NIDA’s Public Health Division: The Division of Epidemiology, Services and Prevention Research

1. 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 Penn State University 29 November 2006

2. Division of Basic Neurosciences & Behavior Research Division of Pharmacotherapies & Medical Consequences of Drug Abuse Division of Clinical Neuroscience, Development & Behavioral Treatment David Shurtleff, PhD Frank Vocci, PhD Joseph Frascella, PhD NIDA National Institute on Drug Abuse Office of the Director Nora D. Volkow, MD Director Director, AIDS Research Special Populations Office 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 Epidemiology, Services & Prevention Research Wilson Compton, MD, MPE

3. 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.

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

5. 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)

6. 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

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

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

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

10. 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

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

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

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

14. And now… A Few Key Findings

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

16. 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. Benefit Cost Zarkin, Dunlap, Hicks, & Mamo. (2005). Benefits & costs of methadone treatment: results from a lifetime simulation model. Health Economics, 14, 1133-1150. SRB: Life Course View of Addiction Refines Understanding of Recovery & Benefit Cost

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

18. 2.0 1.8 1.6 1.4 1.2 1.0 0.8 0.6 0.4 0.2 0.0 200,000 180,000 160,000 140,000 120,000 100,000 80,000 60,000 40,000 20,000 0 Life expectancy Increase in Life Expectancy Due to Screening (Yr) Incremental Cost-Effectiveness of Screening ($/quality-adjusted life year) Quality-adjusted life expectancy Costs and benefits to partners excluded Costs and benefits to partners included 30 40 50 60 70 80 90 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 AGE (Yr) Prevalence of Unidentified HIV (%) Source: Paltiel, et al. and Sanders et al., NEJM 352(6), 2005. HIV Screening Can Be As Cost-Effective As Screening for Hypertension and Other Medical Conditions DESPR:

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

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

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

22. 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?

23. 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

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

25. Translational Research is NOT Unidirectional: There are FeedbackLoops Type 1 Type 2

26. 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?

27. Linking Public Health Research to Neuroscience

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

29. Non Addicted Brain AddictedBrain Control Control STOP Reward Reward Drive Drive GO Memory Memory

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

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

32. 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

33. 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.

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

35. 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?

36. Community Bedside Bench

37. Developing an intervention is only one part of translating research into practice. Access and Engagement Organization Structure and Climate Intervention External Environment (stigma, financing) Provider knowledge and behavior

38. Community Bedside Bench Interagency Collaborations are indispensable

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

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

41. 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)

42. Community Bedside Bench Developing the Health Services Research Program

43. 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

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

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