Mainstreaming Addictions in Medicine:
Improving Substance Abuse Services Through
StandardizationWilson M. Compton, M.D., M.P.E.Director, Division of Epidemiology, Services and
Prevention ResearchNational Institute on Drug Abuse
13 August 2012
Drug use has wide ranging health , social consequences.– Cardiovascular disease,
stroke, cancer, HIV/AIDS, anxiety, depression, sleep problems, as well as financial difficulties and legal, work, and family problems can all result from or be exacerbated by drug use.
Occurrence of Medical Conditions in Diagnosed
Substance Abusers
Source: Mertens JR et al, Arch Intern Med 163: 2511-2517, 2003
Why focus on drug use in general medical settings?
Health Care Reforms are shifting the emphasis to integrated care based in general medical settings.– 2009 Enhanced parity of coverage of
mental illnesses and substance use disorders (compared to coverage of other medical conditions)
– 2010 Health care reform to reduce the number of uninsured persons
Why focus on drug use in general medical settings?
A Continuing Care Model
PrimaryContinuing Care
Primary Care
Specialty Care
Source: A. T. McLellan, 2011
PROBLEM: Physicians don’t routinely screen for drug use.
–Don’t know what to do –No effective treatment–Not medical problem–No time–Health care system doesn’t address addictions routinely
Why focus on drug use in general medical settings?
Mainstreaming Addictions in General Medicine
• Promising Practice: Screening and Brief Intervention or Referral to Treatments (SBIRT).
• Improving development of medications.
• Blending science and services to address practice-relevant research.
Mainstreaming Addictions in General Medicine
• Promising Practice: Screening and Brief Intervention or Referral to Treatments (SBIRT).
• Improving development of medications.
• Blending science and services to address practice-relevant research.
USPSTF - Current Policy Status of SBIRT:
Alcohol and Tobacco -SBIRT accepted
• Tobacco: http://www.ahrq.gov/clinic/uspstf/uspstbac.htm
• Alcohol:
http://www.ahrq.gov/clinic/uspstf/uspsdrin.htm
Illicit Drug Use -SBIRT evidence insufficient
• Drugs: http://www.ahrq.gov/clinic/uspstf/uspsdrug.htm
Some Key Lessons from Alcohol and Tobacco SBIRT:
Impact of SBIRT varies according to Setting and Patient Characteristics
RT is not well addressed
Strength of Evidence for Illicit Drugs: Promising - but sparse results• Bernstein, et al. 2005: Randomized
Controlled Trial (RCT)• WHO study, 2008 & Hermeniuk R, et al.
2012: 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
• Bernstein, et al. 2009: Adolescent RCT in ED, reduction in days MJ smoked at 12 mo after BI
22.3%
40.2%
16.9%
30.6%
0%
20%
40%
60%
Cocaine Opioids
Intervention
Control
Abstinence Among Those Screening Positive for At Baseline (N=1175), comparing those who did and did not receive peer-delivered, brief (~20 minutes) intervention with booster phone call (~5 minutes) 10 days later
p < .05
Bernstein et al. Drug and Alcohol Dependence 2005
Brief motivational intervention reduces 6 mo. cocaine and heroin
use
Total Illicit Substance Involvement
Scores – BI and Control at Baseline and Follow-up
(N=628)
WHO ASSIST Phase III Technical Report, 2008; Hermeniuk R, et al. Addiction 2012
p<0.01
Cannabis Specific Substance Involvement
Scores – BI and Control at Baseline and Follow-up
(N=328)
p<0.05
WHO ASSIST Phase III Technical Report, 2008; Humeniuk R, et al. Addiction 2012
Stimulant Specific Substance Involvement
Scores – BI and Control at Baseline and Follow-up
(N=229)
p<0.005
WHO ASSIST Phase III Technical Report, 2008; Humeniuk R, et al. Addiction 2012
Opioid Specific Substance Involvement Scores – BI and
Control at Baseline and Follow-up (N=73)
p<0.07
WHO ASSIST Phase III Technical Report, 2008; Humeniuk R, et al. Addiction 2012
Program Data, Six SAMHSA SBIRT Sites, Baseline and
F/U Substance UseAmong Those Screening Positive for Drugs At
Baseline (N = 6,262)
%
Madras, et al. Drug Alcohol Dependence, 2009
All are P < 0.001
Intervention Group (INT) Assessed Control Group (AC)0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
0.5 * OR =2.89, p<.014
(N=47) (N = 55)
Perc
ent
Abst
inen
t
Abstinence = no marijuana use in past 30 days at 12 months
* 44.7%
21.8%
Screening and Brief Intervention to Reduce Marijuana Use Among Youth and Young
Adults in a Pediatric ED
Bernstein E et al., Academic Emergency Medicine 2009;16 (1):1174-1185
Intervention Group (INT) Assessed Control Group (AC)0
5
10
15
20
25
30
* OR =3.36, p=.0117
9.3%
Effect of Intervention on Reporting Receiving Referrals to Community Resources
(N=47) (N = 55)
Perc
ent
Repo
rt
Rece
ivin
g Re
ferr
als *
25.5%
Screening and Brief Intervention to Reduce Marijuana Use Among Youth and Young
Adults in a Pediatric ED
Bernstein E et al., Academic Emergency Medicine 2009;16 (1):1174-1185
SBIRT and Cost effectiveness
Evaluation of the first SAMHSA SBIRT cohort in Washington state (WASBIRT)Working –age disabled patientsReceived at least a brief intervention (BI)Results: BI at $70 per person resulted in $185 to $192 saving per member per month and $2.7 to $2.8 million total per year in Washington State
Source: Estee S, He L, Mancuso D, Felver B. Medicaid costs declined among emergency department patients who received brief interventions for substance use disorders through WASBIRT. Washington State Department of Social and Health Services, Research and Data Analysis Division. (2007).
SBIRT and Cost effectivenessCost–benefit analysis of Early Start, an
integrated prenatal intervention program for stopping substance use in pregnancyFour study groups were compared (N=49,261) : 1.) screened-assessed-followed (n=2032), Maternal cost = $9,430, Infant costs = $11,2142.) screened-assessed (n=1181), Maternal cost $9,230, Infant cost $11,3043.) screened-positive-only (n=149), Maternal cost = $10,869, Infant cost = $16,9434.) control group who screened negative (n=45,899), Maternal cost = $8,282, Infant cost = $10,416Program Cost $670,600 v. Benefit $5,946,741 per yearGoler, Armstrong, Osejo, et al. Obstetrics & Gynecology
2012;119(1):102–110
Strength of Evidence about
SBIRT for Illicit Drugs: Promising - but limited data
Additional Studies Also Show the Potential for Prevention
Interventions at the Boundary of Illicit Drug Abuse and Other
Behavioral Health Issues
Intervention for Rape Assault Victims Shows Impact on
Marijuana Use
Screening and Brief Intervention
Dr. Barbara Gerbert (and colleagues) have used the Video Doctor to screen for the following sensitive risk areas:
Nutrition
Physical activity
Intimate partner violence/Domestic violence
HIV risk behaviors
Smoking
Alcohol use
Drugs use
Baseline 1-month0%
20%
40%
60%
80%
100%
16.7%23.5%
81.8%
70.0%
Usual Care
Intervention
Provider - Patient Intimate Partner Violence Discussions
Barbara Gerbert, Presented at NIH Implementation Conference, March 2010
Enhancement • Start process with Single
Questions (prior to ASSIST assessment of
severity) Tobacco Alcohol Prescription Drugs Illegal Drugs
• Expand to include Adolescents (meeting May 27, 2011 and recent supplement program)
• Focusing on measuring illicit and prescription drug abuse for the Electronic Health Record
Smith, Schmidt,
Allensworth-Davies,
Saitz 2010
Electronic Health Record (EHR)
Federal encouragement to adopt with “meaningful use”
Multiple vendors developing EMR Hospital based systems Individual practice based systems Interoperability (EMRs EHR)
Content Clinical care Research
Source: Robert Gore-Langton, PhD, NIDA CTN Data and Statistics Center, The EMMES Corporation
Electronic Health Record (EHR)
Federal meaningful use criteria Incentive through reimbursement Incorporate concepts and data elements to
qualify for meaningful use Example
Meaningful use stage 1 (2011-2012) Screen for tobacco use in > 50% of clinic population
Meaningful use stage 2 (proposed, for 2013) Screen for tobacco use in 80% of clinic population Screen and brief intervention for alcohol use
disorders Screen for illicit and prescription drugs
Source: Robert Gore-Langton, PhD, NIDA CTN Data and Statistics Center, The EMMES Corporation
1 Question Alcohol Screener
1 QuestionDrug Screener
Alcohol Assessment
Drug SeverityAssessment
Initial Presentation3 Screener Questions
NONOYES YES
Further Assessment and/or Referral outside of primary care
NO
1 Question Tobacco Screener
Tobacco Assessment
YES
Source: Robert Gore-Langton, PhD, NIDA CTN Data and Statistics Center, The EMMES Corporation
Summary of Future SBIRT Research:
• Enhance evidence on effectiveness of SBI models of care in a variety of general medical (and related) settings, and differing populations
• Develop and validate brief screening questionnaires, with technology, to detect (and intervene on) prescription drug abuse
• 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)
• Integrate SBIRT/Drugs with all behavioral health behaviors
Mainstreaming Addictions in General Medicine
• Promising Practice: Screening and Brief Intervention or Referral to Treatments (SBIRT).
• Improving development of medications.
• Blending science and services to address practice-relevant research.
Outcomes can be improved by:
Developing interventions that are highly effective as delivered
Translating Basic Science Discoveries Into
New and Better TreatmentsBasic Research
Medications
Basic Research
Medications
OFCSCC
MOTIVATION/DRIVE
Hipp
Amyg MEMORY/
LEARNING
Circuits Involved In Drug Abuse and Addiction
NAcc VP
REWARD
PFC
ACG
EXECUTIVEFUNCTION/ INHIBITORY
CONTROL
NAcc VP
REWARD
1. Reward Circuit
Drugs of Abuse EngageSystems in the Motivation Pathwaysof the Brain
Hipp
Amyg MEMORY/LEARNING
2. Memory circuit
“People, Places and Things…”
Cocaine Film
Cocaine Craving:Population (Cocaine Users, Controls) x Film (cocaine )
Garavan et al A .J. Psych 2000
IFG
Ant Cing
Cingulate
Sign
al In
tens
ity
(AU
)
Controls Cocaine Users
Cocaine Film Erotic Film
Cocaine Craving:Population (Cocaine Users, Controls) x Film (cocaine, erotic)
Garavan et al A .J. Psych 2000
IFG
Ant Cing
Cingulate
Sign
al In
tens
ity
(AU
)
Controls Cocaine Users
Even Unconscious Cues Can Elicit Brain Responses
Brain Regions Activated by 33 millisecond Cocaine Cues (too fast for conscious recognition)
Childress, et al., PLoS ONE 2008
3. Motivation & Executive Control Circuits
ACGOFC SCC
INHIBITORY CONTROL
EXECUTIVEFUNCTION
PFC
MOTIVATION/DRIVE Dopamine is also
associated with motivation and executive function via regulation of frontal activity.
ACG
OFCSCC
Hipp
NAccVP
Amyg
REWARDINHIBITORY
CONTROL
MEMORY/LEARNING
EXECUTIVEFUNCTION
PFC
Becomes severely disrupted in ADDICTION
MOTIVATION/DRIVE
The fine balance in connections that normally exists between brain areas active in reward, motivation, learning and memory, and inhibitory control
Treatments for Relapse Prevention: Medications
Addicted Brain
Drive
Control
Saliency
Memory
GO Strengthen prefrontal-striatal communication
Executive function/Inhibitory control
Interfere with conditioned memoriesTeach new memories
Counteract stress responses that lead to relapse
Interfere with drug’s reinforcing effects
VaccinesEnzymatic degradationNaltrexoneDA D3 antagonistsCB1 antagonists
BiofeedbackModafinilBupropionStimulants
Antiepileptic GVGN-acetylcysteine
Cycloserine
CRF antagonistsOrexin antagonists
STOP Drive
Control
Memory
Non-Addicted Brain
Saliency AdenosineA2 antagonistsDA D3 antagonists
Treatments for Relapse Prevention: PsychotherapiesAddicted
Brain
Drive
Control
Saliency
Memory
GO Strengthen prefrontal-striatal communication
Executive function/Inhibitory control
Interfere with conditioned memoriesTeach new memories
Counteract stress responses that lead to relapse
Interfere with drug’s reinforcing effects
STOP Drive
Control
Memory
Non-Addicted Brain
Saliency
Contingency Management
Cognitive Therapy
BiofeedbackDesensitization
RelaxationBehavioral therapies
Motivation Therapies
Behavioral Therapies
Mainstreaming Addictions in General Medicine
• Promising Practice: Screening and Brief Intervention or Referral to Treatments (SBIRT).
• Improving development of medications.
• Blending science and services to address practice-relevant research.
Outcomes can be improved by:
Developing interventions that are highly effective as delivered
, or Implementing an
effective intervention more widely.
Information Dissemination
Information Dissemination• Essential first step in Type 2
translation research – BUT
• Generally produces only a vague awareness that new science exists
• Does not address the conditions and circumstances of the numerous providers, clients and contexts involved.
Developing an intervention is only one part of translating
research into practice.
Intervention
Access and
Engagement
Provider knowledge and
behavior
Organization Structure
and Climate
External Environm
ent (stigma,
financing)
Methadone Maintenance Dosing Improved, but standards often not met
1988 1990 1995 2000 20050
102030405060708090
100% patients receiving mainte-nance doses of at least 60 mg/day
Low-dose programs characterized by:– More African-
American & Latino patients
– More managed care (pre-authorization requirements)
– Staff endorsement of abstinence orientation, and rejection of HIV prevention activities (syringe exchange)
Pollack & D’Aunno (2008) Health Services Research, 43:2143-2163
Low Uptake of Pharmacotherapy in Specialty
Programs (2007)As % of all
programs surveyed (N=345)
Within adopting programs, % of eligible patients receiving
Rx
Psychiatric meds 54.5 70.1
Opioid tx meds:Methadone 7.8 41.3
Buprenorphine 20.9 37.3
Tablet naltrexone 22.0 10.9
Alcohol meds:Disulfiram 23.8 8.1
Tablet naltrexone 32.2 12.4
Acamprosate 32.5 17.5
Injectable naltrexone 15.9 (too new to report)
Knudsen et al, 2011, J Addict Med; 5:21-2749
Adoption is a Process
x x+sdx-sdx-2sd
Innovators=2.5%
Early Adopters=13.5%
Early Majority=34%
Late Majority=34%
Laggards=16%
Rogers (2005)
Trialability Increases EBP Adoption
51
Early Adoption of Buprenorphine (2005)
Ducharme et al, 2007, JSAT; 32(4):321-9
Implementation science is not intended to test interventions, per se, but to study
how to get evidence-based interventions
adopted, adapted, and sustained.
Implementation Science
Organizational attributesContextual factorsChange process attributesIntervention attributesClient attributesNetworking - cross-agency linkages and collaborations
Measurement Domains
Turnover and Competence Outcomes of Counselors Trained in A-CRA
(N=34 treatment programs, 121 counselors)
Baseline + 6 months + 9 months + 12 months
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Employed, EBP CompetentEmployed, Not EBP CompetentNot Employed, EBP CompetentNot Employed, Not EBP-Com-petent
No return on training invest-ment
Garner et al, 2012, JSAT
1 yr to achieve competence in 50% of
staff
Training Resources Do Not Guarantee Uptake
54
• Substantial investment in health services research aimed at improving the quality of substance abuse treatment
The vision is that Patient Outcomes can be improved by:
• Making effective interventions more widely available to patients
• Improving the system’s ability to deliver interventions
PRIORITIES FOR NIH
• High Throughput Technologies
• Translational Research
• Health Care Reform
• Global Health
• Empowering the Biomedical Research Community
Current Issue: Health Care Reforms in the USA
• Insurance Reforms include–2009 Enhanced parity of coverage of
mental illnesses and substance use disorders
–Patient Protection and Affordability Care Act of 2010 (i.e. health care reform)o Enhanced parityo Emphasis on preventiono Enhanced insurance coverageo Emphasis on primary care
Change in Mental Health and Addiction Services Probability of Use and Expenditures in Oregon Parity Plans Minus Change in Non-Parity Plans
-0.40%
-0.30%
-0.20%
-0.10%
0.00%
0.10%
0.20%
0.30%
-0.28%
∆ Prob. of Use
-$30-$20
-$10$0
$10
$20$30
$15
∆ Expenditures
Does Oregon’s Experience Presage the National Experience with the Mental Health Parity and Addiction Equity Act?
Mcconnell KJ, et al. American Journal of Psychiatry 2012;169:31-38
pooled parity v. non-parity plans
August 17, 2011
Impact of the Affordable Care Act (ACA) on Drug Abuse Prevention
and Treatment Services
Relevant ACA Provisions and Environment:– Extends coverage to more than 30
million persons, many at high risk for drug abuse
– Fundamentally changes the ways drug abuse prevention and treatment services are financed
– Focuses on screening and prevention– Promotes use of electronic health
records– Emphasizes central role of primary
care settingsAll at a time of exciting scientific
advance but extraordinary economic challenges
Impact of the Affordable Care Act (ACA) on Drug Abuse Prevention
and Treatment Services
1996 2001 20060%
10%
20%
30%
40%
50%
60%
40%46%
50%
% of Sites Offering
Lo Sasso and Byck, Health Affairs (2010). Bureau of Primary Health Care, Health Resources and Services Administration, Uniform Data System
Each additional $1 million in federal funding lead to a 3.6% increase in the probability of offering substance abuse services
Substance Abuse Counseling in FHQCs
Typical Challenges/Barriers: • Legislation often has far-reaching
consequences that go unstudied. ACA could cause:– Industry consolidation leading to a new
cost structure– Greater reliance on FQHCs and other
integrated health care settings for DA service delivery
– Enhanced CMS role in defining/approving services
– Changes in the types of interventions developedWill this lead to a greater quantity of
efficiently-produced, effective services that meet patients’ needs?
Impact of the Affordable Care Act (ACA) on Drug Abuse Prevention
and Treatment Services
Portfolio Analysis: • Only one NIDA-funded research
project directly examines impact of ACA on treatment services– Roman (R01DA013110-11): Adoption of
Innovations in Private A&D Centers• Two grants examine impact of
parity legislation on treatment services (RFA-DA-10-004):– Horgan (R01DA029316): Provision of Drug
Abuse Treatment Services Under Parity– Meara (R01DA027414): Parity, Child
Mental Health, and Substance Abuse
Impact of the Affordable Care Act (ACA) on Drug Abuse Prevention
and Treatment Services
• Uptake rate for insurance among those with drug disorders and related (i.e. HIV), and how affected by outreach and offered coverage
• Responsiveness of demand for services among the newly covered. Effect on service types/quantity sought and payer responses
• Models for implementing addiction services (both treatment and prevention) in health care settings
• Training and sustainability models• Use of technology to improve quality of care
(EHR, patient technology, etc.)• Organization and financing strategies
Impact of ACA) on Drug Abuse Prevention and Treatment Services:
Research Topic Examples
2013 RFA: Phased Services Research Studies of Drug Use Prevention,
Addiction Treatment and HIV in an Era of Health Care Reform
Monitor and examine changes in drug use prevention, addiction treatment and associated HIV services that may
occur as a result of health care reforms.
Summary• Embedding substance
interventions into the general health system to improve patient care and outcomes.–Addressing outcomes through practice and system changes.
–Focus on broad substance use services: SBIRT, medications, EHR, and clinician training.
–Health care reforms in the USA provide new opportunities, especially for addiction services.
Revised Dec 2011
Revised Jan 2012
Published Dec 2011Revised Oct 2011
www.drugabuse.gov