Making the Link between Science and Practice: Doing It Well Drug Abuse Prevention and Treatment Zili Sloboda, Sc.D., Senior Research Associate Institute.

Making the Link between Science Making the Link between Science and Practice: Doing It Welland Practice: Doing It WellDrug Abuse Prevention and Drug Abuse Prevention and TreatmentTreatment

Zili Sloboda, Sc.D., Senior Research Associate

Institute for Health and Social Policy

The University of Akron

Akron, Ohio, USA

Identifying Europe´s Information Needs For Effective Drug Policy

Lisbon, 6-8 May 2009

1

Take Home PointsTake 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 evidence-based interventions, the vast majority of interventions being delivered in the United States are NOT considered evidence-based

2

Take Home PointsTake 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 StoryThe Drug Abuse Prevention Story

4

The 1990sThe 1990s

History of Prevention Research in the History of Prevention Research in the

United States—Part 1United 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 History of Prevention Research in the United States—Part 2United 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. ProgramsPrinciples vs. Programs

8

Terminology in Prevention 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

9

Progress?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 Principles of Prevention (National Institute on Drug Abuse—1997; rev. 2003)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 ethnicity12

Principles of Prevention--Principles of Prevention--PlanningPlanning

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--Principles of Prevention--DeliveryDeliveryAdapting 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 age-appropriate learning strategies,

Prevention Programs—Prevention Programs—Composed of…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 Prevention Program Definitions Using the Concept of RiskUsing the Concept of RiskUNIVERSAL programs reach the

general populationSELECTIVE 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 risk-related behaviors

Classroom Classroom Curriculum—Universal/Selected Curriculum—Universal/Selected ProgramsPrograms

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 Classroom Curriculum—Indicated ProgramsPrograms

Common Elements or Principles:– Identify students at high risk for substance abuse or

other associated behavior– Provide self-control, communications and decision-

making skills– Self-esteem/competency enhancement– Create positive peer support

Examples of Programs:– Reconnecting Youth—Eggert– Project Towards No Drug Abuse—Sussman– Project SUCCESS--Morehouse

Universal Selected Indicated

Individual

Family

Peers

Community

Home

Community

School

ClinicalMedia

Other

SETTING

TARG

ET

TYPE

2121stst Century--Incorporation of Century--Incorporation of Evidence-Based ConceptEvidence-Based Concept

20

Evidence-Based Concepts—Not Evidence-Based Concepts—Not StandardizedStandardized

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: Society for Prevention Research: Standards of EvidenceStandards of Evidence

Criteria for EfficacyCriteria for EffectivenessCriteria for DisseminationAvailable at:

– http://www.preventionresearch.org/StandardsofEvidencebook.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 Center for Substance Abuse Prevention: Identifying and Selecting Evidence-Based Interventionsand 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/SMA09-4205/evidence_based.pdf

23

““Lists of Evidence-Based Drug Lists of Evidence-Based Drug Abuse Prevention Interventions”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

24

INSTITUTE OF MEDICINE COMMITTEESINSTITUTE 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 Federal Funding for School-Based Prevention ProgrammingPrevention 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)

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Real World--StudiesReal 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)

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Real World--StudiesReal 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)

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Evaluating Existing Prevention Evaluating Existing Prevention Programming—1990s 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 Evaluating Communities That Care Model-2000sModel-2000s

CTC: The Community Youth CTC: The Community Youth Development StudyDevelopment Study

24 Communities; ~45,000 participantsFagan, Hawkins & Catalano, 2007; Quinby et al, 2007

Creating Communities

That Care

Get Started

Implement andEvaluate

Get Organized

Develop a Profile

Create a Plan

24 Communities; ~45,000 participants

Pre-post change in risk factors prioritized Pre-post change in risk factors prioritized and targeted in CTC Communitiesand targeted in CTC Communities

-0.20

-0.15

-0.10

-0.05

0.00

0.05

0.10

0.15

0.20

0.25

Control Communities CTC Communities

Ave

rage

Lev

el o

f R

isk

0

.25

-.15Grade 5 Grade 7

Triple P (Positive Parental Program)Triple P (Positive Parental Program)

Drug Abuse TreatmentDrug Abuse Treatment

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The 1990s—Summary of findings The 1990s—Summary of findings from two decades of research from two decades of research

Counseling Pharma-cotherapy

CommunityHospital

Jail

SETTING

TYPE

PHASEDetoxification

“Treatment”

Aftercare

Services*

Findings from Controlled StudiesFindings from Controlled Studies

Scientifically Based Approaches to Scientifically Based Approaches to TreatmentTreatment

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 StudiesFindings from Controlled Studiesand Evaluations of Ongoing Treatmentand Evaluations of Ongoing Treatment

Treatment variables associated with better Treatment variables associated with better

outcome from rehabilitation includedoutcome 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 Other Findings from Evaluations of Ongoing “Real World” TreatmentOngoing “Real World” TreatmentTreatment 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 Other Findings from Evaluations of Ongoing “Real World” TreatmentOngoing “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 lowRelapse rates after treatment are

unacceptably high

Principles of Effective Treatment—(National Principles of Effective Treatment—(National Institute on Drug Abuse--1999)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 TreatmentPrinciples 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

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

Principles of Effective Treatment

2121stst Century Incorporation of Century Incorporation of Evidence-Based ConceptEvidence-Based Concept

What Are Evidence-Based Practices?What Are Evidence-Based Practices?

Interventions that show consistent Interventions that show consistent scientific evidence of being related to scientific evidence of being related to preferred client outcomes.preferred client outcomes.

How Are Evidence-Based Practices How Are Evidence-Based Practices Documented?Documented?Gold Standard

• Multiple randomized clinical trialsSecond 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 ForumNational Quality ForumEvidence 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 use treatment.

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Lists--ExamplesLists--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 Evidence-Based Practices for Alcohol TreatmentTreatment

Brief interventionSocial skills trainingMotivational enhancementCommunity reinforcementBehavioral 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 Scientifically-Based Approaches to Addiction Treatmentto 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

SufficientSufficientRetentionRetentionSufficientSufficientRetentionRetention

Early Early EngagementEngagement

Early Early RecoveryRecovery

PosttreatmentPosttreatment

DrugDrugUseUse

DrugDrugUseUse

CrimeCrimeCrimeCrime

SocialSocialRelationsRelations

SocialSocialRelationsRelations

ProgramProgramParticipationParticipation

TherapeuticTherapeuticRelationshipRelationship

BehavioralBehavioralChangeChange

Psycho-SocialPsycho-SocialChangeChange

PatientPatientAttributesAttributesat Intakeat Intake

PatientPatientAttributesAttributesat Intakeat Intake

MotivMotiv

Evidence-Based Treatment ModelEvidence-Based Treatment Model

EnhancedEnhancedCounselingCounseling

BehavioralBehavioralStrategiesStrategies

Social SkillsSocial SkillsTrainingTraining

Family &Family &FriendsFriends

SupportiveSupportiveNetworksNetworks

SupportiveSupportiveNetworksNetworks

InductionInduction Personal Health ServicesPersonal Health Services

Social Support ServicesSocial Support Services

ProgramProgramCharacteristicsCharacteristics

ProgramProgramCharacteristicsCharacteristics

StaffStaffAttributesAttributes

& Skills& Skills

StaffStaffAttributesAttributes

& Skills& Skills

Simpson, 2001 (Addiction)

Real WorldReal WorldRecent 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…However, there still remains…

Treatment Need—2007Treatment Need—2007U.S. National Survey on Drug Use and HealthU.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 availabilityTreatment availability

1990 2002Number 16,000 14,000Residential/Inpatient 55% 14%Outpatient/Drug Free 30% 78% Methadone Maintenance 15% 12%

Source: McLellan et al., 2003

FundingFunding

Federal health care, e.g., medicaid, medicare

Carve-outs in third party insurance

Responses of “Feeling the need Responses of “Feeling the need for treatment”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 IssuesCommon 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 PreventionIssues 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

Pe

r

c

e

n

t

PERCENT DOLLAR CHANGE OVER PERCENT DOLLAR CHANGE OVER TIMETIME

INTERDICTION = 100.2%INTERNATIONAL= 48.4DOMESTIC LAW

ENFORCEMENT = 31.2TREATMENT = 22.2 PREVENTION = -24.5

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

Safe and Drug Free Schools and Communities-- Appropriations: 2001 through 2007

Issues Specific to PreventionIssues 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