Transcript Slide 1

Making the Link between Science
and Practice: Doing It Well
Drug Abuse Prevention and
Treatment
Identifying Europe´s Information Needs For Effective Drug
Policy
Lisbon, 6-8 May 2009
Zili Sloboda, Sc.D., Senior Research Associate
Institute for Health and Social Policy
The University of Akron
Akron, Ohio, USA
1
Take 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 evidencebased interventions, the vast majority of interventions
being delivered in the United States are NOT considered
evidence-based
2
Take 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 Story
4
The 1990s
History of Prevention Research in the
United 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
United 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. Programs
8
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
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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
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 ethnicity
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Principles of Prevention-Planning

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-Delivery
Adapting 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 ageappropriate learning strategies,

Prevention Programs—
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)

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Prevention Program Definitions
Using the Concept of Risk
UNIVERSAL programs reach the
general population
 SELECTIVE 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 riskrelated behaviors

Classroom Curriculum—
Universal/Selected Programs

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
Programs

Common Elements or Principles:
– Identify students at high risk for substance abuse or
other associated behavior
– Provide self-control, communications and decisionmaking skills
– Self-esteem/competency enhancement
– Create positive peer support
 Examples of Programs:
– Reconnecting Youth—Eggert
– Project Towards No Drug Abuse—Sussman
– Project SUCCESS--Morehouse
Other
Media
Clinical
Community
SETTING School
Home
TARGET
Universal
Individual
Family
Peers
Community
TYPE
Selected
Indicated
21st Century--Incorporation of
Evidence-Based Concept
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Evidence-Based Concepts—Not
Standardized

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
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Society for Prevention Research:
Standards of Evidence
Criteria for Efficacy
 Criteria for Effectiveness
 Criteria for Dissemination
 Available at:

– http://www.preventionresearch.org/Standardsof
Evidencebook.pdf
– Flay et al., Standards of evidence: criteria for
efficacy, effectiveness and dissemination.
(2005). Prevention Science, 6(3), 151-178.
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Center for Substance Abuse Prevention: Identifying
and 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/SMA094205/evidence_based.pdf
23
“Lists of Evidence-Based Drug
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
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INSTITUTE 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
Prevention 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--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--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
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
Model-2000s
CTC: The Community Youth
Development Study
Get Started
Implement and
Evaluate
Creating
Communities
That Care
Create a Plan
24 Communities; ~45,000 participants
24 Communities; ~45,000 participants
Get Organized
Develop a
Profile
Fagan, Hawkins & Catalano, 2007;
Quinby et al, 2007
Average Level of Risk
Pre-post change in risk factors prioritized
and targeted in CTC Communities
.25
0.25
0.20
0.15
0.10
0.05
0
0.00
-0.05
-0.10
-.15
-0.15
-0.20
Grade 5
Control Communities
Grade 7
CTC Communities
Triple P (Positive Parental Program)
Drug Abuse Treatment
34
The 1990s—Summary of findings
from two decades of research
Services*
Jail
SETTING Hospital
Community
PHASE
Detoxification
“Treatment”
Aftercare
Counseling
TYPE
Pharmacotherapy
Findings from Controlled Studies
Scientifically Based Approaches to
Treatment

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 Studies
and Evaluations of Ongoing Treatment
Treatment variables associated with better
outcome 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
Ongoing “Real World” Treatment
Treatment 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
Ongoing “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 low
 Relapse rates after treatment are
unacceptably high

Principles of Effective Treatment—(National
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 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
Principles of Effective Treatment
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
21st Century Incorporation of
Evidence-Based Concept
What Are Evidence-Based Practices?
Interventions that show consistent
scientific evidence of being related to
preferred client outcomes.
How Are Evidence-Based Practices
Documented?
Gold Standard
• Multiple randomized clinical trials
Second 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 Forum

Evidence 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
50
use treatment.
Lists--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
Treatment
Brief intervention
 Social skills training
 Motivational enhancement
 Community reinforcement
 Behavioral 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
to 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
Evidence-Based Treatment Model
Induction
Motiv
Patient
Attributes
at Intake
Staff
Attributes
& Skills
Behavioral
Strategies
Family &
Friends
Early
Engagement
Early
Recovery
Program
Participation
Behavioral
Change
Personal Health Services
Supportive
Networks
Sufficient
Retention
Therapeutic Psycho-Social
Relationship
Change
Drug
Use
Crime
Social
Relations
Program
Characteristics
Posttreatment
Enhanced
Counseling
Social Skills
Training
Social Support Services
Simpson, 2001 (Addiction)
Real World
Recent 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…
Treatment Need—2007
U.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 availability
1990
Number
16,000
Residential/Inpatient
55%
Outpatient/Drug Free 30%
Methadone Maintenance 15%
Source: McLellan et al., 2003
2002
14,000
14%
78%
12%
Funding
Federal health care, e.g., medicaid,
medicare
 Carve-outs in third party insurance

Responses of “Feeling the need
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 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 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
P
e
r
c
e
n
t
PERCENT DOLLAR CHANGE OVER
TIME
INTERDICTION =
 INTERNATIONAL=
 DOMESTIC LAW
ENFORCEMENT =
 TREATMENT
=
 PREVENTION
=

100.2%
48.4
31.2
22.2
-24.5
Safe and Drug Free Schools and
Communities-- Appropriations: 2001
through 2007
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
Issues 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
