NIDAMED released

20 April 2009!

www.drugabuse.gov

Our Strategy Involves BLENDINGOur Strategy Involves BLENDING

andandRESEARCHRESEARCH PRACTICEPRACTICE

Bringing User-friendly Science-Based Technologies Into Ongoing Community Practice

Bringing User-friendly Science-Based Technologies Into Ongoing Community Practice

Interagency Collaboratio

ns are indispensabl

e

Bench

Bedside

Community

NIDA-SAMHSA Blending TeamsNIDA-SAMHSA Blending Teams

Motivational Interviewing Supervisory Tools

Promoting Awareness of Motivational Incentives (PAMI)

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 Research Centers Coordinating Center Coordinating Center

National Drug AbuseTreatment 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)

• Saitz, Richard Screening and Brief Intervention Models to Address Unhealthy Drug Use (SAMHSA Site/Team-Boston)

Improving Health Through

Implementation Science

Wilson M. Compton, M.D., M.P.E., Director, Division of Epidemiology, Services and

Prevention ResearchNational 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

Bench

Bedside

Type 1 Translational Research

Outcomes can be improved by:

Developing interventions that are highly effective as delivered

, or

Implementing an effective intervention more widely.

Bedside Practice

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, 43:2143-2163

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 Environm

ent (stigma,

financing)

Type 1

Type 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

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

x x+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

EffectiveImplementation 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

ClinicalPractices

ProgramComponents

Systemic FactorsSystemic FactorsFinancial

Health CareInfrastructure

Legal/Regulatory

Education &Training

Research & KnowledgeTransfer

Org Structure& Culture

PatientEngagement

Staffing

Info &Clinical

Care Systems

Initial Services

Engage &Sustain

TherapeuticInterventions

Assessment

National Quality Forum (2005)

Organizational attributesOrganizational attributes

Contextual factorsContextual factors

Change process attributesChange process attributes

Intervention attributesIntervention attributes

Client attributesClient attributes

Networking - cross-agency Networking - cross-agency linkages and linkages and collaborationscollaborations

Measurement Measurement Domains Domains

Implementation Implementation science is not intended science is not intended to test interventions,to test interventions, per seper se, but to study , but to study

how to get evidence-how to get evidence-based interventions based interventions

adopted, adapted, and adopted, adapted, and sustained.sustained.

Implementation ScienceImplementation 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.

SAMHSA RWJF

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 4th 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 1st to 4th 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

Promoting Extraordinary Public Health Research to

Eradicate Drug Abuse