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NIDA Interests: Focus on Addiction Health Services

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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 Check the subtitle on this

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

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

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

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
Health Services and Economic Research on the Prevention and Treatment of Drug, Alcohol, and Tobacco Abuse (R01, R21, & R03) 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 PA (R21) PA (R03)

11 Methodology & Technology
Technology-Based Interventions to Promote Engagement in Care and Treatment Adherence for Substance Abusing Populations with HIV (R01, R34) 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.

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

13 Implementation Science
PA (R34): Building System Capacity for Implementing EBPs 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

14 Implementation Science
PA (R34): Building System Capacity for Implementing EBPs 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

15 Implementation Science
Implementation science is not intended to test interventions, but to study how to get evidence-based interventions adopted, adapted, & sustained. Our view of implementation science is NOT about effectiveness or efficacy trials

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 You can use slide 8 or this slide.

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
RFA-DA (U01): Translational Research on Interventions for Adolescents in the Legal System: TRIALS 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

20 Special Settings: Criminal Justice, Juvenile Justice, & Child Welfare
RFA-DA (U01): Translational Research on Interventions for Adolescents in the Legal System: TRIALS 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

21 Special Settings: Criminal Justice, Juvenile Justice, & Child Welfare
CJ-DATS 4/14/2017 Special Settings: Criminal Justice, Juvenile Justice, & Child Welfare Key Features of CJ-DATS-2 ( ) 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

22 Special Settings: Criminal Justice, Juvenile Justice, & Child Welfare
Key Features of CJ-DATS-2 ( ) 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

23 Special Settings: Criminal Justice, Juvenile Justice, & Child Welfare
Key Features of CJ-DATS-2 ( ) 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?

24 Key Participants/Stakeholders Intervention Opportunities
Criminal Justice System: Key Participants and Intervention Opportunities Crime victim Police FBI Judge Key Participants/Stakeholders Screening/ Referral Prosecutor Defense Attorney Defendant 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 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 Drug Abuse Dissertation Research (R36) PAR-10-020
Last receipt date: October 2012 2 years, $50k in direct costs Supports research on: Epidemiology Prevention Services Women and Sex/Gender Differences

29 Other Areas of Interest
Clinical Quality Improvement 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

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

31 Other Areas of Interest
Economics 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

32 SRB: We are here to help! Contact Us: (301) 443-6504
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 Strategies promoting diffusion, adoption & sustainability of EBP’s Effectiveness of treatment in a range of settings You can use slide 5 or this slide. Studying effects of organization/ management, economics & policies on implementation & effectiveness of EBP’s Cost, cost-benefit & cost-effectiveness 34

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 BITB CTN Developing interventions that are highly effective as delivered. DBNBR DPMC BITB CTN Implementing effective interventions more widely. CTN OSPC DESPR 37 37

38 SRB Implementation Research Portfolio

39 Other SRB Research Informs Moving Intervention into Practice

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

41 Conceptual Model of CJ-DATS 2 Implementation Research
Implementation Strategies Intervention Strategies Outcomes Systems Environment Organizational Group/Learning Supervision Individual Providers/ Consumers Implementation Outcomes Feasibility Fidelity Penetration Acceptability Sustainability Uptake Costs Service Outcomes* Efficiency Safety Effectiveness Equity Patient- centeredness Timeliness Client Outcomes Satisfaction Function Symptomatology Evidence- Based Practices * IOM Standards of Care Implementation Research Methods Source: Proctor et al., Adm Policy Ment Health 2009;36:24-34.

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

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

44 CJ-DATS-2 Structure (2008-2013)
NIDA Coordinating Center Principal Investigators Steering Committee Co-PIs (CJ Partners) SC Work Groups Data Management Core Measures Publication/Dissemination Qualitative NIDA Scientist Study 1 Work Group Study 2 Work Group Study 3 Work Group Study Management Subgroup Publications Protocol Development Qualitative Measures Outcome Measures Study Management Subgroup Publications Protocol Development Qualitative Measures Outcome Measures Study Management Subgroup Publications Protocol Development Qualitative Measures Outcome Measures

45 Implementation Science
Evidence-Based Drug Abuse Treatments Addiction Medications Psychosocial/Behavioral Therapies HIV Testing & Counseling Implementation Strategies Training Coaching/ Supervising Policy/ Regulatory Financing/ Reimbursement Incentives (Pay-For-Performance) Fidelity/ Benchmark Measures Learning Community Academic Detailing Combined Strategies (RE-AIM, CFIR, NIATx) Community Practice Settings Addiction Translational Core Mental Health Translational Core Medical Setting Translational Core Implementation Outcomes 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 Percentage of Inmates Who Filled an ART Prescription Within 60 Days of Release
100 Only a small percentage of Texas prison inmates Receiving ART while incarcerated filled an initial ART prescription within 60 days of their release 80 60 Percent 40 30% 17.7% 20 5.4% Had prescription filled within: 10 days 30 days 60 days Baillargeon J et al., JAMA 301(8): , 2009.

47 Life Course View of Addiction Refines Understanding of Recovery & Benefit Cost
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. Benefit Cost Zarkin, Dunlap, Hicks, & Mamo. (2005). Benefits & costs of methadone treatment: results from a lifetime simulation model. Health Economics, 14,

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
High turnover workforce with variable education background related to diagnosis, placement, treatment planning and referral to other services Heterogeneous needs and severity characterized by multiple problems, chronic relapse, and multiple episodes of care over several years Lack of access to or use of data at the program level to guide immediate clinical decisions, billing and program planning Missing, bad or misrepresented data that needs to be minimized and incorporated into interpretations Lack of Infrastructure that is needed to support implementation and fidelity

50 The Cost of Substance Abuse Treatment is Trivial Relative to the Costs Treatment Reduces
SBIRT models popular due to ease of implementation and low cost $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 Drug treatment courts - Bhati et al (2008) To Treat or Not To Treat: Evidence on the Prospects of Expanding Treatment to Drug-Involved Offenders. Washington, DC: Urban Institute. Health Serve Res February; 41(1): 192–213. doi: /j x.PMCID: PMC Copyright © Health Research and Education Trust The economic costs of substance abuse treatment: Updated estimates and Susan L Ettner, David Huang, Elizabeth Evans, Danielle Rose Ash, Mary Hardy, Mickel Jourabchi, and Yih-Ing Hser Benefit–Cost in the California Treatment Outcome Project: Does Substance Abuse Treatment “Pay for Itself”? Journal of Substance Abuse Treatment xx (2008) xxx–xxx cost bands for program assessment and reimbursement Michael T. French, (Ph.D.)a,b,c,d,⁎, Ioana Popovici, (Ph.D.)d, Lauren Tapsell, (B.A.)d $22,000 / year to incarcerate an adult $30,000/ child-year in foster care $70,000/year to keep a child in detention Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004 in 2009 dollars

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