By Gregory Brigham, PhD, Maryhaven Research Institute
The report Adoption of NIDA's Evidenced-Based Treatments in Real World Settings addresses a topic of great importance to many stakeholders: persons suffering with addictions and those who love them, policy makers, researchers, healthcare providers, and addiction specialty care providers.
Much of the report relates to the desire for special funding and handling for implementation research and a redesign of the effectiveness research endeavor. The intention seems to be to bring implementation and effectiveness research more in line with healthcare reform and the vision of expanding the impact of substance abuse care into more traditional medical settings. Healthcare reform, with the promise of expanding the impact of healthcare on substance use problems, makes this an exciting and important time in the substance abuse treatment and research field. History will judge the degree to which this vision becomes a reality. I will restrict my comments to the areas with which I have firsthand experience: assessment of the current reality, in which, most addiction care is delivered in the context of community treatment programs, and the assessment of the NIDA Clinical Trials Network (CTN).
The workgroup's description of the utilization of science in practice seems to be a rehash of some well-worn criticisms of the addiction treatment system supplemented with some SAMHSA survey data. It fails to give any serious consideration of research that has failed to replicate those results or of evidence that does not support its conclusions. The report criticizes the NIDA CTN for not doing a better job of promoting the adoption of specific interventions it has evaluated. From my view, as a clinician and researcher working in a community treatment program environment, I see a very different picture. Setting aside the fact that the CTN was not created for the purpose of dissemination, it has actually had a remarkable impact in this area. In my experience, both in my own setting and through my connection with hundreds of treatment providers in my state and across the country, the NIDA CTN has done as much to advance the use of evidence based practices in addiction care as all of NIDA's previous and concurrent dissemination efforts combined.
The goal of the CTN is to use science to improve drug abuse treatment. The achievement of that goal cannot be fully appreciated or measured by a linear approach to adoption of a single or even multiple products (i.e. CTN studied treatment X and CTPs did or did not adopt treatment X). Using science to improve treatment represents a culture change as well as a practice change that should result in the adoption of the best available science to improve treatment, regardless of whether or not it was specifically studied within the CTN. I'll use my own practice setting as an example.
Maryhaven has participated in a number of clinical trials both within the CTN and working with other NIDA sponsored investigators and has also adopted a number of empirically supported treatments. There is not a high correlation between the treatments studied and those adopted, but should that matter? For example, we have adopted Community Reinforcement Approach (CRA), Adolescent CRA, Multi-dimensional Family therapy (MDFT), Motivational Stepped Care, and agonist (methadone), partial agonist (buprenorphine) and antagonist (Vivitrol) therapies for opioid dependence. All patients admitted to our center are offered some form of empirically supported treatment. None of the treatments mentioned here were the subject of any of the clinical studies we participated in to date and none of them were in use in our center before the CTN was implemented. I should mention that Maryhaven did adopt, and has treated over 10,000 patients using, the first intervention studied in the CTN: Buprenorphine Taper Treatment for medically management withdrawal, and is in the process of adopting other CTN tested interventions.
While my view differs from that expressed in the report on the current status of adoption of evidence based practices in the "real world," I agree that considerable improvement is needed. One of the problems is that NIDA's limited budget simply isn't able to support all of the research that is needed. For example, there is a growing acceptance among researchers of the view, long held by addiction care providers, that addiction is a chronic condition and should be treated as such. Unfortunately, nearly all of NIDAs research portfolio is dedicated to research of acute interventions while addiction care centers treat patients who repeatedly relapse and return to treatment repeatedly over extended periods of time. While some approaches to managing chronic addiction have been tested there are no empirically supported chronic disease management approaches for drug dependence that meet the gold standards of science for effectiveness and this seriously limits the practical utility of much of addiction treatment science. Of course there are structural barriers in the way research is funded that make it difficult to study chronic care approaches, just as there are similar barriers in the funding of treatment that promote the continuance of an acute care treatment approach.
The report recommends that the effectiveness research endeavor be adapted to an addiction healthcare environment that does not currently exist. Even if healthcare reform is fully implemented in all 50 states, there will remain a need for a CTN-like system to develop and test treatments for severe drug addiction treatment treated in specialty care settings. Shifting resources away from conducting gold standard multi-site effectiveness research in addiction care will further limit the production of science than can be used to treat those most severely affected by addictive disease. If implemented this would, in my opinion, be a sad outcome for an endeavor which has carried the banner of bridging the gap between research and practice.