NIDAMED released 20 April 2009!

Our Strategy Involves BLENDING and RESEARCHPRACTICE Bringing User-friendly Science-Based Technologies Into Ongoing Community Practice Bringing User-friendly Science-Based Technologies Into Ongoing Community Practice

Interagency Collaborations are indispensable Bench Bedside Community

NIDA-SAMHSA Blending Teams Motivational Interviewing Supervisory Tools Promoting Awareness of Motivational Incentives (PAMI) Treatment Planning Using the Addiction Severity Index (ASI) Short-Term Opioid Withdrawal Using Buprenorphine Buprenorphine Training for Addiction Professionals

Mainstreaming addictions is a focus of AMA’s Department of Healthy Lifestyles and Primary Prevention, including the joint NIDA/AMA -- NIDA - SBIRT Initiatives: Cooperation with AMA Primary Care Physician Outreach Project and Centers of Excellence Grants to 5 Universities to embed addiction/SBIRT in medical student and resident education

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

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)

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

9 Braiding Funding Streams Assessment and Brief Interventions in Primary Care (FY2004 with SAMHSA) NIDA Funding Research on CSAP’s National SPF-SIG Program (FY2004) Service to Science Grants for State Substance Abuse Authorities (FY2005 with SAMHSA) Screening, Brief Interventions and Referral to Treatment (SBIRT) in General Medical Settings (FY2008 with SAMHSA)

Working in “Real-World Settings” is key. Bench Bedside Community

Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) Research Centers Coordinating Center National Drug Abuse Treatment Clinical Trials Network (CTN)

NIDA - SBIRT Initiatives: Grants in 2008 in SAMHSA SBIRT Sites Roy-Byrne, Peter P Brief Intervention in Primary Care for Problem Drug Use and Abuse (SAMHSA Site/Team-Seattle)Roy-Byrne, Peter P Saitz, Richard Screening and Brief Intervention Models to Address Unhealthy Drug Use (SAMHSA Site/Team-Boston)Saitz, Richard

Improving Health Through Implementation Science Wilson M. Compton, M.D., M.P.E., Director, Division of Epidemiology, Services and Prevention Research National Institute on Drug Abuse May 2, 2009 American Society of Addiction Medicine

Outcomes can be improved by:  Developing interventions that are highly effective as delivered

BenchBedside Type 1 Translational Research

Outcomes can be improved by:  Developing interventions that are highly effective as delivered, or  Implementing an effective intervention more widely.

BedsidePractice Type 2 Translational Research

Methadone Maintenance Dosing Improved, but standards often not met Low-dose programs characterized by: –More African- American & Latino patients –More managed care (pre-authorization requirements) –Staff endorsement of abstinence orientation, and rejection of HIV prevention activities (syringe exchange) Pollack & D’Aunno (2008) Health Services Research, 43:

Slow adoption of pharmacotherapies Specialty care addiction treatment settings have been slow to adopt and implement pharmacotherapies Private sector programs should have fewer barriers to medication adoption –More physicians –More patients with insurance coverage –More hospital affiliations / medicalization Yet data from a sample of 300 programs in 2008 showed continued slow adoption, and limited prescribing to patients for whom medications were appropriate Personal Communication: Paul Roman et al., (manuscript in development)

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

Type 1Type 2 Type 2 Translation Requires a Different Science than Type 1 (with feedback linkages)

Key Concepts for Type 2 Translation Information Dissemination Adoption as a Process (Diffusion Theory) Implementation Science

24 Information Dissemination

Essential first step in Type 2 translation research – BUT Generally produces only a vague awareness that new science exists Does not address the conditions and circumstances of the numerous providers, clients and contexts involved.

Adoption is a Process xx+sdx-sdx-2sd Innovators=2.5% Early Adopters=13.5% Early Majority=34% Late Majority=34% Laggards=16% Rogers (2005)

“…the best candidate for rapid adoption would be an evidence- based treatment that was simple, was similar with previous practice, had clear advantage, could be tried out temporarily, and was readily observable.” -Henggeler, Lee, & Burns (2002) Clinical Psychology-Science and Practice

Effective Intervention Practices Effective Implementation Strategies Adoption of EBPs + Successful Implementation of EBPs Fixsen, Naoom, Blase, Friedman, & Wallace, 2005 Enhanced Patient Outcomes

A Comprehensive Approach for Evidence-Based Practice Implementation Clinical Practices Program Components Systemic Factors Financial Health Care Infrastructure Legal/Regulatory Education & Training Research & Knowledge Transfer Org Structure & Culture Patient Engagement Staffing Info & Clinical Care Systems Initial Services Engage & Sustain Therapeutic Interventions Assessment National Quality Forum (2005)

Organizational attributes Contextual factors Change process attributes Intervention attributes Client attributes Networking - cross-agency linkages and collaborations Measurement Domains

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

Outpatient Drug Treatment Programs Increasingly Engaged in HIV Services HIV testing significantly increased at every interval –More likely among programs holding more licenses, having more referral sources, and under public ownership (public funding) Outreach significantly more common in 2000 vs 1988 –More likely among programs with more referral sources, and with directors who used more ways of staying current with the field Pollack et al (2006) Journal of Substance Abuse Treatment

Everybody Wants Innovative Organizations, But…. Barriers to improved performance are typically numerous, complex, and not always evident. Change resources are always limited. Complexity Theory says you only have to improve a few things to improve a lot of things….. –This is because everything is dynamically connected to everything else in an organization (at least a little). –To introduce a single innovation usually requires changing other practices that affect it or enable it. R D Stacey (1996) Complexity and Creativity in Organizations, Berrett-Koehler, San Fransisco.

SAMHSARWJF

Plan, Do, Study, Act (PDSA) Change Cycle “Turning a Change Idea Into Action”

NIATx Outcomes Replicable and Sustainable Two cohorts of treatment programs, each using NIATx for 18 months; cohorts occurred 2 years apart. Both cohorts showed significant reductions in wait times and increases in retention at 4 th tx session Results for Cohort 1 were sustained for an additional 20 months Hoffman et al., (2008). Drug & Alcohol Dependence, 98:63-69

NIATx 200: A randomized trial of process improvement NIATx targets 4 primary outcomes: –Reduced waiting time, reduced no-show rates, increased admissions, increased continuation (from 1 st to 4 th tx session) –Focus is on improving organizational processes (e.g., intake, paperwork, scheduling)

Self-directed “change teams” of program leaders + Web-based process improvement resources Self-directed “change teams” of program leaders + Web-based process improvement resources + Intensive coaching by process improvement experts vs. NIATx 200: RCT

Conclusions Areas for Future Research: Provider Training and Support Intervention Access and Engagement Delivery Methods and Features Financing and Cost/Economic Policies Sustainability Collaborative Research

Type 2 translation (aka implementation science) requires a different set of hypotheses and methods: –Organization and management sciences –Economics –Social behaviors, etc. BOTH Types 1 and 2 translation research are essential to improving public health Conclusions: Implementation Science

National Institute on Drug Abuse Division of Epidemiology, Services and Prevention Research Promoting Extraordinary Public Health Research to Eradicate Drug Abuse