Transcript NIDA - East Bay Community Recovery Project
NIDAMED
released 20 April 2009!
www.drugabuse.gov
Our Strategy Involves BLENDING
RESEARCH
and
PRACTICE
Bringing User-friendly Science-Based Technologies Into Ongoing Community Practice
Community Bedside Bench
Interagency Collaborations are indispensable
NIDA-SAMHSA Blending Teams Buprenorphine Training for Addiction Professionals Motivational Interviewing Supervisory Tools Short-Term Opioid Withdrawal Using Buprenorphine Promoting Awareness of Motivational Incentives (PAMI)
Promoting Awareness of Motivational Incentives (PAMI)
Treatment Planning Using the Addiction Severity Index (ASI)
NIDA - SBIRT Initiatives: Cooperation with AMA
Mainstreaming addictions is a focus of AMA’s Department of
Healthy Lifestyles and Primary
Prevention, including the joint NIDA/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)
NIDA - SBIRT Initiatives: Cooperative actions with other Public Health Agencies • Substance Use Disorders:
CPT Codes Approved 2008, with reimbursement now in 13 state Medicare and Medicaid programs, and 71 commercial carriers (and counting)
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)
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Community Bedside Bench
Working in “Real-World Settings” is key.
National Drug Abuse Treatment Clinical Trials Network (CTN) Criminal Justice Drug Abuse Treatment Studies (CJ-DATS)
Research Centers Coordinating Center
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 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
Type 1 Translational Research
Bench Bedside
Outcomes can be improved by:
Developing interventions that are highly effective as delivered, or
Implementing an effective intervention more widely.
Type 2 Translational Research
Bedside Practice
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.
Access and Engagement Provider knowledge and behavior Intervention Organization Structure and Climate External Environment (stigma, financing)
Type 2 Translation Requires a Different Science than Type 1 (with feedback linkages) Type 1 Type 2
Key Concepts for Type 2 Translation
• Information Dissemination • Adoption as a Process (Diffusion Theory)
Implementation Science
Information Dissemination
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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
Early Majority=34% Early Adopters=13.5% Late Majority=34% Laggards=16% Innovators=2.5% x-2sd x-sd
x
x+sd
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
Successful Implementation of EBPs
Effective Intervention Practices + Effective Implementation Strategies Adoption of EBPs Enhanced Patient Outcomes Fixsen, Naoom, Blase, Friedman, & Wallace, 2005
A Comprehensive Approach for Evidence-Based Practice Implementation
Financial Systemic Factors Legal/Regulatory Org Structure & Culture Program Components Staffing Initial Services Engage & Sustain Health Care Infrastructure Patient Engagement Clinical Practices Therapeutic Interventions Assessment Info & Clinical Care Systems Education & Training Research & Knowledge Transfer National Quality Forum (2005)
Measurement Domains
Organizational attributes Contextual factors Change process attributes Intervention attributes Client attributes Networking - cross-agency linkages and collaborations
Implementation Science
Implementation science is not intended to test interventions, per se, but to study how to get evidence-based interventions adopted, adapted, and sustained.
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 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)
NIATx 200: RCT
Self-directed “change teams” of program leaders + Web-based process improvement resources vs.
Self-directed “change teams” of program leaders + Web-based process improvement resources +
Intensive coaching by process improvement experts
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
Conclusions: Implementation Science
• 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