Mainstreaming Addictions in Medicine: Update on NIDA's SBIRT Efforts in General Medical Settings

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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, Services and
  Prevention Research
• National Institute on Drug Abuse

Advisory Council, National Institute on Drug
Abuse February 4, 2009
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 SBIRT Efforts in General Medical Settings

• What is SBIRT?
• Screening
• Brief Intervention
• Referral to Treatment

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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

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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

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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)

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ExampleStrength 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

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ExampleStrength 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

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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

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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

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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
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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
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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

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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
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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
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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
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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
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SAMHSA Demonstration Program for
SBIRTComparison 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

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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
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Strength of Evidence about SBIRT for Illicit
Drugs

• Promising - but sparse results

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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

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NIDA - SBIRT InitiativesRFA-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

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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

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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

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NIDA - SBIRT InitiativesSmall 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

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NIDA - SBIRT Initiatives Publications
development

• Screening and Brief Intervention for Drug Use
  in Primary Care Settings A Resource Guide for
  Providers

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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

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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)

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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
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NIAAA Website/Guide
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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
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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

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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
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NIDA Screening Resource Pocket Guide
NIDA will also offer a Pocket Guide to facilitate
implementation
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NIDA Screening Resource Pocket Guide

• The Pocket Guide will share the same step-by-step
  format and supporting material

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NIDA - SBIRT InitiativesCooperative 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)

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NIDA - SBIRT InitiativesCooperative
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
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NIDA - SBIRT InitiativesCooperative 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

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NIDA - SBIRT InitiativesCooperative 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)

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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

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 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

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Questions?Comments?Suggestions?