By Gregory Brigham
The ATTC work group has provided a valuable and timely contribution by suggesting a common set of terms and concepts to clarify the dialogue relating to the transfer of technology. If these terms and concepts are agreed upon widely they will assist policy makers, treatment providers and, scientists communicate and advance in this important area.
The technology transfer structure, phases and, definitions suggested by the workgroup seem quite sound. A difficulty emerges in that this model is built on a shifting and ill defined foundation.
The workgroup begins by suggesting that technology transfer is justified by the need to shorten the time from scientific development and evaluation of treatment innovations to their implementation in practice. This is an easy argument to make and is likely to be met with consensus. The problem starts when terms like innovation, promising practice, state-of-the-art treatments, and recovery services are detached from scientific vetting and used interchangeably with evidence-based practice (EBP). This seems vague and problematic for an essay dedicated to providing clarity of thinking and agreed-upon terminology. Of course this can not be blamed on the workgroup; this is a contemporary dilemma of the substance abuse treatment field.
There is no equivalent to the federal Food and Drug Administration (FDA), which regulates the development of medications and medical devices, for regulation of behavioral treatments. This results in the sponsors or innovators of new behavioral treatments and services disseminating directly to providers. Such dissemination carries the risk of promoting the uptake of a change without adequate evidence to justify the resources. More importantly, such diffusion does not include adequate caution about the practice’s limitations and or its potential contra-indications.
The Motivational Interviewing (MI) example used by the workgroup can be used to illustrate this point. While MI is widely accepted as an evidence-based practice that has undoubtedly made a major contribution to improving drug abuse treatment, few MI practitioners are likely to be aware of its limitations or potential contra-indications. In a presentation at the 2010 NIDA Blending Conference, Dr. Bill Miller, the principal architect of this intervention, recently pointed out that there have been over 200 controlled studies of MI and that most of them have been negative (Miller, 2010). This suggests there are many situations in which the adoption of MI is unlikely to be an improvement over current practice.
A recent Cochrane Collaborative review of clinical trials with women who are pregnant and have active substance abuse concluded that there was a slight negative effect for MI (Terplan & Lui, 2007). Were MI a medication, the FDA regulatory process would require that this type of information be disseminated with the treatment. But where are contraindications addressed in the technology transfer model for behavioral treatments?
Within the current technology transfer model, this may not be a problem if the sponsor has set a reasonable scientific threshold for what is safe and worthy of dissemination. The Blending Products developed by the National Institute on Drug Abuse are a good example of this. In that model, the sponsor, the scientists and the technology transfer experts work together to determine exactly what has been discovered in the scientific process and what should be transferred to practice. But what is the threshold for entering technology transfer in the event of promising practices, state-of-the-art treatments, or recovery services which have not been fully vetted through a scientific process? The workgroup seems to have wisely included evaluation in the initial phase of technology transfer process but it stops short of suggesting a standard or even the use of science for this evaluation.
Without scientific vetting of a practice how does technology transfer differ from marketing? Effective marketing facilitates the dissemination and adoption of a sponsored product or service without regard for the true benefit to or well-being of the consumer. In marketing the sponsor is the real customer. As the workgroup has suggested, technology transfer has the primary goal of improving treatment outcomes. But how will this be known to a reasonable degree of certainty without rigorous scientific evaluation and objective evaluation criteria?
With all of this fuss over what is meant by evaluation in the technology transfer model out on the table it should also be noted that evidence-based practices (scientifically vetted practices) are not the only way or perhaps at times even the best way to improve treatment. An analogy with automobile maintenance comes to mind. If you have a poorly maintained car with worn out brakes and tread-bare tires, a Global Positioning Navigation System representing the best of current science and engineering is probably not the next investment you should make. Rather brakes and tires should be addressed first. The analogous example in substance abuse treatment would be a program with a long waiting list, dirty and broken lobby furniture, and poor sound insulation in the counseling areas. Common sense would dictate that shortening waiting lists and attending to the physical environment would be a smarter initial investment then say an expensive and comprehensive investment in training all of the staff in motivational interviewing or some other EBP.
What is needed is an extension of the clear thinking and communication, like that initiated by the workgroup, regarding what is meant by some additional basic terms and concepts fundamental to technology transfer such as: evaluation, evidence, safety and finally effectiveness thresholds for the dissemination of practices vetted by science and technologies emanating from other sources.