By Paul Roman, University of Georgia, The Bridge Editor
While not a "native" to the SUD treatment field, Dave Gustafson is one of the best "new friends" that addiction health services research could have ever imagined. Since my institution is overshadowed in fame and fortune (but not charisma) by the strongly resented "North Avenue Trade School," I would have never guessed that we could learn anything from an engineer. But without any doubt, Dave and his team have, through multiple creative projects, challenged much of the traditional thinking in the specialty treatment of SUDs.
My favorite of his many ideas is that the addition of a new position to an organizational chart without significant organizational expansion is usually a marker that the overall system is not working and needs to be studied; "case manager" was the example he used. I interpret that as always raising questions about interrelations within "the system" when someone asserts that more resources are needed to do the job. This is a huge idea for a specialty that has long been convinced that most if not all problems would be solved with "more" resources.
His contribution for this issue of The Bridge only adds to his reputation as an innovator. Dave and his laboratory family of researchers brought us NIATx, which offered a badly needed perspective when our health services research had seemed to have dove a bit too deep into the grotto of quality improvement. Dave taught us that the individual-level thinking about adoption and implementation was an inadequate perspective. We needed to think about systems and management and processes. NIATx gave us a critical context that, from my perspective, raises a host of critical questions needed to understand evidence-based practice adoption and treatment generally. Through NIATx-stimulated experiences, many treatment programs have made their first inroads in understanding how their systems do and do not work. And, practicing what he preaches, Dave and his CHESS team diffused their perspective with great effectiveness throughout the field of treatment practice.
We have before us now some more forward thinking, the results of focus group deliberations on the essential guidelines or commandments for a successful future for SUD treatment. My first reaction was that none of these ideas is controversial and bringing these ideas together in one place immediately stimulates an urge for action. But my overall reaction, after some reflection, is that while it seems we're ready for prime time, prime time is not quite ready for us. My reasoning reflects my perception of the avalanche of forces to integrate SUD treatment into mainstream US medical care. Evaluating Dave's list of essential ingredients against that backdrop is, to me, very challenging.
Taking Dave's very first ingredient of being available when and where assistance for a SUD is needed carries me back to "The Man on the Bed," one of AA's best known graphics which demonstrates emphatically "being there when needed" and "I am responsible," albeit that within AA principles the visitors are at the bedside only because they've been invited. With a bit of irony, aren't the visitors to the man on the bed there because no one else would come…..i.e. medical professionals?
So an assessment of the focus group's contribution requires some vision as to whether and how medical care in the US might be altered to implement these ideas for all forms of needed treatment, i.e. the rather insane vision that medical care will adapt systemically to offer what is needed for SUDs and in the process improve all types of care!
With the SUD treatment specialty, apparent progress is being made with the second ingredient, standardization of practice, but I feel it is more apparent than real. It's really an old idea when treatment was dominated by the rather rigidly defined Minnesota Model, the classic therapeutic community, and the methadone clinic. These programs had very standardized procedures. We now seem to be in a wonderland where all sorts of combinations and permutations of technology are allowed, as long as they don't waddle and quack like the old-timey models. So how do we get from today's encouragement of diversity and alternatives to standardization?
Moving to the third, fourth and fifth ingredients, progress is clearly being made is taking advantage of electronic technologies (right in Dave's shop), and there is minimal in-field debate about the value of comprehensive care. Good hand-offs are closely linked, but remain poorly understood from a research perspective in that they are rarely studied or the topic of an RCT.
Evidence-based practices, the perennial darling of both policy makers and researchers associated with our specialty interest, occupies the sixth slot on the list. According to the focus group, the more EBPs the better. My own efforts have been heavily directed toward this topic for more than a decade, and either I or maybe everyone seems stuck in a very non-productive paradigm.
As I have suggested before, I think that the issue is the quality of management, not EBPs. My illustrative example is that if you examine the "promotion" of EBPs from the multitude of directions from whence these influences flow, the ideal manager seems to be the one who adopts every new EBP that comes down the pike, i.e. a fool. Some research analyses, including a few in which I have participated, include the implicit judgment of treatment center excellence associated with a greater magnitude of reported adoption from a stated set of EBPs.
Obviously this poses a ridiculous situation. We expect good managers to use judgment and make decisions. There is no doubt that in the real world those decisions are not going to be the same across all organizations involved in treating SUDs. Yet the EBP literature would seem to suggest some kind of "failure" when the managerial decision is (1) non-adoption, (2) adaptation (infidelity, the behavior of infidels) or the ugliest outcome of all (3) adoption followed by abandonment. "Diffusion success" seems to demand the thoughtless manager who adopts every EBP that appears, making the problem of this implicit paradigm obvious, at least to me. But from a policy viewpoint, counting EBPs that have been adopted and then calling the index a measure of quality is a bureaucrat's dream.
It seems we've talked too little and certainly spent far few research dollars on effective dissemination. An alternative to counting EBPs is to think of an effective EBP diffusion strategy as being one that places a singular clearly articulated set of facts and alternatives before the managers of treatment programs. At present promotion of EBPs comes flying from all directions, each claiming special "authority." True "authority" is going to have to be vested somewhere, perhaps in a not-yet-formed organization.
The second essential component of this alternative model is for managers to have the appropriate level of skills to evaluate evidence. The third component is for managers to completely understand the current treatment and management technologies that drive their own organizations, and how well current performance is linked with strategic goals. Finally, managers need to be able to see how proposed change would or would not make a strategic difference. Under this scenario, the outcome variable for a successful EBP "campaign" is the quality of the decision-making process that has been used to address the EBP and its interface with a particular treatment organization, not the extent of adoption or the extent of implementation of the EBP.
The remaining five of the derived ingredients offer further challenges. As with comprehensive care, the field has high collective cognizance of the importance of moving those ingredients of care into a pattern of customized delivery over time. "Assembling all the players" for this to happen would be great, but how is it done? Achieving it through integration with primary care seems to be a trick question when one looks at the breadth and the longitudinal features of contemporary primary care. Good measurement is of course important, but is only as good as those who are given the measuring tools. Finally, pay for performance seems intuitively correct, but it both brings up all of the issues of standardization while at the same time ignoring the consistent reality that all SUD patients do not arrive in treatment at the same starting points.
I left the ninth ingredient for last, namely aiding patients' recovery in a hostile environment. There seems to be independent impetus within the "recovery movement" to address this absolutely key issue, but the movement has not been studied in any way that has gauged its impact. Within the "hostile environment," repeated and repeated studies have shown us that employment is central to long term recovery and stability. However, SUD policy leaders have allowed employee assistance programs, which once were mechanisms for reducing stigma and normalizing workplace recovery from SUDs, to operate with a very flimsy research base, to morph primarily into work-family problem orientations. There has been almost no exploration of their massive potential to contribute to early identification of SUDs without the breach of unemployment as well as serving as gateways into "friendly" employment settings for those who otherwise struggle against stigma. Much of this stigma is a still-breathing residual of the pro-stigma campaign launched in the mid-1980s by Nancy and Ronald Reagan, and its core of "drug hatred" continues to flourish.
When he offered this piece for publication in The Bridge, Dave expected plenty of criticism, hopefully constructive. As activity such as the measurement work of the Washington Circle group goes forward, the Gustafson work has the potential for use as the intermediate step toward acting upon the opportunities presented by the combination of parity legislation and health care reform.