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 Portfolio15

39. Other SRB Research Informs Moving Intervention into Practice16

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