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NIDA Interests: Focus on Addiction Health Services Tisha Wiley, Ph.D. Service Research Branch Division of Epidemiology, Services, and Prevention Research.

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Presentation on theme: "NIDA Interests: Focus on Addiction Health Services Tisha Wiley, Ph.D. Service Research Branch Division of Epidemiology, Services, and Prevention Research."— Presentation transcript:

1 NIDA Interests: Focus on Addiction Health Services Tisha Wiley, Ph.D. Service Research Branch Division of Epidemiology, Services, and Prevention Research National Institute on Drug Abuse August 14, 2012 CALDAR Early Career Track

2 SERVICES RESEARCH BRANCHPREVENTION RESEARCH BRANCH EPIDEMIOLOGY RESEARCH BRANCH Division of Epidemiology, Services and Prevention Research (DESPR): NIDA’s Public Health Division DESPR promotes epidemiology, services & prevention research to understand and address the range of problems related to drug abuse, in order to improve public health.

3 SERVICES RESEARCH BRANCHPREVENTION RESEARCH BRANCH EPIDEMIOLOGY RESEARCH BRANCH Division of Epidemiology, Services and Prevention Research (DESPR): NIDA’s Public Health Division DESPR promotes epidemiology, services & prevention research to understand and address the range of problems related to drug abuse, in order to improve public health.

4 Service Research Branch Mission  Support rigorous research to improve the quality of addiction treatment and recovery support services  SERVICES: Drug, alcohol, nicotine disorder services & HIV/HCV services for drug-involved individuals  DELIVERY SYSTEMS: Specialty treatment programs, general health care settings, criminal justice settings, social service agencies, etc.  QUALITY: effective services for all who need them at reasonable a cost Availability, access, appropriateness, effectiveness, safety, efficiency, cost

5 Our Research Vision NIDA’s Services Research Branch supports science that leads addiction treatment services toward the highest possible levels of quality, efficiency, & economy.

6 About NIDA’s Service Research Branch  238 Active Grants (as of August 2012)  $75m in Direct Costs  83% of funding goes to Research Project Grants  R01, R21, R03s, etc.

7 Defining service needs Refining practices for real- world use Testing service delivery models Pre- implementation research Implementation Trials Systems Overlap (e.g., child welfare) Use of technology in treatment Co- & Multi-morbidity CJ services EBP uptake Seek, Test, Treat, Retain Justice Involved Adolescents (U01) CJDATS (U01) Workforce SBIRT Primary Care Other D&I Trials Tx engagement/retention Drug use trajectories Health disparities Alternative service models PIPELINE SRB GRANT TOPICS Services Research Continuum Measures/methods

8 Selected SRB Areas of Interest Technology & Methodology Implementation, Sustainability & Outcomes of EBP’s Special Settings: Criminal Justice, Juvenile Justice, Child Welfare Healthcare Reform Impact

9 Methodology & Technology  Relevant Funding Announcements  SRB Flagship PA’s PA (R01) – 5 years, unlimited* PA (R21) – 2 years, $275k direct total PA (R03) – 2 years, $100k direct total PA (R34) – 3 years, $435 direct total  Technology/HIV PA’s PA (R01) PA (R34)

10 Methodology & Technology  Our “Flagship” PA’s  PA (R01)  Supports “developing, refining, and validating new approaches for conducting treatment and prevention services research”  Study Designs  Measurement Tools  Simulation Modeling  Quality/Performance Measures  Statistical Models Health Services and Economic Research on the Prevention and Treatment of Drug, Alcohol, and Tobacco Abuse (R01, R21, & R03)  PA (R21)  PA (R03)

11 Methodology & Technology  Use of technology to directly improve patient-level outcomes (i.e., adherence)  Capacity of HIV treatment providers and related service delivery organizations to adopt and integrate such technologies to promote HIV treatment outcomes;  Use of technology to improve the organization and delivery of HIV treatment and services. Technology-Based Interventions to Promote Engagement in Care and Treatment Adherence for Substance Abusing Populations with HIV (R01, R34)

12 Implementation Science  Relevant Funding Announcements  SRB Flagship PA’s, especially R34  RFA-DA (R21/R33) (August 22 Deadline)

13 Implementation Science  Organizational and/or systems-level interventions that may optimize access, utilization, delivery, quality, and/or cost of treatment services through the use of EPBs  Organizational and/or systems-specific adaptations to existing EBPs  Novel service delivery models to be pilot tested in preparation for larger-scale effectiveness trials PA (R34): Building System Capacity for Implementing EBPs

14 Implementation Science  Hypothesis-driven research that: Addresses systems-level implementation research questions Builds provider/funder capacity for conducting research beyond life of the grant  Designed to implement (not develop) evidence-based drug treatment or prevention practices  Ideally, projects will involve: One or more treatment or prevention settings An external agency that impacts their services (e.g., SSA, SMA) An academic partner experienced in doing NIH research PA (R34): Building System Capacity for Implementing EBPs

15 Implementation science is not intended to test interventions, how but to study how to get evidence-based interventions adopted, adapted, & sustained. Implementation Science

16 Implementation Research: Studying the Technology Transfer Process  How do we move EBP’s into everyday use?  How do we organize treatment to support EBPs?  How do we train and supervise staff to use EBPs?  How do we change business practices to value EBPs?  Client-level outcomes are NOT the focal outcome.  Research questions are about finding effective implementation strategies.

17 What are implementation strategies? Determining organization’s needs and alternative solutions STRATEGIC PLANNING Determining organization’s readiness for change READINESS ASSESSMENT Monitoring and modifying organizational processes and procedures to implement and sustain new practices (e.g., NIATx) PROCESS IMPROVEMENT Who is trained (e.g., clinical staff, correctional staff, administrative staff), on what, and required resources? TRAINING AND SUPERVISION Modifying what information is collected, how it is accessed and used to support decision-making. INFORMATION SYSTEMS How can organizational culture be changed to support the infrastructure needed to maintain new services? ORGANIZATIONAL CULTURE

18 Special Settings: Criminal Justice, Juvenile Justice, & Child Welfare  Relevant Funding Announcements  Flagship PA  TRIALS (RFA-DA ) Deadline: November 28, 2012  Relevant Funded Projects  CJ-DATS (U01, 10 Research Centers)  Seek, Test & Treat: Addressing HIV in the Criminal Justice System (R01s, 13 awards) Data Harmonization

19 Special Settings: Criminal Justice, Juvenile Justice, & Child Welfare  Purpose  Test implementation strategies and associated measures to improve the continuum of substance abuse prevention and treatment services delivered to youth under juvenile justice supervision  Structure  Multisite collaborative Agreement  Two Types of Applications  Coordinating Center  Research Center RFA-DA (U01): Translational Research on Interventions for Adolescents in the Legal System: TRIALS

20 Special Settings: Criminal Justice, Juvenile Justice, & Child Welfare  Need  Youth and adolescents in juvenile justice system at high risk and need effective drug use prevention and treatment services  Most juvenile justice systems do not provide adequate services  Opportunity  We have effective, evidence-based prevention and treatment interventions for adolescents  Involvement in the juvenile justice system provides window to intervene with drug abuse & HIV  Researchers can partner with juvenile justice agencies: Adolescent drug courts; truancy, teen, family courts Juvenile detention Juvenile probation RFA-DA (U01): Translational Research on Interventions for Adolescents in the Legal System: TRIALS

21 Special Settings: Criminal Justice, Juvenile Justice, & Child Welfare  Focus on implementation research  Transfer of evidence-based practices  Criminal justice re-entry-systems improvement  Correctional Facilities, Probation, & Parole  Test of different implementation & quality improvement strategies Key Features of CJ-DATS-2 ( )

22 Special Settings: Criminal Justice, Juvenile Justice, & Child Welfare  3 Research Protocols  10 Research Centers  62 Correctional Facilities  11 States  2 NIDA FTEs  $26.8 million over 5 years  $2.7 million from CSAT and DOJ co-funders Key Features of CJ-DATS-2 ( )

23 Special Settings: Criminal Justice, Juvenile Justice, & Child Welfare  MAT  Does strategic planning intervention + staff training improve MAT utilization?  HIV  Does a local change team improve utilization of HIV services along the continuum of care?  Assessment  Does a local change team improve the case planning process? Key Features of CJ-DATS-2 ( )

24 Criminal Justice System: Key Participants and Intervention Opportunities Crime victim Police FBI Crime victim Police FBI Judge Key Participants/Stakeholders Screening/ Referral Prosecutor Defense Attorney Defendant Jury Judge Jury Probation Officers Correctional Personnel Probation/ Parole Officers Family Community- based providers Diversion Programs Drug Courts Community Treatment TASC Drug Court Terms of Incarceration Release Conditions Drug Treatment Aftercare Housing Employment Mental Health Half-way House TASC N/A SENTENCING (Fines, Community Supervision, Incarceration) ADJUDICATION (Trial) PROSECUTION (Court, Pre-Trial Release, Jail) ENTRY (Arrest) CORRECTIONS (Probation, Jail, Prison) COMMUNITY REENTRY (Probation, Parole, Release) Intervention Opportunities

25 Healthcare Reform Impact  Relevant ACA Provisions & Environment:  Expands coverage to more than 30 million individuals, many at high risk for drug abuse  Fundamentally changes the way many drug abuse prevention and treatment services are financed  Emphasizes central role of primary care settings  Focuses on screening and prevention  Promotes use of electronic health records

26 Healthcare Reform Impact  Relevant RFA: RFA-DA (R21/R33)  Closes August 22, but still an area of interest  Research Topic Examples:  Uptake rate for insurance among those with drug use disorders and related conditions and how this is affected by outreach and types of offered coverage  Responsiveness of demand for services among the newly covered Effect on types and quantity of services sought and responses by payers  Effect on financing and cost of treatment

27 Other FOAs Time-Sensitive Drug Abuse Research (R01) PAR  “Rapidly evolving areas where opportunities for empirical study are, by their very nature, only available through expedited review and award of support.”  3 Criteria  scientific value and feasibility are clear,  rapid review and funding are required  knowledge gained from the study is time-sensitive –regular review cycle = missed opportunity

28 Other FOAs  Last receipt date: October 2012  2 years, $50k in direct costs  Supports research on:  Epidemiology  Prevention  Services  Women and Sex/Gender Differences Drug Abuse Dissertation Research (R36) PAR

29 Other Areas of Interest  Adaptive service delivery strategies to adjust level, dosage, and type of intervention in response to changing needs  Continuity of care within and across settings  Integrated addiction and other medical treatment  Performance measurement and management  Impact of IT systems and system changes Clinical Quality Improvement

30 Other Areas of Interest  Service delivery models (e.g. collaboration, co-location)  Management and human resources (e.g. recruitment, training, retention)  Business practices Services Organization and Management

31 Other Areas of Interest  Financing, e.g.  Effect of health insurance on demand for treatment  Effect of reimbursement mechanisms on supply of treatment  Economic incentives for quality improvement  Economic evaluation (CEA, CUA, CBA)  Economic efficiency Economics

32 SRB: We are here to help! Contact Us: (301) Branch Chief Redonna Chandler, Ph.D. Medication-assisted treatment, SBIRT, NIDA-MED Richard Denisco, M.D. Organization & management, implementation science Lori Ducharme, Ph.D. Economics research, performance measurement Sarah Duffy, Ph.D. HIV, vulnerable populations Dionne Jones, Ph.D. HIV prevention & adherence, child & adolescent drug treatment Shoshana Kahana, Ph.D. Science Officer for CJDATS; criminal justice research, methodology Tisha Wiley, Ph.D.

33 Unanswered Research Questions  How can HIV services be integrated across the criminal justice system?  What is the resistance?  What organizational change is needed?  What workforce is needed?  What implementation strategies work?  What will it cost and is it cost-effective?  What interventions are needed to reduce stigma associated with drug use, HIV, criminal justice involvement?

34 Potential Research Areas for Networks Innovative business practices to improve efficiency & effectiveness of treatment Effectiveness of commonly used interventions & practices Effectiveness of treatment in a range of settings Strategies promoting diffusion, adoption & sustainability of EBP’s Studying effects of organization/ management, economics & policies on implementation & effectiveness of EBP’s Cost, cost-benefit & cost-effectiveness

35 Recent Funding Initiatives  Seek, Test & Treat: Addressing HIV in the Criminal Justice System  RFA-DA (13 awards)  Seek, Test, Treat & Retain: Addressing HIV among Vulnerable Populations  RFA-DA (10 awards)  Economic Studies of Health Insurance Coverage on Drug Abuse Treatment Availability, Access, Costs and Quality  RFA-DA (2 awards)  Integration of Drug Abuse Prevention and Treatment in Primary Care Settings  RFA-DA ; Applications reviewed March 1, 2012

36 Developing an intervention is only one part of translating research into practice. Access and Engagement Provider knowledge and behavior Organization Structure and Climate External Environment (e.g., stigma, financing) INTERVENTION 36

37 Patient Outcomes can be Improved by: Developing interventions that are highly effective as delivered. DBNBR DPMC BITBCTN Implementing effective interventions more widely. CTNOSPCDESPR 37 Developing interventions that are highly effective as delivered. DBNBR DPMC BITBCTN

38 15 SRB Implementation Research Portfolio

39 Other SRB Research Informs Moving Intervention into Practice 16

40 Services Research Questions An Alternative Model for Intervention Development Services Research Questions (Type II) Efficacy Research Basic Research Large-scale Effectiveness Research Systems Research Practice Small-scale Effectiveness Research Robertson, 2002, Schematic Conceptualization of Prevention Science 17

41 Systems Environment Organizational Group/Learning Supervision Individual Providers/ Consumers Implementati on Outcomes FeasibilityFidelityPenetrationAcceptabilitySustainabilityUptakeCosts Outcomes Service Outcomes* EfficiencySafety Effectiveness Equity Patient- centeredness Timeliness Client Outcomes SatisfactionFunction Symptomatolog y * IOM Standards of Care Intervention Strategies Evidence- Based Practices Implementation Strategies Implementation Research Methods Source: Proctor et al., Adm Policy Ment Health 2009;36: Conceptual Model of CJ-DATS 2 Implementation Research

42 Drug / Alc Education Standardized SA Assessmt TC (Segregated) Case Mgmt/ TASC Tuberculosis Screening Mental Health Assessment HIV TestingHIV Tmt, Counseling PrisonJail Community Corrections Source: Taxman et al., JSAT 2007;32: and Crim Just Beh 2007;34: % Facilities Providing Service Drug Treatment Services & Health Screening in Adult CJ

43 Collaborative Behavioral Mgmt Std Parole Source: Friedmann, et al., J Exp Criminol 2009; 32: Working Alliance # Parole Sessions PO Tmt Avg Total Face- to-Face Parole & Tmt Same Day % Parole Sessions All p<.01 Step’N Out: Implementing Contingency Management

44 Steering Committee Study 3 Work Group Study 2 Work Group Study 1 Work Group Study Management Subgroup Publications Protocol Development Qualitative Measures Outcome Measures NIDA Coordinating Center SC Work Groups Data Management Core Measures Publication/Dissemination Qualitative Principal Investigators Co-PIs (CJ Partners) NIDA Scientist Study Management Subgroup Publications Protocol Development Qualitative Measures Outcome Measures Study Management Subgroup Publications Protocol Development Qualitative Measures Outcome Measures CJ-DATS-2 Structure ( )

45 Implementation Science Evidence-Based Drug Abuse Treatments Addiction Medications Psychosocial/Behavioral Therapies HIV Testing & Counseling Community Practice Settings Addiction Translational Core Mental Health Translational CoreMedical Setting Translational Core Implementation Outcomes Implementation Strategies Training Coaching/ Supervising Policy/ Regulatory Financing/ Reimbursement Incentives (Pay- For-Performance ) Learning Community Academic Detailing Combined Strategies (RE-AIM, CFIR, NIATx ) Fidelity/ Benchmark Measures Organization-Level Outcomes Acceptability Feasibility Adoption Fidelity Appropriateness Penetration Costs Sustainability Services-Level Outcomes Efficiency Safety Effectiveness Equity Patient-Centered Timeliness Patient-Level Outcomes Symptom reduction Risk reduction Functioning Satisfaction

46 Baillargeon J et al., JAMA 301(8): , Percent 5.4% 17.7% 30% days30 days60 days Only a small percentage of Texas prison inmates Receiving ART while incarcerated filled an initial ART prescription within 60 days of their release Had prescription filled within: Percentage of Inmates Who Filled an ART Prescription Within 60 Days of Release

47 Life Course View of Addiction Refines Understanding of Recovery & Benefit Cost Benefit Cost Zarkin, Dunlap, Hicks, & Mamo. (2005). Benefits & costs of methadone treatment: results from a lifetime simulation model. Health Economics, 14, Recovery Multiple treatment episodes is the norm. 27 years = Median time from first to last drug use 9 years = Median time from first treatment episode to last use Dennis, Scott, Funk, & Foss. (2005). The duration & correlates of addiction & treatment. JSAT, 28, S51-S62.

48 Programs often LACK Evidenced Based Assessment to Identify and Practices to Treat:  Substance use disorders (e.g., abuse, dependence, withdrawal), readiness for change, relapse potential and recovery environment  Common mental health disorders (e.g., conduct, attention deficit-hyperactivity, depression, anxiety, trauma, self-mutilation and suicidal thoughts)  Crime and violence (e.g., inter-personal violence, drug related crime, property crime, violent crime)  HIV risk behaviors (needle use, sexual risk, victimization)  Child maltreatment (physical, sexual, emotional)  Recovery environment and peer risk

49 Other Structural Challenges to Delivery of Quality Care in Behavioral Health Systems 1.High turnover workforce with variable education background related to diagnosis, placement, treatment planning and referral to other services 2.Heterogeneous needs and severity characterized by multiple problems, chronic relapse, and multiple episodes of care over several years 3.Lack of access to or use of data at the program level to guide immediate clinical decisions, billing and program planning 4.Missing, bad or misrepresented data that needs to be minimized and incorporated into interpretations 5.Lack of Infrastructure that is needed to support implementation and fidelity

50 Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004 in 2009 dollars The Cost of Substance Abuse Treatment is Trivial Relative to the Costs Treatment Reduces $22,000 / year to incarcerate an adult $30,000/ child-year in foster care $70,000/year to keep a child in detention $750 per night in Medical Detox $1,115 per night in hospital $13,000 per week in intensive care for premature baby $27,000 per robbery $67,000 per assault SBIRT models popular due to ease of implementation and low cost


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