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 AbuseDepartment of Health and Human Services

Penn State University29 November 2006

Penn State University29 November 2006

National Institute on Drug Abuse

Special Populations Office

EEO

Office ofExtramural

Affairs

Teresa Levitin, PhD

Office of Planning& Resource

Management

Laura Rosenthal

Office of Science Policy & Communications

Timothy Condon, PhD

Center for theClinical Trials

Network

Betty Tai, PhD

Intramural ResearchProgram

Barry Hoffer, MD, PhD

Office of the DirectorNora D. Volkow, MD

Director

Timothy P. Condon, Ph.D.Deputy Director

Laura S. RosenthalAssociate Directorfor Management

Director, AIDS Research

Division of ClinicalNeuroscience,

Development &BehavioralTreatment

Joseph Frascella, PhD

Division of Basic Neurosciences

& Behavior Research

David Shurtleff, PhD

Division ofPharmacotherapies &Medical Consequences

of Drug Abuse

Frank Vocci, PhD

Division ofDivision ofEpidemiology, Epidemiology,

Services & Services & Prevention Research Prevention Research

Wilson Compton, MD, MPEWilson Compton, MD, MPE

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.

First, a story exemplifying linkages

of Epidemiology, Prevention and

Services…

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)

8.0

11.310.2 10.9

11.914.0

12.8 12.5

15.1

18.7

02468

101214161820

Alcohol

Any Dru

g

Mar

ijuan

a

Cocain

e

Amph

etam

ine

Hallu

cinog

en

Opioid

Sedat

ive

Tranqu

ilize

r

Inhala

nt

Early AggressionPoor academic

achievement

Adolescent/Early Adult Antisocial Behavior and Drug Abuse

From Longitudinal Epidemiology comes evidence for a plausible pathway:

Deviant peer association

— Support for theory and development of

practical and useful interventions.

From Prevention: comes tests of the theory and tests of a plausible

intervention strategy:

From Prevention: Reducing Early Aggressive Behaviors Reduces Drug Use

13121110987

ES

TIM

AT

ED

CU

MU

LA

TIV

E R

ISK

Control: 33%, reference CC: 25%, aRR 0.61 (0.37-1.00) FSP: 25%, aRR 0.70 (0.50-0.98)

CC=Classroom Centered FSP=Family-School Partnership

AGE OF FIRST TOBACCO USE

Modified from: Storr, et al., Drug and Alcohol Dependence, 66:51-60, 2002.

From Prevention: Enhancing Social Bonding Reduces Violence

Hawkins, et al., Arch Pediatr Adolesc Med 1999

48%

60%

72%

83%

00.10.20.30.40.50.60.70.80.9

Violence Sexual Activity

SSDP Intervention Comparison

From Services: Early Interventions Can Be Cost-Effective

Cost per TaxpayerParticipant 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

Ongoing Problem: To Reap Any Benefits

From Scientific Knowledge It Needs To Be Used In

Practice

Ongoing Problem: To Reap Any Benefits

From Scientific Knowledge It Needs To Be Used In

Practice

From Services: Few Schools Use Effective Prevention Programs

26.8%34.6%

12.6%

0%

10%20%

30%

40%50%

60%

Percentage Using One of the Top 12 Effective Programs

Ringwalt, et al. (2002), Prevention Science

Thus, all three branches of DESPR

contribute to a unified story about

pathways to drug use and how to

intervene in these pathways.

And now…

A Few Key FindingsA Few Key Findings

Cigarette Smoking Declines Markedly Since Mid-1990’s

ERB:

Lifetime

20

30

40

50

60

70

91 92 93 94 95 96 97 98 99 00 01 02 03 04 05

8th Grade 10th Grade 12th Grade

***

* Denotes significant difference between recent peak year and current year.

Denotes significant difference between 2004 and 2005.

Source: University of Michigan, MTF 2005

Life Course View of Addiction Refines Understanding of Recovery & Benefit Cost

SRB:

05

10152025303540

1 Tx Episode Life Course

Lifetime Benefit-Cost Ratio for Tx of Heroin

Use

Benefit Cost

Zarkin, Dunlap, Hicks, & Mamo. (2005). Zarkin, Dunlap, Hicks, & Mamo. (2005). Benefits & costs of methadone treatment: Benefits & costs of methadone treatment: results from a lifetime simulation model. results from a lifetime simulation model. Health Economics, 14, 1133-1150.Health Economics, 14, 1133-1150.

Recovery

Multiple treatment episodes is the norm.27 years = Median time from first to last drug use9 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.

Source: Spoth, et al. (2005). Two randomized studies of the long-term effects of brief, partnership-based universal preventive interventions on adolescent methamphetamine use

0

1

2

3

4

5

6

7

8

%

Past Year Use* Lifetime--Past Year Plus Prior Use

ISFP PDFY ControlStudy 1 (12th Grade)

SFP+LST LST Control Study 2 (11th Grade)

SFP+LST LST Control Study 2 (12th Grade)

5.18

4.15

2.51

.53

7.61

2.402.12

2.63

3.45 3.21

4.59

1.44

Lifetime and Past Year Meth Use at 4½-6½ Years Past Baseline

Universal Family-based Prevention Interventions Reduce Methamphetamine

PRB:

HIV Screening Can Be As Cost-Effective As Screening for Hypertension and Other Medical Conditions

Source: Paltiel, et al. and Sanders et al., NEJM 352(6), 2005.

Incr

ease

in L

ife

Exp

ecta

ncy

D

ue

to S

cree

nin

g (Y

r)

2.0

1.8

1.6

1.4

1.2

1.0

0.8

0.6

0.4

0.2

0.030 40 50 60 70 80 90

Life expectancy

Quality-adjustedlife expectancy

AGE (Yr)0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

200,000

180,000

160,000

140,000

120,000

100,000

80,000

60,000

40,000

20,000

0

Incr

emen

tal C

ost-

Eff

ecti

vene

ss o

f Sc

reen

ing

($/q

ual

ity-

adju

sted

life

yea

r)

Costs and benefits to partners excluded

Costs and benefits to partners included

Prevalence of Unidentified HIV (%)

DESPR:

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

Priority Areas for NIDA

Treatment Interventions (New Targets & New Strategies)

Prevention Research Children and AdolescentsGeneticsComorbidityDevelopment

HIV/AIDS Research

HIV/AIDSHIV/AIDS

DRUG ABUSEDRUG ABUSE

DRUGS OF ABUSE

Summary: Drug Abuse Research Needs a Systems Approach

social

genome

protein expression

neuronal circuits

behavior

DESPR: 20062006 Major Research Questions

1. What new theoretical approaches can inform our research?

2. What intrapersonal and environmental factors interact with each other and with genetic factors?

3. How can we blend science and services to measurably impact public health outcomes?

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

What are we doing to develop and promote these

themes?

Workgroups, Meetings, Publications, etc.

Type 1 Type 2

Translational Research is NOT Unidirectional: There are Feedback Loops

• 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?

Bi-Directional Influences

Linking Public Health Research to Linking Public Health Research to NeuroscienceNeuroscience

Linking Public Health Research to Linking Public Health Research to NeuroscienceNeuroscience

OFCSCC

MOTIVATION/MOTIVATION/DRIVEDRIVE

Hipp

Amyg

MEMORY/MEMORY/LEARNINGLEARNING

Circuits Involved In Drug Abuse and Addiction

NAcc

VP

REWARDREWARD

PFC

ACG

INHIBITORY INHIBITORY

CONTROLCONTROL

All Should Be Considered InStrategies to Prevent and

Treat Addiction

Non Addicted Brain

Control

DriveReward

Memory

Addicted Brain

Control

DriveReward

Memory

GO

STOPSTOP

0

0.2

0.4

0.6

0.8

1

wakeup mid morning bedtime

Initial

3 Month

6 Month

Promise of Translation: HPA axis plasticity

Psychosocial intervention

Brandon's PDR

0

5

10

15

20

25

30

35

Total PDR

# of Beh.

Linear (Total PDR)

Linear (# of Beh.)

Init.

3 mo.

6 mo.

Concordant behavior change

Source: Fisher P, OSLC

0.000

0.002

0.004

0.006

0.008

0.010

0.012

5 10 15 20 25 30 35 40 45 50 55 60

Age

Ha

zard

Ra

te

DSM-IV Abuse

DSM-IVDependence

Source: NESARC Study, 2001-2002

Key Basic Epidemiology Finding: Addiction is a Developmental Disorder

With Onset During Adolescence

Brain areas where volumesdiffer in adolescents compared to young adults

Source: Sowell, E.R. et al., Nature Neuroscience, 2(10), pp. 859-861, 1999

Recent Studies Have Shown that Maturation of theBrain’s Gray Matter Moves from Back to Front

Source: Cunningham, M et al., J Comp Neurol 453, pp 116-130, 2002.

During Adolescence the COGNITION-EMOTION Connection is Still Undergoing Development

Low-power light photomicrographs of immunoperoxidase-labeled, biocytin-containing amygdalofugal varicose fibers within the mPFC of animals at 6 stages of development

Amygdalo-cortical Sprouting Continues Into Early Adulthood

• Developmental differences must be considered in designing prevention strategies.

–Can frontal lobe functioning be strengthened?

Implications:

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?

BenchBench

BedsideBedside

CommunityCommunity

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)

Interagency Collaborations

are indispensable

BenchBench

BedsideBedside

CommunityCommunity

DHHSDHHS

NIDANIDA

SAMHSANIH

Collaborations to Translate Research Findings Into Relevant Clinical PracticeCollaborations to Translate Research

Findings Into Relevant Clinical Practice

NIDANIDA

Research Centers Research Centers Coordinating Center Coordinating Center

Testing the Communities That Care (CTC) Prevention System

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)

Developing the Health Services Research

Program

BenchBench

BedsideBedside

CommunityCommunity

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

NIDA Blue Ribbon Task Force on Health Services Research

NIDA Blue Ribbon Task Force on Health Services Research

New Opportunities:• Science to Services

Medical Settings– Screening (especially SBIRTs)– Prescription Drug Abuse

(especially opioids) HIV

• Interactions Implementation Science

• New Theories Economics Organization/Management

Division of Epidemiology, Services and Prevention Research

Providing a foundation for NIDA’s public health mission.