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Mainstreaming Addictions in Medicine: Update on NIDA's SBIRT

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Mainstreaming Addictions in Medicine: Update on NIDA's SBIRT Efforts in General Medical Settings. Wilson M. Compton, M.D., M.P.E. Director, Division of Epidemiology ... – PowerPoint PPT presentation

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Title: Mainstreaming Addictions in Medicine: Update on NIDA's SBIRT


1
Mainstreaming Addictions in Medicine  Update on
NIDA's SBIRT Efforts in General Medical Settings
  • Wilson M. Compton, M.D., M.P.E.
  • Director, Division of Epidemiology, Services and
    Prevention Research
  • National Institute on Drug Abuse

Advisory Council, National Institute on Drug
Abuse February 4, 2009
2
 SBIRT Efforts in General Medical Settings
  • What is SBIRT?
  • Screening
  • Brief Intervention
  • Referral to Treatment

3
US Preventive Services Task Force
(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


4
Illicit Drug SBIRT Reviews
  • 1995 USPSTF Report Review of SBIRT effectiveness
    for drugs. Insufficient evidence to recommend
    for or against
  • 2005 Review by Babor and Kadden, Journal of
    Trauma. Further work needed before routine
    screening for drug use disorders is warranted
  • 2008 USPSTF Report Update The evidence is
    insufficient to determine the benefits and harms
    of screening for illicit drug use

5
USPTF 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)

6
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7
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


8
Example Strength of Evidence for Tobacco/Smoking
  • A meta-analysis of 43 studies
  • Improvement in cessation 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


9
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, et al. 2009 SAMHSA program evaluation of
    (SBIRT) for illicit drug and alcohol use at
    multiple sites Comparison at intake and 6 months
    later

10
Brief motivational intervention reduces 6 mo.
cocaine and heroin use
Bernstein et al. Drug and Alcohol Dependence
20057749-59
  • RCT (n1175) 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

11
Brief motivational intervention reduces 6 mo.
cocaine and heroin use
  • Abstinent from Adjusted Odds Ratio
  • Cocaine 1.51 (1.01, 2.24)
    p 0.045
  • Opiates 1.57 (1.00, 2.47)
    p 0.050
  • Logistic regression model adjusted for variables
    that groups differed on at baseline (health
    insurance, homelessness)

Bernstein et al. Drug and Alcohol Dependence 2005
12
Brief motivational intervention reduces 6 mo.
cocaine and heroin use
Abstinence Among Those Screening Positive for At
Baseline
p lt .05
Bernstein et al. Drug and Alcohol Dependence 2005
13
WHO ASSIST Phase III Project
WHO ASSIST Phase III Technical Report, 2008
  • An international randomised controlled trial
    (RCT) evaluating the effectiveness of a Screening
    and Brief Intervention (SBI) for cannabis,
    stimulants opioids
  • Participants recruited from PHCs in Australia,
    Brazil, India, USA (R01 DA016592, PI T Babor )
  • Randomly allocated to intervention or waitlist
    control group at baseline with follow up three
    months later
  • Both groups administered the ASSIST and
    intervention participants received a brief
    intervention for the drug for which they scored
    the highest on the ASSIST

14
Total Illicit Substance Involvement Scores BI
and Control at Baseline and Follow-up (N628)
WHO ASSIST Phase III Technical Report, 2008
Pooled data
plt0.01
15
Cannabis Specific Substance Involvement Scores
BI and Control at Baseline and Follow-up (N328)
WHO ASSIST Phase III Technical Report, 2008
Pooled data
plt0.05
16
Stimulant Specific Substance Involvement Scores
BI and Control at Baseline and Follow-up (N229)
WHO ASSIST Phase III Technical Report, 2008
Pooled data
plt0.005
17
Opioid Specific Substance Involvement Scores BI
and Control at Baseline and Follow-up (N73)
WHO ASSIST Phase III Technical Report, 2008
Pooled data
plt0.07
18
SAMHSA Demonstration Program for
SBIRT Comparison of intake and 6 month follow up
Madras, et al. Drug and Alcohol Dependence 99
(2009) 280295
  • Federally SBIRT programs in six states across a
    range of medical settings
  • Emergency/trauma departments, primary care
    centers, hospital inpatient/outpatient settings
  • Patients screened and offered interventions
  • Brief intervention, brief treatment, referral to
    specialty treatment
  • Six months follow-up on those screening positive
    at baseline

19
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 lt 0.001

Madras, et al. Drug Alcohol Dependence, 2009
20
Strength of Evidence about SBIRT for Illicit
Drugs
  • Promising - but sparse results

21
NIDA - SBIRT Initiatives
  • NIDA has supported initiatives for SBIRT in
    Primary Care and Mainstreaming of Addiction
    Treatment since initial findings of USPSTF
  • RFA in 2004 for Screening and MI in adolescents
    (with SAMHSA)
  • Findings showing effectiveness of MI, computer
    platforms and EMRs in adolescent general medical
    settings

22
NIDA - SBIRT Initiatives RFA-08-021 (SBIRT) for
Illicit Drug Abuse in General Medical Settings
  • RFA in 2008 Screening, Brief Intervention and
    Referral to Treatment (SBIRT) for Illicit Drug
    Abuse in General Medical Settings (R01
    only) RFA-DA-08-021 (R01)
  • Over 30 applications received
  • 4 Funded Grants
  • Well designed RCTs in various general medical
    settings, testing effectiveness of various SBIRT
    models

23
NIDA - SBIRT Initiatives RFA-08-021 SBIRT for
Illicit Drugs 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 (SAMHSA
    Site/Team)
  • Svikis, Dace S Computer vs Therapist-Delivered
    Brief Intervention for Drug Abuse in Primary Care

24
NIDA - SBIRT Initiatives Other FY2008 Grants
  • Saitz, Richard Screening and Brief Intervention
    Models to Address Unhealthy Drug Use (SAMHSA
    Site/Team)
  • Gelberg, Lillian Preventing Drug Use in Low
    Income Clinic Populations

25
NIDA - SBIRT Initiatives Small Business
Innovation Research (SBIR) and Technology
Transfer (STTR) Programs at NIDA
  • SBIR Grants to address RT problem
  • Computer and web based patient referral systems,
    to reduce one of main objections to screening,
    i.e. time consuming and difficult to place
    patients in specialty care by general medical
    office
  • One study underway and one pending funding

26
NIDA - SBIRT Initiatives Publications
development
  • Screening and Brief Intervention for Drug Use
    in Primary Care Settings A Resource Guide for
    Providers

27
NIDA Screening Resource Guide
  • Targets adult primary care with a key goal of
    increasing screening for illicit drug abuse
  • Provides a clinician-friendly guide to support
    screening and brief intervention
  • Strengthens clinicians ability to discuss
    screening results with patients

28
NIDA Screening Resource Guide
  • Brief, graphical introduction to screening and
    brief intervention steps for primary care
    providers
  • Will be on the NIDA website
  • Based on the WHO ASSIST (Alcohol, Smoking, and
    Substance Involvement Screening Test)

29

NIDA Screening Resource Guide
Under Development Target date for distribution
early spring/summer 2009 NIDA Guide anticipated
to have similar feel as the NIAAA Guide which
is familiar to general medical clinicians to
facilitate adoption
30
NIAAA Website/Guide
31
Screening and Brief Intervention (SBI) For Drug
Use in Primary Care Settings Resource Guide for
Providers
Introduction Before You Begin Screening and brief
intervention for drug use Step 1 Ask about drug
use Step 2 Screen for substance use
disorders Step 3 Discuss results conduct brief
intervention Step 4 Offer continuing care at
follow-up visits Appendices Support
Materials Frequently Asked Questions
Glossary of Terms
Download PDF Version
32
NIDA Screening Resource Guide
  • A user-friendly quick guide targeted to medical
    providers, especially physicians
  • Developed by NIDA staff
  • Peer reviewed by 8 university-based experts
  • Reviewed in collaboration with representatives
    from WHO, ONDCP, SAMHSA, CDC and NIAAA

33
NIDA Screening Resource Guide
Like the NIAAA guide, will primarily be laid-out
as a flow-chart, which is familiar to general
medical clinicians and is easy to use in a
fast-paced clinical environment
34
NIDA Screening Resource Pocket Guide
NIDA will also offer a Pocket Guide to facilitate
implementation
35
NIDA Screening Resource Pocket Guide
  • The Pocket Guide will share the same step-by-step
    format and supporting material

36
NIDA - SBIRT Initiatives Cooperative actions
with other public health agencies
  • Workshop on SBIRT for prescription drug abuse,
    2008 (with ONDCP and Health Canada)
  • Support Meeting and Workshops for American
    Medical Education and Research on Substance Abuse
    (AMERSA), (with SAMHSA and NIAAA)
  • Conference on SBIRT, 2007 (with SAMHSA, ONDCP)

37
NIDA - SBIRT Initiatives Cooperative
actions with WHO
  • NIDA participates in the international WHO ASSIST
    project (WHO Lead Vladimir Pozniak Program
    Director Robert Ali), part of a key policy for
    the WHO Department of Mental Health and Substance
    Dependence --

To integrate mental health and substance
dependence care into general health care
38
NIDA - SBIRT Initiatives Cooperative actions
with AMA
  • Mainstreaming addictions is a focus of AMAs
    Department of Healthy Lifestyles and Primary
    Prevention, including the joint NIDA/AMA --
  • Primary Care Physician Outreach Project and
    Centers of Excellence Grants to 5 Universities to
    embed addiction and SBIRT concepts in medical
    student and resident education

39
NIDA - SBIRT Initiatives Cooperative actions
with other Public Health Agencies
  • Substance Use Disorders CPT Codes Approved 2008,
    with reimbursement now in 13 state Medicare and
    Medicaid programs, and 71 commercial carriers
    (and counting)

40
Future SBIRT Research
  • Enhance evidence base regarding effectiveness in
    a variety of medical (and related) settings
  • SBI for prescription drug abuse
  • New technologies (internet, tablet, PDA, etc.)
  • Models for referral and/or direct care in general
    medical settings (the RT of SBIRT)
  • Linking SBIRT interventions to important
    morbidity and mortality outcomes

41
 Update on NIDA's SBIRT Efforts in General
Medical Settings Summary
  • SBIRT is efficacious for alcohol and tobacco
    evidence for illicit drugs is promising but not
    yet sufficient
  • NIDA has numerous initiatives to enhance the
    evidence base in next few years, and to
    disseminate SBIRT training to medical
    professionals
  • NIDAs collaborations with other
    organizations/agencies is key to this process

42
Questions? Comments? Suggestions?
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