ED-Based Public Health Research:ED-Based Public Health Research:
NIDA’s PortfolioNIDA’s Portfolio
Richard A. Denisco, M.D....
Summary of NIDA ED Research
Projects:
• Sixty Research Projects in ED’s
• Includes Research Grants ( e.g. R01, R03, R21),
...
Clinical and Translational Science Awards
(CTSAs):
Director
National Center for
Research Resources
e
National Institute on...
Impetus for the CTSA Program
CTSAWeb.org
 Implement biomedical discoveries
 Develop, test, and bring new prevention stra...
CTSAs – Building a National Consortium of Academic
Health Centers
Members 2006 & 2007
Participating Institutions
WA
OR
CA
...
Encouraging and Enhancing Collaboration
Opportunities
CTSA Thematic Research Networks/CTSA Interest Groups
 Emergency Med...
Program Announcement (PA) with
Set-Aside, Number: PAS-09-001
• Drug Abuse Epidemiology and Services
Research in Cooperatio...
SBIRT Efforts inSBIRT Efforts in
General Medical SettingsGeneral Medical Settings
What is SBIRT?What is SBIRT?
Screening
B...
USPSTF Model
• Evidence needed that intervention, including referral to
treatment, impacts long-term morbidity and mortali...
Example:
Strength of Evidence for Alcohol
• A meta-analysis suggests an overall reduction of 56%
in number of drinks.
• Th...
Example:
Strength of Evidence for Tobacco/Smoking
• A meta-analysis of 43 studies.
• The improvement in cessation rates ov...
Strength of Evidence for Illicit Drugs:
Promising - but sparse results
• Bernstein, et al. 2005: Randomized Controlled
Tri...
• RCT (n=1175) urban walk-in clinic patients,
presenting for non-acute problems and use of
heroin or cocaine, confirmed by...
Abstinence Among Those Screening Positive for At Baseline
Brief motivational intervention at a clinic visit
reduces cocain...
Total Illicit Substance Involvement
Scores – BI and Control at Baseline and
Follow-up (N=628)
WHO ASSIST Phase III Technic...
NIDA - SBIRT Initiatives:
• NIDA has supported initiatives for SBIRT in
General Medical Settings since initial findings of...
NIDA - SBIRT Initiatives:
RFA-08-021 (SBIRT) for Drug Abuse in General
Medical Settings
• RFA in 2008: Screening, Brief In...
NIDA - SBIRT Initiatives:
RFA-08-021 (SBIRT) for Drug Abuse in General
Medical Settings
• D'Onofrio, Gail Models of SBIRT ...
Screening for Drug Abuse in
General Medical Settings:
Resources for Clinicians, 2009
• Makes the case for screening for il...
NIDA Screening and
Treatment Resources
for Medical and
Health Professionals
•Website
•Online Screening Tool
•Quick Referen...
NIDAMED Online Screening
Tool
•Based on the WHO ASSIST
•Screens for tobacco,
alcohol, illicit, and non-
medical prescripti...
Quick Reference
Guide
Online Resource Guide
• Introduction
– Why screen for drug use in general medical settings?
– How do you screen and provid...
Patient Postcard
NIDA - SBIRT Initiatives:
Cooperative actions with other
Public Health Agencies
• Mainstreaming Efforts by W.H.O. and SBIR...
• Mainstreaming addictions is a focus
of activities in the AMA Department
of Healthy Lifestyles and Primary
Prevention.
• ...
• Substance Use Disorders: CPT Codes
Approved July 2008, with reimbursement
now in 13 state Medicare and Medicaid
programs...
Update on NIDA's SBIRT Efforts in GeneralUpdate on NIDA's SBIRT Efforts in General
Medical Settings: SummaryMedical Settin...
Future SBIRT Research:
• Enhance drug abuse SBIRT evidence base in a variety of
medical settings, such as EDs
• Develop an...
National Institute on Drug Abuse
Division of Epidemiology, Services and
Prevention Research
Promoting Extraordinary Public...
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How Does SBIRT Fit into the NIDA Research Program?

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  • Wilson, I thought it might be worth-while to show what the WHO and AMA are doing to “mainstream SA treatment” and then focus down on NIDA efforts. This is a slide to introduce W.H.O. efforts, which have NIDA support.
  • AMA is a partner with NIDA in the Primary Care Physician Outreach Project and Centers of Excellence in addiction education, which I will mention again later.
  • How Does SBIRT Fit into the NIDA Research Program?

    1. 1. ED-Based Public Health Research:ED-Based Public Health Research: NIDA’s PortfolioNIDA’s Portfolio Richard A. Denisco, M.D., M.P.H.Richard A. Denisco, M.D., M.P.H. Medical OfficerMedical Officer Division of Epidemiology, Services and Prevention ResearchDivision of Epidemiology, Services and Prevention Research Services Research BranchServices Research Branch National Institute on Drug AbuseNational Institute on Drug Abuse SAEM Consensus ConferenceSAEM Consensus Conference May 13, 2009May 13, 2009
    2. 2. 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
    3. 3. Clinical and Translational Science Awards (CTSAs): Director National Center for Research Resources e National Institute on Drug Abuse
    4. 4. Impetus for the CTSA Program CTSAWeb.org  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 To ensure new discoveries lead to improved public health, clinical science must evolve to better:
    5. 5. CTSAs – Building a National Consortium of Academic Health Centers Members 2006 & 2007 Participating Institutions WA OR CA NV AZ NM MT UT WY CO SD ND NE KS OK TXAK 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 New Members 2008 CT Currently 38 CTSAs Sites Across the Country
    6. 6. Encouraging and Enhancing Collaboration Opportunities CTSA Thematic Research Networks/CTSA Interest Groups  Emergency Medicine  Sleep Research Network  Critical Care  Neurology  Neuroimaging
    7. 7. 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)
    8. 8. SBIRT Efforts inSBIRT Efforts in General Medical SettingsGeneral Medical Settings What is SBIRT?What is SBIRT? Screening Brief Intervention Referral to Treatment
    9. 9. 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)
    10. 10. 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
    11. 11. 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
    12. 12. 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
    13. 13. • 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
    14. 14. 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
    15. 15. 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
    16. 16. 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
    17. 17. 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.
    18. 18. 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)
    19. 19. 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
    20. 20. NIDA Screening and Treatment Resources for Medical and Health Professionals •Website •Online Screening Tool •Quick Reference Guide •Online Resource Guide •Patient Postcard
    21. 21. 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: oLeads to next appropriate question oDetermines substance involvement score • Links to additional resources 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: oLeads to next appropriate question oDetermines substance involvement score • Links to additional resources
    22. 22. Quick Reference Guide
    23. 23. 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
    24. 24. Patient Postcard
    25. 25. 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.
    26. 26. • 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
    27. 27. • 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
    28. 28. Update on NIDA's SBIRT Efforts in GeneralUpdate on NIDA's SBIRT Efforts in General Medical Settings: SummaryMedical 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.
    29. 29. 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
    30. 30. National Institute on Drug Abuse Division of Epidemiology, Services and Prevention Research Promoting Extraordinary Public Health Research to Eradicate Drug Abuse

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