Title: Mainstreaming Addictions in Medicine: Update on NIDA's SBIRT Efforts in General Medical Settings
1Mainstreaming Addictions in Medicine Update on
NIDA's SBIRT Efforts in General Medical Settings
- Wilson M. Compton, M.D., M.P.E.
- Director, Division of Epidemiology, Services and
Prevention Research - National Institute on Drug Abuse
Advisory Council, National Institute on Drug
Abuse February 4, 2009
2 SBIRT Efforts in General Medical Settings
- What is SBIRT?
- Screening
- Brief Intervention
- Referral to Treatment
3US Preventive Services Task Force
(USPSTF)Current Policy Status of SBIRT
- Alcohol and Tobacco -SBIRT accepted
- Tobacco
- http//www.ahrq.gov/clinic/uspstf/uspstbac.htm
- Alcohol
- http//www.ahrq.gov/clinic/uspstf/uspsdrin.htm
-
4Illicit Drug SBIRT Reviews
- 1995 USPSTF Report Review of SBIRT effectiveness
for drugs. Insufficient evidence to recommend
for or against - 2005 Review by Babor and Kadden, Journal of
Trauma. Further work needed before routine
screening for drug use disorders is warranted - 2008 USPSTF Report Update The evidence is
insufficient to determine the benefits and harms
of screening for illicit drug use
5USPTF Model
- Evidence needed that intervention, including
referral to treatment, impacts long-term
morbidity and mortality within primary care
populations - Accepted outcomes for SBIRT (abstinence vs.
health, social, legal, economic, and vocational
outcomes)
6(No Transcript)
7ExampleStrength of Evidence for Alcohol
- A meta-analysis suggests an overall reduction of
56 in number of drinks - The effect size for motivational intervention of
all types ranged from 0.25 to 0.57, with
participants followed from 3 to 24 months -
- Burke et. al., 2003
8ExampleStrength of Evidence for Tobacco/Smoking
- A meta-analysis of 43 studies
- Improvement in cessation for behavioral
intervention of all types ranged from 4 to 15,
with an intervention as brief as 3 minutes
improving abstinence rates - Pharmacotherapy as much as triples these rates
-
- Fiore et. al., 2000
9Strength of Evidence for Illicit Drugs
Promising - but sparse results
- Bernstein, et al. 2005 Randomized Controlled
Trial (RCT) - WHO study, 2008 Randomized Controlled Trial
(RCT) in Multiple Sites Internationally - Madras, et al. 2009 SAMHSA program evaluation of
(SBIRT) for illicit drug and alcohol use at
multiple sites Comparison at intake and 6 months
later
10Brief motivational intervention reduces 6 mo.
cocaine and heroin use
Bernstein et al. Drug and Alcohol Dependence
20057749-59
- RCT (n1175) urban walk-in clinic patients,
presenting for non-acute problems and use of
heroin or cocaine, confirmed by hair analysis - Intervention semi-scripted BMI of 20 min.
(10-45), 10 days later a 5-10 min. booster call - ASI at intake, 3 and 6 months, HA 6 month
11Brief motivational intervention reduces 6 mo.
cocaine and heroin use
- Abstinent from Adjusted Odds Ratio
- Cocaine 1.51 (1.01, 2.24)
p 0.045 - Opiates 1.57 (1.00, 2.47)
p 0.050 - Logistic regression model adjusted for variables
that groups differed on at baseline (health
insurance, homelessness)
Bernstein et al. Drug and Alcohol Dependence 2005
12Brief motivational intervention reduces 6 mo.
cocaine and heroin use
Abstinence Among Those Screening Positive for At
Baseline
p lt .05
Bernstein et al. Drug and Alcohol Dependence 2005
13WHO ASSIST Phase III Project
WHO ASSIST Phase III Technical Report, 2008
- An international randomised controlled trial
(RCT) evaluating the effectiveness of a Screening
and Brief Intervention (SBI) for cannabis,
stimulants opioids - Participants recruited from PHCs in Australia,
Brazil, India, USA (R01 DA016592, PI T Babor ) - Randomly allocated to intervention or waitlist
control group at baseline with follow up three
months later - Both groups administered the ASSIST and
intervention participants received a brief
intervention for the drug for which they scored
the highest on the ASSIST
14Total Illicit Substance Involvement Scores BI
and Control at Baseline and Follow-up (N628)
WHO ASSIST Phase III Technical Report, 2008
Pooled data
plt0.01
15Cannabis Specific Substance Involvement Scores
BI and Control at Baseline and Follow-up (N328)
WHO ASSIST Phase III Technical Report, 2008
Pooled data
plt0.05
16Stimulant Specific Substance Involvement Scores
BI and Control at Baseline and Follow-up (N229)
WHO ASSIST Phase III Technical Report, 2008
Pooled data
plt0.005
17Opioid Specific Substance Involvement Scores BI
and Control at Baseline and Follow-up (N73)
WHO ASSIST Phase III Technical Report, 2008
Pooled data
plt0.07
18SAMHSA Demonstration Program for
SBIRTComparison of intake and 6 month follow up
Madras, et al. Drug and Alcohol Dependence 99
(2009) 280295
- Federally SBIRT programs in six states across a
range of medical settings - Emergency/trauma departments, primary care
centers, hospital inpatient/outpatient settings - Patients screened and offered interventions
- Brief intervention, brief treatment, referral to
specialty treatment - Six months follow-up on those screening positive
at baseline
19Program Data, Six SAMHSA SBIRT Sites, Baseline
and F/U Substance Use
Among Those Screening Positive for Drugs At
Baseline (N 6,262)
All are P lt 0.001
Madras, et al. Drug Alcohol Dependence, 2009
20Strength of Evidence about SBIRT for Illicit
Drugs
- Promising - but sparse results
21NIDA - SBIRT Initiatives
- NIDA has supported initiatives for SBIRT in
Primary Care and Mainstreaming of Addiction
Treatment since initial findings of USPSTF - RFA in 2004 for Screening and MI in adolescents
(with SAMHSA) - Findings showing effectiveness of MI, computer
platforms and EMRs in adolescent general medical
settings
22NIDA - SBIRT InitiativesRFA-08-021 (SBIRT) for
Illicit Drug Abuse in General Medical Settings
- RFA in 2008 Screening, Brief Intervention and
Referral to Treatment (SBIRT) for Illicit Drug
Abuse in General Medical Settings (R01
only)RFA-DA-08-021 (R01) - Over 30 applications received
- 4 Funded Grants
- Well designed RCTs in various general medical
settings, testing effectiveness of various SBIRT
models
23NIDA - SBIRT Initiatives RFA-08-021 SBIRT for
Illicit Drugs in General Medical Settings
- D'Onofrio, Gail Models of SBIRT for Opioid
Dependent Patients in the Emergency Department - Velasquez, Mary Marden Multidisciplinary Approach
to Reduce Injury and Substance Abuse - Roy-Byrne, Peter P Brief Intervention in Primary
Care for Problem Drug Use and Abuse (SAMHSA
Site/Team) - Svikis, Dace S Computer vs Therapist-Delivered
Brief Intervention for Drug Abuse in Primary Care
24NIDA - SBIRT Initiatives Other FY2008 Grants
- Saitz, Richard Screening and Brief Intervention
Models to Address Unhealthy Drug Use (SAMHSA
Site/Team) - Gelberg, Lillian Preventing Drug Use in Low
Income Clinic Populations
25NIDA - SBIRT InitiativesSmall Business
Innovation Research (SBIR) and Technology
Transfer (STTR) Programs at NIDA
- SBIR Grants to address RT problem
- Computer and web based patient referral systems,
to reduce one of main objections to screening,
i.e. time consuming and difficult to place
patients in specialty care by general medical
office - One study underway and one pending funding
26NIDA - SBIRT Initiatives Publications
development
- Screening and Brief Intervention for Drug Use
in Primary Care Settings A Resource Guide for
Providers
27NIDA Screening Resource Guide
- Targets adult primary care with a key goal of
increasing screening for illicit drug abuse - Provides a clinician-friendly guide to support
screening and brief intervention - Strengthens clinicians ability to discuss
screening results with patients
28NIDA Screening Resource Guide
- Brief, graphical introduction to screening and
brief intervention steps for primary care
providers - Will be on the NIDA website
- Based on the WHO ASSIST (Alcohol, Smoking, and
Substance Involvement Screening Test)
29 NIDA Screening Resource Guide
Under Development Target date for distribution
early spring/summer 2009 NIDA Guide anticipated
to have similar feel as the NIAAA Guide which
is familiar to general medical clinicians to
facilitate adoption
30NIAAA Website/Guide
31Screening and Brief Intervention (SBI) For Drug
Use in Primary Care Settings Resource Guide for
Providers
Introduction Before You Begin Screening and brief
intervention for drug use Step 1 Ask about drug
use Step 2 Screen for substance use
disorders Step 3 Discuss results conduct brief
intervention Step 4 Offer continuing care at
follow-up visits Appendices Support
Materials Frequently Asked Questions
Glossary of Terms
Download PDF Version
32NIDA Screening Resource Guide
- A user-friendly quick guide targeted to medical
providers, especially physicians - Developed by NIDA staff
- Peer reviewed by 8 university-based experts
- Reviewed in collaboration with representatives
from WHO, ONDCP, SAMHSA, CDC and NIAAA
33NIDA Screening Resource Guide
Like the NIAAA guide, will primarily be laid-out
as a flow-chart, which is familiar to general
medical clinicians and is easy to use in a
fast-paced clinical environment
34NIDA Screening Resource Pocket Guide
NIDA will also offer a Pocket Guide to facilitate
implementation
35NIDA Screening Resource Pocket Guide
- The Pocket Guide will share the same step-by-step
format and supporting material
36NIDA - SBIRT InitiativesCooperative 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)
37 NIDA - SBIRT InitiativesCooperative
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
38NIDA - SBIRT InitiativesCooperative actions
with AMA
- Mainstreaming addictions is a focus of AMAs
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 and SBIRT concepts in medical
student and resident education
39 NIDA - SBIRT InitiativesCooperative 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)
40Future SBIRT Research
- Enhance evidence base regarding effectiveness in
a variety of medical (and related) settings - SBI for prescription drug abuse
- New technologies (internet, tablet, PDA, etc.)
- Models for referral and/or direct care in general
medical settings (the RT of SBIRT) - Linking SBIRT interventions to important
morbidity and mortality outcomes
41 Update on NIDA's SBIRT Efforts in General
Medical Settings Summary
- SBIRT is efficacious for alcohol and tobacco
evidence for illicit drugs is promising but not
yet sufficient - NIDA has numerous initiatives to enhance the
evidence base in next few years, and to
disseminate SBIRT training to medical
professionals - NIDAs collaborations with other
organizations/agencies is key to this process
42Questions?Comments?Suggestions?