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
Preliminary procedure to evaluate likelihood
of substance use disorder or risk for negative
consequences
Brief Intervention
Time-limited efforts for advice/information,
motivation to avoid SU, or behavior change
skills to reduce use
Referral to Treatment
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)
“RT”
N=26
Brief Intervention
(N=58)
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
NIDA Funded SBIRT Studies – Primary Care
PI
N
Age
Severity
SBIRT
Primary
Substance(s)
Gelberg
(QUIT)
334
41.7 avg
Medium
(Non-dependent)
SBIRT
Highest Scoring
Drug
Merchant
1,023
18-64 y/o
Low
SBI
Ries
431
>18 y/o
Low – Severe
SBI
Saitz
528
>18 y/o
Moderate-Heavy
SBIR
Schwartz
360
>18 y/o
Moderate
BI
Svikis
713
18-70 y/o
Heavy/Problem
Use
SBI
Werch
1,314
18-25 y/o
Low - High
(High Risk)
SBIRT
Wu
(CTN)
400
>18 y/o
Low - High
Type 2 Diabetes
SBIRT
Primary
Outcome
Alcohol; Tobacco;
Illicit; Prescription
?
Alcohol; Tobacco
Opioid; Marijuana;
Stimulant; Sedative
?
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
N
Age
Severity
SBIRT
Primary
Substance(s)
Primary
Outcome
Blow
700
18 to 60 y/o
Low
SBI
Alcohol; Opioids;
Prescription; Illicit
?
Bogenschutz
(CTN)
1,285
24-48 y/o
Low to High
SBIRT
Cannabis; Opioid;
Illicit
D’Onofrio
329
>18 y/o
High
SBIRT
SBI+ Bup
Opioids
Knowlton
130
>18 y/o
High
SBIRT
Velasquez
417
>18 y/o
Moderate
(mean DAST)
SBI
Opioids
Alcohol; Cannabis;
Opioid; Sedative;
Stimulant
?
?
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
Source: Dennis et al., 2005, Scott et al 2005
28
.
Likelihood of Sustaining
Abstinence Another Year Starts
Small Yet Grows Over Time
100%
% Sustaining Abstinence
Another Year
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
86%
After 4 years
of abstinence,
about 86%
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)
4 to 7 years
But even after 7 years
of abstinence, about
14% relapse each year
29
Sustained Abstinence Reduces Risk of Death
15%
14%
13%
12%
11%
10%
9%
8%
7%
6%
5%
4%
3%
2%
1%
0%
The Risk of Death
goes down with
years of sustained
abstinence
Users and Early
Abstainers are
2.87 times more
likely to die in
the next year
11.9%
7.1%
4.5%
Household
It takes 4 or
more years of
abstinence for
risk to get
down to
community
levels
3.8%
Less than 1
(OR=1.00)
Source: Scott, Dennis, Laudet, Funk & Simeone (2011)
(OR=2.87)
1-3
-3 Years
(OR=1.61)
4-8
8 Years
(OR=0.84)
31
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/
36
Questions/Discussion