By Holly Hagle, PhD, Institute for Research, Education and Training in Addictions (IRETA)
The National Institute on Drug Abuse (NIDA), like all other National Institute of Health (NIH) institutions, "has the responsibility to ensure that a significant proportion of its research will result in broadly applied interventions with public health value and economic sustainability." This is a compelling statement of purpose and sets the tone of the resulting sections of Adoption of NIDA's Evidence-Based Treatments in Real World Settings: A National Advisory Council on Drug Abuse Workgroup Report. The workgroup rightly mentions the research-to-practice gap and the limited use of evidence-based practices (EBPs) in real world settings. They state, "Research evidence can be useful in promoting and encouraging change but is rarely by itself sufficiently powerful to change behaviors or systems." The purpose of the workgroup was nicely articulated and is relevant not only in light of the research-to-practice gap but also in light of changes to the US healthcare system due to the passage of the Affordable Care Act (ACA). The workgroup's stated five recommendations are listed with specific goals where needed and accompanied by detailed action items. Overall, I agree with all of the five recommendations and have a written a short commentary for each. I am glad the workgroup stated both NIDA and Substance Abuse and Mental Health Services Administration (SAMHSA) missions in relation to their recommendations, since each entity plays an important role in research and service delivery. Both of these entities have roles in translation activities for evidenced-based substance use disorder and addictions treatment. I compliment the workgroup on using a systems-level approach to their recommendations and references.
The workgroup's general introduction to the problem illustrates a central concern for the addictions field: the infrequent use of EBPs for addiction treatment. The workgroup expresses a valid and true criticism of the field. The Institute of Medicine (IOM) highlighted this concern in multiple reports, which state that "the challenge of the health care system is to provide safe, effective, patient-centered, efficient, equitable, and timely services." With the passage of the ACA, that challenge has never been more important. In light of these changes to the healthcare system, it is vital to reduce the gap between research and practice in real world settings. Consequently the workgroup's recommendation that "validated research protocols and treatment manuals that improve identification and treatment of substance use disorders have impact only if they are scalable, translated, widely implemented in practice, and sustainable" has never been more true.
The workgroup highlighted the deficiencies of the current addiction treatment system. They correctly identified problems such as poor integration with health care systems, poor uptake of best practices, and inadequate records and reporting systems.
The five recommendations that the workgroup outlines are necessary to further the up-take of evidenced-based practices in a more seamless and timely manner so as to address the goals outlined by the IOM, "to provide safe, effective, patient-centered, efficient, equitable, and timely services". These recommendations followed by action items are encouraging.
Recommendation 1: Create a New Entity for Translation and Implementation Science Within NIDA to Help Bring Its Scientific Findings on Treatment Efficacy Into Broad Practice
On its face value the recommendation seems to restate the essential purpose of NIDA. However, as the workgroup points out, translating scientific research into broadly applied treatments and services differs significantly from bench research. While NIDA has expertise in the important and necessary basic research and clinical trials, purposely seeking new expertise in translation and implementation is a worthy pursuit. The action items the work group suggests mix NIDA's current strengths with new expertise that should tackle the current gap in research to practice.
Recommendation 2: Establish NIDA Guidelines for Funding Consideration of Treatment Development Research Projects that Consider the Potential for Implementation, Adoption, Scalability, and Sustainability in Various Practice Settings
This is an essential recommendation in that it is important to "put your money where your mouth is." We must dedicate resources to specifically fund translation and implementation research in and of itself. The workgroup outlined a harsh truth, "some interventions that have strong scientific support have little or no chance of being adopted in the real world, in part because there has been insufficient consideration of implementation potential." I think that providers feel this the most when considering implementing an EBP. Most providers have the authentic desire to help the people they serve and have a willingness to serve them better, but at times the very interventions that would achieve this are not only costly to implement but maybe cumbersome in the day-to-day operations of a facility. Facilities are often pulled in a million directions with administrative requirements, shrinking funding streams, and an underpaid and aging workforce.
Recommendation 3: Establish Systems-Based Research Networks within Naturalistic Settings to Evaluate Intervention Effectiveness, Adoption and Sustainability in Practice
This is a forward-thinking recommendation that will allow for new ideas and innovations to come into the process, especially with an evolving healthcare system. This recommendation also addresses an absent consideration in the current research environment. All too often a major barrier to the uptake of an EBP is the very system that is trying to adopt it. Therefore, systems-based research networks seem like an essential recommendation. It is laudable to include a revamping of the way NIDA addresses implementation to include evaluation that could look specifically at adoption, scalability, and sustainability of EBPs within real world settings. The action items of including networks that shift from traditional addiction treatment programs is not only needed but necessary in the ACA environment, since the current treatment systems only address a fraction of the people who could benefit from services. I applaud the recommendation to seek new more naturalistic settings such as FQHCs, EAPs, Accountable Care Organizations, college campuses, and schools, as outlined in the action item section to create service networks that can learn from one another.
Recommendation 4: Target Funding to Expand the Grant Portfolio for Implementation Science
As I mentioned in my response to Recommendation 2, to move ahead with a translational and implementation science research portfolio, NIDA has to dedicate financial resources in order to advance the knowledge base and develop practical mechanisms to shorten the research to practice gap and bring effective treatments to scale. The workgroup members write that the operational definition of implementation science is to "establish a knowledge base about the ways evidence-based substance use disorder treatments are being utilized in practice settings and systems as well as the optimal methods to promote adoption into healthcare policy and practice". The recommendations put forth in this report indeed set a path for NIDA to realize this definition, especially if NIDA is explicitly funding an implementation portfolio.
Recommendation 5: Establish a Recurring NIDA-Based Peer Review Panel Charged with Evaluating Research Applications that Focus Specifically on Advancing Rapid Adoption of Evidence-Based Interventions
The fifth and final recommendation is again essential if NIDA is serious about shortening the research to practice gap. This recommendation, if fully realized, would represent an innovation in substance use research. The workgroup committee recommends that a "specific science of rapid translation and adoption of evidence-based findings for drug use disorders" is pioneering.
I found this report to be a forward thinking piece, a document that I have on my desk for the purposes of citing in my own writing or to guide my thinking. Most of the recommendations are meaningful and relevant to the current state of addictions research and treatment. In fact these recommendations are essential in light of the changes to healthcare as a result of the ACA. The recommendations are visionary of the future direction of addiction research and treatment, a direction that we must progress towards for the next decade and beyond. Finally, the action items that the workgroup proposes are measureable and most are accomplishable.