GHB - Pennsylvania State University

GHB - Pennsylvania State University

NIDAs Public Health Division: The Division of Epidemiology, Services and Prevention Research Wilson M. Compton, M.D., M.P.E. Director, Division of Epidemiology, Services and Prevention Research National Institute on Drug Abuse Department of Health and Human Services Penn State University 29 November 2006 National Institute on Drug Abuse Office of the Director Special Populations Office EEO Office of Extramural Affairs Teresa Levitin, PhD

Nora D. Volkow, MD Director Timothy P. Condon, Ph.D. Deputy Director Laura S. Rosenthal Associate Director for Management Office of Planning & Resource Management Office of Science Policy & Communications Laura Rosenthal Timothy Condon, PhD Director, AIDS Research

Center for the Clinical Trials Network Betty Tai, PhD Intramural Research Program Barry Hoffer, MD, PhD Division of Basic Neurosciences & Behavior Research Division of Pharmacotherapies & Medical Consequences of Drug Abuse Division of

Epidemiology, Services & Prevention Research Division of Clinical Neuroscience, Development & Behavioral Treatment David Shurtleff, PhD Frank Vocci, PhD Wilson Compton, MD, MPE Joseph Frascella, PhD DESPR Organization and Vision EPIDEMIOLOGY RESEARCH BRANCH

DESPR seeks to improve the nations public health by promoting integrated approaches to understand and address interactions between individuals and environments that contribute to the continuum of problems related to drug use. Our goal is to develop scientific knowledge with clear application to practice and public policy. PREVENTION RESEARCH BRANCH SERVICES RESEARCH BRANCH First, a story exemplifying linkages of Epidemiology, Prevention and Services Epidemiological Finding: Childhood and Adult Antisocial Behavior Strongly Associated with Drug Use/Disorders 20

18 16 14 12 10 8 6 4 2 0 18.7 14.0 11.3 10.2 10.9 11.9 15.1 12.8 12.5

8.0 r t e g a d n e e e i n n n u e z v

n i i r a g io la li ti o a i o u m a D p a c

c j u l h d in o ta O q ri n e c A e ny a C I

n S A llu ph M ra a T m H A Odds Ratios for Lifetime Antisocial Personality Disorder by Specific Drug Disorders, Reference group is persons without the drug disorder (NESARC Study, Compton 2004) l ho From Longitudinal Epidemiology comes evidence for a plausible pathway: Early Aggression

Adolescent/Early Adult Antisocial Behavior and Drug Abuse Poor academic achievement Deviant peer association From Prevention: comes tests of the theory and tests of a plausible intervention strategy: Support for theory and development of practical and useful interventions. ESTIMATED CUMULATIVE RISK From Prevention: Reducing Early Aggressive Behaviors Reduces Drug Use Control: 33%, reference

CC: 25%, aRR 0.61 (0.37-1.00) FSP: 25%, aRR 0.70 (0.50-0.98) CC=Classroom Centered 7 8 9 FSP=Family-School Partnership 10 11 12 13

AGE OF FIRST TOBACCO USE Modified from: Storr, et al., Drug and Alcohol Dependence, 66:51-60, 2002. From Prevention: Enhancing Social Bonding Reduces Violence 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 83% 72% 60% 48%

Violence Sexual Activity SSDP Intervention Comparison Hawkins, et al., Arch Pediatr Adolesc Med 1999 From Services: Early Interventions Can Be Cost-Effective Nurse Home Visiting Program Cost per Participant Taxpayer and Crime Victims Net

Benefit $ 7,733 $15,981 $ 4,355 $14,169 $ 1,054 $ 4,524 Seattle Social Development Project Big Brothers/Sisters Mentoring Aos, et al., The Comparative Costs and Benefits of Programs to Reduce Crime, Washington State Institute for Public Policy, 2001

Ongoing Problem: To Reap Any Benefits From Scientific Knowledge It Needs To Be Used In Practice From Services: Few Schools Use Effective Prevention Programs 60% 50% 40% 30% 20% 10% 0% 26.8% 34.6% 12.6%

Percentage Using One of the Top 12 Effective Programs Ringwalt, et al. (2002), Prevention Science Thus, all three branches of DESPR contribute to a unified story about pathways to drug use and how to intervene in these pathways. And now A Few Key Findings ERB: Cigarette Smoking Declines Markedly Since Mid-1990s Lifetime 70 60 50

* * * 40 30 20 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 8th Grade 10th Grade 12th Grade * Denotes significant difference between recent peak year and current year. Denotes significant difference between 2004 and 2005. Source: University of Michigan, MTF 2005

SRB: Life Course View of Addiction Refines Understanding of Recovery & Benefit Cost Recovery Multiple treatment episodes is the norm. 27 years = Median time from first to last drug use 9 years = Median time from first treatment episode to last use Dennis, Scott, Funk, & Foss. (2005). The duration & correlates of addiction & treatment. JSAT, 28, S51-S62. Benefit Cost Lifetime Benefi t-Cost

Ratio for Tx of Heroin Use 40 35 30 25 20 15 10 5 0 1Tx Episode Life Course Zarkin, Dunlap, Hicks, & Mamo. (2005). Benefits & costs of methadone treatment: results from a lifetime simulation model. Health Economics, 14, 1133-1150.

PRB: Universal Family-based Prevention Interventions Reduce Methamphetamine Lifetime and Past Year Meth Use at 4-6 Years Past Baseline 8 Past Year Use* Lifetime--Past Year Plus Prior Use 7.61 7 6 5 5.18 % 4

4.15 3 3.45 3.21 2.51 2 1 0 4.59 2.63 2.40 2.12 1.44 .53 ISFP PDFY Control

Study 1 (12th Grade) SFP+LST LST Control Study 2 (11th Grade) SFP+LST LST Control Study 2 (12th Grade) Source: Spoth, et al. (2005). Two randomized studies of the long-term effects of brief, partnershipbased universal preventive interventions on adolescent methamphetamine use 2.0 1.8 1.6 Life expectancy 1.4 1.2 1.0 0.8 0.6

0.4 Quality-adjusted life expectancy 0.2 0.0 30 40 50 60 AGE (Yr) 70 80

90 Incremental Cost-Effectiveness of Screening ($/quality-adjusted life year) Increase in Life Expectancy Due to Screening (Yr) DESPR: HIV Screening Can Be As CostEffective As Screening for Hypertension and Other Medical Conditions 200,000 180,000 160,000 140,000 120,000 100,000 80,000

60,000 40,000 20,000 Costs and benefits to partners excluded Costs and benefits to partners included 0 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Prevalence of Unidentified HIV (%) Source: Paltiel, et al. and Sanders et al., NEJM 352(6), 2005. DESPR provides a foundation for NIDAs Public Health Mission. Priority Areas for NIDA Prevention Research

Children and Adolescents Genetics Comorbidity Development Treatment Interventions (New Targets & New Strategies) HIV/AIDS Research DRUG ABUSE HIV/AIDS Summary: Drug Abuse Research Needs a Systems Approach social DRUGS OF ABUSE behavior

neuronal circuits protein expression genome DESPR: 2006 Major Research Questions 1. What new theoretical approaches can inform our research? 2. What intrapersonal and environmental factors interact with each other and with genetic factors? 3. How can we blend science and services to measurably impact public health outcomes? Prevention 2006 Key Research Goal Develop and maximize use of high quality preventive interventions in real world settings through research on Individual factors Relationship of drug abuse prevention to HIV prevention

Environmental strategies Community-based participatory research What are we doing to develop and promote these themes? Workgroups, Meetings, Publications, etc. Translational Research is NOT Unidirectional: There are Feedback Loops Type 1 Type 2 Bi-Directional Influences Basic science laboratories prevention:

Sensation Seeking Neurobehavioral disinhibition Early-onset antisocial behavior Psychiatric co-morbidity Stress reactivity Prevention basic neuroscience laboratories: What are the biological mechanisms that explain the emergence of drug abuse during adolescence? What specific vulnerabilities are familial? What are the biological mediators of social interactions? Linking Public Health Research to Neuroscience Circuits Involved In Drug Abuse and Addiction INHIBITORY CONTROL


All Should Be Considered In Strategies to Prevent and Treat Addiction Non Addicted Brain Addicted Brain Control Control STOP Reward Drive Memory Reward

Drive GO Memory Promise of Translation: HPA axis plasticity Psychosocial intervention 1 0.8 0.6 0.4 6 Mont 3 Month 0.2 0 wakeup Initial mid morning

bedtime Source: Fisher P, OSLC Brandon's PDR Concordant behavior change 35 30 25 Init. 20 Total PDR # of Beh. Linear (Total PDR)

15 10 5 0 Linear (# of Beh.) 3 mo. 6 mo. Key Basic Epidemiology Finding: Addiction is a Developmental Disorder With Onset During Adolescence 0.012 DSM-IV Abuse

Hazard Rate 0.010 DSM-IV Dependence 0.008 0.006 0.004 0.002 0.000 5 10 15 20 25

30 35 Age 40 45 50 55 60 Source: NESARC Study, 2001-2002 Recent Studies Have Shown that Maturation of the Brains Gray Matter Moves from Back to Front

Brain areas where volumes differ in adolescents compared to young adults Source: Sowell, E.R. et al., Nature Neuroscience, 2(10), pp. 859-861, 1999 During Adolescence the COGNITION-EMOTION Connection is Still Undergoing Development Amygdalo-cortical Sprouting Continues Into Early Adulthood Low-power light photomicrographs of immunoperoxidase-labeled, biocytin-containing amygdalofugal varicose fibers within the mPFC of animals at 6 stages of development Source: Cunningham, M et al., J Comp Neurol 453, pp 116-130, 2002. Implications: Developmental differences must be considered in designing prevention strategies. Can frontal lobe functioning be strengthened?

Translating Sensation Seeking Research into Clinical Study: Communications Research Sensation-Seeking Targeting (Palmgreen et al., 2001) Used Activation model of information exposure to design messages for target audiences RESULTS: All 3 targeted television campaigns reversed upward trends in 30-day marijuana use among high SS How will D2 receptor research inform this field? Community Bedside Bench 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) Community Bedside

Bench Interagency Collaborations are indispensable DHHS NIH SAMHSA NIDA NIDA Collaborations to Translate Research Findings Into Relevant Clinical Practice Testing the Communities That Care (CTC) Prevention System Research Centers Coordinating Center

Linking grant programs Braiding funding streams to enhance both research and services Each agency doing what it does best Examples: Adolescent Services Including Brief Interventions (FY2003 with SAMHSA) Assessment and Brief Interventions in Primary Care (FY2004 with SAMHSA) NIDA Funding Research on CSAPs National SPF-SIG Program (FY2004) Service to Science Grants for State Substance Abuse Authorities (FY2005) and for CBOs (FY2006) Community Bedside Bench Developing the Health Services Research Program

NIDA Blue Ribbon Task Force on Health Services Research Co-Chairs: Thomas McLellan, PhD, Constance Weisner, DrPH, MSW Andrea Barthwell, MD Caryn Blitz, PhD Rick Catalano, PhD Mady Chalk, PhD Linda Chinnia, MEd Lorraine Collins, PhD Wilson Compton, MD, MPE Michael Dennis, PhD Richard Frank, PhD Warren Hewitt, MS James Inciardi, PhD Marguerita Lightfoot, PhD Isaac Montoya, PhD Claire Sterk, PhD Janet Wood, MBA, MEd

New Opportunities: Science to Services Medical Settings Screening (especially SBIRTs) Prescription Drug Abuse (especially opioids) HIV Interactions Implementation Science New Theories

Economics Organization/Management Division of Epidemiology, Services and Prevention Research Providing a foundation for NIDAs public health mission.

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