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Mainstreaming Addictions in Medicine:  Update on NIDA's SBIRT Efforts in General Medical Settings

Mainstreaming Addictions in Medicine:  Update on NIDA's SBIRT Efforts in General Medical Settings. Wilson M. Compton, M.D., M.P.E. Director, Division of Epidemiology, Services and Prevention Research National Institute on Drug Abuse. Advisory Council, National Institute on Drug Abuse

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Mainstreaming Addictions in Medicine:  Update on NIDA's SBIRT Efforts in General Medical Settings

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  1. Mainstreaming Addictions in Medicine:  Update on NIDA's SBIRT Efforts in General Medical Settings Wilson M. Compton, M.D., M.P.E. Director, Division of Epidemiology, Services and Prevention Research National Institute on Drug Abuse Advisory Council, National Institute on Drug Abuse February 4, 2009

  2.  SBIRT Efforts in General Medical Settings: What is SBIRT? Screening Brief Intervention Referral to Treatment

  3. US Preventive Services Task Force (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

  4. Illicit Drug SBIRT Reviews • 1995 USPSTF Report: Review of SBIRT effectiveness for drugs. “Insufficient evidence to recommend for or against” • 2005 Review by Babor and Kadden, Journal of Trauma. “Further work needed before routine screening for drug use disorders is warranted” • 2008 USPSTF Report Update: “The evidence is insufficient to determine the benefits and harms of screening for illicit drug use”

  5. USPTF Model • Evidence needed that intervention, including referral to treatment, impacts long-term morbidity and mortality within primary care populations • Accepted outcomes for SBIRT (abstinence vs. health, social, legal, economic, and vocational outcomes)

  6. Example:Strength of Evidence for Alcohol • A meta-analysis suggests an overall reduction of 56% in number of drinks • The effect size for motivational intervention of all types ranged from 0.25 to 0.57, with participants followed from 3 to 24 months Burke et. al., 2003

  7. Example:Strength of Evidence for Tobacco/Smoking • A meta-analysis of 43 studies • Improvement in cessation for behavioral intervention of all types ranged from 4% to 15%, with an intervention as brief as 3 minutes improving abstinence rates • Pharmacotherapy as much as triples these rates Fiore et. al., 2000

  8. Strength of Evidence for Illicit Drugs:Promising - but sparse results • Bernstein, et al. 2005: Randomized Controlled Trial (RCT) • WHO study, 2008: Randomized Controlled Trial (RCT) in Multiple Sites Internationally • Madras, et al. 2009: SAMHSA program evaluation of (SBIRT) for illicit drug and alcohol use at multiple sites: Comparison at intake and 6 months later

  9. Brief motivational intervention reduces 6 mo. cocaine and heroin use Bernstein et al. Drug and Alcohol Dependence 2005;77:49-59 • RCT (n=1175) urban walk-in clinic patients, presenting for non-acute problems and use of heroin or cocaine, confirmed by hair analysis • Intervention – semi-scripted BMI of 20 min. (10-45), 10 days later a 5-10 min. booster call • ASI at intake, 3 and 6 months, HA 6 month

  10. Brief motivational intervention reduces 6 mo. cocaine and heroin use Abstinent from Adjusted Odds Ratio Cocaine 1.51 (1.01, 2.24) p = 0.045 Opiates 1.57 (1.00, 2.47) p = 0.050 Logistic regression model adjusted for variables that groups differed on at baseline (health insurance, homelessness) Bernstein et al. Drug and Alcohol Dependence 2005

  11. Brief motivational intervention reduces 6 mo. cocaine and heroin use Abstinence Among Those Screening Positive for At Baseline p < .05 Bernstein et al. Drug and Alcohol Dependence 2005

  12. WHO ASSIST Phase III Project WHO ASSIST Phase III Technical Report, 2008 • An international randomised controlled trial (RCT) evaluating the effectiveness of a Screening and Brief Intervention (SBI) for cannabis, stimulants & opioids • Participants recruited from PHCs in Australia, Brazil, India, USA (R01 DA016592, PI: T Babor ) • Randomly allocated to intervention or waitlist control group at baseline with follow up three months later • Both groups administered the ASSIST and intervention participants received a brief intervention for the drug for which they scored the highest on the ASSIST

  13. Total Illicit Substance Involvement Scores – BI and Control at Baseline and Follow-up (N=628) WHO ASSIST Phase III Technical Report, 2008: Pooled data p<0.01

  14. Cannabis Specific Substance Involvement Scores – BI and Control at Baseline and Follow-up (N=328) WHO ASSIST Phase III Technical Report, 2008: Pooled data p<0.05

  15. Stimulant Specific Substance Involvement Scores – BI and Control at Baseline and Follow-up (N=229) WHO ASSIST Phase III Technical Report, 2008: Pooled data p<0.005

  16. Opioid Specific Substance Involvement Scores – BI and Control at Baseline and Follow-up (N=73) WHO ASSIST Phase III Technical Report, 2008: Pooled data p<0.07

  17. SAMHSA Demonstration Program for SBIRT:Comparison of intake and 6 month follow up Madras, et al. Drug and Alcohol Dependence 99 (2009) 280–295 • Federally SBIRT programs in six states across a range of medical settings • Emergency/trauma departments, primary care centers, hospital inpatient/outpatient settings • Patients screened and offered interventions • Brief intervention, brief treatment, referral to specialty treatment • Six months follow-up on those screening positive at baseline

  18. 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

  19. Strength of Evidence about SBIRT for Illicit Drugs: Promising - but sparse results

  20. NIDA - SBIRT Initiatives: • NIDA has supported initiatives for SBIRT in Primary Care and Mainstreaming of Addiction Treatment since initial findings of USPSTF • RFA in 2004 for Screening and MI in adolescents (with SAMHSA) • Findings showing effectiveness of MI, computer platforms and EMRs in adolescent general medical settings

  21. NIDA - SBIRT Initiatives:RFA-08-021 (SBIRT) for Illicit Drug Abuse in General Medical Settings • RFA in 2008: Screening, Brief Intervention and Referral to Treatment (SBIRT) for Illicit Drug Abuse in General Medical Settings (R01 only)RFA-DA-08-021 (R01) • Over 30 applications received • 4 Funded Grants • Well designed RCTs in various general medical settings, testing effectiveness of various SBIRT models

  22. NIDA - SBIRT Initiatives: RFA-08-021 SBIRT for Illicit Drugs in General Medical Settings • D'Onofrio, Gail Models of SBIRT for Opioid Dependent Patients in the Emergency Department • Velasquez, Mary Marden Multidisciplinary Approach to Reduce Injury and Substance Abuse • Roy-Byrne, Peter P Brief Intervention in Primary Care for Problem Drug Use and Abuse (SAMHSA Site/Team) • Svikis, Dace S Computer vs Therapist-Delivered Brief Intervention for Drug Abuse in Primary Care

  23. NIDA - SBIRT Initiatives:Other FY2008 Grants • Saitz, Richard Screening and Brief Intervention Models to Address Unhealthy Drug Use (SAMHSA Site/Team) • Gelberg, Lillian Preventing Drug Use in Low Income Clinic Populations

  24. NIDA - SBIRT Initiatives:Small Business Innovation Research (SBIR) and Technology Transfer (STTR) Programs at NIDA SBIR Grants to address RT problem: • Computerand web based patient referral systems, to reduce one of main objections to screening, i.e. time consuming and difficult to place patients in specialty care by general medical office • One study underway and one pending funding

  25. NIDA - SBIRT Initiatives:Publications development “Screening and Brief Intervention for Drug Use in Primary Care Settings: A Resource Guide for Providers”

  26. NIDA Screening Resource Guide • Targets adult primary care with a key goal of increasing screening for illicit drug abuse • Provides a clinician-friendly guide to support screening and brief intervention • Strengthens clinicians’ ability to discuss screening results with patients

  27. NIDA Screening Resource Guide • Brief, graphical introduction to screening and brief intervention steps for primary care providers • Will be on the NIDA website • Based on the WHO ASSIST (Alcohol, Smoking, and Substance Involvement Screening Test)

  28. NIDA Screening Resource Guide Under Development – Target date for distribution early spring/summer 2009 NIDA Guide anticipated to have similar “feel” as the NIAAA Guide which is familiar to general medical clinicians to facilitate adoption

  29. NIAAA Website/Guide

  30. Screening and Brief Intervention (SBI) For Drug Use in Primary Care Settings: Resource Guide for Providers • Introduction • Before You Begin • Screening and brief intervention for drug use • Step 1: Ask about drug use • Step 2: Screen for substance use disorders • Step 3: Discuss results & conduct brief intervention • Step 4: Offer continuing care at follow-up visits • Appendices • Support Materials • Frequently Asked Questions • Glossary of Terms Download PDF Version

  31. NIDA Screening Resource Guide • A user-friendly quick guide targeted to medical providers, especially physicians • Developed by NIDA staff • Peer reviewed by 8 university-based experts • Reviewed in collaboration with representatives from WHO, ONDCP, SAMHSA, CDC and NIAAA

  32. NIDA Screening Resource Guide Like the NIAAA guide, will primarily be laid-out as a “flow-chart”, which is familiar to general medical clinicians and is easy to use in a fast-paced clinical environment

  33. NIDA Screening Resource Pocket Guide Updated NIDA will also offer a Pocket Guide to facilitate implementation

  34. NIDA Screening Resource Pocket Guide • The Pocket Guide will share the same step-by-step format and supporting material

  35. NIDA - SBIRT Initiatives:Cooperative actions with other public health agencies • Workshop on SBIRT for prescription drug abuse, 2008 (with ONDCP and Health Canada) • Support Meeting and Workshops for American Medical Education and Research on Substance Abuse (AMERSA), (with SAMHSA and NIAAA) • Conference on SBIRT, 2007 (with SAMHSA, ONDCP)

  36. NIDA - SBIRT Initiatives:Cooperative actions with WHO • NIDA participates in the international WHO ASSIST project (WHO Lead: Vladimir Pozniak; Program Director: Robert Ali), part of a key policy for the WHO Department of Mental Health and Substance Dependence -- To integrate mental health and substance dependence care into general health care

  37. NIDA - SBIRT Initiatives:Cooperative actions with AMA Mainstreaming addictions is a focus of AMA’s Department of Healthy Lifestyles and Primary Prevention, including the joint NIDA/AMA -- • Primary Care Physician Outreach Project and Centers of Excellence Grants to 5 Universities to embed addiction and SBIRT concepts in medical student and resident education

  38. NIDA - SBIRT Initiatives:Cooperative actions with other Public Health Agencies • Substance Use Disorders: CPT Codes Approved 2008, with reimbursement now in 13 state Medicare and Medicaid programs, and 71 commercial carriers (and counting)

  39. Future SBIRT Research • Enhance evidence base regarding effectiveness in a variety of medical (and related) settings • SBI for prescription drug abuse • New technologies (internet, tablet, PDA, etc.) • Models for referral and/or direct care in general medical settings (the “RT” of SBIRT) • Linking SBIRT interventions to important morbidity and mortality outcomes

  40. Update on NIDA's SBIRT Efforts in General Medical Settings: Summary • SBIRT is efficacious for alcohol and tobacco; evidence for illicit drugs is promising but not yet sufficient • NIDA has numerous initiatives to enhance the evidence base in next few years, and to disseminate SBIRT training to medical professionals • NIDA’s collaborations with other organizations/agencies is key to this process

  41. Questions?Comments?Suggestions?

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