APT FOUNDATION’S LEGACY OF RESEARCH
Dr. Declan Barry, Director 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. Gaeta Gazzola, M., Carmichael, I.D., Madden. L.M., Dasgupta, N., Beitel, M., Zheng, X., Eggert, K.F., Farnum, S.O., Barry, D.T. A cohort study examining the relationship among housing status, patient characteristics, and retention among individuals enrolled in low-barrier-to-treatment-access methadone maintenance treatment. Journal of Substance Abuse Treatment 2022
Few studies have directly compared patient characteristics and retention among those enrolled in methadone maintenance treatment (MMT) based on housing status. Conclusions were that patients entering MMT experiencing homelessness have multiple clinical vulnerabilities and are at increased risk for 12-month MMT discontinuation. Low-barrier-to-treatment-access MMT programs are an important venue for identifying and addressing vulnerabilities associated with homelessness.
2. Adams, Z. M., Ginapp, C.M., Price, C.R., Qin, Y., Madden, L.M., Yonkers, K., Meyer, J.P. “A good mother”: Impact of motherhood identity on women’s substance use and engagement in treatment across the lifespan. J Subst Abuse Treat 2021
Interpersonal and structural factors affect women’s access to SUD treatment, but limited research evaluates how motherhood is a potential barrier and facilitator to engagement in SUD treatment. Women with SUD who are mothers experience specific barriers to treatment engagement and recovery. Women need SUD treatment programs that address these interpersonal and structural factors across the lifespan.
3. DiMeola, K. A., Haynes, J., Barone, M., Beitel, M., Madden, L.M., Cutter, C.J., Raso, A., Gaeta, M., Zheng, X., Barry, D.T. A Pilot Investigation of Nonpharmacological Pain Management Intervention Groups in Methadone Maintenance Treatment. J Addict Med. 2021
The objective of this study was to examine the feasibility (i.e., single-session attendance) of conducting 3 counselor-delivered nonpharmacological pain management intervention (NPMI) groups in methadone maintenance treatment (MMT): (1) Coping with Pain, an intervention based on cognitive-behavioral therapy, (2) Wii-Covery, an exergame intervention to facilitate exercise, and (3) Juggling Group, an intervention to promote social inclusion and reduce stress. We found acute improvements in current pain intensity and specific mood states associated with a single session attendance point to the importance of examining systematically the efficacy of these and other NPMIs in MMT.
4. Barry, D. T., Beitel, M., Cutter, C.J., Fiellin, D.A., Madden, L.M., Lipkind, N., Bollampally, P., Liong, C., Schottenfeld, R.S. Psychiatric comorbidity and order of condition onset among patients seeking treatment for chronic pain and opioid use disorder. Drug Alcohol Depend 2021
This study found that varying pathways may exist for the emergence of chronic pain and OUD; further research should investigate potential treatment implications.
5. Du, C.X., Shi, J., Tetrault, J.T., Madden, L.M., Barry, D.T. Primary care and medication management characteristics among patients receiving office-based opioid treatment with buprenorphine. Fam Pract. 2021 (Online ahead of print).
The objective of the study was to characterize the medical conditions, medications, and treatment outcomes among patients receiving office-based treatment for opioid use disorder with buprenorphine, and to describe differences among patients by age and by time in care. Findings were clear and significant: the clinical needs of this patient group are not unlike those of the general population.
6. Haque, L. Y., Butner, J.L., Shi, J.M., Henry, S., Deng, Y., Ciarleglio, M.M., Madden, L.M., Tetrault, J.M. Primary Care Associated With Follow Up Viral Load Testing in Patients Cured of Hepatitis C Infection With Direct Acting Antivirals at a Multidisciplinary Addiction Treatment Program: Insights From a Real-World Setting. J Addict Med. 2021
Treatment of hepatitis C virus infection (HCV) with direct acting antiviral therapy is encouraged regardless of substance use status. Patients with substance use disorder are at risk of HCV reinfection after cure. Follow up viral load testing (FUVL) with HCV RNA is recommended. The relationship between FUVL and engagement in primary medical and substance use treatment highlights the importance of integrated systems in providing longitudinal care for patients cured of HCV. Standardized interventions that facilitate FUVL testing and management of infectious complications of SUD in addiction treatment settings are needed.
7. Oberleitner, D. E., Marcus, R., Beitel, M., Muthulingam, D., Oberleitner, L.M.S., Madden, L.M., Eller, A., Barry, D.T. “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 2021
Psychologists in medication for addiction treatment (MAT) settings routinely oversee the work of addiction counselors as supervisors, administrators, and human resource specialists. Limited research has explored the lived experiences of counselors who work in programs that have scaled-up MAT in response to the opioid crisis in the U.S. Responses from clients were largely 1. positive and focused on appreciation and respect. Psychologists in MAT settings can enhance the lived experiences of addiction counselors by helping them to savor positive feedback from clients and others, to recognize and appreciate their unique skillsets, and to recognize and address (not internalize) the multiple sources of stigma they encounter as addiction counselors. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
8. 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
9. 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.
10. 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.
11. 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.
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.
Many people are addicted to opioids such as painkillers and heroin. Treatment with methadone and buprenorphine helps people to cut down or stop using opioids. We want to better understand what helps or gets in the way of people doing well in this treatment. We are recruiting people who are in the first 6 weeks of treatment with methadone or buprenorphine at APT for the CLOUDS study. We will track participants’ sleep, drug use, and how they are feeling over time. We pay participants for their time in the CLOUDS study. Information from this study may help to improve existing treatment with methadone and buprenorphine. We are currently enrolling participants. This study will continue enrollment till December 2024. If you are interested in learning more about the CLOUDS study, please contact Anthony at (203) 285-2716.
HIV-Risk Reduction for Opiate-Dependent Adult
The Harm Reduction Unit (HRU), located on the second floor of the APT Foundation, is currently conducting aresearch study involving HIV-risk reduction strategies for opiate-dependent adults. If you would like to screen for the study to see if you qualify, please go to the HRU on the second floor of the Welch Building (495 Congress Avenue, New Haven). We have daily open screening hours from 8:30 until 1:30. Please call 203-781-4690 for more information.
FOR FURTHER REFERENCE
Explanation of Open Access Model
Backed by the latest scientific research, APT employs an Open Access treatment model. An Open Access Model rapidly enrolls prospective patients, irrespective of ability to pay, and provides real-time access to multiple voluntary treatment options. Between 2006, when our treatment program initially implemented this model, and 2020, the census of clients receiving methadone maintenance at the APT Foundation grew from 1431 to 4500.
APT contributes significantly to bodies of knowledge and datasets nationally and internationally as we keep abreast of other’s latest research. See, for example these important references for the field:
- National Academy of Sciences 2019 Report – Medications for Opioid Use Disorder Save Lives
- Data from the federal Substance Abuse and Mental Health Services Administration, including National Surveys on Drug Use and Health
- Latest in Addiction Science at the National Institutes of Health
- National Institute on Drug Addiction Research Tools
- Implementation of the Open Access Model in Connecticut – contact information for programs may be found in this Access to Recovery Service Directory
- For more information on evidence-based treatments and strategies for reducing harms from substance use, visit Resources for Self-Management and Resources for Families/Friends.