NIDA’s Public Health Division: The Division of Epidemiology, Services and Prevention Research Wilson M. Compton, M.D., M.P.E. Director, Division of Epidemiology, Services and Prevention Research National Institute on Drug Abuse Department of Health and Human Services I’m not crazy about this title NIDA’s 2005 Operational Plan: DESPR’s Report Or The Report from DESPR Penn State University 29 November 2006

NIDA National Institute on Drug Abuse Office of the Director EEO Nora D. Volkow, MD Director Special Populations Office Director, AIDS Research Timothy P. Condon, Ph.D. Deputy Director Laura S. Rosenthal EEO Associate Director for Management Office of Extramural Affairs Office of Planning & Resource Management Office of Science Policy & Communications Center for the Clinical Trials Network Intramural Research Program Teresa Levitin, PhD Laura Rosenthal Timothy Condon, PhD Betty Tai, PhD Barry Hoffer, MD, PhD Division of Basic Neurosciences & Behavior Research David Shurtleff, PhD Division of Pharmacotherapies & Medical Consequences of Drug Abuse Frank Vocci, PhD Division of Clinical Neuroscience, Development & Behavioral Treatment Joseph Frascella, PhD Division of Epidemiology, Services & Prevention Research Wilson Compton, MD, MPE

DESPR Organization and Vision EPIDEMIOLOGY RESEARCH BRANCH PREVENTION RESEARCH BRANCH SERVICES RESEARCH BRANCH DESPR seeks to improve the nation’s public health by promoting integrated approaches to understand and address interactions between individuals and environments that contribute to the continuum of problems related to drug use. Our goal is to develop scientific knowledge with clear application to practice and public policy.

First, a story exemplifying linkages of Epidemiology, Prevention and Services…

Epidemiological Finding: Childhood and Adult Antisocial Behavior Strongly Associated with Drug Use/Disorders Odds Ratios for Lifetime Antisocial Personality Disorder by Specific Drug Disorders, Reference group is persons without the drug disorder (NESARC Study, Compton 2004)

From Longitudinal Epidemiology comes evidence for a plausible pathway: Poor academic achievement Early Aggression Deviant peer association Adolescent/Early Adult Antisocial Behavior and Drug Abuse

From Prevention: comes tests of the theory and tests of a plausible intervention strategy: — Support for theory and development of practical and useful interventions.

From Prevention: Reducing Early Aggressive Behaviors Reduces Drug Use 13 12 11 10 9 8 7 ESTIMATED CUMULATIVE RISK Control: 33%, reference CC: 25%, aRR 0.61 (0.37-1.00) FSP: 25%, aRR 0.70 (0.50-0.98) CC=Classroom Centered FSP=Family-School Partnership AGE OF FIRST TOBACCO USE Modified from: Storr, et al., Drug and Alcohol Dependence, 66:51-60, 2002.

From Prevention: Enhancing Social Bonding Reduces Violence Hawkins, et al., Arch Pediatr Adolesc Med 1999

From Services: Early Interventions Can Be Cost-Effective Cost per Taxpayer Participant and Crime Victims Net Benefit Nurse Home Visiting Program $ 7,733 $15,981 Seattle Social Development Project $ 4,355 $14,169 Big Brothers/Sisters Mentoring $ 1,054 $ 4,524 Aos, et al., The Comparative Costs and Benefits of Programs to Reduce Crime, Washington State Institute for Public Policy, 2001

From Scientific Knowledge It Needs To Be Used In Practice Ongoing Problem: To Reap Any Benefits From Scientific Knowledge It Needs To Be Used In Practice

From Services: Few Schools Use Effective Prevention Programs Ringwalt, et al. (2002), Prevention Science

Thus, all three branches of DESPR contribute to a unified story about pathways to drug use and how to intervene in these pathways.

And now… A Few Key Findings

Cigarette Smoking Declines Markedly Since Mid-1990’s ERB: Cigarette Smoking Declines Markedly Since Mid-1990’s * * Denotes significant difference between recent peak year and current year. Denotes significant difference between 2004 and 2005. Source: University of Michigan, MTF 2005

Life Course View of Addiction Refines Understanding of Recovery & Benefit Cost SRB: Benefit Cost Zarkin, Dunlap, Hicks, & Mamo. (2005). Benefits & costs of methadone treatment: results from a lifetime simulation model. Health Economics, 14, 1133-1150. Recovery Multiple treatment episodes is the norm. 27 years = Median time from first to last drug use 9 years = Median time from first treatment episode to last use Dennis, Scott, Funk, & Foss. (2005). The duration & correlates of addiction & treatment. JSAT, 28, S51-S62. MacLeod and colleagues demonstrated in a RCT significant differences in 90-day continuous abstinence rates, with the combination treatment showing greater efficacy than NRT alone at both 3 months and 6 months. Zhu also studied the California quitline as an adjunct to NRT, but the control group was not compelling (those who dropped out of the counseling program). Sydney, Australia

Lifetime and Past Year Meth Use at 4½-6½ Years Past Baseline Universal Family-based Prevention Interventions Reduce Methamphetamine PRB: Source: Spoth, et al. (2005). Two randomized studies of the long-term effects of brief, partnership-based universal preventive interventions on adolescent methamphetamine use Lifetime and Past Year Meth Use at 4½-6½ Years Past Baseline

HIV Screening Can Be As Cost-Effective As Screening for Hypertension and Other Medical Conditions DESPR: Source: Paltiel, et al. and Sanders et al., NEJM 352(6), 2005. Increase in Life Expectancy Due to Screening (Yr) 2.0 1.8 1.6 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0 30 40 50 60 70 80 90 Life expectancy Quality-adjusted life expectancy AGE (Yr) 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 200,000 180,000 160,000 140,000 120,000 100,000 80,000 60,000 40,000 20,000 Screening ($/quality-adjusted life year) Incremental Cost-Effectiveness of Costs and benefits to partners excluded Costs and benefits to partners included Prevalence of Unidentified HIV (%)

DESPR provides a foundation for NIDA’s Public Health Mission.

Priority Areas for NIDA Prevention Research Children and Adolescents Genetics Comorbidity Development Treatment Interventions (New Targets & New Strategies) HIV/AIDS Research HIV/AIDS DRUG ABUSE

Summary: Drug Abuse Research Needs a Systems Approach social DRUGS OF ABUSE behavior neuronal circuits protein expression genome

DESPR: 2006 Major Research Questions What new theoretical approaches can inform our research? What intrapersonal and environmental factors interact with each other and with genetic factors? How can we blend science and services to measurably impact public health outcomes?

Prevention 2006 Key Research Goal Develop and maximize use of high quality preventive interventions in real world settings through research on Individual factors Relationship of drug abuse prevention to HIV prevention Environmental strategies Community-based participatory research

What are we doing to develop and promote these themes? Workgroups, Meetings, Publications, etc.

Translational Research is NOT Unidirectional: There are Feedback Loops So what we are talking about is two types of Translational Research that the field is now calling Types 1 and 2, which reflects a linear conceptualization. I contend that it is not a linear process, feedback is possible at all points in the research process. However, for consistency I will use the current NIH terminology – there is already enough confusion. Type 1 Type 2

Bi-Directional Influences Basic science laboratories prevention: Sensation Seeking Neurobehavioral disinhibition Early-onset antisocial behavior Psychiatric co-morbidity Stress reactivity Prevention basic neuroscience laboratories: What are the biological mechanisms that explain the emergence of drug abuse during adolescence? What specific vulnerabilities are familial? What are the biological mediators of social interactions?

Linking Public Health Research to Neuroscience

Circuits Involved In Drug Abuse and Addiction PFC ACG INHIBITORY CONTROL OFC SCC MOTIVATION/ DRIVE Hipp Amyg MEMORY/ LEARNING NAcc VP REWARD All Should Be Considered In Strategies to Prevent and Treat Addiction

GO Non Addicted Brain Addicted Brain STOP Control Drive Reward Memory

Promise of Translation: HPA axis plasticity Psychosocial intervention Init. 3 mo. 6 mo. Concordant behavior change Source: Fisher P, OSLC

Key Basic Epidemiology Finding: Addiction is a Developmental Disorder With Onset During Adolescence Source: NESARC Study, 2001-2002

Recent Studies Have Shown that Maturation of the Brain’s Gray Matter Moves from Back to Front Brain areas where volumes differ in adolescents compared to young adults Source: Sowell, E.R. et al., Nature Neuroscience, 2(10), pp. 859-861, 1999

During Adolescence the COGNITION-EMOTION Connection is Still Undergoing Development Amygdalo-cortical Sprouting Continues Into Early Adulthood Low-power light photomicrographs of immunoperoxidase-labeled, biocytin-containing amygdalofugal varicose fibers within the mPFC of animals at 6 stages of development Source: Cunningham, M et al., J Comp Neurol 453, pp 116-130, 2002.

Implications: Developmental differences must be considered in designing prevention strategies. Can frontal lobe functioning be strengthened?

Sensation-Seeking Targeting Translating Sensation Seeking Research into Clinical Study: Communications Research Sensation-Seeking Targeting (Palmgreen et al., 2001) Used Activation model of information exposure to design messages for target audiences RESULTS: All 3 targeted television campaigns reversed upward trends in 30-day marijuana use among high SS How will D2 receptor research inform this field?

Community Bedside Bench

Developing an intervention is only one part of translating research into practice. Access and Engagement Organization Structure and Climate Intervention I think this slide is a nice visual to emphasize that it is not just about having evidence – there are a lot of things that impact on the use of that evidence and what evidence is needed to improve the lives of those with mental illnesses. We need to research all these interfaces --- in fact, we are doing that now. We are developing the sciences of dissemination/implementation, and adaptation (of EBPs) External Environment (stigma, financing) Provider knowledge and behavior

Interagency Collaborations are indispensable Bench Bedside Community Interagency Collaborations are indispensable

DHHS Collaborations to Translate Research NIH SAMHSA NIDA NIDA Collaborations to Translate Research Findings Into Relevant Clinical Practice

Testing the Communities That Care (CTC) Prevention System Research Centers Coordinating Center

Linking grant programs “Braiding” funding streams to enhance both research and services Each agency doing what it does best Examples: Adolescent Services Including Brief Interventions (FY2003 with SAMHSA) Assessment and Brief Interventions in Primary Care (FY2004 with SAMHSA) NIDA Funding Research on CSAP’s National SPF-SIG Program (FY2004) Service to Science Grants for State Substance Abuse Authorities (FY2005) and for CBOs (FY2006)

Developing the Health Services Research Program Bench Bedside Community Developing the Health Services Research Program

NIDA Blue Ribbon Task Force on Health Services Research Co-Chairs: Thomas McLellan, PhD, Constance Weisner, DrPH, MSW Andrea Barthwell, MD Caryn Blitz, PhD Rick Catalano, PhD Mady Chalk, PhD Linda Chinnia, MEd Lorraine Collins, PhD Wilson Compton, MD, MPE Michael Dennis, PhD Richard Frank, PhD Warren Hewitt, MS James Inciardi, PhD Marguerita Lightfoot, PhD Isaac Montoya, PhD Claire Sterk, PhD Janet Wood, MBA, MEd

New Opportunities: Science to Services Interactions New Theories Medical Settings Screening (especially SBIRTs) Prescription Drug Abuse (especially opioids) HIV Interactions Implementation Science New Theories Economics Organization/Management

Division of Epidemiology, Services and Prevention Research Providing a foundation for NIDA’s public health mission.