Making science speak to policy and practice: An introduction to the difficulties that exist on the road from scientific evidence to practice outlining current developments, challenges and opportunities. Speaker: Michael Farrell, National Addiction Centre, London, UK

… from Faith to Science …

Political and moral values of the social system Research Evidence SERVICE Provider AND USER VIEW A model for evidence-based clinical decisions (from Haynes et al, 1996)

Policy Development Identifying Need, Identify options for effective interventions No single option effective Define balance of options Consultation process with stakeholders to develop new approaches. Translate new knowledge into developmental practice Into mainstream clinical practice

Scientific Development Importance of investment in basic biological research, neuroscience, molecular genetics, development of new agents for treatment. Investment in other types of treatment, And psychosocial interventions. Social policy evaluation

Challenge of technology transfer Some basic science increases theoretical understanding but gap when it comes to application, thus the bench to bedside gap can be very large Application of new policies and treatment can take a very long time to be put in place, anything from 10 years to 30 years Problem that life span of policy officials often much shorter than that

Copyright ©2000 BMJ Publishing Group Ltd. Peto, R. et al. BMJ 2000;321: Prevalence of smoking, 1950 thru 2000

Copyright ©1994 BMJ Publishing Group Ltd. Townsend, J et al. BMJ 1994;309: FIG 2 - Prevalence of smoking in British men and women during by socioeconomic group. (From Wald and Nicolaides Bouman3

Copyright ©1994 BMJ Publishing Group Ltd. Townsend, J et al. BMJ 1994;309: FIG 1 - Relation between consumption (pounds sterling billion at 1992 prices) and real price (1992=1.0) of cigarettes in Britain during (From Office of Population Censuses and Surveys2)

Time-trends in liver cirrhosis age-standardised mortality rates per 100,000 by age group, sex and country (Leon & McCambridge, Lancet, 2006)

Options in drug policy Prevention Demand Reduction Supply Reduction Treatment Demand Reduction

Implementation of Substitution Treatment Dole studies published 1968 First roll out US 1973, faltered Low level provision until late 1980s AIDs driven change especially Spain France obstacle 73 people in treatment from 68 to 93 intoduced Buprenorphine Slow change in Asia Heroin prescription Swiss studies, gradual change Germany, Netherlands, UK

Implementation Mass public health provision versus pilot level small population provision Challenge to Implement properly Need for outcome data to convince After implmentation need for outcome data to determine impact, limited information on most effective approach to large scale delivery, Prisons major challenge

10-year trend in the number of substitution treatment clients in Europe (EU-15) 73, , , , , , , , , , ,

Estimated number of drug users in substitution treatment in 29 European countries (2003) per population aged 15-64

QUESTION WHAT IS THE TIME PERIOD OF INCREASED RISK FOR DRUG RELATED DEATH AFTER RELEASE FROM PRISON FOR MALES AND SEPARATELY FOR FEMALES 2WEEKS ONE MONTH THREE MONTHS

Post-release mortality rates (males) Farrell & Marsden [2008] n = 36,515

Post-release mortality rates (females) Farrell & Marsden [2008] n = 12,256

Post-release mortality 20- to 50-fold increase in drug-related deaths in the 1st week after release –drops by 50% / week –plateaus at 4 weeks Odds of drug-related death in 1st wk post- release –Among women > 10 x that observed at 52 wks (OR 10.6; 95 %CI ) 70 x that in age-matched population –Among men ~ 8 x that observed at 52 weeks (OR 8.3: 95 %CI ). 30 x that in age-matched population Seaman et al 1996; Bird et al 2003; Singleton, Farrell, Marsden et al 2003; Farrell, Marsden (50,000 releases). Addiction 2008; Stewart et al (2004) Western Aus; Graham (2004) Victoria; Singleton, Farrell et al

Countries involved in prison substitution Treatment  Spain  France  Germany  Denmark  Ireland

NHS STRUCTURES NIHR Health Technology Assessment National Institute for Clinical Effectiveness National Treatment Agency Clinical Guidelines for the management of Drug Dependence

NICE NICE produces guidance in three areas of health: public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector health technologies - guidance on the use of new and existing medicines, treatments and procedures within the NHS clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

NICE Decision making process Incorporates Cochrane Evidence Base Conducts on metanalysis Becomes more complex as areas of review broaden, Major controversies, on oncology care and dementiae care.