Wilson M. Compton, M.D., M.P.E

Mainstreaming Addictions in Medicine:

Improving Substance Abuse Services Through

StandardizationWilson M. Compton, M.D., M.P.E.Director, Division of Epidemiology, Services and

Prevention ResearchNational Institute on Drug Abuse

13 August 2012

Drug use has wide ranging health , social consequences.– Cardiovascular disease,

stroke, cancer, HIV/AIDS, anxiety, depression, sleep problems, as well as financial difficulties and legal, work, and family problems can all result from or be exacerbated by drug use.

Occurrence of Medical Conditions in Diagnosed

Substance Abusers

Source: Mertens JR et al, Arch Intern Med 163: 2511-2517, 2003

Why focus on drug use in general medical settings?

Health Care Reforms are shifting the emphasis to integrated care based in general medical settings.– 2009 Enhanced parity of coverage of

mental illnesses and substance use disorders (compared to coverage of other medical conditions)

– 2010 Health care reform to reduce the number of uninsured persons


A Continuing Care Model

PrimaryContinuing Care

Primary Care

Specialty Care

Source: A. T. McLellan, 2011

PROBLEM: Physicians don’t routinely screen for drug use.

–Don’t know what to do –No effective treatment–Not medical problem–No time–Health care system doesn’t address addictions routinely


Mainstreaming Addictions in General Medicine

• Promising Practice: Screening and Brief Intervention or Referral to Treatments (SBIRT).

• Improving development of medications.

• Blending science and services to address practice-relevant research.





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

Illicit Drug Use -SBIRT evidence insufficient

• Drugs: http://www.ahrq.gov/clinic/uspstf/uspsdrug.htm

http://www.ahrq.gov/clinic/uspstf/uspstbac.htm

http://www.ahrq.gov/clinic/uspstf/uspstbac.htm



http://www.ahrq.gov/clinic/uspstf/uspsdrug.htm

http://www.ahrq.gov/clinic/uspstf/uspsdrug.htm

Some Key Lessons from Alcohol and Tobacco SBIRT:

Impact of SBIRT varies according to Setting and Patient Characteristics

RT is not well addressed

Strength of Evidence for Illicit Drugs: Promising - but sparse results• Bernstein, et al. 2005: Randomized

Controlled Trial (RCT)• WHO study, 2008 & Hermeniuk R, et al.

2012: 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

• Bernstein, et al. 2009: Adolescent RCT in ED, reduction in days MJ smoked at 12 mo after BI

22.3%

40.2%

16.9%

30.6%

0%

20%

40%

60%

Cocaine Opioids

Intervention

Control

Abstinence Among Those Screening Positive for At Baseline (N=1175), comparing those who did and did not receive peer-delivered, brief (~20 minutes) intervention with booster phone call (~5 minutes) 10 days later

p < .05

Bernstein et al. Drug and Alcohol Dependence 2005

Brief motivational intervention reduces 6 mo. cocaine and heroin

use

Total Illicit Substance Involvement

Scores – BI and Control at Baseline and Follow-up

(N=628)

WHO ASSIST Phase III Technical Report, 2008; Hermeniuk R, et al. Addiction 2012

p<0.01

Cannabis Specific Substance Involvement


(N=328)

p<0.05

WHO ASSIST Phase III Technical Report, 2008; Humeniuk R, et al. Addiction 2012

Stimulant Specific Substance Involvement


(N=229)

p<0.005


Opioid Specific Substance Involvement Scores – BI and

Control at Baseline and Follow-up (N=73)

p<0.07


Program Data, Six SAMHSA SBIRT Sites, Baseline and

F/U Substance UseAmong Those Screening Positive for Drugs At

Baseline (N = 6,262)

%

Madras, et al. Drug Alcohol Dependence, 2009

All are P < 0.001

Intervention Group (INT) Assessed Control Group (AC)0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

0.5 * OR =2.89, p<.014

(N=47) (N = 55)

Perc

ent

Abst

inen

t

Abstinence = no marijuana use in past 30 days at 12 months

* 44.7%

21.8%

Screening and Brief Intervention to Reduce Marijuana Use Among Youth and Young

Adults in a Pediatric ED

Bernstein E et al., Academic Emergency Medicine 2009;16 (1):1174-1185

Intervention Group (INT) Assessed Control Group (AC)0

5

10

15

20

25

30

* OR =3.36, p=.0117

9.3%

Effect of Intervention on Reporting Receiving Referrals to Community Resources

(N=47) (N = 55)

Perc

ent

Repo

rt

Rece

ivin

g Re

ferr

als *

25.5%

Screening and Brief Intervention to Reduce Marijuana Use Among Youth and Young

Adults in a Pediatric ED

Bernstein E et al., Academic Emergency Medicine 2009;16 (1):1174-1185

SBIRT and Cost effectiveness

Evaluation of the first SAMHSA SBIRT cohort in Washington state (WASBIRT)Working –age disabled patientsReceived at least a brief intervention (BI)Results: BI at $70 per person resulted in $185 to $192 saving per member per month and $2.7 to $2.8 million total per year in Washington State

Source: Estee S, He L, Mancuso D, Felver B. Medicaid costs declined among emergency department patients who received brief interventions for substance use disorders through WASBIRT. Washington State Department of Social and Health Services, Research and Data Analysis Division. (2007).

SBIRT and Cost effectivenessCost–benefit analysis of Early Start, an

integrated prenatal intervention program for stopping substance use in pregnancyFour study groups were compared (N=49,261) : 1.) screened-assessed-followed (n=2032), Maternal cost = $9,430, Infant costs = $11,2142.) screened-assessed (n=1181), Maternal cost $9,230, Infant cost $11,3043.) screened-positive-only (n=149), Maternal cost = $10,869, Infant cost = $16,9434.) control group who screened negative (n=45,899), Maternal cost = $8,282, Infant cost = $10,416Program Cost $670,600 v. Benefit $5,946,741 per yearGoler, Armstrong, Osejo, et al. Obstetrics & Gynecology

2012;119(1):102–110

Strength of Evidence about

SBIRT for Illicit Drugs: Promising - but limited data

Additional Studies Also Show the Potential for Prevention

Interventions at the Boundary of Illicit Drug Abuse and Other

Behavioral Health Issues

Intervention for Rape Assault Victims Shows Impact on

Marijuana Use

Screening and Brief Intervention

Dr. Barbara Gerbert (and colleagues) have used the Video Doctor to screen for the following sensitive risk areas:

Nutrition

Physical activity

Intimate partner violence/Domestic violence

HIV risk behaviors

Smoking

Alcohol use

Drugs use

Baseline 1-month0%

20%

40%

60%

80%

100%

16.7%23.5%

81.8%

70.0%

Usual Care

Intervention

Provider - Patient Intimate Partner Violence Discussions

Barbara Gerbert, Presented at NIH Implementation Conference, March 2010

Enhancement • Start process with Single

Questions (prior to ASSIST assessment of

severity) Tobacco Alcohol Prescription Drugs Illegal Drugs

• Expand to include Adolescents (meeting May 27, 2011 and recent supplement program)

• Focusing on measuring illicit and prescription drug abuse for the Electronic Health Record

Smith, Schmidt,

Allensworth-Davies,

Saitz 2010

Electronic Health Record (EHR)

Federal encouragement to adopt with “meaningful use”

Multiple vendors developing EMR Hospital based systems Individual practice based systems Interoperability (EMRs EHR)

Content Clinical care Research

Source: Robert Gore-Langton, PhD, NIDA CTN Data and Statistics Center, The EMMES Corporation

Electronic Health Record (EHR)

Federal meaningful use criteria Incentive through reimbursement Incorporate concepts and data elements to

qualify for meaningful use Example

Meaningful use stage 1 (2011-2012) Screen for tobacco use in > 50% of clinic population

Meaningful use stage 2 (proposed, for 2013) Screen for tobacco use in 80% of clinic population Screen and brief intervention for alcohol use

disorders Screen for illicit and prescription drugs


1 Question Alcohol Screener

1 QuestionDrug Screener

Alcohol Assessment

Drug SeverityAssessment

Initial Presentation3 Screener Questions

NONOYES YES

Further Assessment and/or Referral outside of primary care

NO

1 Question Tobacco Screener

Tobacco Assessment

YES


Summary of Future SBIRT Research:

• Enhance evidence on effectiveness of SBI models of care in a variety of general medical (and related) settings, and differing populations

• Develop and validate brief screening questionnaires, with technology, to detect (and intervene on) prescription drug abuse

• 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)

• Integrate SBIRT/Drugs with all behavioral health behaviors





Outcomes can be improved by:

Developing interventions that are highly effective as delivered

Translating Basic Science Discoveries Into

New and Better TreatmentsBasic Research

Medications

Basic Research

Medications

OFCSCC

MOTIVATION/DRIVE

Hipp

Amyg MEMORY/

LEARNING

Circuits Involved In Drug Abuse and Addiction

NAcc VP

REWARD

PFC

ACG

EXECUTIVEFUNCTION/ INHIBITORY

CONTROL

NAcc VP

REWARD

1. Reward Circuit

Drugs of Abuse EngageSystems in the Motivation Pathwaysof the Brain

Hipp

Amyg MEMORY/LEARNING

2. Memory circuit

“People, Places and Things…”

Cocaine Film

Cocaine Craving:Population (Cocaine Users, Controls) x Film (cocaine )

Garavan et al A .J. Psych 2000

IFG

Ant Cing

Cingulate

Sign

al In

tens

ity

(AU

)

Controls Cocaine Users

Cocaine Film Erotic Film

Cocaine Craving:Population (Cocaine Users, Controls) x Film (cocaine, erotic)

Garavan et al A .J. Psych 2000

IFG

Ant Cing

Cingulate

Sign

al In

tens

ity

(AU

)

Controls Cocaine Users

Even Unconscious Cues Can Elicit Brain Responses

Brain Regions Activated by 33 millisecond Cocaine Cues (too fast for conscious recognition)

Childress, et al., PLoS ONE 2008

3. Motivation & Executive Control Circuits

ACGOFC SCC

INHIBITORY CONTROL

EXECUTIVEFUNCTION

PFC

MOTIVATION/DRIVE Dopamine is also

associated with motivation and executive function via regulation of frontal activity.

ACG

OFCSCC

Hipp

NAccVP

Amyg

REWARDINHIBITORY

CONTROL

MEMORY/LEARNING

EXECUTIVEFUNCTION

PFC

Becomes severely disrupted in ADDICTION

MOTIVATION/DRIVE

The fine balance in connections that normally exists between brain areas active in reward, motivation, learning and memory, and inhibitory control

Treatments for Relapse Prevention: Medications

Addicted Brain

Drive

Control

Saliency

Memory

GO Strengthen prefrontal-striatal communication

Executive function/Inhibitory control

Interfere with conditioned memoriesTeach new memories

Counteract stress responses that lead to relapse

Interfere with drug’s reinforcing effects

VaccinesEnzymatic degradationNaltrexoneDA D3 antagonistsCB1 antagonists

BiofeedbackModafinilBupropionStimulants

Antiepileptic GVGN-acetylcysteine

Cycloserine

CRF antagonistsOrexin antagonists

STOP Drive

Control

Memory

Non-Addicted Brain

Saliency AdenosineA2 antagonistsDA D3 antagonists

Treatments for Relapse Prevention: PsychotherapiesAddicted

Brain

Drive

Control

Saliency

Memory

GO Strengthen prefrontal-striatal communication

Executive function/Inhibitory control

Interfere with conditioned memoriesTeach new memories

Counteract stress responses that lead to relapse

Interfere with drug’s reinforcing effects

STOP Drive

Control

Memory

Non-Addicted Brain

Saliency

Contingency Management

Cognitive Therapy

BiofeedbackDesensitization

RelaxationBehavioral therapies

Motivation Therapies

Behavioral Therapies





Outcomes can be improved by:

Developing interventions that are highly effective as delivered

, or Implementing an

effective intervention more widely.

Information Dissemination

Information Dissemination• Essential first step in Type 2

translation research – BUT

• Generally produces only a vague awareness that new science exists

• Does not address the conditions and circumstances of the numerous providers, clients and contexts involved.

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 Environm

ent (stigma,

financing)

Methadone Maintenance Dosing Improved, but standards often not met

1988 1990 1995 2000 20050

102030405060708090

100% patients receiving mainte-nance doses of at least 60 mg/day

Low-dose programs characterized by:– More African-

American & Latino patients

– More managed care (pre-authorization requirements)

– Staff endorsement of abstinence orientation, and rejection of HIV prevention activities (syringe exchange)

Pollack & D’Aunno (2008) Health Services Research, 43:2143-2163

Low Uptake of Pharmacotherapy in Specialty

Programs (2007)As % of all

programs surveyed (N=345)

Within adopting programs, % of eligible patients receiving

Rx

Psychiatric meds 54.5 70.1

Opioid tx meds:Methadone 7.8 41.3

Buprenorphine 20.9 37.3

Tablet naltrexone 22.0 10.9

Alcohol meds:Disulfiram 23.8 8.1

Tablet naltrexone 32.2 12.4

Acamprosate 32.5 17.5

Injectable naltrexone 15.9 (too new to report)

Knudsen et al, 2011, J Addict Med; 5:21-2749

Adoption is a Process

x x+sdx-sdx-2sd

Innovators=2.5%

Early Adopters=13.5%

Early Majority=34%

Late Majority=34%

Laggards=16%

Rogers (2005)

Trialability Increases EBP Adoption

51

Early Adoption of Buprenorphine (2005)

Ducharme et al, 2007, JSAT; 32(4):321-9

Implementation science is not intended to test interventions, per se, but to study

how to get evidence-based interventions

adopted, adapted, and sustained.

Implementation Science

Organizational attributesContextual factorsChange process attributesIntervention attributesClient attributesNetworking - cross-agency linkages and collaborations

Measurement Domains

Turnover and Competence Outcomes of Counselors Trained in A-CRA

(N=34 treatment programs, 121 counselors)

Baseline + 6 months + 9 months + 12 months

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Employed, EBP CompetentEmployed, Not EBP CompetentNot Employed, EBP CompetentNot Employed, Not EBP-Com-petent

No return on training invest-ment

Garner et al, 2012, JSAT

1 yr to achieve competence in 50% of

staff

Training Resources Do Not Guarantee Uptake

54

• Substantial investment in health services research aimed at improving the quality of substance abuse treatment

The vision is that Patient Outcomes can be improved by:

• Making effective interventions more widely available to patients

• Improving the system’s ability to deliver interventions

PRIORITIES FOR NIH

• High Throughput Technologies

• Translational Research

• Health Care Reform

• Global Health

• Empowering the Biomedical Research Community

Current Issue: Health Care Reforms in the USA

• Insurance Reforms include–2009 Enhanced parity of coverage of

mental illnesses and substance use disorders

–Patient Protection and Affordability Care Act of 2010 (i.e. health care reform)o Enhanced parityo Emphasis on preventiono Enhanced insurance coverageo Emphasis on primary care

Change in Mental Health and Addiction Services Probability of Use and Expenditures in Oregon Parity Plans Minus Change in Non-Parity Plans

-0.40%

-0.30%

-0.20%

-0.10%

0.00%

0.10%

0.20%

0.30%

-0.28%

∆ Prob. of Use

-$30-$20

-$10$0

$10

$20$30

$15

∆ Expenditures

Does Oregon’s Experience Presage the National Experience with the Mental Health Parity and Addiction Equity Act?

Mcconnell KJ, et al. American Journal of Psychiatry 2012;169:31-38

pooled parity v. non-parity plans

August 17, 2011

Impact of the Affordable Care Act (ACA) on Drug Abuse Prevention

and Treatment Services

Relevant ACA Provisions and Environment:– Extends coverage to more than 30

million persons, many at high risk for drug abuse

– Fundamentally changes the ways drug abuse prevention and treatment services are financed

– Focuses on screening and prevention– Promotes use of electronic health

records– Emphasizes central role of primary

care settingsAll at a time of exciting scientific

advance but extraordinary economic challenges



1996 2001 20060%

10%

20%

30%

40%

50%

60%

40%46%

50%

% of Sites Offering

Lo Sasso and Byck, Health Affairs (2010). Bureau of Primary Health Care, Health Resources and Services Administration, Uniform Data System

Each additional $1 million in federal funding lead to a 3.6% increase in the probability of offering substance abuse services

Substance Abuse Counseling in FHQCs

Typical Challenges/Barriers: • Legislation often has far-reaching

consequences that go unstudied. ACA could cause:– Industry consolidation leading to a new

cost structure– Greater reliance on FQHCs and other

integrated health care settings for DA service delivery

– Enhanced CMS role in defining/approving services

– Changes in the types of interventions developedWill this lead to a greater quantity of

efficiently-produced, effective services that meet patients’ needs?



Portfolio Analysis: • Only one NIDA-funded research

project directly examines impact of ACA on treatment services– Roman (R01DA013110-11): Adoption of

Innovations in Private A&D Centers• Two grants examine impact of

parity legislation on treatment services (RFA-DA-10-004):– Horgan (R01DA029316): Provision of Drug

Abuse Treatment Services Under Parity– Meara (R01DA027414): Parity, Child

Mental Health, and Substance Abuse



• Uptake rate for insurance among those with drug disorders and related (i.e. HIV), and how affected by outreach and offered coverage

• Responsiveness of demand for services among the newly covered. Effect on service types/quantity sought and payer responses

• Models for implementing addiction services (both treatment and prevention) in health care settings

• Training and sustainability models• Use of technology to improve quality of care

(EHR, patient technology, etc.)• Organization and financing strategies

Impact of ACA) on Drug Abuse Prevention and Treatment Services:

Research Topic Examples

2013 RFA: Phased Services Research Studies of Drug Use Prevention,

Addiction Treatment and HIV in an Era of Health Care Reform

Monitor and examine changes in drug use prevention, addiction treatment and associated HIV services that may

occur as a result of health care reforms.

Summary• Embedding substance

interventions into the general health system to improve patient care and outcomes.–Addressing outcomes through practice and system changes.

–Focus on broad substance use services: SBIRT, medications, EHR, and clinician training.

–Health care reforms in the USA provide new opportunities, especially for addiction services.

Revised Dec 2011

Revised Jan 2012

Published Dec 2011Revised Oct 2011

www.drugabuse.gov

Documents

Wilson M. Compton, M.D., M.P.E