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

1. Mainstreaming Addictions in Medicine: Improving Substance Abuse Services Through Standardization Wilson M. Compton, M.D., M.P.E. Director, Division of Epidemiology, Services and Prevention Research National Institute on Drug Abuse 13 August 2012

2. Why focus on drug use in general medical settings? 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

3. 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

4. A Continuing Care Model Primary Care Specialty Care Primary Continuing Care Source: A. T. McLellan, 2011

5. Why focus on drug use in general medical settings? 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

6. 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.

7. 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.

8. 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

9. Some Key Lessons from Alcohol and Tobacco SBIRT: Impact of SBIRT varies according to Setting and Patient Characteristics RT is not well addressed

10. 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

11. Brief motivational intervention reduces 6 mo. cocaine and heroin use 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

12. Total Illicit Substance Involvement Scores – BI and Control at Baseline and Follow-up (N=628) p<0.01 WHO ASSIST Phase III Technical Report, 2008; Hermeniuk R, et al. Addiction 2012

13. Cannabis Specific Substance Involvement Scores – BI and Control at Baseline and Follow-up (N=328) p<0.05 WHO ASSIST Phase III Technical Report, 2008; Humeniuk R, et al. Addiction 2012

14. Stimulant Specific Substance Involvement Scores – BI and Control at Baseline and Follow-up (N=229) p<0.005 WHO ASSIST Phase III Technical Report, 2008; Humeniuk R, et al. Addiction 2012

15. Opioid Specific Substance Involvement Scores – BI and Control at Baseline and Follow-up (N=73) p<0.07 WHO ASSIST Phase III Technical Report, 2008; Humeniuk R, et al. Addiction 2012

16. 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

17. Screening and Brief Intervention to Reduce Marijuana Use Among Youth and Young Adults in a Pediatric ED Abstinence = no marijuana use in past 30 days at 12 months * 44.7% 21.8% Percent Abstinent (N=47) (N = 55) Bernstein E et al., Academic Emergency Medicine 2009;16 (1):1174-1185

18. Screening and Brief Intervention to Reduce Marijuana Use Among Youth and Young Adults in a Pediatric ED Effect of Intervention on Reporting Receiving Referrals to Community Resources * 25.5% Percent Report Receiving Referrals (N=47) (N = 55) Bernstein E et al., Academic Emergency Medicine 2009;16 (1):1174-1185

19. SBIRT and Cost effectiveness Evaluation of the first SAMHSA SBIRT cohort in Washington state (WASBIRT) Working –age disabled patients Received 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).

20. SBIRT and Cost effectiveness Cost–benefit analysis of Early Start, an integrated prenatal intervention program for stopping substance use in pregnancy Four study groups were compared (N=49,261) : 1.) screened-assessed-followed (n=2032), Maternal cost = $9,430, Infant costs = $11,214 2.) screened-assessed (n=1181), Maternal cost $9,230, Infant cost $11,304 3.) screened-positive-only (n=149), Maternal cost = $10,869, Infant cost = $16,943 4.) control group who screened negative (n=45,899), Maternal cost = $8,282, Infant cost = $10,416 Program Cost $670,600 v. Benefit $5,946,741 per year Goler, Armstrong, Osejo, et al. Obstetrics & Gynecology 2012;119(1):102–110

21. 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

22. Intervention for Rape Assault Victims Shows Impact on Marijuana Use

23. Screening and Brief Intervention Dr. Barbara Gerbert (and colleagues) have used the Video Doctor to screen for the following sensitive risk areas: HIV risk behaviors Smoking Alcohol use Drugs use Nutrition Physical activity Intimate partner violence/ Domestic violence

24. Provider - Patient Intimate Partner Violence Discussions Barbara Gerbert, Presented at NIH Implementation Conference, March 2010

25. Smith, Schmidt, Allensworth-Davies, Saitz 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

26. 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

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

28. Initial Presentation 3 Screener Questions 1 Question Alcohol Screener 1 Question Tobacco Screener 1 Question Drug Screener YES YES NO YES NO NO Drug Severity Assessment Alcohol Assessment Tobacco Assessment Further Assessment and/or Referral outside of primary care Source: Robert Gore-Langton, PhD, NIDA CTN Data and Statistics Center, The EMMES Corporation

29. 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

30. 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.

31. Outcomes can be improved by: • Developing interventions that are highly effective as delivered

32. Basic Research Medications Medications Basic Research Translating Basic Science Discoveries Into New and Better Treatments

33. EXECUTIVEFUNCTION/ INHIBITORY CONTROL PFC ACG Hipp OFC SCC NAcc REWARD MOTIVATION/ DRIVE VP MEMORY/ LEARNING Amyg Circuits Involved In Drug Abuse and Addiction

34. REWARD NAcc VP • Reward Circuit Drugs of Abuse Engage Systems in the Motivation Pathways of the Brain

35. Hipp MEMORY/ LEARNING Amyg 2. Memory circuit “People, Places and Things…”

36. Cocaine Craving: Population (Cocaine Users, Controls) x Film (cocaine ) Cingulate Ant Cing Signal Intensity (AU) Cocaine Film IFG Controls Cocaine Users Garavan et al A .J. Psych 2000

37. Cocaine Craving: Population (Cocaine Users, Controls) x Film (cocaine, erotic) Cingulate Ant Cing Signal Intensity (AU) IFG Controls Cocaine Users Garavan et al A .J. Psych 2000

38. 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

39. EXECUTIVE FUNCTION PFC ACG INHIBITORY CONTROL OFC SCC MOTIVATION/ DRIVE • Motivation & Executive • Control Circuits Dopamine is also associated with motivation and executive function via regulation of frontal activity.

40. The fine balance in connections that normally exists between brain areas active in reward, motivation, learning and memory, and inhibitory control Hipp NAcc VP Amyg EXECUTIVE FUNCTION PFC ACG INHIBITORY CONTROL OFC REWARD SCC MOTIVATION/ DRIVE MEMORY/ LEARNING Becomes severely disrupted in ADDICTION

41. Non-Addicted Brain Control STOP Saliency Drive Cycloserine Memory Treatments for Relapse Prevention: Medications Vaccines Enzymatic degradation Naltrexone DA D3 antagonists CB1 antagonists AddictedBrain Interfere with drug’s reinforcing effects Control Biofeedback Modafinil Bupropion Stimulants Executive function/ Inhibitory control GO Adenosine A2 antagonists DA D3 antagonists Strengthen prefrontal- striatal communication Drive Saliency Interfere with conditioned memories Antiepileptic GVG N-acetylcysteine Memory Teach new memories Counteract stress responses that lead to relapse CRF antagonists Orexin antagonists

42. Non-Addicted Brain Control STOP Saliency Drive Memory Treatments for Relapse Prevention: Psychotherapies AddictedBrain Interfere with drug’s reinforcing effects Contingency Management Control Executive function/ Inhibitory control Cognitive Therapy GO Strengthen prefrontal- striatal communication Drive Saliency Motivation Therapies Interfere with conditioned memories Biofeedback Desensitization Memory Behavioral Therapies Teach new memories Counteract stress responses that lead to relapse Relaxation Behavioral therapies

43. 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.

44. Outcomes can be improved by: • Developing interventions that are highly effective as delivered • , or • Implementing an effective intervention more widely.

45. Information Dissemination

46. 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.

47. Access and Engagement Organization Structure and Climate Intervention External Environment (stigma, financing) Provider knowledge and behavior Developing an intervention is only one part of translating research into practice.

48. Methadone Maintenance Dosing Improved, but standards often not met 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

49. Low Uptake of Pharmacotherapy in Specialty Programs (2007) Knudsen et al, 2011, J Addict Med; 5:21-27 49

50. Adoption is a Process Early Majority=34% Late Majority=34% Early Adopters=13.5% Laggards=16% Innovators=2.5% x-2sd x-sd x x+sd Rogers (2005)