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

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: , 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 Primary Continuing Care Primary Care Specialty Care Source: A. T. McLellan, 2011

PROBLEM 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 PROBLEM 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: Alcohol: Illicit Drug Use -SBIRT evidence insufficient Drugs:

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

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 Use Among Those Screening Positive for Drugs At Baseline (N = 6,262) % Madras, et al. Drug Alcohol Dependence, 2009 All are P < 0.001

(N=47) (N = 55) Percent Abstinent 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):

Effect of Intervention on Reporting Receiving Referrals to Community Resources (N=47) (N = 55) Percent Report Receiving Referrals * 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):

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

Sc 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

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

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 ( )  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 Question Drug Screener Alcohol Assessment Drug Severity Assessment Initial Presentation 3 Screener Questions NO 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 Treatments Basic Research Medications Basic Research Medications

OFC SCC MOTIVATION/ DRIVE MOTIVATION/ DRIVE Hipp Amy g MEMORY/ LEARNING MEMORY/ LEARNING Circuits Involved In Drug Abuse and Addiction Circuits Involved In Drug Abuse and Addiction NAcc VP REWARD PFC ACG EXECUTIVE FUNCTION/ INHIBITORY CONTROL EXECUTIVE FUNCTION/ INHIBITORY CONTROL

NAcc VP REWARD 1. Reward Circuit Drugs of Abuse Engage Systems in the Motivation Pathways of 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 Signal Intensity (AU) Controls Cocaine Users

Cocaine Craving: Population (Cocaine Users, Controls) x Film (cocaine, erotic) Garavan et al A.J. Psych 2000 IFG Ant Cing Cingulate Signal Intensity (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 ACG OFC SCC INHIBITORY CONTROL INHIBITORY CONTROL EXECUTIVE FUNCTION EXECUTIVE FUNCTION PFC MOTIVATION/ DRIVE MOTIVATION/ DRIVE Dopamine is also associated with motivation and executive function via regulation of frontal activity.

ACG OFC SCC Hipp NAcc VP Amyg REWARD INHIBITORY CONTROL INHIBITORY CONTROL MEMORY/ LEARNING MEMORY/ LEARNING EXECUTIVE FUNCTION EXECUTIVE FUNCTION PFC Becomes severely disrupted in ADDICTION MOTIVATION/ DRIVE 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 Strengthen prefrontal- striatal communication Executive function/ Inhibitory control Executive function/ Inhibitory control Interfere with conditioned memories Interfere with conditioned memories Teach new memories Counteract stress responses that lead to relapse Counteract stress responses that lead to relapse Interfere with drug’s reinforcing effects Interfere with drug’s reinforcing effects Vaccines Enzymatic degradation Naltrexone DA D3 antagonists CB 1 antagonists Vaccines Enzymatic degradation Naltrexone DA D3 antagonists CB 1 antagonists Biofeedback Modafinil Bupropion Stimulants Biofeedback Modafinil Bupropion Stimulants Antiepileptic GVG N-acetylcysteine Antiepileptic GVG N-acetylcysteine Cycloserine CRF antagonists Orexin antagonists CRF antagonists Orexin antagonists STOP Drive Control Memory Non-Addicted Brain Saliency Adenosine A2 antagonists DA D3 antagonists Adenosine A2 antagonists DA D3 antagonists

Treatments for Relapse Prevention: Psychotherapies Addicted Brain Drive Control Saliency Memory GO Strengthen prefrontal- striatal communication Executive function/ Inhibitory control Interfere with conditioned memories Teach 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 Biofeedback Desensitization Relaxation Behavioral 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

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 Environment (stigma, financing)

Methadone Maintenance Dosing Improved, but standards often not met 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:

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 Opioid tx meds: Methadone Buprenorphine Tablet naltrexone Alcohol meds: Disulfiram Tablet naltrexone Acamprosate Injectable naltrexone15.9(too new to report) Knudsen et al, 2011, J Addict Med; 5:

Adoption is a Process xx+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 attributes Contextual factors Change process attributes Intervention attributes Client attributes Networking - cross-agency linkages and collaborations Measurement Domains

Turnover and Competence Outcomes of Counselors Trained in A-CRA (N=34 treatment programs, 121 counselors) 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 parity o Emphasis on prevention o Enhanced insurance coverage o 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 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 settings All 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

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 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 (R01DA ): Adoption of Innovations in Private A&D Centers Two grants examine impact of parity legislation on treatment services (RFA-DA ): –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 2011 Revised Oct