By Hannah K. Knudsen, University of Kentucky
We are living in turbulent and unsettling times, and the addiction treatment system is certainly not immune to this turbulence. Changes appear to be on the horizon, although the form and content of those changes have yet to be fully determined. But it seems clear that the cascading impacts of federal health care reform, changes in the federal block grants for treatment providers, and ever-tightening state budgets will re-shape the addiction treatment field as we know it. These upcoming changes make Dr. Gustafson's article on re-designing the addiction treatment system particularly timely. I particularly appreciated that his model of essential ingredients drew upon the perspectives of a broad base of stakeholders—including patients, their families, and health care providers—as well as experts in addiction and systems change to produce a set of 11 essential ingredients for system redesign.
One section of Dr. Gustafson's article that really resonated with me was his question, "What makes Apple so good?" (and not just because I use four Apple devices in my daily life). Dr. Gustafson points to four essential ingredients, namely that Apple products: "1) focus on a very specific customer; 2) work exactly as promised (no bugs), 3) reward the producers of the content, and 4) provide content, marketing, and distribution all in one stop." In his article, he repeatedly asks us to think about what we can learn from Apple and other successful organizations. So as I thought about my response to his article, I decided to apply these points about Apple to my view of the US treatment system.
Using these four ingredients as a lens for analyzing the treatment system brings to light the multitude of challenges facing the addiction treatment field. Starting with the first ingredient, one could argue that it is difficult to even fully identify our customers. At first glance, it seems obvious: the customer is the client receiving treatment. But as Dr. Gustafson notes, families of clients are both a vital resource for the system and may be customers if they are paying for the treatment (e.g., parents of adolescents with substance use disorders). However, the current system is structured such that most of the reimbursement for treatment services comes from governmental entities or, to a lesser extent, insurance companies (Mark, Levit, Vandivort-Warren, Buck, & Coffey, 2011). Are these organizations also customers? And if so, how much weight do we give to their interests, particularly if those interests conflict with the needs of clients? If nothing else, the challenge in defining the customers of addiction treatment highlights how difficult it may be to focus on the customer experience.
The challenge of "working exactly as promised" is one that researchers, clinicians, and purchasers of services continue to grapple with. There is an ever-growing list of therapeutic interventions—both psychosocial and pharmacological—that fall into the rubric of "evidence-based practices" (EBPs). And indeed, evidence-based practices are superior when compared to placebo (i.e., no medication, or no therapy), and they do yield measurable improvements on average. But nonetheless, we are a long way from "working exactly as promised" in the sense of knowing which intervention will work best for which patient. Addiction treatment is not unique in this regard—it is a challenge that is ubiquitous throughout health care. Research using adaptive designs, where the course of treatment is not determined by a standardized set of sessions (as per many of our manualized EBPs) but rather is titrated to greater or lesser intensity based on patient progress (Murphy, Lynch, Oslin, McKay, & TenHave, 2007), may move us toward treatment strategies that are closer to working as promised. But the potential of using adaptive strategies and other technological tools to inform treatment decision-making remains relatively under-utilized at this point in time.
"Rewarding the producers of the content" is an interesting notion that is perhaps gaining some traction in the addiction treatment field, particularly in the use of pay-for-performance, an ingredient that Dr. Gustafson also discussed. Recent research has looked at the impact of pay-for-performance at the systems-level (i.e., state governments tying reimbursement to treatment providers based on pre-determined outcomes or mandating the use of EBPs; see Haley, Dugosh, & Lynch, 2011 and Rieckmann, Kovas, Fussell, & Stettler, 2009) as well as strategies for rewarding individual counselors based on their clients' outcomes (Garner, Godley, Bair, 2011; Vandrey, Stitzer, Acquavita, & Quinn-Stabile, 2011). But much more research is needed to really understand how to incentivize both individual clinicians and treatment organizations in order to yield content (i.e., treatment services) that also "works as promised."
And the last ingredient—embedding multiple functions into "one stop"—is perhaps analogous to calls for comprehensive services within addiction treatment organizations. Such a model combines the core services of addiction treatment (e.g., therapy, medications, continuing care) with wraparound services that address the complex needs of SUD clients (e.g., medical and mental health care, education, employment, etc.). This model of service delivery is recommended in the National Institute on Drug Abuse's (2009) Principles of Drug Addiction Treatment, yet few programs have adopted all of these services. An analysis of 754 treatment programs in the National Treatment Center Study found that the average program offered just 6.5 of 14 core and wraparound services recommended in the NIDA guidelines (Ducharme et al., 2007). The concept of "one stop" is not yet the norm within our system.
The US addiction treatment system faces an uncertain future, but Dr. Gustafson has raised a number of questions that can help us to think about how the system might better help individuals with substance use disorders. I found these questions to be useful for not only considering what our field might learn from other industries, but also as a lens for considering the current state of our system and our science. Many complex challenges remain, but hopefully Dr. Gustafson’s article will begin an ongoing dialog about future directions for our field.