Transcript GHB

NIDA’s Public Health Division:
The Division of Epidemiology, Services and
Prevention Research
Wilson M. Compton, M.D., M.P.E.
Director, Division of Epidemiology, Services and Prevention Research
National Institute on Drug Abuse
Department of Health and Human Services
Penn State University
29 November 2006
National Institute on Drug Abuse
Office of the Director
Special Populations Office
EEO
Office of
Extramural
Affairs
Teresa Levitin, PhD
Nora D. Volkow, MD
Director
Timothy P. Condon, Ph.D.
Deputy Director
Laura S. Rosenthal
Associate Director
for Management
Director, AIDS Research
Office of Planning
& Resource
Management
Office of
Science Policy &
Communications
Center for the
Clinical Trials
Network
Intramural
Research
Program
Laura Rosenthal
Timothy Condon, PhD
Betty Tai, PhD
Barry Hoffer, MD, PhD
Division of
Basic Neurosciences
& Behavior Research
Division of
Pharmacotherapies &
Medical Consequences
of Drug Abuse
Division of
Epidemiology,
Services &
Prevention Research
Division of Clinical
Neuroscience,
Development &
Behavioral
Treatment
David Shurtleff, PhD
Frank Vocci, PhD
Wilson Compton, MD, MPE
Joseph Frascella, PhD
DESPR Organization and Vision
EPIDEMIOLOGY RESEARCH BRANCH
DESPR seeks to improve
the nation’s public health by
promoting integrated approaches to
understand and address interactions
between individuals and environments
that contribute to the continuum of problems
related to drug use.
Our goal is to develop scientific knowledge with clear
application to practice and public policy.
PREVENTION RESEARCH BRANCH
SERVICES RESEARCH BRANCH
First, a story exemplifying linkages
of Epidemiology, Prevention and
Services…
Epidemiological Finding: Childhood and
Adult Antisocial Behavior Strongly
Associated with Drug Use/Disorders
20
18
16
14
12
10
8
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4
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Odds Ratios for Lifetime Antisocial Personality Disorder by Specific Drug Disorders,
Reference group is persons without the drug disorder (NESARC Study, Compton 2004)
From Longitudinal Epidemiology
comes evidence for a plausible pathway:
Early Aggression
Adolescent/Early Adult
Antisocial Behavior
and Drug Abuse
Deviant peer
association
From Prevention: comes tests of the
theory and tests of a plausible
intervention strategy:
— Support for theory and development of
practical and useful interventions.
ESTIMATED CUMULATIVE RISK
From Prevention: Reducing Early Aggressive
Behaviors Reduces Drug Use
Control: 33%, reference
 CC: 25%, aRR 0.61 (0.37-1.00)
 FSP: 25%, aRR 0.70 (0.50-0.98)

CC=Classroom Centered FSP=Family-School Partnership
7
8
9
10
11
12
13
AGE OF FIRST TOBACCO USE
Modified from: Storr, et al., Drug and Alcohol Dependence, 66:51-60, 2002.
From Prevention: Enhancing Social
Bonding Reduces Violence
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
83%
72%
60%
48%
Violence
Sexual Activity
SSDP Intervention
Comparison
Hawkins, et al., Arch Pediatr Adolesc Med 1999
From Services: Early Interventions Can Be
Cost-Effective
Nurse Home Visiting Program
Cost per
Participant
Taxpayer
and Crime
Victims Net
Benefit
$ 7,733
$15,981
$ 4,355
$14,169
$ 1,054
$ 4,524
Seattle Social Development
Project
Big Brothers/Sisters Mentoring
Aos, et al., The Comparative Costs and Benefits of Programs to Reduce Crime,
Washington State Institute for Public Policy, 2001
Ongoing Problem:
To Reap Any Benefits
From Scientific Knowledge
It Needs To Be Used In Practice
From Services: Few Schools Use Effective
Prevention Programs
60%
50%
40%
30%
20%
10%
0%
L
L
A
H
C
S
26.8%
34.6%
12.6%
S
L
OO
P
lic
b
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P
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Percentage Using One of the Top 12 Effective Programs
Ringwalt, et al. (2002), Prevention Science
Thus, all three branches of DESPR
contribute to a unified story about
pathways to drug use and how to
intervene in these pathways.
And now…
A Few Key Findings
ERB:
Cigarette Smoking Declines Markedly
Since Mid-1990’s
Lifetime
70
60
50
*
*
*
40
30
20
91 92 93 94 95 96 97 98 99 00 01 02 03 04 05
8th Grade
10th Grade
12th Grade
* Denotes significant difference between recent peak year and current year.
Denotes significant difference between 2004 and 2005.
Source: University of Michigan, MTF 2005
SRB:
Life Course View of Addiction Refines
Understanding of Recovery & Benefit Cost
Recovery
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
Lifetime Benefit-Cost
Ratio for Tx of Heroin
Use
40
35
30
25
20
15
10
5
0
1 Tx Episode
Life Course
Zarkin, Dunlap, Hicks, & Mamo. (2005).
Benefits & costs of methadone treatment:
results from a lifetime simulation model.
Health Economics, 14, 1133-1150.
PRB:
Universal Family-based Prevention
Interventions Reduce Methamphetamine
Lifetime and Past Year Meth Use at 4½-6½ Years Past Baseline
8
Past Year Use*
Lifetim e--Past Year Plus Prior Use
7.61
7
6
5
5.18
% 4
4.15
3
3.45 3.21
2.51
2
1
0
4.59
2.63
2.40
2.12
1.44
.53
ISFP PDFY Control
Study 1 (12th Grade)
SFP+LST LST Control
Study 2 (11th Grade)
SFP+LST LST Control
Study 2 (12th Grade)
Source: Spoth, et al. (2005). Two randomized studies of the long-term effects of brief, partnershipbased universal preventive interventions on adolescent methamphetamine use
2.0
1.8
1.6
Life expectancy
1.4
1.2
1.0
0.8
0.6
Quality-adjusted
life expectancy
0.4
0.2
0.0
30
40
50
60
AGE (Yr)
70
80
90
Incremental Cost-Effectiveness of
Screening ($/quality-adjusted life year)
Increase in Life Expectancy
Due to Screening (Yr)
DESPR:
HIV Screening Can Be As CostEffective As Screening for Hypertension
and Other Medical Conditions
200,000
180,000
160,000
140,000
120,000
100,000
80,000
Costs and benefits to partners excluded
60,000
40,000
Costs and benefits to partners included
20,000
0
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
Prevalence of Unidentified HIV (%)
Source: Paltiel, et al. and Sanders et al., NEJM 352(6), 2005.
DESPR provides a
foundation for NIDA’s
Public Health Mission.
Priority Areas for NIDA
Prevention Research
Children and Adolescents
Genetics
Comorbidity
Development
Treatment Interventions
(New Targets & New Strategies)
HIV/AIDS Research
DRUG ABUSE
HIV/AIDS
Summary: Drug Abuse Research Needs a
Systems Approach
social
DRUGS
OF
ABUSE
behavior
neuronal circuits
protein expression
genome
DESPR:
2006 Major Research Questions
1. What new theoretical approaches can
inform our research?
2. What intrapersonal and environmental
factors interact with each other and with
genetic factors?
3. How can we blend science and services to
measurably impact public health
outcomes?
Prevention 2006 Key Research Goal
Develop and maximize use of high quality
preventive interventions in real world settings
through research on
– Individual factors
– Relationship of drug abuse prevention to
HIV prevention
– Environmental strategies
– Community-based participatory research
What are we doing to
develop and promote these
themes?
Workgroups, Meetings, Publications, etc.
Translational Research is NOT
Unidirectional: There are Feedback Loops
Type 1
Type 2
Bi-Directional Influences
• Basic science laboratories
– Sensation Seeking
– Neurobehavioral disinhibition
– Early-onset antisocial behavior
– Psychiatric co-morbidity
– Stress reactivity
• Prevention
prevention:
basic neuroscience laboratories:
– What are the biological mechanisms that explain the
emergence of drug abuse during adolescence?
– What specific vulnerabilities are familial?
– What are the biological mediators of social interactions?
Linking Public Health Research to
Neuroscience
Circuits Involved In
Drug Abuse and Addiction
INHIBITORY
CONTROL
PFC
ACG
Hipp
OFC
SCC
MOTIVATION/
DRIVE
REWARD
NAcc
VP
Amyg
MEMORY/
LEARNING
All Should Be Considered In
Strategies to Prevent and
Treat Addiction
Non Addicted Brain
Addicted Brain
Control
Control
STOP
Reward
Drive
Memory
Reward
Drive
GO
Memory
Promise of Translation: HPA axis plasticity
Psychosocial intervention
1
0.8
0.6
0.4
6 Mont
3 Month
0.2
0
wakeup
Initial
mid morning
bedtime
Source: Fisher P, OSLC
Brandon's PDR
Concordant behavior change
35
30
25
Init.
20
Total PDR
# of Beh.
Linear (Total PDR)
15
10
Linear (# of Beh.)
3 mo.
6 mo.
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Key Basic Epidemiology Finding:
Addiction is a Developmental Disorder
With Onset During Adolescence
0.012
DSM-IV Abuse
Hazard Rate
0.010
DSM-IV
Dependence
0.008
0.006
0.004
0.002
0.000
5
10
15
20
25
30
35
Age
40
45
50
55
60
Source: NESARC Study, 2001-2002
Recent Studies Have Shown that Maturation of the
Brain’s Gray Matter Moves from Back to Front
Brain areas where volumes
differ in adolescents compared to young adults
Source: Sowell, E.R. et al., Nature Neuroscience, 2(10), pp. 859-861, 1999
During Adolescence the COGNITION-EMOTION
Connection is Still Undergoing Development
Amygdalo-cortical
Sprouting Continues
Into Early Adulthood
Low-power light photomicrographs of immunoperoxidase-labeled, biocytin-containing
amygdalofugal varicose fibers within the mPFC of animals at 6 stages of development
Source: Cunningham, M et al., J Comp Neurol 453, pp 116-130, 2002.
Implications:
• Developmental differences must be
considered in designing prevention
strategies.
–Can frontal lobe functioning be
strengthened?
Translating Sensation Seeking Research into
Clinical Study: Communications Research
Sensation-Seeking Targeting
(Palmgreen et al., 2001)
• Used Activation model of information exposure
to design messages for target audiences
• RESULTS: All 3 targeted television campaigns
reversed upward trends in 30-day marijuana use
among high SS
How will D2 receptor research inform this field?
Community
Bedside
Bench
Developing an intervention is only one
part of translating research into practice.
Access
and
Engagement
Organization
Structure and
Climate
Intervention
Provider
knowledge
and
behavior
External
Environment
(stigma,
financing)
Community
Bedside
Bench
Interagency
Collaborations
are indispensable
DHHS
NIH
SAMHSA
NIDA
NIDA
Collaborations to Translate Research
Findings Into Relevant Clinical Practice
Testing the Communities That Care
(CTC) Prevention System
Research Centers
Coordinating Center
Linking grant programs
• “Braiding” funding streams to enhance both research and
services
• Each agency doing what it does best
• Examples:
– Adolescent Services Including Brief Interventions
(FY2003 with SAMHSA)
– 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) and for CBOs (FY2006)
Community
Bedside
Bench
Developing the Health
Services Research
Program
NIDA Blue Ribbon Task Force on
Health Services Research
Co-Chairs:
Thomas McLellan, PhD,
Constance Weisner, DrPH, MSW
Andrea Barthwell, MD
Caryn Blitz, PhD
Rick Catalano, PhD
Mady Chalk, PhD
Linda Chinnia, MEd
Lorraine Collins, PhD
Wilson Compton, MD, MPE
Michael Dennis, PhD
Richard Frank, PhD
Warren Hewitt, MS
James Inciardi, PhD
Marguerita Lightfoot, PhD
Isaac Montoya, PhD
Claire Sterk, PhD
Janet Wood, MBA, MEd
New Opportunities:
• Science to Services


Medical Settings
– Screening (especially SBIRTs)
– Prescription Drug Abuse
(especially opioids)
HIV
• Interactions

Implementation Science
• New Theories


Economics
Organization/Management
Division of Epidemiology, Services and
Prevention Research
Providing a foundation for
NIDA’s public health mission.