How Does SBIRT Fit into the NIDA Research Program?

ED-Based Public Health Research: NIDA’s Portfolio Richard A. Denisco, M.D., M.P.H. Medical Officer Division of Epidemiology, Services and Prevention Research Services Research Branch National Institute on Drug Abuse SAEM Consensus Conference May 13, 2009

Summary of NIDA ED Research Projects:
Sixty Research Projects in ED’s
Includes Research Grants ( e.g. R01, R03, R21), Career Development ( e.g. K23), and Small Business (SBIR and STTR)
Focus on Tobacco Cessation, Computer Assisted Treatments in ED’s, Treatment Disparities, Co-Occurring Medical Disorders, and SBIRT

Clinical and Translational Science Awards (CTSAs): Director National Center for Research Resources e National Institute on Drug Abuse

Impetus for the CTSA Program
Implement biomedical discoveries
Develop, test, and bring new prevention strategies into medical practice more rapidly
Catalyze change - lower barriers between disciplines
Encourage creative and innovative approaches
Major Area of Interest is Emergency Medicine
CTSAWeb.org To ensure new discoveries lead to improved public health, clinical science must evolve to better :

CTSAs – Building a National Consortium of Academic Health Centers Members 2006 & 2007 Participating Institutions New Members 2008 CT Currently 38 CTSAs Sites Across the Country WA OR CA NV AZ NM MT UT WY CO SD ND NE KS OK TX AK AR MO IA MN WI IL IN MI OH KY TN MS AL GA FL LA NC SC VA WV PA NY VT NH ME MA DE MD RI ID HI NJ PR

Emergency Medicine
Sleep Research Network
Critical Care
Neurology
Neuroimaging
Encouraging and Enhancing Collaboration Opportunities CTSA Thematic Research Networks/CTSA Interest Groups

Program Announcement (PA) with Set-Aside, Number: PAS-09-001
Drug Abuse Epidemiology and Services Research in Cooperation with the Clinical and Translational Science Awards Consortium (R01)

SBIRT Efforts in General Medical Settings
What is SBIRT?
S creening
B rief I ntervention
R eferral to T reatment

USPSTF 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)

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

Example: Strength of Evidence for Tobacco/Smoking
A meta-analysis of 43 studies.
The improvement in cessation rates over controls 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

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, 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

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
Bernstein et al. Drug and Alcohol Dependence 2005;77:49-59 Brief motivational intervention at a clinic visit reduces cocaine and heroin use

Abstinence Among Those Screening Positive for At Baseline Brief motivational intervention at a clinic visit reduces cocaine and heroin use p < .05 Bernstein et al. Drug and Alcohol Dependence 2005

Total Illicit Substance Involvement Scores – BI and Control at Baseline and Follow-up (N=628) WHO ASSIST Phase III Technical Report , 2008: Pooled data (F(1,624) = 7.6, p<0.01, observed power = 78.4%, alpha=0.05

NIDA - SBIRT Initiatives:
NIDA has supported initiatives for SBIRT in General Medical Settings since initial findings of USPSTF
RFA in 2004 for Screening and MI in adolescents (with SAMHSA) – 12 Grants
Findings showing effectiveness of MI, computer platforms and EMRs in adolescent general medical settings

NIDA - SBIRT Initiatives: RFA-08-021 (SBIRT) for Drug Abuse in General Medical Settings
RFA in 2008: Screening, Brief Intervention and Referral to Treatment (SBIRT) for Drug Abuse in General Medical Settings (R01 only) RFA-DA-08-021 (R01)
~$3.5 million with SAMHSA, 5 Funded Grants
Well designed RCTs in various general medical settings, testing effectiveness of various SBIRT models.

NIDA - SBIRT Initiatives: RFA-08-021 (SBIRT) for Drug Abuse 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
Svikis, Dace S Computer vs Therapist-Delivered Brief Intervention for Drug Abuse in Primary Care
Merchant, Roland C Brief Intervention for Drug Misuse for the Emergency Department (BIDMED)

Screening for Drug Abuse in General Medical Settings: Resources for Clinicians, 2009
Makes the case for screening for illicit drugs in general medical care settings
Details the use of NIDA – ASSIST for SBIRT
Provides an overview of implementing screening programs in general medical settings
Offers strategies for discussing screening results with patients

NIDA Screening and Treatment Resources for Medical and Health Professionals
Website
Online Screening Tool
Quick Reference Guide
Online Resource Guide
Patient Postcard

NIDAMED Online Screening Tool
Based on the WHO ASSIST
Screens for tobacco, alcohol, illicit, and non-medical prescription drug use
Based on patients’ responses, automatically:
Leads to next appropriate question
Determines substance involvement score
Links to additional resources

Quick Reference Guide

Online Resource Guide
Introduction
Why screen for drug use in general medical settings?
How do you screen and provide feedback—the 5 As
Ask, Advise, Assess, Assist, and Arrange
Before you begin screening patients
Determine staffing roles and train staff
Decide how screening results will be used
Find reimbursement information for your state (SAMHSA website)
Establish relationships and linkages with treatment providers

Patient Postcard

NIDA - SBIRT Initiatives: Cooperative actions with other Public Health Agencies
Mainstreaming Efforts by W.H.O. and SBIRT are occurring, NIDA participates and supports worldwide ASSIST project, Robert Ali, PI
One of three key policy directions for the W.H.O. Department of Mental Health and Substance Dependence:
To integrate mental health and substance
dependence care into general health care.

Mainstreaming addictions is a focus of activities in the AMA Department of Healthy Lifestyles and Primary Prevention.
NIDA Primary Care Physician Outreach Project and Centers of Excellence.
Centers of Excellence : 5 Universities given grants to develop ways to teach medical students and residents Addiction Medicine and SBIRT Embedding drug addiction concepts in medical education.
NIDA - SBIRT Initiatives: Cooperative actions with other Public Health Agencies

Substance Use Disorders: CPT Codes Approved July 2008, with reimbursement now in 13 state Medicare and Medicaid programs, and 71 commercial carriers.
Physician Performance Measurement Set
To develop clinician-level performance measures that will help to improve the quality of care for patients with substance use disorders.
Component of the ongoing CPT 2 Code Development Process.
NIDA - SBIRT Initiatives: Cooperative actions with other Public Health Agencies-AMA

Update on NIDA's SBIRT Efforts in General Medical Settings: Summary
SBIRT has been shown efficacious for alcohol and tobacco; evidence for drugs is building but not yet sufficient for USPSTF.
NIDA has numerous initiatives to provide this evidence base in next few years, and to disseminate SBIRT training to medical profession.
NIDA has affiliations with Federal other Public Health Agencies to leverage its position.

Future SBIRT Research:
Enhance drug abuse SBIRT evidence base in a variety of medical settings, such as EDs
Develop and validate brief screening questionnaires to detect (and interventions for) prescription drug abuse that can be applied in general medical settings
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)
Linking results of SBIRT interventions to important morbidity and mortality outcomes

National Institute on Drug Abuse Division of Epidemiology, Services and Prevention Research Promoting Extraordinary Public Health Research to Eradicate Drug Abuse

How Does SBIRT Fit into the NIDA Research Program?

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