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Translation to Community Settings
As important as the challenge of developing new treatments is the challenge of disseminating and implementing effective interventions already developed. This challenge cuts across all aspects of healthcare but is particularly salient in the addictions arena which – for a variety of historical-, policy-, funding-, workforce-, and stigma- related reasons – exists largely outside of mainstream medicine. Despite substantial progress in developing, testing and refining behavioral and pharmacological therapies, there is insufficient adoption of evidence-based intervention in practice and community settings. For nearly a decade we have been deeply engaged in addictions dissemination and implementation work and, because of our close affiliations with the NYC HHC, NYC DOHMH, NYC DOC, NYC DOE, the VA NYHHS and the NIDA CTN, we are uniquely positioned to contribute to this critically important area of translational research.
A particular focus has been on integration of medical primary care services into addictions settings (e.g., methadone programs) and more recently on addictions service into medical settings (e.g., primary care, ERs, etc.). With generous support from the NYC DOHMH and HHC, Drs. Marc Gourevitch, Joshua Lee and Jennifer McNeely were able to establish a buprenorphine clinic in the medical primary care setting in Bellevue. The adult primary care program at Bellevue serves approximately 20,000 unique patients who make 60,000 annual visits and has proven an invaluable laboratory in which to study integrated care. To date over a hundred opioid (mostly heroin) dependent patients have been safely and effectively treated with buprenorphine using a novel lower intensity “at-home” induction procedure and standard medical management strategies. This work was recently reported in the Journal of General Internal Medicine and is the basis of a proposal to NIDA for a much larger two-center effectiveness and cost-effectiveness study which is pending review. Also in this same medical primary care setting, the NIDA CTN Prescription Opioid Addiction Treatment Study (POATS, CTN-0030) is now nearing completion.
We have been working with Alkermes, Inc. on a 30-day extended release injectable form of naltrexone (XR-NTX) since 2003. The original studies (Casadonte) contributed to establishing efficacy in alcoholics; subsequent, as yet unpublished, studies (Rotrosen) focused on safety in alcoholics and opiate addicts. This agent is now marketed as Vivitrol, but uptake by the addictions community (which is not primarily “medical”, does not have routine capacity to give injections, etc.) has been slow. Alkermes provided support for an investigator-initiated (Gourevitch, Lee) demonstration project to treat alcoholism in medical primary care settings at Bellevue and at the NYC HHC Gouverneur clinic downtown. Seventy-two volunteers were enrolled, with treatment retention at 90-days a robust 56%.
Unique to our XR-NTX and buprenorphine work is delivery of these treatments in a public hospital medical primary care setting, allowing us to extend treatment to populations that may otherwise not access specialized addictions programs. This allows us to reach patients earlier in the course of disease, and to destigmatize treatment by integrating it with care for other common chronic conditions. The psychiatry and medicine programs have a strong track record of collaboration around clinical care, training and research, as well as current and pending collaborative grant support.
Dr. Donna Shelley’s work on special populations includes an NIH-, CDC-, NYC DOHMH study on the effectiveness of community-based smoking cessation interventions among Chinese Americans living in NYC. This work was instrumental in demonstrating effective strategies for disseminating evidence-based treatment to underserved populations. An ongoing NY State DOH-, NYC Department for Homeless Services study focuses on smoking cessation among sheltered homeless enrolled in chemical dependency programs, and is unique in its use of shelter case managers and social work staff as interventionists. Dr. Shelley’s dual appointments in the NYU Colleges of Dentistry and Nursing offer an opportunity to use dental settings and nursing faculty practice as venues for addiction screening and intervention.
NIDA CTN studies of behavioral interventions (e.g., contingency management, motivational interviewing) have been carried out in a variety of community-based addictions specialty settings. Emerging from a workshop at a CTN “Blending Research and Practice” Conference we hosted in NY, an alliance formed between Dr. Scott Kellogg who played a lead role in a CTN study on contingency management, and Drs. Marylee Burns and Peter Coleman from HHC’s Office of Behavioral Health. A small grant from HHC enabled implementation of site-specific contingency management-based interventions in five HHC addictions programs, which became the centerpieces of their respective psychosocial interventions. These programs were widely applauded by patients, staff, and administrators, and HHC subsequently showcased these in a day-long conference, “Science in the Trenches – Contingency Management at HHC,” at Pace University for close to 200 HHC and NY State providers. The HHC project is probably the largest ever adoption of contingency management by an addiction treatment system anywhere in the world.
SBIRT (Screening, Brief Intervention, Referral to Treatment) is an initiative that has been highlighted and generously funded by the ONDCP, SAMHSA, NIDA and CMS, to move addictions services into mainstream healthcare practices. We are leading an innovative initiative to study the impact of integrating SBIRT into dental practice settings in conjunction with the NIDA CTN and an NIDCR dental practice-based research network. In collaboration with the NYC DOHMH we are planning an implementation and evaluation project to incorporate the NIDA-MED electronic ASSIST screening tool into the NYC DOHMH electronic health record. This will be a large-scale implementation initiative carried out with NYC’s pathbreaking health department.