ED-Based Public Health ED-Based Public Health Research: Research:

NIDA’s PortfolioNIDA’s Portfolio

Richard A. Denisco, M.D., M.P.H.Richard A. Denisco, M.D., M.P.H.Medical OfficerMedical Officer

Division of Epidemiology, Services and Prevention ResearchDivision of Epidemiology, Services and Prevention ResearchServices Research BranchServices Research Branch

National Institute on Drug AbuseNational Institute on Drug Abuse

SAEM Consensus Conference SAEM Consensus Conference May 13, 2009May 13, 2009

Summary of NIDA ED Research Projects:

• Sixty Research Projects in ED’s

• Includes Research Grants ( e.g. R01, R03, R21), Career Development ( e.g. K23), and Small Business (SBIR and STTR)

• Focus on Tobacco Cessation, Computer Assisted Treatments in ED’s, Treatment Disparities, Co-Occurring Medical Disorders, and SBIRT

Clinical and Translational Science Awards (CTSAs):

Director

National Center forResearch Resources

e

National Institute on Drug Abuse

Impetus for the CTSA Program

CTSAWeb.org

Implement biomedical discoveries Develop, test, and bring new prevention

strategies into medical practice more rapidly Catalyze change - lower barriers between

disciplines Encourage creative and innovative approaches Major Area of Interest is Emergency

Medicine

To ensure new discoveries lead to improved public health, clinical science must evolve to

better:

CTSAs – Building a National Consortium of Academic Health Centers

Members 2006 & 2007Participating Institutions

WA

OR

CA

NV

AZNM

MT

UT

WY

CO

SD

ND

NE

KS

OK

TXAK

AR

MO

IA

MN

WI

IL IN

MI

OH

KY

TN

MS AL GA

FL

LA

NC

SC

VAWV

PA

NY

VT

NH

ME

MA

DEMD

RI

ID

HI

NJ

PR

New Members 2008

CT

Currently 38 CTSAs Sites Across the Country

Encouraging and Enhancing Collaboration Opportunities

CTSA Thematic Research Networks/CTSA Interest Groups

Emergency Medicine

Sleep Research Network

Critical Care

Neurology

Neuroimaging

Program Announcement (PA) with Set-Aside, Number: PAS-09-001

• Drug Abuse Epidemiology and Services Research in Cooperation with the Clinical and Translational Science Awards Consortium (R01)

   SBIRT Efforts in SBIRT Efforts in General Medical General Medical Settings Settings

What is SBIRT?What is SBIRT?

Screening

Brief Intervention

Referral to Treatment

USPSTF Model

• Evidence needed that intervention, including referral to treatment, impacts long-term morbidity and mortality within primary care populations

• Accepted outcomes for SBIRT (abstinence vs. health, social, legal, economic, and vocational outcomes)

Example:Strength of Evidence for Alcohol

• A meta-analysis suggests an overall reduction of 56% in number of drinks.

• The effect size for motivational intervention of all types ranged from 0.25 to 0.57, with participants followed from 3 to 24 months

Burke et. al., 2003

Example:Strength of Evidence for Tobacco/Smoking

• A meta-analysis of 43 studies.

• The improvement in cessation rates over controls for behavioral intervention of all types ranged from 4% to 15%, with an intervention as brief as 3 minutes improving abstinence rates.

• Pharmacotherapy as much as triples these rates.

Fiore et. al., 2000

Strength of Evidence for Illicit Drugs: Promising - but sparse results

• Bernstein, et al. 2005: Randomized Controlled Trial (RCT)

• WHO study, 2008: Randomized Controlled Trial (RCT) in Multiple Sites Internationally

• Madras, Compton, Avula, et al. 2009: SAMHSA program evaluation of (SBIRT) for illicit drug and alcohol use at multiple sites: Comparison at intake and 6 months later

• RCT (n=1175) urban walk-in clinic patients, presenting for non-acute problems and use of heroin or cocaine, confirmed by hair analysis

• Intervention – semi-scripted BMI of 20 min. (10-45), 10 days later a 5-10 min. booster call.

• ASI at intake, 3 and 6 months, HA 6 month

Bernstein et al. Drug and Alcohol Dependence 2005;77:49-59

Brief motivational intervention at a clinic visit reduces cocaine and

heroin use

Abstinence Among Those Screening Positive for At Baseline

Brief motivational intervention at a clinic visit reduces cocaine and heroin

use

p < .05

Bernstein et al. Drug and Alcohol Dependence 2005

Total Illicit Substance Involvement

Scores – BI and Control at Baseline and Follow-up (N=628) WHO ASSIST Phase III Technical Report, 2008: Pooled data

(F(1,624) = 7.6, p<0.01, observed power = 78.4%, alpha=0.05

NIDA - SBIRT Initiatives:

• NIDA has supported initiatives for SBIRT in General Medical Settings since initial findings of USPSTF

• RFA in 2004 for Screening and MI in adolescents (with SAMHSA) – 12 Grants

• Findings showing effectiveness of MI, computer platforms and EMRs in adolescent general medical settings

NIDA - SBIRT Initiatives:RFA-08-021 (SBIRT) for Drug Abuse in

General Medical Settings

• RFA in 2008: Screening, Brief Intervention and Referral to Treatment (SBIRT) for Drug Abuse in General Medical Settings (R01 only)RFA-DA-08-021 (R01)

• ~$3.5 million with SAMHSA, 5 Funded Grants

• Well designed RCTs in various general medical settings, testing effectiveness of various SBIRT models.

NIDA - SBIRT Initiatives:RFA-08-021 (SBIRT) for Drug Abuse in

General Medical Settings • D'Onofrio, Gail Models of SBIRT for Opioid

Dependent Patients in the Emergency Department

• Velasquez, Mary Marden Multidisciplinary Approach to Reduce Injury and Substance Abuse

• Roy-Byrne, Peter P Brief Intervention in Primary Care for Problem Drug Use and Abuse

• Svikis, Dace S Computer vs Therapist-Delivered Brief Intervention for Drug Abuse in Primary Care

• Merchant, Roland C Brief Intervention for Drug Misuse for the Emergency Department (BIDMED)

Screening for Drug Abuse in General Medical

Settings: Resources for Clinicians, 2009

• Makes the case for screening for illicit drugs in general medical care settings

• Details the use of NIDA – ASSIST for SBIRT

• Provides an overview of implementing screening programs in general medical settings

• Offers strategies for discussing screening results with patients

NIDA Screening and Treatment Resources for Medical and

Health Professionals

•Website

•Online Screening Tool

•Quick Reference Guide

•Online Resource Guide

•Patient Postcard

NIDAMED Online Screening Tool•Based on the WHO ASSIST•Screens for tobacco, alcohol, illicit, and non-medical prescription drug use•Based on patients’ responses, automatically:

oLeads to next appropriate question

oDetermines substance involvement score• Links to

additional resources

NIDAMED Online Screening Tool•Based on the WHO ASSIST•Screens for tobacco, alcohol, illicit, and non-medical prescription drug use•Based on patients’ responses, automatically:

oLeads to next appropriate question

oDetermines substance involvement score• Links to

additional resources

Quick Reference Guide

Online Resource Guide• Introduction

– Why screen for drug use in general medical settings?– How do you screen and provide feedback—the 5 As Ask, Advise, Assess, Assist, and Arrange

• Before you begin screening patients– Determine staffing roles and train staff– Decide how screening results will be used– Find reimbursement information for your state

(SAMHSA website)– Establish relationships and linkages with treatment

providers

Patient Postcard

NIDA - SBIRT Initiatives:

Cooperative actions with other Public Health Agencies

• Mainstreaming Efforts by W.H.O. and

SBIRT are occurring, NIDA participates and supports worldwide ASSIST project, Robert Ali, PI

• One of three key policy directions for the W.H.O. Department of Mental Health and Substance Dependence:

To integrate mental health and substance

dependence care into general health care.

• Mainstreaming addictions is a focus of activities in the AMA Department of Healthy Lifestyles and Primary Prevention.

• NIDA Primary Care Physician Outreach Project and Centers of Excellence. – Centers of Excellence: 5

Universities given grants to develop ways to teach medical students and residents Addiction Medicine and SBIRT Embedding drug addiction concepts in medical education.

NIDA - SBIRT Initiatives:Cooperative actions with other

Public Health Agencies

• Substance Use Disorders: CPT Codes Approved July 2008, with reimbursement now in 13 state Medicare and Medicaid programs, and 71 commercial carriers.

• Physician Performance Measurement Set

To develop clinician-level performance measures that will help to improve the quality of care for patients with substance use disorders.

• Component of the ongoing CPT 2 Code Development Process.

NIDA - SBIRT Initiatives:Cooperative actions with

other Public Health Agencies-AMA

  Update on NIDA's SBIRT Efforts in Update on NIDA's SBIRT Efforts in General Medical Settings: SummaryGeneral Medical Settings: Summary

• SBIRT has been shown efficacious for alcohol and tobacco; evidence for drugs is building but not yet sufficient for USPSTF.

• NIDA has numerous initiatives to provide this evidence base in next few years, and to disseminate SBIRT training to medical profession.

• NIDA has affiliations with Federal other Public Health Agencies to leverage its position.

Future SBIRT Research:

• Enhance drug abuse SBIRT evidence base in a variety of medical settings, such as EDs

• Develop and validate brief screening questionnaires to detect (and interventions for) prescription drug abuse that can be applied in general medical settings

• Test new technologies for implementing SBI (internet, tablet, PDA, etc.)

• Developing models for referral and/or direct treatment in general medical settings (the “RT” of SBIRT)

• Linking results of SBIRT interventions to important morbidity and mortality outcomes

National Institute on Drug Abuse

Division of Epidemiology, Services and Prevention

Research

Promoting Extraordinary Public Health Research to Eradicate

Drug Abuse

Promoting Extraordinary Public Health Research to Eradicate

Drug Abuse