Policy Approaches to Improving the Quality of Substance Abuse and

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					   Mainstreaming Addictions in
  Medicine: Improving Substance
     Abuse Services Through
         Standardization
           Wilson M. Compton, M.D., M.P.E.
Director, Division of Epidemiology, Services and Prevention Research
                 National Institute on Drug Abuse

                          13 August 2012
Why focus on drug use in
general medical settings?
                                  Occurrence of Medical Conditions in
 Drug use has wide                  Diagnosed Substance Abusers

 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       Source: Mertens JR et al, Arch Intern Med 163: 2511-2517, 2003
   from or be exacerbated 
   by drug use.
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
     A Continuing Care Model

Primary Care

               Specialty Care


                         Primary
                      Continuing Care
                                Source: A. T. McLellan, 2011
Why focus on drug use in
general medical settings?

 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
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
Brief motivational intervention reduces 6 mo.
           cocaine and heroin use
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
Total Illicit Substance Involvement
Scores – BI and Control at Baseline
      and Follow-up (N=628)



                                      p<0.01




    WHO ASSIST Phase III Technical Report, 2008; Hermeniuk R, et al. Addiction 2012
    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 Use
Among Those Screening Positive for Drugs At Baseline (N = 6,262)

                       All are P < 0.001


 %




                                     Madras, et al. Drug Alcohol Dependence, 2009
 Screening and Brief Intervention to Reduce Marijuana Use
     Among Youth and Young Adults in a Pediatric ED

            Abstinence = no marijuana use in past 30 days at 12 months
                     0.5
                                  * 44.7%              * OR =2.89, p<.014
                    0.45
                     0.4
Percent Abstinent




                    0.35
                     0.3
                    0.25                                                      21.8%
                     0.2
                    0.15
                     0.1
                    0.05
                      0
                            Intervention Group (INT)            Assessed Control Group (AC)
                               (N=47)                              (N = 55)

                              Bernstein E et al., Academic Emergency Medicine 2009;16 (1):1174-1185
    Screening and Brief Intervention to Reduce Marijuana Use
        Among Youth and Young Adults in a Pediatric ED
          Effect of Intervention on Reporting Receiving Referrals to Community 
                                        Resources
                           30
                                        * 25.5%
Percent Report Receiving




                           25
                                                           * OR =3.36, p=.0117
                           20

                           15                                                   9.3%

                           10
Referrals




                            5

                            0
                                Intervention Group (INT)            Assessed Control Group (AC)
                                     (N=47)                              (N = 55)
                                    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 patients
Received 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 effectiveness
Cost–benefit analysis of Early Start, an integrated prenatal 
intervention program for stopping substance use in 
pregnancy
Four study groups were compared (N=49,261) :
1.) screened-assessed-followed (n=2032), Maternal cost = 
$9,430, Infant costs =  $11,214
2.) screened-assessed (n=1181), Maternal cost $9,230, 
Infant cost $11,304
3.) screened-positive-only (n=149),  Maternal cost = 
$10,869, Infant cost = $16,943
4.) control group who screened negative (n=45,899), 
Maternal cost = $8,282, Infant cost = $10,416
Program Cost $670,600 v. Benefit $5,946,741 per year

    Goler, 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
 Sc

Dr. Barbara Gerbert (and colleagues) have used
the Video Doctor to screen for the following
sensitive risk areas:
  HIV risk behaviors     Nutrition
 Smoking                Physical activity
 Alcohol use            Intimate partner violence/
                        Domestic violence
 Drugs use
Provider - Patient Intimate Partner Violence
                Discussions
 100%

                81.8%
  80%
                                              70.0%

  60%                                                             Usual Care

                                                                  Intervention
  40%
                                  23.5%
  20%   16.7%


  0%
          Baseline                     1-month


                 Barbara Gerbert, Presented at NIH Implementation Conference, March 2010
                 Enhancement
• Start process with Single Questions
  (prior to ASSIST assessment of severity)
                                                Smith,
  ü   Tobacco                                  Schmidt,
  ü   Alcohol                                Allensworth-
                                             Davies, Saitz
  ü   Prescription Drugs                         2010
  ü   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
Electronic Health Record (EHR)
n Federal encouragement to adopt with
  “meaningful use”
n Multiple vendors developing EMR
    n Hospital based systems
    n Individual practice based systems
    n Interoperability (EMRs  EHR)
n Content
    n Clinical care
    n Research

Source: Robert Gore-Langton, PhD, NIDA CTN Data and Statistics Center, The EMMES Corporation
Electronic Health Record (EHR)
n Federal meaningful use criteria
    n Incentive through reimbursement
    n Incorporate concepts and data elements to
      qualify for meaningful use
    n Example
          nMeaningful use stage 1 (2011-2012)
               § Screen for tobacco use in > 50% of clinic population
          nMeaningful 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
                                  Initial Presentation
                                3 Screener Questions




      1 Question                     1 Question                      1 Question
   Alcohol Screener               Tobacco Screener                 Drug Screener
 NO           YES                NO           YES               NO          YES
        Alcohol                        Tobacco                       Drug Severity
      Assessment                      Assessment                     Assessment




                           Further Assessment and/or
                          Referral outside of primary care



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:
 Ø Developing interventions
    that are highly effective as
    delivered
 Translating Basic Science Discoveries Into
        New and Better Treatments
        Basic Research



                             Medications




                                     Medications

Basic Research
       Circuits Involved In
    Drug Abuse and Addiction
 EXECUTIVE          PFC
FUNCTION/
INHIBITORY         ACG

  CONTROL    OFC                  Hipp
                   SCC
                          NAcc           REWARD
 MOTIVATION/                      VP

   DRIVE                 Amy
                          g       MEMORY/
                                 LEARNING
1. Reward Circuit
                                 REWARD
                         NAcc   VP




                Drugs of Abuse
                Engage
                Systems in the
                Motivation
                Pathways
                of the Brain
2. Memory circuit
                           Hipp



                    Amyg
                        MEMORY/
                       LEARNING




  “People, Places
  and Things…”
                                                     Cocaine Craving:
                              Population (Cocaine Users, Controls) x Film (cocaine )



                                                   Cingulate
Signal Intensity (AU)




                                                   Ant Cing



                                   Cocaine Film

                                                   IFG


                        Controls   Cocaine Users               Garavan et al A .J. Psych 2000
                                                         Cocaine Craving:
                          Population (Cocaine Users, Controls) x Film (cocaine, erotic)



                                                   Cingulate
Signal Intensity (AU)




                                                   Ant Cing




                                                   IFG


                        Controls   Cocaine Users               Garavan et al A .J. Psych 2000
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     EXECUTIVE
                              FUNCTION
  Control Circuits                          PFC
                                             ACG
                            INHIBITORY    OFC
                                                SCC
                             CONTROL

                                MOTIVATION/
   Dopamine is also               DRIVE


   associated with
   motivation and
   executive function via
   regulation of frontal
   activity.
The fine balance in connections that normally exists
between brain areas active in reward, motivation,
learning and memory, and inhibitory control

     EXECUTIVE
     FUNCTION
                  PFC
                         ACG
   INHIBITORY                          Hipp
    CONTROL       OFC
                        SCC    NAcc           REWARD
                                       VP
        MOTIVATION/
          DRIVE                Amyg
                                       MEMORY/
                                      LEARNING

Becomes severely disrupted in
ADDICTION
Treatments for Relapse Prevention:
Medications                  Vaccines
  Addicted Brain
Non-Addicted
                         Interfere with
                         drug’s reinforcing
                                                  Enzymatic degradation
                                                  Naltrexone
                         effects                  DA D3 antagonists
Brain       Control
                                                  CB1 antagonists
        Control
                         Executive function/      Biofeedback
                                                  Modafinil
                         Inhibitory control       Bupropion
                                                  Stimulants


                    GO
                  STOP
                                                  Adenosine
Saliency    Drive
Saliency Drive           Strengthen prefrontal-   A2 antagonists
                         striatal communication   DA D3 antagonists

                         Interfere with           Antiepileptic GVG
                         conditioned memories     N-acetylcysteine
          Memory
         Memory
                         Teach new memories       Cycloserine

                         Counteract stress        CRF antagonists
                         responses that lead to   Orexin antagonists
                         relapse
Treatments for Relapse Prevention:
Psychotherapies
  Addicted Brain
Non-Addicted
                         Interfere with
                         drug’s reinforcing
                                                   Contingency
                                                   Management
                         effects
Brain       Control
        Control
                         Executive function/      Cognitive Therapy
                         Inhibitory control


            Drive
Saliency Drive
Saliency            GO
                  STOP   Strengthen prefrontal-
                         striatal communication
                                                  Motivation Therapies


                         Interfere with           Biofeedback
                         conditioned memories     Desensitization
          Memory
         Memory
                         Teach new memories       Behavioral Therapies

                         Counteract stress        Relaxation
                         responses that lead to   Behavioral therapies
                         relapse
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:
 Ø Developing interventions
    that are highly effective as
    delivered , or
 Ø 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.

     Access
       and                     Organization
   Engagement                  Structure and
                                  Climate

                Intervention

     Provider                    External
    knowledge                  Environment
       and                       (stigma,
     behavior                   financing)
  Methadone Maintenance Dosing
Improved, but standards often not met
 100
  90   % patients receiving maintenance
                                                      Low-dose programs
       doses of at least 60 mg/day
                                                      characterized by:
  80
  70
                                                        – More African-
                                                          American & Latino
  60                                                      patients
  50                                                    – More managed care
  40
                                                          (pre-authorization
                                                          requirements)
  30
                                                        – Staff endorsement of
  20                                                      abstinence
  10                                                      orientation, and
                                                          rejection of HIV
   0                                                      prevention activities
       1988    1990    1995     2000      2005            (syringe exchange)

                        Pollack & D’Aunno (2008) Health Services Research, 43:2143-2163
         Low Uptake of Pharmacotherapy in
             Specialty Programs (2007)
                                                 As % of all     Within adopting programs,
                                             programs surveyed     % of eligible patients
                                                  (N=345)               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; 5:21-27
                                                                                             49
Adoption is a Process

        Early Majority=34%


                                  Late Majority=34%
Early Adopters=13.5%
                                            Laggards=16%



Innovators=2.5%




          x-2sd        x-sd   x      x+sd
                                            Rogers (2005)
          Trialability Increases EBP Adoption
                                  Early Adoption of Buprenorphine (2005)




Ducharme et al, 2007, JSAT; 32(4):321-9                                    51
 Implementation Science

 Implementation science is not
intended to test interventions,
per se, but to study how to get
 evidence-based interventions
    adopted, adapted, and
           sustained.
 Measurement Domains
Organizational attributes
Contextual factors
Change process attributes
Intervention attributes
Client attributes
Networking - cross-agency linkages
 and collaborations
        Training Resources Do Not Guarantee Uptake
                 Turnover and Competence Outcomes of Counselors Trained in A-CRA
                             (N=34 treatment programs, 121 counselors)

       100%                                                                    1 yr to achieve
                                                                            competence in 50% of
        90%                                                                          staff

        80%

        70%                                                               Employed, EBP
                                                                          Competent
        60%
                                                                          Employed, Not EBP
        50%                                                               Competent
                                                                          Not Employed, EBP
        40%                                                               Competent
                                                                          Not Employed, Not
        30%                                                               EBP-Competent
        20%

        10%                                                              No return on training
                                                                         investment
          0%
                      Baseline   + 6 months   + 9 months   + 12 months


Garner et al, 2012, JSAT                                                                           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 parity
     o Emphasis on prevention
     o Enhanced insurance coverage
     o Emphasis on primary care
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




Change in Mental Health and Addiction Services Probability of Use and
Expenditures in Oregon Parity Plans Minus Change in Non-Parity Plans
      0.30%                                       $30
      0.20%    ∆ Prob. of Use                     $20              $15
      0.10%
                                                 $10
      0.00%                      pooled parity v.
      -0.10%                     non-parity plans$0
                                                -$10
      -0.20%                                               ∆ Expenditures
      -0.30%                                      -$20
                      -0.28%
      -0.40%                                      -$30
  Impact of the Affordable Care Act (ACA) on
Drug Abuse Prevention and Treatment Services



                  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 settings
       All at a time of exciting scientific advance but
             extraordinary economic challenges
      Substance Abuse Counseling in FHQCs
60%                                                                          Each additional
                                                            50%
                                                                             $1 million in
50%
                                    46%
                                                                             federal funding
             40%
                                                                             lead to a 3.6%
40%                                                                          increase in the
                                                                             probability of
30%                                                                          offering
                                                                             substance abuse
20%
                                                                             services
10%
                                                                         % of Sites Offering
0%
             1996                   2001                   2006

  Lo Sasso and Byck, Health Affairs (2010). Bureau of Primary Health Care, Health Resources and Services
  Administration, Uniform Data System
  Impact of the Affordable Care Act (ACA) on
Drug Abuse Prevention and Treatment Services
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 developed
     Will 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 ACA) on Drug Abuse Prevention and
Treatment Services: Research Topic Examples
• 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
 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.
www.drugabuse.gov
                                Revised Jan 2012


            Revised Dec 2011




       Published Dec 2011      Revised Oct 2011

				
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