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Making science speak to
policy and practice:
An introduction to the difficulties that exist on the road
from scientific evidence to practice outlining current
developments, challenges and opportunities.
Speaker: Michael Farrell, National Addiction Centre,
London, UK
… from Faith to Science …
Political and moral
values of the social
system
SERVICE
Provider
AND USER
VIEW
A model for evidence-based clinical decisions
Research
Evidence
(from Haynes et al, 1996)
Policy Development
•
•
•
•
•
Identifying Need,
Identify options for effective interventions
No single option effective
Define balance of options
Consultation process with stakeholders to
develop new approaches.
• Translate new knowledge into developmental
practice
• Into mainstream clinical practice
Scientific Development
• Importance of investment in basic
biological research, neuroscience,
molecular genetics, development of new
agents for treatment.
• Investment in other types of treatment,
• And psychosocial interventions.
• Social policy evaluation
Challenge of technology transfer
• Some basic science increases theoretical
understanding but gap when it comes to
application, thus the bench to bedside gap
can be very large
• Application of new policies and treatment
can take a very long time to be put in
place, anything from 10 years to 30 years
• Problem that life span of policy officials
often much shorter than that
Prevalence of smoking, 1950 thru 2000
Peto, R. et al. BMJ 2000;321:323-329
Copyright ©2000 BMJ Publishing Group Ltd.
FIG 2 - Prevalence of smoking in British men and women during 1961-91 by socioeconomic
group. (From Wald and Nicolaides Bouman3
Townsend, J et al. BMJ 1994;309:923-927
Copyright ©1994 BMJ Publishing Group Ltd.
FIG 1 - Relation between consumption (pounds sterling billion at 1992 prices) and real price
(1992=1.0) of cigarettes in Britain during 1972-92. (From Office of Population Censuses and
Surveys2)
Townsend, J et al. BMJ 1994;309:923-927
Copyright ©1994 BMJ Publishing Group Ltd.
UK per capita alcohol consumption 1948-2003:
on the watch of the NHS
10
9
8
Litres pure alcohol
7
6
Spirits
5
PreMix
Wine
4
Cider
Beer
3
2
1
0
1948 1952 1956 1960 1964 1968 1972 1976 1980 1984 1988 1992 1998 2002
a) Males age 15-44 years
c) Males age 45-64 years
18
80
16
70
14
60
12
50
10
40
8
30
6
20
4
10
2
0
1950
1960
1970
1980
1990
2000
0
1950
1960
1970
1980
1990
2000
Time-trends in liver cirrhosis age-standardised mortality rates per 100,000 by
age group, sex and country 1950-2002 (Leon & McCambridge, Lancet, 2006)
b) Females age 15-44 years
d) Females aged 45-64
8
35
7
30
6
25
5
20
4
15
3
10
2
5
1
0
1950
1960
1970
1980
1990
2000
0
1950
1960
1970
1980
1990
2000
Time-trends in liver cirrhosis age-standardised mortality rates per 100,000 by
age group, sex and country 1950-2002 (Leon & McCambridge, Lancet, 2006)
Options in drug policy
• Prevention
• Demand Reduction
• Supply Reduction
• Treatment
• Demand Reduction
Implementation of Substitution
Treatment
• Dole studies published 1968
• First roll out US 1973, faltered
• Low level provision until late 1980s AIDs
driven change especially Spain
• France obstacle 73 people in treatment
from 68 to 93 intoduced Buprenorphine
• Slow change in Asia
• Heroin prescription Swiss studies, gradual
change Germany, Netherlands, UK
Implementation
• Mass public health provision versus pilot
level small population provision
• Challenge to Implement properly
• Need for outcome data to convince
• After implmentation need for outcome data
to determine impact, limited information on
most effective approach to large scale
delivery,
• Prisons major challenge
10-year trend in the number of substitution treatment clients
in Europe (EU-15)
600,000
537,000
500,000
400,000
351,000
265,000
300,000
207,000
200,000
100,000
73,400
0
1993
1995
1997
2000
2003
Estimated number of drug users in
substitution treatment in 29 European
countries (2003) per 100.000 population
aged 15-64
450
400
350
300
250
200
150
100
50
0
LU UK ES IE MT FR PT IT SI DK EU DE NL NO SE EL BE CZ LT
+4
FI HU BG LV PL RO
QUESTION
• WHAT IS THE TIME PERIOD OF
INCREASED RISK FOR DRUG RELATED
DEATH AFTER RELEASE FROM
PRISON
• FOR MALES AND SEPARATELY FOR
FEMALES
• 2WEEKS
• ONE MONTH
• THREE MONTHS
Post-release mortality rates (males)
Farrell & Marsden [2008] n = 36,515
Post-release mortality rates (females)
Farrell & Marsden [2008] n = 12,256
Post-release mortality
• 20- to 50-fold increase in drug-related deaths in
the 1st week after release
– drops by 50% / week
– plateaus at 4 weeks
• Odds of drug-related death in 1st wk postrelease
– Among women
• > 10 x that observed at 52 wks (OR 10.6; 95 %CI 4.8-22.0)
• 70 x that in age-matched population
– Among men
• ~ 8 x that observed at 52 weeks (OR 8.3: 95 %CI 5.0-13.3).
• 30 x that in age-matched population
Seaman et al 1996; Bird et al 2003; Singleton, Farrell, Marsden et al 2003; Farrell, Marsden (50,000 releases).
Addiction 2008; Stewart et al (2004) Western Aus; Graham (2004) Victoria; Singleton, Farrell et al
Countries involved in prison
substitution Treatment
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Spain
France
Germany
Denmark
Ireland
NHS STRUCTURES
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•
•
•
NIHR Health Technology Assessment
National Institute for Clinical Effectiveness
National Treatment Agency
Clinical Guidelines for the management of
Drug Dependence
NICE
• NICE produces guidance in three areas of
health:
• public health - guidance on the promotion of
good health and the prevention of ill health for
those working in the NHS, local authorities and
the wider public and voluntary sector
• health technologies - guidance on the use of
new and existing medicines, treatments and
procedures within the NHS
• clinical practice - guidance on the appropriate
treatment and care of people with specific
diseases and conditions within the NHS.
NICE
Decision making process
Incorporates Cochrane Evidence Base
Conducts on metanalysis
Becomes more complex as areas of review
broaden,
Major controversies, on oncology care and
dementiae care.