APT FOUNDATION’S LEGACY OF RESEARCH
In 1970, Dr Herb Kleber, a faculty member in the Department of Psychiatry at Yale School of Medicine, founded the Addiction Prevention and Treatment Foundation, which later became known as the APT Foundation. Dr. Kleber is now recognized as a pioneering researcher in addiction medicine.
Early mentees of Dr Kleber included Drs.Tom Kosten, Bruce Rounsaville, and Richard Schottenfeld. Together, they conducted groundbreaking research at APT that elucidated the medical and psychiatric co-morbidities of substance use disorders, and they evaluated innovative treatment approaches for a variety of substance use disorders which often combined pharmacotherapy and psychotherapy.
This illustrious trio went on to mentor other APT-affiliated researchers who have had a lasting impact on the field, including Drs. Kelly Avants, Sam Ball, Kathy Carroll, David Fiellin, Joel Gelertner, Sonja Luthar, Art Margolin, Alison Olivetto, Patrick O’Connor, Marc Potenza, Elise Triffleman, and others.
Currently, APT is a research home to a cadre of well-known addiction researchers with expertise in internal medicine (e.g., Drs. Kenny Moreford, Julia Shi, and Jeanette Tetrault), neuroimaging (Drs. Kathleen Garrison, Helena Rutherford, Dustin Scheinost, and Sarah Yip), infectious disease (e.g., Drs. Rick Altice, Michael Copenhaver, Jaimie Meyer, and Sandra Springer), pain management (Drs. Declan Barry, Mark Beitel, and Christopher Cutter), parenting (e.g., Drs. Tom McMahon and Nancy Suchman), sleep medicine (e.g., Drs. Nancy Redeker and Klar Yaggi), and public health (e.g., Drs. Robert Heimer and Lynn Madden).
In addition to conducting randomized clinical trials on treatment efficacy and effectiveness, researchers at APT are conducting novel studies to facilitate the training of providers in evidence-based practices. A robust team of APT research assistants and information technology specialists have been instrumental in supporting APT-generated research. Since we have assembled a rich trove of clinical data, Addiction Medicine and Addiction Psychiatry Fellows who train here have the opportunity to write up findings for publication under the mentorship of APT researchers.
We honor the legacy of our founder Dr. Kleber by being the location of innovative, cutting-edge research funded by our National Institutes of Health and other agencies. APT remains on the forefront of applying research to clinical practice to benefit our patients and the community.
I went to the key movers and shakers in New Haven, the key leaders of the Black, Jewish, Italian, Irish, Puerto Rican communities, the bankers, etc., and I said, “I want to set up a foundation to help prevent and treat addiction among our youth and young adults. I know you are too busy to be on the board, but would you suggest someone that would be speaking for you”. And, interestingly enough, many of them said, “I’ll be on the board” – Herbert Kleber interview with Andrea Tone, San Juan, Puerto Rico, December 7, 2003
“Dr. Kleber changed the landscape of addiction treatment, allowing patients to be diagnosed and treated rather than shamed—and saving countless lives in the process.”
– On Oct 1, 2019 Google Doodle celebrated the 23rd anniversary of Dr. Kleber’s election to the National Academy of Medicine
It is with sadness that we acknowledge the loss of Dr. Kathleen (Kathy) Carroll (1958 ~ 2020) just a few months after honoring her at APT’s 50th Anniversary Golden Gala. Dr. Carroll’s contributions to the field of addiction treatment are unparallelled. She helped establish the Stage Model of Behavioral Therapies Development that facilitated important advances by defining stages of science for behavioral therapies development, from pilot testing of novel approaches translated from basic clinical science (“Stage 1”) to efficacy testing via randomized clinical trials (“Stage 2″) to effectiveness research based in community settings (Stage 3”). This required a set of methodological advances (e.g., systemization of interventions in manuals, development of fidelity rating systems, therapist training strategies) to which she made multiple contributions. She received a NIH MERIT award for her work which led to the development of an effective web-based version of Cognitive Behavioral Therapy (“CBT4CBT”), now validated in eight independent trials. CBT4CBT became one of the first evidence-based computerized interventions for a range of substance use disorders and is currently being adapted and implemented for various co-occurring conditions.
Another untimely loss to our scientific community, the APT Foundation, and the field of addiction treatment research was the passing of Nancy E. Suchman, PhD (1957-2020). An Associate Professor in Yale’s Department of Psychiatry and Child Study Center, Dr. Suchman dedicated her career to developing clinical interventions for women struggling with substance use disorders. Through her research and clinical care, she made significant contributions to the science of addiction, parenting, and child development. The one most meaningful to her was the development of Mothering from the Inside Out, an attachment-based parent intervention. This empirically based individual psychotherapy is designed to help mothers grappling with addiction and other threats to effective parenting develop the capacity for reflective functioning in their relationships with their children. Over more than 15 years, she partnered with Cindy DeCoste, her project director, and a long list of co-investigators, consultants, clinicians, and research assistants to develop and test this clinical intervention. As this novel intervention captured the attention of the research community interested in the impact of addiction on parenting, she began an academic tour to speak, teach, and consult, not just in this country, but in Finland, South Africa, Australia, Canada, France, Italy, Germany, and the United Kingdom.
RECENT RESEARCH PUBLISHED OUT OF APT
1. DiMeola, K.M., J. Haynes, M. Barone, M. Beitel, L.M. Madden, C.J. Cutter, A. Raso, M. Gaeta, X. Zheng, D.T. Barry. A pilot investigation of nonpharmacological pain management intervention groups in methadone maintenance treatment. J. Addict Med. In Press.
2. Oberleitner, LMS., Madden, LM, Muthulingam, D., Marcus, R., Oberleitner, DE., Beitel, M., Gaeta, M., Tamberelli, JF, Barry, DT. A qualitative investigation of addiction counselors’ perceptions and experiences implementing an open-access model for treating opioid use disorder, J Subst Abuse Treat. 2020
In an interview study of addiction counselors at APT, participants identified positives and negatives to scaling up treatment. Advantages and disadvantages to clients include reduced barriers to treatment and greater autonomy, and lack of structure. Advantages and disadvantages to counselors include stimulating work environment and fewer demands, and uneven workloads. Participants did not identify any disadvantages to the community; possible advantages to the community include less crime and treatment offered to vulnerable members
3. Gaeta, M., M. Beitel, L.M.S. Oberleitner, D.E. Oberleitner, L.M. Madden, J.F. Tamberelli, D.T. Barry. Correlates of homelessness among patients in methadone maintenance treatment. Med Care. Nov 2020
APT’s open-access model allows treatment access for individuals who are potentially vulnerable, including those who are homeless. In a cross-sectional study of APT patients, we found that those who were homeless (vs. domiciled) were more likely to be male and report higher symptoms of depression.
4. Baldasarri, S.R., M. Beitel, A. Zinchuk, N.S. Redeker, D.E. Oberleitner, L.M. Oberleitner, D.Carrasco, L.M. Madden, N. Lipkind, D.A. Fiellin, L.A. Bastian, K. Chen, K. Yaggi, D.T. Barry. Correlates of sleep quality and excessive daytime sleepiness in people with opioid use disorder receiving methadone treatment. Sleep Breath. Dec 2020
In a study of patients receiving methadone treatment for opioid use disorder at APT, we found that poor sleep quality and excessive daytime sleepiness were common. Predictors of sleep problems, which may be modifiable, included chronic pain, somatization (i.e., bodily manifestation of emotional stress), employment status, and obesity.
5. Oberleitner, D.E., R. Marcus, M. Beitel., D. Muthulingam., L.M.S. Oberleitner, L.M. Madden, A. Eller, D.T. Barry, in press. “Day-to-day, it’s a roller coaster. It’s frustrating. It’s rewarding. It’s maddening and it’s enjoyable”: A qualitative investigation of the lived experiences of addiction counselors. Psychol Serv. 2019
We examined work roles, work motivation, and perceived responses of others to their work among addiction counselors at APT. . Interviews were taped and transcribed. An interdisciplinary team reviewed and coded the transcripts. The main work roles that emerged were counselor, educator, and advocate. Counselors described multiple factors related to intrinsic motivation for their work: family and personal history, altruism, enjoyment of challenges and client complexity, and witnessing and fostering change. Factors related to extrinsic motivation were workplace opportunities and positive feedback.
6. Baldasarri, S.R., D.A. Fiellin, M.E. Savage, L.M. Madden, M. Beitel, L.K. Dhingra, L. Fucito, D. Camenga, P. Bollampally, D.T. Barry. Electronic cigarette and tobacco use in individuals entering methadone or buprenorphine treatment. Drug Alcohol Depend. 2019, 197:37-41.
This study found that electronic cigarette use is common among people with opioid use disorder who smoke cigarettes. Those with daily electronic cigarette use had higher odds of being former smokers than current smokers. These findings led APT to augment its nicotine cessation interventions.
7. Madden, L.M., S.O Farnum, K.F. Eggert, A.R. Quanbeck, R. Freeman, S.A. Ball, R.S. Schottenfeld, J.M. Shi, M.E. Savage, D.T. Barry. An investigation of an open-access model for scaling up methadone maintenance treatment. Addiction. 2018, 113: 1450–1458.
Despite the dramatic rise in the prevalence of opioid use disorder in the U.S., few treatment organizations have scaled up medication-assisted treatment to address the magnitude of the current opioid epidemic. Beginning in May 2007, the CEO and senior staff at APT began developing and implementing an “open-access” model in which prospective patients were enrolled rapidly in methadone maintenance treatment, irrespective of ability to pay, and provided real-time access to multiple voluntary treatment options. Medical and administrative records were abstracted to compare data for one year before and 9 years after initiating the implementation of the open-access treatment model. In the 9 years following the initial implementation, patient census increased by 183% from 1,431 to 4,051, and average wait-time days decreased from 21 to .3 (same day) without apparent deleterious effects on rates of retention, nonmedical opioid use, or mortality. Between fiscal year (FY) 06 and FY 15, net operating margin rose from 2% to 10%, while state-block grant revenues declined 14% and the proportion of total revenue from state-block grant revenue decreased from 49% to 21%. Further investigation of the open-access model is merited as it offers one of the few published models for assisting program managers to scale up medication-assisted treatment.
8. Beitel, M., L.M. Oberleitner, D. Muthulingam, D. Oberleitner, L.M. Madden, R. Marcus, A. Eller, M.H. Bono, D.T. Barry. Experiences of burnout among drug counselors in a large opioid treatment program: A qualitative investigation. Subst Abuse. 2018, 39:211-217.
Rates of reported burnout (in response to an open-ended question) were lower than expected (26%), suggesting that drug counselor burnout is not inevitable, even in opioid treatment program settings whose treatment capacities are expanding. Participants described both self-initiated (e.g., engaging in pleasurable activities, exercising, taking breaks during workday) and system-supported strategies for managing or preventing burnout (e.g., availing of supervision and paid time off). Counselors provided recommendations for system-level changes to attenuate counselor risk of burnout (e.g., increased staff-wide encounters, improved communication, accessible paid time off, and increased clinical supervision).
9. Butner, J.L., C. Bone, C.C. Ponce Martinez, G. Kwon, M. Beitel, L.M. Madden, M.H. Bono, A. Eller, D.T. Barry. Training addiction counselors to deliver a brief psychoeducational intervention for chronic pain among patients in opioid agonist treatment: A pilot investigation. Subst Abuse. 2018, 39:199-205.
Our team developed a 90-minute training for APT counselors that reviewed prior research regarding the characteristics of patients with chronic pain who receive opioid agonist treatment and the clinical challenges reported by their providers. Attendees were trained on a brief psychoeducational intervention that involved setting a movement goal. Findings from this pilot study suggest that it is both feasible and acceptable to train front-line drug counselors on an inexpensive, brief, onsite psychoeducational intervention for assessing and addressing chronic pain. This study found that, on average, six months after the training, attendees
continued to perceive a beneficial effect on their clinical work with patients with chronic pain.
10. Beitel, M., L.M. Oberleitner, M. Kahn, R.D. Kerns, C. Liong, L.M. Madden, J. Ginn, D.T. Barry. Drug counselor responses to patients’ pain reports: A qualitative investigation of barriers and facilitators to treating patients with chronic pain in methadone maintenance treatment. Pain Med. 2017, 18:2152-2161.
In this qualitative study of APT counselors, we found that many participants embraced a biomedical model of chronic pain, and over-relied on referrals to medical providers for addressing chronic pain. These findings informed a subsequent counselor training that emphasized the biopsychosocial model and underscored how existing skillsets could be adapted to address chronic pain.
11. Beitel, M., M. Stults-Kolehmainen, C.J. Cutter, R.S. Schottenfeld, K. Eggert, L.M. Madden, R.D. Kerns, C. Liong, J. Ginn, D.T. Barry. Physical activity, psychiatric distress, and interest in exercise group participation among individuals seeking methadone maintenance treatment with and without chronic pain. Am. J. Addict. 2016, 25:125-131.
This study of individuals seeking methadone maintenance treatment at the APT Foundation found that the overall prevalence of meeting recommended public health guidelines for physical activity was low (30%), especially among those with co-occurring chronic pain (20%). These findings resulted in APT offering an increased number of exercise-related groups, including walking, Tai Chi, Yoga, and Nintendo Wii.
ONGOING OPEN RESEARCH
The APT Foundation is fortunate to have multiple staff members with research expertise. As part of our ongoing commitment to quality assessment and quality improvement, APT’s patients may consent to participate in research studies. At present, several studies are actively enrolling participants who meet certain criteria. Please see below.