It s Epidemic: Prescription Drug Abuse and How to Prevent It. May 23, 2012

Transcription

1 It s Epidemic: Prescription Drug Abuse and How to Prevent It May 23,

2 Today s Presenters Wilson M. Compton, M.D. Director, Division of Epidemiology, Services, and Prevention Research, National Institute on Drug Abuse, National Institutes of Health Elizabeth Robertson, Ph.D. Senior Advisor for Prevention Research, National Institute on Drug Abuse, National Institutes of Health Richard Spoth, Ph.D. F. Wendell Miller Senior Prevention Scientist and Director, Partnerships in Prevention Science Institute, Iowa State University 2

3 Overview Jack B. Stein, Ph.D. Chief, Prevention Branch White House Office of National Drug Control Policy 3

4 Poll Question: Who are You? 1. Extension educator 2. Teacher 3. Youth worker 4. Researcher 5. Substance use disorder specialist 6. Concerned citizen 4

5 What is the Extent of the Prescription Drug Abuse Problem? Wilson M. Compton, MD National Institute on Drug Abuse 5

6 Prescription Drug Abuse is a Major Problem in USA: Current Drug Use Rates in Persons Ages Numbers in Millions Source: SAMHSA, 2010 National Survey on Drug Use and Health 1 Illicit Drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or prescriptiontype psychotherapeutics used nonmedically. 6

7 2011 Monitoring the Future Study Prevalence of Past Year Drug Use Among 12 th graders Drug Prev. Drug Prev. Alcohol 63.5 OxyContin* 4.9 Marijuana/Hashish 36.4 Sedatives* 4.3 Synthetic Marijuana 11.4 Hall other than LSD 4.3 Amphetamines* 8.2 Inhalants 3.2 Vicodin* 8.1 Cocaine (any form) 2.9 Adderall* 6.5 LSD 2.7 Salvia 5.9 Ritalin* 2.6 Tranquilizers* 5.6 Ketamine 1.7 Cough Medicine* 5.3 Provigil 1.5 MDMA (Ecstasy) 5.3 GHB 1.4 Hallucinogens 5.2 Methamphetamine 1.4 * Nonmedical use Categories not mutually exclusive

8 Numbers in Thousands Large Number of Past Year Initiates of Pharmaceuticals: Persons Aged 12 or Older, 2010 Source: 2010 National Survey on Drug Use and Health, SAMHSA, 2011.

9 66% Increase in Treatment Admissions Increasing for Pharmaceutical Opioids: Ages 12+ in USA Numbers in Thousands * Difference between this estimate and the 2008 estimate is statistically significant at the.05 level. SAMHSA: 2008 Treatment Episode Data Set 9

10 Death Rate* per 100,000 population DEATHS: Marked Increase in Unintentional Drug Overdose Drug overdose death rates in the US have more than tripled since Nearly 15,000 persons died of prescription opioid overdoses in * Poisoning by drugs (illicit, prescription and over-the-counter) was the underlying cause of death Source: CDC Vital Signs, November

11 Increases in deaths parallel opioid sales increases as well as prescription opioid treatment admissions Source: CDC Vital Signs, November 2011

12 Deaths from Overdose Vary by State: Unintentional Overdose Deaths in U.S. States 2008 Source: CDC Vital Signs, November

13 Availability of Prescription Opioids Varies by State: Kilograms of Painkillers per 10,000 in U.S. States 2010 Source: CDC Vital Signs, November

14 Poll Question: Where Do Most People Who Abuse Prescription Analgesics Obtain Them? 1. Bought them from a friend/relative 2. Got them for free from a friend/relative 3. Over the internet 4. From a doctor 5. From their veterinarian 14

15 People Abusing Analgesics Mostly Do Not Obtain Them by Prescription: Most Recent Source for Ages 12+ Source Where Respondent Obtained More than One Doctor One Doctor (2.1%) (17.3%) Other 1 (4.6%) Bought on Internet (0.4%) Drug Dealer/ Stranger (4.4%) Bought/Took from Friend/Relative (16.2%) Free from Friend/ Relative (55.0%) One Doctor (79.4%) 1 Other category includes Wrote Fake Prescription," "Stole from Doctor s Office/Clinic/Hospital/Pharmacy," and "Some Other Way." Source Where Friend/Relative Obtained More than One Doctor (3.6%) Free from Friend/Relative (6.3%) Bought/Took from Friend/Relative (6.5%) Drug Dealer/ Stranger (2.3%) Bought on Internet (0.2%) Other 1 (1.7%) Source: SAMHSA, 2009 and 2010 National Survey on Drug Use and Health

16 Prescriptions (millions) Number of Opioid Prescriptions Dispensed by U.S. Retail Pharmacies, Years Opioids Hydrocodone Oxycodone Source: IMS s Source Prescription Audit (SPA) & Vector One: National (VONA)

17 Number of Stimulant Prescriptions Dispensed by U.S. Retail Pharmacies, Years

18 Preventing Prescription Drug Abuse: A Need for New Thinking Availability of drugs within homes Abuse and misuse as an intervention targets Relaxed attitudes and misperceptions about prescription drugs Drug disposal resistance and concerns Multiple drug effects Friends as a key source of drugs

19 Summary Abuse of pharmaceuticals, especially opioids, is an urgent matter requiring coordinated federal, state and local responses. Yet, when used properly, opioid, sedative and stimulant pharmaceutical agents have many benefits. Balancing these competing issues is necessary.

20 Revised Jan 2012 Revised Dec 2011 Published Dec 2011 Revised Oct 2011

21 What are the Key Elements of Drug Prevention? Elizabeth Robertson, Ph.D. National Institute on Drug Abuse

22 NIDA s Prevention Branch: Mission NIDA s Prevention Research Branch supports a theory driven program of basic, clinical, and services research across the lifespan to reduce risks and prevent the initiation and progression of drug use to abuse and prevent drug-related HIV acquisition, transmission and progression.

23 Putting Prevention In Context Time

24 Target Group Characteristics Genetic Vulnerability Gender Learning Style Developmental Status Sexual Orientation Race/Ethnicity Geographic Location Socio-economic status

25 Level of Risk Universal Selective Indicated Tiered

26 Environments and Level of Risk Universal Selective Indicated Family Peer group School Community Workplace Clinic Media Policy Foster Care WIC Juvenile Justice Pre-natal Clinics Rape Clinics STD Clinics Age Risk Continuation Schools College Drug Violation Programs

27 Intervention Strategy Emotional Regulation Social Skills Intrapersonal Academic Competency Resistance Skills Parenting Skills Interpersonal Normative Change Surrounding Environment Change (e.g., Teacher, Practitioner Training) Larger Environment Change (e.g., Tobacco Policy)

28 Poll Question: Which factors can be modified to reduce the risk of drug use? 1. Academic problems 2. Misperceived drug use norms 3. Association with deviant peers 4. Neighborhood availability 5. All of the above 28

29 How do Prevention Interventions Work? Period of Vulnerability MODERATORS MODIFIABLE RISKS INTERVENTION Heritability Age Gender Race/ethnicity Poverty level Early aggression Social skills deficit Academic problem Misperceived drug use norms Association with deviant peers Neighborhood availability Media glamorization Parent skills training Social skills training Tutoring Norms training Refusal skills Community policing Health Literacy

30 Drug Abuse Prevention Does Works

31 Middle/Junior High School Universal Life Skills Training (LST) Program 6.5 Year Follow-up P<.05 P<.05 P<.05 P<.05 Inhalants Hallucinogens Botvin, et al., 2000

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33 Preventive Interventions Can Have Long-term Effects on Drug Use and Abuse

34 Kellam et al. (2008). Drug and Alcohol Dependence 95 S, S5-S28. Probability of Drug Abuse/Depend School-aged (Universal) GBG vs. All Controls on Drug Abuse or Dependence Disorders for Males in Young Adulthood.8.6 GBG (n = 72 ) All Controls (n = 134 ) Low Teacher Ratings of Aggression: Fall of 1st Grade High

35 Prevention Interventions Can Have Unintended Positive Effects on Other Health Risking Behaviors, including Emerging Drugs of Abuse

36 Universal Family-based Prevention Reduces Methamphetamine Use Lifetime and Past Year Meth Use at 4½-6½ Years Past Baseline * * * * * * Source: Spoth, et al Arch Pediatr Adolesc Med. Two randomized studies of the long-term effects of brief universal preventive interventions on adolescent methamphetamine use

37 High Risk Populations May Benefit The Most From Prevention Interventions, EVEN Universal Interventions

38 Percent Lifetime Use Illustrative Findings #4 PROSPER Sustainability Trial Impact on Marijuana Use Among Higher-Risk Students Outcomes at 4½ Years Past Baseline 60% 50% 40% 30% Higher Risk, Control Higher Risk, Intervention Lower Risk, Control Lower Risk, Intervention 20% 10% 0% Source: Spoth, Redmond, Greenberg, Shin, et al. (2009). Addressing Addiction with Community Health Partnerships and Evidence-Based Intervention: Substance Use Outcomes 4½ Years Past Baseline. Manuscript in preparation.

39 Public Health Impact Public Health Impact + Cost Benefit = Universal Intervention IF Epidemiological Data Intended Target Not Clear (e.g., Emerging Trend) Population-based Problem Proximal Risk to Distal Outcome Significant Number Intended Targets Pop can be Reached

40 Cooperative Extension System (CES) Opportunities for National Impact: Universal Prevention of Prescription Drug Misuse* Richard Spoth, Ph.D. Iowa State University * Studies funded by the National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism and the National Institute of Mental Health at the National Institutes of Health, the Centers for Disease Control and Prevention and the Annie E. Casey Foundation. 40

41 Part 1. Context Four Core Components of a Population Impact Strategy with Evidence-Based Preventive Interventions Translating Prevention Science Into Practice 4. Federal/State Collaborations 3. Translational Infrastructures/ Systems 2. Necessary Community Delivery/Impact the CES Could Play a Key Role in All Four Core Components. 1. Necessary Evidence- Based Interventions

42 Part 1. Context Two Important Points to Consider See Spoth, R. (2008) Translating family-focused prevention science into effective practice. Toward a translational impact paradigm. Current Directions in Psychological Science, 17(6), ; Spoth, Reyes, Redmond, & Shin (1999). Assessing a public health approach to delay onset and progression of adolescent substance use: Latent transition and log-linear analyses of longitudinal family preventive intervention outcomes. Journal of Consulting and Clinical Psychology, 67. Point #1 Need Effective Universal Intervention, addressing the 4 E Impact Factors: Proven Effectiveness, Engagement of participants, Efficiency, Extensiveness of population coverage Point #2 There are Two Windows of Opportunity for Impact No Use Substance Initiation Intervene to Reduce Probability of Transition Advanced Use

43 Poll Question: What do Cooperative Extension System (CES) staff state is the biggest obstacle to implementing prevention programs? 1. Community members don t see a need for it. 2. There are no financial resources to support it. 3. Local agency partners are not interested in it. 4. It is outside the scope of CES.

44 Part 2. CES-Based Universal Intervention Effectiveness Illustrative Results from Three CES Partnershipbased Randomized Controlled Trials Community-university partnerships Evolved across three prevention trials, over 23 years Based in linkage of existing infrastructures, CES and public school systems Project Family Trial II 33 rural Iowa school districts Capable Families and Youth Trial (CaFaY) 36 school districts PROSPER Trial 24 school districts, collaboration with Pennsylvania State University* *PROSPER is funded by a grant from the National Institute on Drug Abuse #DA R. Spoth (PI, Iowa State University), M. Greenberg (PI on subcontract, Pennsylvania State University), C. Redmond (Co-PI at ISU), M. Feinberg (Co-PI at PSU), with co-funding from the National Institute on Alcohol Abuse and Alcoholism.

45 Example of Tested Universal Program in the Project Family Trial The Strengthening Families Program: For Parents and Youth 10-14* * A seven-session program with 6 th graders and their parents, formerly called the Iowa Strengthening Families Program (ISFP).

46 Illustrative Project Family Young Adult Outcomes Lifetime Prescription Drug Misuse 18.0% 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% Family Program Control 1.2** *** ** ** Age 21 General Age 21 Narcotics Age 25 General Age 25 Narcotics **p<.01; ***p<.001; RRRs = 65-93% Relative Reduction Rates (RRRs)= 65-93% 13.5 If a 65% RRR were to hold, for every 100 young adults in the general/normal population initiating use, only 35 young adults from an intervention community would initiate. Also see Spoth, Trudeau, Shin & Redmond (2008). Long-term effects of universal preventive interventions on prescription drug misuse. Addiction, 103(7), Notes: General=Misuse of narcotics or CNS depressants or stimulants.

47 Example of Tested Universal Programs in the CaFaY Trial LifeSkills Training* A 15-session in-class program for 7 th graders, combined with the Strengthening Families Program: For Parents and Youth All intervention-control tests for the higher-risk subgroup significant at ages 21 & 22, with RRRs from 61-79%.

48 3rd Generation Community-University Partnership Delivery Model Addresses Challenges, Like Sustainability PROSPER Local Community Teams Extension Agent, Public School Staff, Social Service Agency Representatives, Parent/Youth Representatives Prevention Coordinator Team Extension Prevention Coordinators University/State-Level Team University Researchers, Extension Program Directors

49 II. CES-Based Universal Intervention Effectiveness PROSPER Community Team Linkages to University-based Prevention Researchers Teams receive ongoing technical assistance from Prevention Coordinators (PCs) PCs are Extension staff, with backgrounds in relevant programming PCs provide interface between the community teams and university research team Team delivers family (e.g., SFP 10-14) and school (e.g., LST) EBPs from a menu

50 PROSPER Late Adolescent Outcomes Lifetime Prescription Drug Misuse 40.0% 30.0% PROSPER Control 23.1* 22.1* 20.0% 10.0% 0.0% *p<.05; RRRs = 20-21% Grade 12 General Grade 12 Narcotics Also see Spoth, Redmond, Clair, Shin, Greenberg, & Feinberg (2011). Preventing substance misuse through community-university partnerships: Randomized controlled trial outcomes 4½ years past baseline. AJPM, 40(4), Notes: General=Misuse of narcotics or CNS depressants or stimulants.

51 Key PROSPER Partnership Delivery System Findings Positive effects on family strengthening, parenting, and youth skill outcomes Youth score significantly lower on a range of problem behavior outcomes (both substance misuse and conduct problems Indications that more cost efficient than regular programming; also, that cost effective and cost beneficial

52 Part 3. Future Directions Two Lessons Learned from Past 20+ Years of CESbased Partnership Research CES-based partnerships provide a practical way to have the best of both worlds practice (community driven) and science (quality implementation, larger effect sizes) Core factors in PROSPER success are clear, at least in a general sense, e.g., need ongoing, proactive TA; multiphase developmental process, with benchmarking See Spoth & Greenberg (2011). Impact challenges in community science-with-practice: Lessons from PROSPER on transformative practitioner-scientist partnerships and prevention infrastructure development. American Journal of Community Psychology, 48(1-2),

53 Recent Grants are Funding the Development of a Network of PROSPER States PROSPER Network Team Prevention Scientists, TA Providers, IT and Data managers/analysts PROSPER State Partnership Community Teams in State Site State-Level Prevention Coordinator Team State Management Team

54 Part 3. Future Directions A Formula for the Future: Universal EBIs that Reduce Prescription Drug Misuse + PROSPER-like Delivery System + Network Based in CES National Infrastructure = Population Impact Potential

55 Envision the Potential for Population Impact

56 One Life Course at a Time Like One of Our Participating Youth, Who Said: The program gave me the building blocks I needed to begin opening up...my family benefited...six years later I continue to have an open and honest relationship with my mom and dad...

57 Together, We Can Make a Difference.

58 The PROSPER Partnership Group Iowa State University Pennsylvania State University Partnership in Prevention Science Institute Prevention Research Center Richard Spoth, Director Mark Greenberg, Director PPSI Scientists: PRC Scientists: Cleve Redmond Chungyeol Shin Mark Feinberg Daniel F. Perkins Lisa Schainker Kate Ralston Claudia Mincemoyer Janet Welsh Sarah Meyer Chilenski Funded by Human Interaction Research Institute The Centers for Disease Control and Prevention The Annie E. Casey Foundation Tom Backer, Director The National Institute on Drug Abuse

59 Please visit our websites at Funded by the National Institute on Drug Abuse Grant #DA Spoth (PI, Iowa State University), Greenberg (PI on subcontract, Pennsylvania State University), Redmond (Co-PI at ISU), Feinberg (Co-PI at PSU)

60 Questions? 60