations) in changing
treatment practices or affecting adoption of research-based interventions.

o  Attributes of effective health care staff and leadership (including
professional skills, training, and experience) and approaches to improve the
effectiveness of staff to deliver treatment interventions and services or to
implement new research-based interventions.

o  Alternative models for systematic organizational change (including integration
of drug abuse and other health or social service models or development and
maintenance of linkages with other resources); effective clinical or
organizational decision-making processes or models; or processes for defining,
monitoring, and evaluating program performance; or systematic efforts to improve
treatment quality.

o  Treatment process, including integrating drug abuse treatment interventions
into existing treatment practices or into new settings (for example, primary
care), addressing patient motivation and needs, or matching interventions to a
staged recovery model.

o  Practice guidelines for drug abuse treatment and "wrap-around" services. 
Research on organizational roles such as assessment of need and establishment and
maintenance of linkages with other service providers.

o  Organizational models to improve the treatment of drug dependence as a chronic
disorder (for example, continuity of care models, expectation of recurring need
for care, application of management of care practices from treatment of other
chronic diseases).

Financing

o  Decision-making processes to approve new treatment services, approaches, or
interventions for reimbursement by various payers.

o  The impact of managed care and other financing mechanisms on availability,
access, and utilization of research-based treatment interventions.

Applications submitted under this request for applications may focus on specialty
or non-specialty (e.g., health and mental health care, correctional, social, and
welfare programs) settings that provide drug abuse treatment services.  Research
may also focus on factors that facilitate or impede effective and efficient
translation of research-based treatment interventions into clinical across
service settings and organizations.  Research projects that examine innovative
organizational and management models are of particular interest.

Investigators are encouraged to utilize the most rigorous methodology consistent
with the purposes of the research study.  It is expected that applications may
use quantitative or qualitative approaches, or both, to examine these systems. 
Projects that solely propose case studies or other forms of qualitative
evaluative research will not be considered responsive to this RFA.

Timely reporting of findings is emphasized with specific attention to the
development of dissemination plans that facilitate access to current findings
among researchers and practitioners.

INCLUSION OF WOMEN AND MINORITIES IN RESEARCH INVOLVING HUMAN SUBJECTS

It is the policy of the NIH that women and members of minority groups and their
subpopulations must be included in all NIH supported biomedical and behavioral
research projects involving human subjects, unless a clear and compelling
rationale and justification is provided that inclusion is inappropriate with
respect to the health of the subjects or the purpose of the research.  This
policy results from the NIH Revitalization Act of 1993 (Section 492B of Public
Law 103-43).

All investigators proposing research involving human subjects should read the
"NIH Guidelines for Inclusion of Women and Minorities as Subjects in Clinical
Research," which were published in the Federal Register on March 28, 1994 (FR 59
14508-14513) and in the NIH Guide for Grants and Contracts, Volume 23, Number 11,
March 18, 1994.

Investigators also may obtain copies of the policy from the program staff listed
under INQUIRIES.  Program staff may also provide additional relevant information
concerning the policy.

INCLUSION OF CHILDREN AS PARTICIPANTS IN RESEARCH INVOLVING HUMAN SUBJECTS

It is the policy of NIH that children (i.e., individuals under the age of 21)
must be included in all human subjects research, conducted or supported by the
NIH, unless there are scientific and ethical reasons not to include them.  This
policy applies to all initial (Type 1) applications submitted for receipt dates
after October 1, 1998.

All investigators proposing research involving human subjects should read the
"NIH Policy and Guidelines on the Inclusion of Children as Participants in
Research Involving Human Subjects" that was published in the NIH Guide for Grants
and Contracts, March 6, 1998, and is available at the following URL address:
http://www.nih.gov/grants/guide/notice-files/not98-024.html

GUIDELINES FOR THE ADMINISTRATION OF DRUGS TO HUMAN SUBJECTS

The National Advisory Council on Drug Abuse recognizes the importance of research
involving the administration of drugs to human subjects and has developed
guidelines relevant to such research.  Potential applicants are encouraged to
obtain and review these recommendations before submitting an application that
involves the administration of compounds to human subjects.  The guidelines are
available on the NIDA Home Page at http://www.nida.nih.gov/ or may
be obtained by calling (301) 443-2755.

LETTER OF INTENT

Prospective applicants are asked to submit, by March 29, 1999, a letter of intent
that includes a descriptive title of the proposed research; the name, address,
and telephone number of the Principal Investigator; the identities of other key
personnel and participating institutions; and the number and title of the RFA in
response to which the application may be submitted.  Although a letter of intent
is not required, is not binding, and does not enter into the review of a
subsequent application, the information that it contains is helpful in planning
for the review of the applications.

The letter of intent is to be sent to:

Director, Office of Extramural Program Review
National Institute on Drug Abuse
6001 Executive Boulevard, Room 3158  MSC 9547
Bethesda, MD  20892-9547
Telephone:  (301) 443-2755
FAX:  (301) 443-0538

APPLICATION PROCEDURES

Applications are to be submitted on the grant application form PHS 398 (rev.
4/98).  Application kits are available at most institutional offices of sponsored
research and may be obtained from the Division of Extramural Outreach and
Information Resources, National Institutes of Health, 6701 Rockledge Drive, MSC
7910, Bethesda, MD 20892-7910, telephone (301) 710-0267, E-mail:
GrantsInfo@nih.gov.  The title and number of this RFA must be typed in Item 2 on
the face page of the application.

The RFA label available in the PHS 398 (rev. 4/98) application form must be
affixed to the bottom of the face page of the application.  Failure to use this
label could result in delayed processing of the application such that it may not
reach the review committee in time for review.

Submit a signed, typewritten original of the application, including the
Checklist, and three signed photocopies, in one package, to:

CENTER FOR SCIENTIFIC REVIEW
NATIONAL INSTITUTES OF HEALTH
6701 ROCKLEDGE DRIVE, ROOM 1040 - MSC 7710
BETHESDA, MD  20892-7710
BETHESDA, MD  20817 (for express/courier service)

At the time of submission, two additional copies of the application must be sent
to:

Director, Office of Extramural Program Review
National Institute on Drug Abuse
Room 3158  MSC 9547
6001 Executive Boulevard
Bethesda, Maryland  20892-9547

Applications must be received by April 29, 1999.  If an application is received
after that date, it will be returned to the applicant without review.  The Center
for Scientific Review (CSR) will not accept any application in response to this
RFA that is essentially the same as one currently pending initial review, unless
the applicant withdraws the pending application.  The CSR will not accept any
application that is essentially the same as one already reviewed.  This does not
preclude the submission of substantial revisions of applications already
reviewed, but such applications must include an introduction addressing the
previous critique.

REVIEW CONSIDERATIONS

Upon receipt, applications will be reviewed for completeness by the CSR and
responsiveness by NIDA.  Applications that are incomplete and/or nonresponsive
will be returned to the applicant without review.  Applications that are complete
will be evaluated for scientific and technical merit by a peer review group
convened by NIDA in accordance with the standard NIH peer review procedures.  As
part of the initial merit review, all applications will receive a written
critique and undergo a process in which only those applications deemed to have
the highest scientific merit, generally the top half of applications under
review, will be discussed, assigned a priority score and receive a second level
review by the National Advisory Drug Abuse Council.

Review Criteria

The goals of NIH-supported research are to advance our understanding of
biological systems, improve the control of disease, and enhance health.  In the
written comments, reviewers will be asked to discuss the following aspects of the
application in order to judge the likelihood that the proposed research will have
a substantial impact on the pursuit of these goals.  Each of these criteria will
be addressed and considered in assigning the overall score, weighting them as
appropriate for each application.  Note that the application does not need to be
strong in all categories to be judged likely to have major scientific impact and
thus deserve a high priority score.  For example, an investigator may propose to
carry out important work that by its nature is not innovative but is essential
to move a field forward.

(1)  Significance:  The extent the goals and objectives of this application are
relevant to the RFA?  Does this study address an important problem?  If the aims
of the application are achieved, how will scientific knowledge be advanced?  What
will be the effect of these studies on the concepts or methods that drive this
field?

(2)  Approach:  Are the conceptual framework, design, methods, and analyses
adequately developed, well-integrated, and appropriate to the aims of the
project?  Does the applicant acknowledge potential problem areas and consider
alternative tactics?

(3)  Innovation:  Does the project employ novel concepts, approaches, or method?
Are the aims original and innovative?  Does the project challenge existing
paradigms or develop new methodologies or technologies?

(4)  Investigator:  Is the investigator appropriately trained and well suited to
carry out this work?  Is the work proposed appropriate to the experience level
of the principal investigator and other researchers (if any)?

(5)  Environment:  Does the scientific environment in which the work will be done
contribute to the probability of success?  Do the proposed experiments take
advantage of unique features of the scientific environment or employ useful
collaborative arrangements?  Is there evidence of institutional support?

In addition to the above criteria, in accordance with NIH policy, all
applications will also be reviewed with respect to the following:

o  The adequacy of plans to include both genders, minorities and their subgroups,
and children as appropriate for the scientific goals of the research.  Plans for
the recruitment and retention of subjects will also be evaluated.

o  The reasonableness of the proposed budget and duration in relation to the
proposed research.

o  The adequacy of the proposed protection for humans, animals, or the
environment, to the extent they may be adversely affected by the project proposed
in the application.

Schedule

Letter of Intent Receipt Date:  March 29, 1999
Application Receipt Date:       April 29, 1999
Scientific Review Date:         July 1999
Council Meeting Date:           September 1999
Earliest Award Date:            September 1999

AWARD CRITERIA

Award criteria that will be used to make award decisions include: scientific and
technical merit of the proposal as determined by peer review, availability of
funds, program needs and balance, and adequacy of provisions for the protection
of subjects.

INQUIRIES

Inquiries concerning this RFA are encouraged.  The opportunity to clarify issues
or questions from potential applicants is welcomed.

Direct inquiries regarding programmatic issues to:

Bennett W. Fletcher, Ph.D.
Division of Clinical and Services Research
National Institute on Drug Abuse
6001 Executive Boulevard, Room 4222, MSC 9565
Bethesda, MD  20892-9565
Telephone:  (301) 443-4060
FAX:  (301) 443-6815
Email:  Bennett_Fletcher@nih.gov

Direct inquiries regarding fiscal matters to:

Gary Fleming, J.D., M.S.
Grants Management Branch
National Institute on Drug Abuse
6001 Executive Boulevard, Room 3131, MSC 9541
Bethesda, MD  20892-9541
Telephone:  (301) 443-6710
FAX:  (301) 594-6847
Email:  gf6s@nih.gov

AUTHORITY AND REGULATIONS

This program is described in the Catalog of Federal Domestic Assistance No.
93.279.  Awards are made under authorization of the Public Health Service Act,
Title IV, Part A (Public Law 78-410, as amended by Public Law 99-158, 42 USC 241
and 285) and are administered under PHS grants policies and Federal Regulations
42 CFR 52 and 45 CFR Part 74.  This program is not subject to the
intergovernmental review requirements of Executive Order 12372 or Health Systems
Agency review.

The Public Health Service (PHS) strongly encourages all grant recipients to
provide a smoke-free workplace and promote the non-use of all tobacco products. 
In addition, Public Law 103-227, the Pro-Children Act of 1994, prohibits smoking
in certain facilities (or in some cases, any portion of a facility) in which
regular or routine education, library, day care, health care or early childhood
development services are provided to children.  This is consistent with the PHS
mission to protect and advance the physical and mental health of the American
people.

REFERENCES

Backer, T.E., David, S.L., Soucy, G. (eds.) (1995).  Reviewing the Behavioral
Science Knowledge Base on Technology Transfer.  NIDA Monograph Series 155,
Rockville, MD.

Ball, J.C. & Ross, A. (1991).  The effectiveness of methadone maintenance
treatment.  New York: Springer Verlag.

Becker, M.H. (1970a, February).  Factors affecting diffusion of innovations among
health professional.  American Journal of Public Health, 60(2), 294-304.

Brahen, L.S., Capone, T., Bloom, S., et al. (1978).  An alternative to methadone
for probationer addicts: Narcotic agonist treatment.  Contemporary Drug Issues,
13, 117-132.

Brown, B.S. (1998).  Making a difference:  Is journal publication enough? 
Journal of Substance Abuse Treatment, 15(2), 87-88.

D'Aunno, T., Foltz-Murphy, N., & Lin, X. (in press). Changes in methadone
treatment practices, 1988-1995.  American Journal of Drug and Alcohol Abuse.

D'Aunno, T. & Vaughn, T.E. (1995). The organizational analysis of service
patterns in outpatient drug abuse treatment units. Journal of Substance Abuse
Treatment, 7, 27-42.

Etheridge, R.M., Craddock, S.G., Dunteman, G.H., & Hubbard, R.L. (1995).
Treatment services in two national studies of community-based drug treatment
programs.  Journal of Substance Abuse Treatment, 7, 9-26.

Grella, C.E. (1996).  Background and overview of mental health and substance
abuse treatment systems: Meeting the needs of women who are pregnant or
parenting.  Journal of Psychoactive Drugs,  28(4), 319-343.

Higgins, S.T., Budney, A.J., Bickel, W.K., et al. (1994).  Incentives improve
outcome in patient behavioral treatment of cocaine dependence. Archives of
General Psychiatry, 51(7), 568-576.

Lamb, S., Greenlick, M., McCarty, D. (1998).  Bridging the Gap Between Practice
and Research: Forging Partnerships with Community-Based Drug and Alcohol
Treatment.  Washington, D.C.:  National Academy Press.

McLellan, A.T., Alterman, A.I., Metzger, D.S., et al. (1994).  Similarity of
outcome predictors across opiate, cocaine, and alcohol treatments:  Role of
treatment services.  Journal of Consulting and Clinical Psychology, 62(6),
1141-1158.

Rahdert, E.R. (ed.) (1996).  Treatment for Drug-Exposed Women and Their Children:
Advances in Research Methodology.  NIDA Research Monograph 165.  Rockville, MD:
National Institute on Drug Abuse.

Selwyn, P.A. (1996).  The impact of HIV infection on medical services in drug
abuse treatment programs.  Journal of Substance Abuse Treatment, 13(5), 397-410.

Silverman, K., Higgins, S.T., Brooner, R.K. et al. (1996).  Sustained cocaine
abstinence in methadone maintenance patients through voucher based reinforcement
therapy.  Archives of General Psychiatry, 53(5),409-415.

Simpson, D.D., Joe, G.W., & Brown, B.S. (1997).  Treatment retention and follow-
up outcomes in the drug abuse treatment outcome study (DATOS).  Psychology of
Addictive Behaviors, 11(4), 294-307.

Sorensen, J.L., Hall, S.M., Loeb, P., et al. (1988).  Dissemination of a job
seekers' workshop to drug treatment programs.  Behavior Therapy, 19, 143-155.

Widman, M., Platt, J.J., Lidz, V., et al. (1997).  Patterns of service use and
treatment involvement of methadone maintenance patients.  Journal of Substance
Abuse Treatment, 14(1), 29-35.

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