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
Promoting Awareness
of Motivational
Incentives (PAMI)
Short-Term Opioid
Withdrawal Using
Buprenorphine
Treatment Planning
Using the Addiction
Severity Index (ASI)
Promoting Awareness of
Motivational Incentives (PAMI)
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 AfricanAmerican & 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
Organization
Structure and
Climate
Intervention
Provider
knowledge
and
behavior
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
24
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%
Late Majority=34%
Early Adopters=13.5%
Laggards=16%
Innovators=2.5%
x-2sd
x-sd
x
x+sd
Rogers (2005)
“…the best candidate for rapid
adoption would be an evidencebased 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
Systemic Factors
Financial
Legal/Regulatory
Org
Structure
& Culture
Program
Components
Engage &
Sustain
Health Care
Infrastructure
Initial Services
Clinical
Practices
Therapeutic
Interventions
Patient
Engagement
Staffing
Assessment
Info &
Clinical
Care
Systems
Research & Knowledge
Transfer
Education &
Training
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 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)
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
National Institute on Drug Abuse
Division of Epidemiology, Services and
Prevention Research
Promoting Extraordinary Public Health
Research to Eradicate Drug Abuse