Transcript Breakfast Plenary 2014
Addressing Substance Use in Medical Settings: Expanding Our Reach
Harold Perl, PhD National Institute on Drug Abuse
Greetings from the NIH
2
Grateful Acknowledgements
• Redonna Chandler, Ph.D.
National Institute on Drug Abuse • Lori Ducharme, Ph.D.
National Institute on Alcohol Abuse and Alcoholism
Addressing Substance Use in Medical Settings:
Important Directions for NIDA & NIAAA
• • Increase knowledge on coordinating substance use and abuse with medical care in general
medical settings
Broaden the range of our research and practice – Preventing substance use and abuse – Identifying and engaging SUD patients in medical care settings – Managing chronic medical disease and conditions – – Managing recovery from SUD Patient-centered care – Paying for coordinated care
What are “General Medical Settings”?
• • Primary care – Internal medicine; family practice; pediatrics; OB/GYN – Hospital clinics; individual or group practices; HMOs; Community Health Centers (FQHCs); college (and other school) health centers; public health clinics; VA settings Emergency care – Emergency rooms; urgent care; trauma centers
Dental practices; “Minute Clinics”
Healthcare Reform
• • • 2 major events – Mental Health Parity and Addiction Equity Act
(Parity Act)
– Patient Protection and Affordable Care Act
(Obamacare or ACA)
These laws’ focus on Behavioral Health includes Substance Use Disorders 2 Key issues: – Coverage Expansion – Promoting Innovation in Delivery
Healthcare Reform (2)
• • Coverage Expansion – Parity Act: group insurers cannot set any limitations on
behavioral health treatment that is different (i.e., more restrictive) than those for other medical care treatments
– ACA: expands Parity Act requirements to individual and
“small group” coverage markets
– ACA: behavioral health coverage must be equivalent to the
“typical employee plan”
Innovation in Delivery – Integration of medical and behavioral health activities – Home and community-based services – Prevention activities
Preventing Substance Use and Abuse In General Medical Settings
National Prevention and Health Promotion Strategy
“The scientific foundation has been created … to begin to create a society in which young people arrive at adulthood with the skills, interests, assets, and health habits needed to live healthy, happy, and productive lives in caring relationships with others.” National Research Council and Institute of Medicine, 2009
NIDA Research on Prevention in Healthcare
• • • • RCT integrating evidence-based screening and brief intervention approaches into pediatric primary care with youth (10-13) and parents RCT to replicate efficacy of brief video intervention in ED to prevent later drug abuse and mental health problems in rape victims Supplement to study of Coordinated Care Organizations in Oregon that examines
prevention activities targeting young children
Need more work in this area
Identifying & Engaging SUD Patients In General Medical Settings
SBIRT: A bundle of activities
Screening Brief Intervention Referral to Treatment
Preliminary procedure to evaluate likelihood of substance use disorder or risk for negative consequences Time-limited efforts for advice/information, motivation to avoid SU, or behavior change skills to reduce use Facilitates access to care (including brief treatment) for those who have more serious signs of substance dependence and require a level of care beyond brief services
Most NIDA & NIAAA grants address <3 SBIRT components
Babor, 2008
NIDA/NIAAA SBIRT Portfolio
• • Without limiting to time/mechanism/division, identified 69 relevant grants (23 NIDA; 46 NIAAA).
Combined, these grants included data on 953,250 patients.
Screening (N=48) Brief Intervention (N=58) “RT” N=26
Summary of Alcohol SBIRT Findings for Primary Care
SBIRT for Alcohol in Primary Care
• • • • • SBI deemed effective in reducing alcohol use with non-dependent patients Systematic reviews (Saitz 2010) found: – 12% reduction in risky drinking, SBI vs controls – 39 gram per week reduction in consumption Lack of evidence for SBI among patients with heavy drinking/alcohol dependence Lack of “RT” models linking alcohol dependent patients with more intensive treatment
USPSTF: “B” grade for SBI for adults 18+
Next Steps for Alcohol SBIRT Research
• • • Screening: – RFA-AA-12-008, Evaluation of NIAAA’s Alcohol
Screening Guide for Children & Adolescents
– Awarded 6 grants to validate NIAAA’s recommended 2-item screener for youth age 9-18 Brief Intervention: – Alternative options for effectively delivering BI – Testing SBI in non-medical settings – Implementation studies to promote scale-up Referral to Treatment: – Need strategies to effectively engage dependent drinkers in treatment
Summary of Drug Use SBIRT Findings for Primary Care & Emergency Departments
PI
NIDA Funded SBIRT Studies – Primary Care
N
Age
Severity SBIRT Primary Substance(s) Primary Outcome
Gelberg (QUIT) Merchant 334
41.7 avg
1,023
18-64 y/o
Medium (Non-dependent) Low SBIRT SBI Highest Scoring Drug Alcohol; Tobacco; Illicit; Prescription
?
Ries 431 >18 y/o Low – Severe SBI Alcohol; Tobacco Opioid; Marijuana; Stimulant; Sedative
?
Saitz Schwartz Svikis Werch Wu (CTN) 528
>18 y/o
360
>18 y/o
713
18-70 y/o
1,314
18-25 y/o
400
>18 y/o
Moderate-Heavy SBIR Moderate Heavy/Problem Use Low - High (High Risk) Low - High Type 2 Diabetes BI SBI SBIRT SBIRT Opioid; Cocaine; Marijuana; Other Opioid; Cocaine Marijuana; Stimulant Illicit and Prescription Alcohol; Tobacco; Prescription; Illicit Alcohol; Tobacco; Prescription; Illicit
?
?
?
NIDA-Funded SBIRT Studies – Emergency and Internet-based
PI
Blow Bogenschutz (CTN) D’Onofrio Knowlton Velasquez
N
Age
700
18 to 60 y/o
1,285
24-48 y/o
329
>18 y/o
130
>18 y/o
417
>18 y/o
Severity
Low Low to High High High Moderate (mean DAST)
SBIRT
SBI SBIRT
Primary Substance(s)
Alcohol; Opioids; Prescription; Illicit Cannabis; Opioid; Illicit SBIRT SBI+ Bup SBIRT Opioids Opioids SBI Alcohol; Cannabis; Opioid; Sedative; Stimulant
Primary Outcome ?
?
?
Next Steps for Drug Abuse SBIRT Research
• • • • Adolescents/Young Adults: – Screening tools – BI for alcohol/tobacco/marijuana/prescription drugs Test longer term outcomes for SBIRT delivered in primary care setting MAT induction as brief intervention Linkage strategies for immediate referral to treatment; brief interventions to support successful referrals
Chronic Disease Management
Chronic Disease Management / Coordinated Care Grants
• • • • • Identification & treatment of “high utilizers” Integrated management of SUD and co-occurring medical (chronic pain, psychiatric, HIV) Models for delivering treatment (beyond BI) in medical settings NIDA RFA-DA-12-008, Integration of Drug Abuse Prevention
& Treatment in Primary Care
– Funded 6 R01’s testing implementation strategies to promote service integration & care coordination NIDA RFA-DA-13-001, Phased Services Research Studies of
Drug Use Prevention, Addiction Treatment, HIV in Era of Health Care Reform
– Funded 7 projects: 6 look at coordinated care
drugabuse.gov/blending-initiative/cme-ce-simulation
Managing Recovery from Substance Use Disorders
After Substance Abuse Treatment …
• • • Relapse is common, particularly for those who: – Are younger – Have already been to treatment multiple times – Have more mental health issues or pain It takes an average of 3 to 4 treatment admissions over 9 years before ½ patients reach a year of abstinence Yet over ⅔ do eventually abstain 28
Source: Dennis et al., 2005, Scott et al 2005
Likelihood of Sustaining Abstinence Another Year Starts Small Yet Grows Over Time 100% 90% 80% 70% 60%
Only 1/3 of people with 1 to 12 months of abstinence will sustain it another year After 1 to 3 years of abstinence, 2/3 will make it another year 66%
50%
36%
40% 30% 20% 10% 0% 1 to 12 months 1 to 3 years Duration of Abstinence
Source: Dennis, Foss & Scott (2007)
86% After 4 years of abstinence, about 86% will make it another year
4 to 7 years
But even after 7 years of abstinence, about 14% relapse each year 29
Sustained Abstinence Reduces Risk of Death
Users
and
Early Abstainers
are 2.87 times more likely to die in the next year 11.9% 7.1% The Risk of Death goes down with years of sustained abstinence It takes 4 or more years of abstinence for risk to get down to community levels 4.5% 3.8% 1 -3 Years 4 -8 Years 31
Source: Scott, Dennis, Laudet, Funk & Simeone (2011)
Patient-Centered Care
Patient-Centered Care Grants
• • • • Technology solutions to deliver more personalized/customized treatment Pragmatic trials identifying patient preferences Qualitative studies to understand patient compliance/retention
Need more work in this area
Paying for Coordinated Care
Grants on Economic Aspects of Care Coordination
• • • • • Identification of economic barriers to service integration Estimating costs of integrated care Development of quality measures Studies capitalizing on “natural experiments” – Affordable Care Act – Parity Act – State-specific legislation (e.g., Medicaid changes; Oregon’s parity act) NIDA RFA-DA-13-001, Phased Services Research Studies of
Drug Use Prevention, Addiction Treatment, HIV in Era of Health Care Reform
– Funded 7 projects: 4 examine payer/provider strategies
www.integration.samhsa.gov/
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