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Making the Link between Science and Practice: Doing It Well Drug Abuse Prevention and Treatment Zili Sloboda, Sc.D., Senior Research Associate Institute.

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Presentation on theme: "Making the Link between Science and Practice: Doing It Well Drug Abuse Prevention and Treatment Zili Sloboda, Sc.D., Senior Research Associate Institute."— Presentation transcript:

1 Making the Link between Science and Practice: Doing It Well Drug Abuse Prevention and Treatment Zili Sloboda, Sc.D., Senior Research Associate Institute for Health and Social Policy The University of Akron Akron, Ohio, USA Identifying Europe´s Information Needs For Effective Drug Policy Lisbon, 6-8 May 2009 1

2 Take Home Points The concept of evidence-based interventions and practice is new. Funding, particularly for drug abuse prevention, is tied to the delivery of evidence-based interventions Although funding is based on the delivery of evidence- based interventions, the vast majority of interventions being delivered in the United States are NOT considered evidence-based 2

3 Take Home Points There are many issues that have yet to be addressed including: –Definitions and criteria for determining what is evidence-based –Whether the focus is on evidence-based practices or programs –Locally vs. research-developed interventions –Many gaps in our knowledge-base regarding interventions –There is no infrastructure in place to support and sustain evidence-based prevention practices and/or programs. –Issues of funding, organization, and management of services

4 The Drug Abuse Prevention Story 4

5 The 1990s

6 History of Prevention Research in the United StatesPart 1 Prior to 1974mostly intuitive-based approaches, e.g., information dissemination, affective education and alternative programming 1974Establishment of the National Institute on Drug Abuse and a national program to study the drug abuse problem

7 History of Prevention Research in the United StatesPart 2 Through NIDA –Establishment of longitudinal studies of adolescents –Support of national household and school surveys on drug abuse –Support of research on model prevention programs Through other NIH research programs –Cancer Controlsmoking prevention –Cardiovascularcommunity studies on smoking prevention and health promotion

8 Principles vs. Programs 8

9 Terminology in Prevention Late 1990s to 2005: –Science-based--strategies and approaches have a basis in behavioral, cognitive or biological science –Research-basedstrategies and approaches have been researched/studied Early 2000s to now: –Evidence-basedstrategies and approaches have evidence of effectiveness through research –Principles of preventioncomponents or elements or strategies that have been found consistently in effective prevention approaches –Principles of effectivenesscriteria used to determine how strong is the evidence of effectiveness 9

10 Progress? Principles of prevention developed in 1997 by the National Institute on Drug Abuse: Preventing Drug Abuse Among Children and Adolescents Principles of effectiveness developed in 1998 by the U.S. Department of Education for school-based interventions Principles of effectiveness developed in 1998 by the White House Office of National Drug Control Policy 10


12 Principles of Prevention (National Institute on Drug Abuse1997; rev. 2003) Risk Factors and Protective Factors –Prevention programs should enhance protective factors and reverse risk factors –Prevention programs should address all forms of drug abuse, alone or in combination, including underage use of tobacco and alcohol, use of illegal drugs and inappropriate use of legally obtained substances –Prevention programs should address the type of drug abuse problem in the local community –Prevention programs should be tailored to address risks specific to population or audience characteristics, such as age, gender, and ethnicity 12

13 Principles of Prevention-- Planning Family programs: enhance family bonding and relationships and include parenting skills. School Programs: –intervene early as preschool to address risk factors such as aggressive behavior, poor social skills and academic difficult, –interventions for children of all ages should target academic and social emotional risk factors. Community Programs –focus on transitions, –combine two or more effective programs –Reach populations in multiple settings

14 Principles of Prevention-- Delivery Adapting programs to meet community needs but retain core elements of original intervention, Interventions should be long-term with repeated interventions, Include training on group management skills, Interventions should include age- appropriate learning strategies,

15 Prevention Programs Composed of… Integration of principles or key elements of prevention Developmentally and culturally relevant messaging Appropriate instructional strategies when relevant (e.g., media messages, school-based curriculum) 15

16 Prevention Program Definitions Using the Concept of Risk UNIVERSAL programs reach the general population SELECTIVE programs target groups at risk or subsets of the general population (e.g., children of drug users or poor school achievers) INDICATED programs are designed for groups who are already using substances or who exhibit other risk- related behaviors

17 Classroom Curriculum Universal/Selected Programs Common elements: –Dispel misconceptions regarding normative nature of substance use and expectancies –Impact perceptions of risks associated with substance use as children and adolescents –Provide resistance skills to refuse use of tobacco, alcohol and illicit drugs –Provided over multiple yearsmiddle school and high school Examples of Programs: –Life Skills Training--Botvin –Project Alert--Ellickson –Project STAR--Pentz

18 Classroom CurriculumIndicated Programs Common Elements or Principles: –Identify students at high risk for substance abuse or other associated behavior –Provide self-control, communications and decision- making skills –Self-esteem/competency enhancement –Create positive peer support Examples of Programs: –Reconnecting YouthEggert –Project Towards No Drug AbuseSussman –Project SUCCESS--Morehouse

19 UniversalSelected Indicated Individual Family Peers Community Home Community School Clinical Media Other SETTING TARGET TYPE

20 21 st Century--Incorporation of Evidence-Based Concept 20

21 Evidence-Based ConceptsNot Standardized Criteria developed in 2005 by the Society for Prevention Research: Standards of Evidence Criteria developed in 2009 by the Center for Substance Abuse Prevention: Identifying and Selecting Evidence-Based Interventions 21

22 Society for Prevention Research: Standards of Evidence Criteria for Efficacy Criteria for Effectiveness Criteria for Dissemination Available at: – Evidencebook.pdf Evidencebook.pdf –Flay et al., Standards of evidence: criteria for efficacy, effectiveness and dissemination. (2005). Prevention Science, 6(3), 151-178. 22

23 Center for Substance Abuse Prevention: Identifying and Selecting Evidence-Based Interventions Federal registries of evidence-based interventions Reported (with positive effects on the primary targeted outcome) in peer-reviewed journals Documented effectiveness supported by other sources of information, meeting all of the following guidelines –theory-based –similar in content and structure to interventions on registries –supported by documentation that it has been effectively implemented in the past and multiple times –deemed acceptable by a team of experts. Available: 4205/evidence_based.pdf 23

24 Lists of Evidence-Based Drug Abuse Prevention Interventions Exemplary and Promising Programs--U.S. Department of Education: Safe and Drug Free Schools and Communities (available in 1998) National Registry of Evidence-Based Programs and PracticesU.S. Substance Abuse and Mental Health Services Administration (available in 1998-1999) Blueprints for Violence PreventionUniversity of Colorado (U.S. Department of Juvenile Justice and Delinquency Prevention) Different criteria and programs listed 24

25 INSTITUTE OF MEDICINE COMMITTEES Understanding and Preventing Violence (1993 ) Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research (1994) Reducing Underage Drinking--a Collective Responsibility (2003) Ending the Tobacco Problem: A Blueprint for the Nation (2007)

26 Federal Funding for School-Based Prevention Programming U.S. Department of Education (Safe and Drug Free Schools and Community Grants) –1998 Principles of Effectiveness –2001 No Child Left Behind Substance Abuse and Mental Health Services Administration (Block Grants) 26

27 Real World--Studies In 2002; it was found that only 19% of school districts across the country were implementing a research-based curriculum with fidelity (Hallfors and Godette ; 2002) In 2005, 42.6% of middle schools (grades 5-8; ages 11-14) used an evidence-based program; up 8% from 34.4% in 1999 (Ringwalt et al; 2009) In 2005, 10.3% of high schools (grades 9-12; ages 15-18) used evidence-based programs (Ringwalt et al;, 2008) 27

28 Real World--Studies Over the period of 2001 through 2006, in a sample of 103 middle and high schools, 36.5% of schools offered a named program in the 7 th grade dropping to 10% in high school In addition, many substance use non-evidence – based prevention activities were made available to students including in class lessons, assemblies, and group activities: 49.2% of schools offered these activities in 7 th grade with increases to 80% when students were in the 11 th grade (Sloboda et al., 2008) 28

29 Evaluating Existing Prevention Programming1990s D.A.R.E. (1990s) –These studies showed short-term outcomes that werent sustained over time –But most of these studies were of curricula targeting children when they were about 12 years old without reinforcing boosters for the at risk years Community coalitions –Initial evaluations showed a variety of prevention programming –Evaluations were made at the population level while interventions were at individual, family or school level

30 Evaluating Communities That Care Model-2000s

31 CTC: The Community Youth Development Study 24 Communities; ~45,000 participants Fagan, Hawkins & Catalano, 2007; Quinby et al, 2007 Creating Communities That Care Get Started Implement and Evaluate Get Organized Develop a Profile Create a Plan 24 Communities; ~45,000 participants

32 Pre-post change in risk factors prioritized and targeted in CTC Communities Average Level of Risk 0.25 -.15 Grade 5 Grade 7

33 Triple P (Positive Parental Program)

34 Drug Abuse Treatment 34

35 The 1990sSummary of findings from two decades of research

36 CounselingPharma- cotherapy Community Hospital Jail SETTING TYPE PHASE Detoxification Treatment Aftercare Services*

37 Findings from Controlled Studies

38 Scientifically Based Approaches to Treatment Relapse Prevention Supportive-expressive Psychotherapy Individualized Drug Counseling Motivational Enhancement Therapy Multidimensional Family Therapy Behavioral Therapy Multisystemic Therapy Combined Behavioral and Nicotine Replacement Therapy Community Reinforcement Approach Plus Vouchers Voucher-Based Reinforcement Therapy in MM Treatment Day Treatment with Abstinence Contingencies and Vouchers The Matrix Model

39 Findings from Controlled Studies and Evaluations of Ongoing Treatment

40 Treatment variables associated with better outcome from rehabilitation included : staying longer in/ being more compliant with treatmentespecially through behavioral contracting for positive reinforcement; having an individual counselor or therapist; having specialized services provided for associated medical, psychiatric, and/or family problem; receiving proper medicationsboth for psychiatric conditions and anticraving medications; and participating in AA or NA following treatment

41 Other Findings from Evaluations of Ongoing Real World Treatment Treatment programs have not adopted useful research findings into clinical practice (e.g., minimal use of methadone and naltrexone, contingency management) Morale of staff in treatment programs is too low Services provided have been reduced over time.

42 Other Findings from Evaluations of Ongoing Real World Treatment Too few drug abusers attracted to treatment Rates of illicit drug use by clients in treatment are unacceptably high Clients are not clinically matched with treatment programs, e.g., psychiatric severity Treatment retention rates are too low Relapse rates after treatment are unacceptably high


44 Principles of Effective Treatment(National Institute on Drug Abuse--1999) 1. No single treatment is appropriate for all 2. Treatment needs to be readily available 3. Effective treatment attends to the multiple needs of the individual 4. Treatment plans must be assessed and modified continually to meet changing needs 5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness

45 Principles of Effective Treatment 6. Counseling and other behavioral therapies are critical components of effective treatment 7. Medications are an important element of treatment for many patients 8. Co-existing disorders should be treated in an integrated way 9. Medical detoxification is only the first stage of treatment 10. Treatment does not need to be voluntary to be effective

46 11. Possible drug use during treatment must be monitored continuously 12. Treatment programs should assess for HIV/AIDS, Hepatitis B & C, Tuberculosis and other infectious diseases and help clients modify at-risk behaviors 13. Recovery can be a long-term process and frequently requires multiple episodes of treatment - NIDA (1999) Principles of Drug Addiction Treatment Principles of Effective Treatment

47 21 st Century Incorporation of Evidence-Based Concept

48 What Are Evidence-Based Practices? Interventions that show consistent scientific evidence of being related to preferred client outcomes.

49 How Are Evidence-Based Practices Documented? Gold Standard Multiple randomized clinical trials Second Tier Consensus reviews of available science Third Tier Expert opinion based on clinical observation (Drake, et al. 2001. Implementing evidence based practices in routine mental health service settings. Psychiatric Services, 52, 179 – 182)

50 National Quality Forum Evidence of Effectiveness: –Research studies (syntheses) showing a direct connection between practice and improved clinical outcomes –Experiential data showing the practice is obviously beneficial or self-evident or organization or program data linking the practice to improved outcomes –Research findings or experiential data from other healthcare or non-healthcare settings that should be transferable to substance use treatment. 50

51 Lists--Examples National Institute on Drug Abuse –Clinical Trials Network Substance and Mental Health Services Administration –National Registry of Effective Programs and Practices –CSAT Inventory of Effective Substance Abuse Treatment Practices –CSAT Networks National Institutes of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction

52 Evidence-Based Practices for Alcohol Treatment Brief intervention Social skills training Motivational enhancement Community reinforcement Behavioral contracting Miller et al., (1995) What works: A methodological analysis of the alcohol treatment outcome literature. In R. K. Hester & W. R. Miller (eds.) Handbook of Alcoholism Treatment Approaches: Effective Alternatives. (2 nd ed., pp 12 – 44). Boston: Allyn & Bacon.

53 Scientifically-Based Approaches to Addiction Treatment Cognitive–behavioral interventions Community reinforcement Motivational enhancement therapy 12-step facilitation Contingency management Pharmacological therapies Systems treatment 1. Principles of Drug Addiction Treatment: A research-based guide (1999). National Institute on Drug Abuse

54 SufficientRetentionSufficientRetention EarlyEngagementEarlyRecovery Posttreatment DrugUseDrugUse CrimeCrime SocialRelationsSocialRelations ProgramParticipationProgramParticipation TherapeuticRelationshipTherapeuticRelationship BehavioralChangeBehavioralChange Psycho-SocialChangePsycho-SocialChange PatientAttributes at Intake PatientAttributes Motiv Evidence-Based Treatment Model EnhancedCounseling BehavioralStrategies Social Skills Training Family & Friends SupportiveNetworksSupportiveNetworks Induction Personal Health Services Social Support Services ProgramCharacteristicsProgramCharacteristicsStaffAttributes & Skills StaffAttributes Simpson, 2001 (Addiction)

55 Real World Recent studies (DAnno & Pollack, 2002; DAnno et al., 1999; Friedman et al., 2003) are showing indications of improved service delivery Concerted efforts on the parts of federal and state agencies and professional groups to enhance treatment services through training, organizational structuring, funding requirements


57 However, there still remains…

58 Treatment Need2007 U.S. National Survey on Drug Use and Health 19.9 Million Were Current (Past Month) Users of an Illicit Drug –19.9%-marijuana –14.4%-prescription drugs –6.9%-cocaine –0.2%-heroin 7 Million Estimated to be Dependent or Abusers –57.4% -marijuana –31.5% -prescription drugs –23.3% -cocaine –3%-heroin –46%-drugs and alcohol 58

59 Treatment availability 19902002 Number 16,00014,000 Residential/Inpatient 55% 14% Outpatient/Drug Free 30% 78% Methadone Maintenance 15% 12% Source: McLellan et al., 2003

60 Funding Federal health care, e.g., medicaid, medicare Carve-outs in third party insurance

61 Responses of Feeling the need for treatment Of those who used within the past month or were considered abusers or dependent –93.6%Did NOT feel they needed treatment –4.6%Felt they needed treatment BUT did not make an effort –1.8%Felt the needed treatment AND made the effort 61

62 Common Issues Public, policy makers, other professionals including practitioners are not aware of –the availability of effective preventive and treatment interventions –the science behind prevention and treatment Lack of formal training in addiction science Drug policies driven by ideology and not sustained

63 Issues Specific to Prevention Lack of an infrastructure to support prevention programming at the community level –No clear identification or site for prevention outside of schools –D.A.R.E. comes closest with its network of D.A.R.E. trained and identified officer-instructors in local communities Erratic funding

64 PercentPercent


66 YearAppropriation% Change 2001$346,000,000n/a 2002$374,000,0008.09 2003$372,000,000-0.53 2004$349,126,742-6.15 2005$345,035,929-1.17 2006$270,147,294-21.71 2007$270,147,2940.00 Safe and Drug Free Schools and Communities-- Appropriations: 2001 through 2007

67 Issues Specific to Prevention High turnover of licensed prevention specialists Lack of a list of existing prevention programs Lack of evaluation studies of ongoing real world prevention programming

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