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Making the Link between Science Making the Link between Science and Practice: Doing It Welland Practice: Doing It WellDrug Abuse Prevention and Drug Abuse Prevention and TreatmentTreatment
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
Take Home PointsTake 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
Take Home PointsTake 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
The Drug Abuse Prevention StoryThe Drug Abuse Prevention Story
4
The 1990sThe 1990s
History of Prevention Research in the History of Prevention Research in the
United States—Part 1United States—Part 1 Prior to 1974—mostly intuitive-based
approaches, e.g., information dissemination, affective education and alternative programming
1974—Establishment of the National Institute on Drug Abuse and a national program to study the drug abuse problem
History of Prevention Research in the History of Prevention Research in the United States—Part 2United States—Part 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 Control—smoking prevention– Cardiovascular—community studies on smoking
prevention and health promotion
Principles vs. ProgramsPrinciples vs. Programs
8
Terminology in Prevention Terminology in Prevention Late 1990s to 2005:
– Science-based--strategies and approaches have a basis in behavioral, cognitive or biological science
– Research-based—strategies and approaches have been researched/studied
Early 2000s to now:– Evidence-based—strategies and approaches have
evidence of effectiveness through research– Principles of prevention—components or elements
or strategies that have been found consistently in effective prevention approaches
– Principles of effectiveness—criteria used to determine how strong is the evidence of effectiveness
9
Progress?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
Principles of Prevention (National Institute Principles of Prevention (National Institute on Drug Abuse—1997; rev. 2003)on Drug Abuse—1997; 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 ethnicity12
Principles of Prevention--Principles of Prevention--PlanningPlanning
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
Principles of Prevention--Principles of Prevention--DeliveryDeliveryAdapting 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,
Prevention Programs—Prevention Programs—Composed of…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
Prevention Program Definitions Prevention Program Definitions Using the Concept of RiskUsing the Concept of RiskUNIVERSAL programs reach the
general populationSELECTIVE 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
Classroom Classroom Curriculum—Universal/Selected Curriculum—Universal/Selected ProgramsPrograms
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 years—middle school and high
school Examples of Programs:
– Life Skills Training--Botvin– Project Alert--Ellickson– Project STAR--Pentz
Classroom Curriculum—Indicated Classroom Curriculum—Indicated ProgramsPrograms
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 Youth—Eggert– Project Towards No Drug Abuse—Sussman– Project SUCCESS--Morehouse
Universal Selected Indicated
Individual
Family
Peers
Community
Home
Community
School
ClinicalMedia
Other
SETTING
TARG
ET
TYPE
2121stst Century--Incorporation of Century--Incorporation of Evidence-Based ConceptEvidence-Based Concept
20
Evidence-Based Concepts—Not Evidence-Based Concepts—Not StandardizedStandardized
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
Society for Prevention Research: Society for Prevention Research: Standards of EvidenceStandards of Evidence
Criteria for EfficacyCriteria for EffectivenessCriteria for DisseminationAvailable at:
– http://www.preventionresearch.org/StandardsofEvidencebook.pdf
– Flay et al., Standards of evidence: criteria for efficacy, effectiveness and dissemination. (2005). Prevention Science, 6(3), 151-178.
22
Center for Substance Abuse Prevention: Identifying Center for Substance Abuse Prevention: Identifying and Selecting Evidence-Based Interventionsand 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: http://download.ncadi.samhsa.gov/csap/SMA09-4205/evidence_based.pdf
23
““Lists of Evidence-Based Drug Lists of Evidence-Based Drug Abuse Prevention Interventions”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 Practices—U.S. Substance Abuse and Mental Health Services Administration (available in 1998-1999)
Blueprints for Violence Prevention—University of Colorado (U.S. Department of Juvenile Justice and Delinquency Prevention)
Different criteria and programs listed
24
INSTITUTE OF MEDICINE COMMITTEESINSTITUTE 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)
Federal Funding for School-Based Federal Funding for School-Based Prevention ProgrammingPrevention 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
Real World--StudiesReal 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
Real World--StudiesReal 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 7th 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 7th grade with increases to 80% when students were in the 11th grade (Sloboda et al., 2008)
28
Evaluating Existing Prevention Evaluating Existing Prevention Programming—1990s Programming—1990s
D.A.R.E. (1990s)– These studies showed short-term outcomes that
weren’t 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
Evaluating Communities That Care Evaluating Communities That Care Model-2000sModel-2000s
CTC: The Community Youth CTC: The Community Youth Development StudyDevelopment Study
24 Communities; ~45,000 participantsFagan, Hawkins & Catalano, 2007; Quinby et al, 2007
Creating Communities
That Care
Get Started
Implement andEvaluate
Get Organized
Develop a Profile
Create a Plan
24 Communities; ~45,000 participants
Pre-post change in risk factors prioritized Pre-post change in risk factors prioritized and targeted in CTC Communitiesand targeted in CTC Communities
-0.20
-0.15
-0.10
-0.05
0.00
0.05
0.10
0.15
0.20
0.25
Control Communities CTC Communities
Ave
rage
Lev
el o
f R
isk
0
.25
-.15Grade 5 Grade 7
Triple P (Positive Parental Program)Triple P (Positive Parental Program)
Drug Abuse TreatmentDrug Abuse Treatment
34
The 1990s—Summary of findings The 1990s—Summary of findings from two decades of research from two decades of research
Counseling Pharma-cotherapy
CommunityHospital
Jail
SETTING
TYPE
PHASEDetoxification
“Treatment”
Aftercare
Services*
Findings from Controlled StudiesFindings from Controlled Studies
Scientifically Based Approaches to Scientifically Based Approaches to TreatmentTreatment
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
Findings from Controlled StudiesFindings from Controlled Studiesand Evaluations of Ongoing Treatmentand Evaluations of Ongoing Treatment
Treatment variables associated with better Treatment variables associated with better
outcome from rehabilitation includedoutcome from rehabilitation included:: staying longer in/ being more compliant with
treatment—especially 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 medications—both for psychiatric conditions and anticraving medications; and
participating in AA or NA following treatment
Other Findings from Evaluations of Other Findings from Evaluations of Ongoing “Real World” TreatmentOngoing “Real World” TreatmentTreatment 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.
Other Findings from Evaluations of Other Findings from Evaluations of Ongoing “Real World” TreatmentOngoing “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 lowRelapse rates after treatment are
unacceptably high
Principles of Effective Treatment—(National Principles of Effective Treatment—(National Institute on Drug Abuse--1999)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
Principles of Effective TreatmentPrinciples 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
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
2121stst Century Incorporation of Century Incorporation of Evidence-Based ConceptEvidence-Based Concept
What Are Evidence-Based Practices?What Are Evidence-Based Practices?
Interventions that show consistent Interventions that show consistent scientific evidence of being related to scientific evidence of being related to preferred client outcomes.preferred client outcomes.
How Are Evidence-Based Practices How Are Evidence-Based Practices Documented?Documented?Gold Standard
• Multiple randomized clinical trialsSecond 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)
National Quality ForumNational Quality ForumEvidence 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
Lists--ExamplesLists--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
Evidence-Based Practices for Alcohol Evidence-Based Practices for Alcohol TreatmentTreatment
Brief interventionSocial skills trainingMotivational enhancementCommunity reinforcementBehavioral 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. (2nd ed., pp 12 – 44). Boston: Allyn & Bacon.
Scientifically-Based Approaches Scientifically-Based Approaches to Addiction Treatmentto 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
SufficientSufficientRetentionRetentionSufficientSufficientRetentionRetention
Early Early EngagementEngagement
Early Early RecoveryRecovery
PosttreatmentPosttreatment
DrugDrugUseUse
DrugDrugUseUse
CrimeCrimeCrimeCrime
SocialSocialRelationsRelations
SocialSocialRelationsRelations
ProgramProgramParticipationParticipation
TherapeuticTherapeuticRelationshipRelationship
BehavioralBehavioralChangeChange
Psycho-SocialPsycho-SocialChangeChange
PatientPatientAttributesAttributesat Intakeat Intake
PatientPatientAttributesAttributesat Intakeat Intake
MotivMotiv
Evidence-Based Treatment ModelEvidence-Based Treatment Model
EnhancedEnhancedCounselingCounseling
BehavioralBehavioralStrategiesStrategies
Social SkillsSocial SkillsTrainingTraining
Family &Family &FriendsFriends
SupportiveSupportiveNetworksNetworks
SupportiveSupportiveNetworksNetworks
InductionInduction Personal Health ServicesPersonal Health Services
Social Support ServicesSocial Support Services
ProgramProgramCharacteristicsCharacteristics
ProgramProgramCharacteristicsCharacteristics
StaffStaffAttributesAttributes
& Skills& Skills
StaffStaffAttributesAttributes
& Skills& Skills
Simpson, 2001 (Addiction)
Real WorldReal WorldRecent studies (D’Anno & Pollack,
2002; D’Anno 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
However, there still remains…However, there still remains…
Treatment Need—2007Treatment Need—2007U.S. National Survey on Drug Use and HealthU.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
Treatment availabilityTreatment availability
1990 2002Number 16,000 14,000Residential/Inpatient 55% 14%Outpatient/Drug Free 30% 78% Methadone Maintenance 15% 12%
Source: McLellan et al., 2003
FundingFunding
Federal health care, e.g., medicaid, medicare
Carve-outs in third party insurance
Responses of “Feeling the need Responses of “Feeling the need for treatment”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
Common IssuesCommon 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
Issues Specific to PreventionIssues 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
Pe
r
c
e
n
t
PERCENT DOLLAR CHANGE OVER PERCENT DOLLAR CHANGE OVER TIMETIME
INTERDICTION = 100.2%INTERNATIONAL= 48.4DOMESTIC LAW
ENFORCEMENT = 31.2TREATMENT = 22.2 PREVENTION = -24.5
Year Appropriation % Change
2001 $346,000,000 n/a
2002 $374,000,000 8.09
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 $270,147,294 0.00
Safe and Drug Free Schools and Communities-- Appropriations: 2001 through 2007
Issues Specific to PreventionIssues 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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