Volume 3, Issue 1

Repeating the Mantra in Splendid Isolation
By Paul Roman, PhD, University of Georgia

The report, Adoption of NIDA's Evidence-Based Treatments in Real World Settings (September 2012) generated by a NIDA-appointed workgroup (WG) is an ironic document. It offers what appear to be extremely valuable "micro-observations" about needed change within the various operating Divisions of NIDA, but in its principal recommendations consist of suggestions that I believe would move both research and practice in a backward direction. A further irony is that it uses the theme of integration repeatedly in multiple contexts, and ends up promoting segregation and isolation. Thus I conclude that the report ultimately contributes little to progress in that part of health services research concerned with the organizational changes entailed in the adoption and implementation of new treatment practices.

Like many such government "reports" it is in a twilight zone of publication: not "really" published as a printed document, and presently not known to be advertised on lists of Government Documents available to inform the public or the research community. Being "not quite" a statement of policy, it nonetheless reflects the received knowledge of a distinguished group, and evidently was screened in some manner for legitimacy before becoming available. Nonetheless, with the context of current Internet technology, it is readily available to anyone who wants to find it. In such a context, its short or long term influence is unknown.

As such, the document is another in a long line of castigations of the organizations and personnel in the US involved in the treatment of substance use disorders (SUDs). If one wants to believe that this specialty is rife with incompetence and mismanagement, this report joins a multitude of others, some with the imprimatur of highly prestigious sources. The critical visions of nearly all of these documents are clouded by a failure to understand at least three key facts:

  • The relative newness of the SUD treatment specialty in the health care delivery system (together with its current marginality in that system)
  • The lack of understanding of treatment within the general population and among potentially supportive constituencies;
  • The importance to nearly every treatment organization of effective cost management on a day-to-day basis in order to survive as an organization (otherwise known as the absence of "organizational slack")

In addition, there is the unchallenged premise that there is not "enough" quality in SUD treatment. Compared to what? Compared to whom? Compared to when? Yardsticks are practically never offered. And indeed, when a few boundary-spanners have looked closely at conformity with evidence-based practices (EBPs) in other medical specialties, they almost invariably find parallels with the alleged "backwardness" of SUD treatment.

The basic premise of the WG is based in a very significant social movement to gain bureaucratic control over the practice of medicine in the US. Over the past decade or so, an extremely effective campaign has almost institutionalized the idea that in order to achieve excellence in quality, health care delivery must consist of the best EBPs that the provider can identify. It is not a new idea, but an activation of what was formerly a passive assumption.

Certain sets of needed services in human societies have long been delegated to specialists who receive from society the status of professionals. Core to the professionals' societal assignments are their particular "mandates," definitions of the content and boundaries of their fields of practice. Within the boundaries of their mandates, it has long been assumed that professionals had complete autonomy in their choice of strategy and tactics and of tools and techniques. Rules for making such choices were enveloped in professionals' training and acquired talents, but composite judgments based on experience and knowledge rather than recourse to rules. Nonetheless, use of and payment to these professionals was centered largely on this core of decision-making, which could not be replicated by the "laity," including everyone who did not have the particular professional mandate.

In this context, there were only two categories of "deviance." First was when those without a mandate posed as members of a profession and were punished when their fraud was detected. Second is malpractice, nearly always defined by an injurious outcome that is linked to negligence or misconduct. Malpractice is not defined by rules, but by a complicated combination of implied standards subject to negotiation and judgment in the context of litigation.

The walls around the professional mandates of the various practitioners of medical care have been breached. Standards for practice are yielding to measurement, which is the core technique of bureaucratic social control. Without measurement, bureaucratic rules cannot be enforced. The insistence on the use of EBPs is transforming from an assumption about behavior "inside" the professional mandate into an active standard that will have external bases for judging conformity and thus defining quality.

This is more than a principle; it is a pervasive ideology, the effects of which have spread into every sector of health care practice. Institutionalization is best described when a norm or practice seems "natural," is "taken for granted," or if challenged, generates surprise. Institutionalization usually takes a long time. Our best example is right in front of us, namely the institutionalization of the idea that "addiction" to potent substances requires or deserves the response of medical care. It is easy to see that (at least in the US) treatment for SUDs is not yet fully institutionalized. A great deal of what most researchers and practitioners are doing every day in this specialty is more or less geared toward further institutionalization of "the treatment response" to SUDs.

But, as a sort of supreme irony, while SUD treatment itself is not institutionalized in the larger society, the expectation of the presence of EBPs in SUD treatment has indeed come close to reaching that level within the SUD treatment and research specialties, as is well demonstrated by the WG report. The mantra about inadequate use of EBPs in SUD treatment is sustained by the WG report, oddly using a descriptive overview from SAMHSA's N-SSATS survey rather than reviewing the substantial literature on diffusion and adoption developed by NIDA's grantees. This oddity derives from the fact that the WG evidently sees itself exempt from its own admonitions about using an evidence-base as a guide for quality practice, in this case using a survey from a semi-commercial vendor rather than peer-reviewed research in their attempt at advocating for a change in NIDA policy.

The WG's core recommendation is that NIDA set up its own shop to study adoption and implementation. In many ways, this fits the cliché of re-inventing the wheel, although in this case it would come at a substantial expense, borne by the research community who are now in a zero-sum game in competition for scarce NIH funding. This supports a subtle admonition for the continued isolation of the SUD research and treatment enterprise, isolation reflected in the struggle for SUD treatment to become mainstreamed into overall health care. Instead of attempting to draw upon what others have done and are doing, the WG recommends that NIDA "go it alone" in developing its own highly specific portfolio of research on implementation. One might observe that if SUD treatment does not or cannot adhere to the principles involved in the delivery of other health care, what is the point of mainstreaming it?

In addition to giving almost no attention to the work of NIDA's health services research grantees, the WG shows little recognition of the existence of theoretical and research specialties focused on communication, dissemination, and organizational change found in universities, libraries, journals and within NIH itself. Indeed, as the report implies, one will find a relatively sparse set of conclusions if one looks through the published literature for implementation studies focused solely on SUDs. That's where the art of generalization and conceptualization comes in.

There is an abundance published literature relevant to questions related to implementation and sustainability of change and new practices within organizations. It will indeed take substantial effort to review that literature from the lens of SUD treatment, but such an effort would seem to be the clear starting point rather than attempting to re-invent a new research subspecialty with a singular application to issues related to SUD treatment.

Perhaps of even greater concern is the understatement of how the SUD research and treatment enterprise within NIDA could effectively link with and become integrated into what appears to be a massive enterprise in translating research from bench to bedside throughout the NIH. Not only is this found within the National Center for Advancing Translational Sciences which is essentially a new NIH institute centered on clinical translation across all disorders of interest to NIH, but which houses a massive national project guiding the 60+ Clinical and Translational Science Awards. While the WG makes mention of NIDA "interacting" and "partnering" with efforts on implementation that are already Federally funded, its core recommendation is to set up a new organization within NIDA, with its own NIDA-oriented expertise and its own NIDA-based grant review committee, by definition "siloed" from these other endeavors and consistent with the isolationism that has long characterized the SUD research and treatment specialty.

The research work of interest here has been partly addressed by NIDA-funded scientists, which the WG decides for some reason to ignore. Perhaps more importantly, the research that needs to be done is best addressed by those in the scientific specialties of communication and organizational change, which is not directly related to research on SUDs. The WG is suggesting that NIDA move beyond its core technology of conducting high quality research on SUDs and recruit its own personnel for developing a specialty brand of "implementation science." When the parent organization of NIH is already investing so heavily in these issues and when resources are already scarce without even considering the impact of extant and future Federal budget cuts, the WG's recommendations seem far out of step with reality. That the recommendations are driven by a culture of insularity and isolation is only an hypothesis, but an hypothesis that is remarkably credible in light of the scope of research activity relevant to the focal production that is already underway and doubtlessly accessible within NIH itself as well as in the literatures of organizational management and communication.

As mentioned, the extent of adoption and use of EBPs in SUD treatment may be seen as very slow, or very fast, but without a clear standard, neither conclusion makes any sense. On the basis of my own research experience, I believe that the WG largely neglects three other considerations that are vital to future implementation of new ideas.

First, while in many ways remarkable, the EBPs offered to the SUD specialty are not blockbusters in the sense of offering revolutionary cures to suffering people. Many of the clinical trials oriented toward SUD treatment find only marginal effects of EBPs. As introductory methods classes always tell us, statistical significance does not equal substantive significance. Many of these clinical trials, if not most of them, find a robust effect of "treatment as usual" that is the control condition. This can be read as saying that conventional practice may be close if not equal in effectiveness to new practices. Emphasizing this point here is not to "put down" the new practices, but to empathize with practitioners who, viewing these findings or their honest translation, are not going to be easily convinced that the cost of change (in the broad sense) is really worth it.

Second, and closely related, NIDA has offered the field very few high quality cost-benefit and cost-effectiveness studies regarding EBP adoption and use. Generally, when managers of treatment programs are considering a minimal or large scale adoption of an EBP, they have no tools to answer the questions of whether this adoption will "pay off." Instead it seems that managers are offered value statements that imply a greater research base equals "better," or offering "more" is better. In contexts of severe economic strain, these arguments are often not adequately compelling to lead to change. Little is found in the WG's report to support attention to this crucial barrier to change.

Third, adoption of new ideas in the marketplace is driven by demand. While there seems to be more than enough documentation that treatment providers are not demanding many of the proffered EBPs, or are not demanding them enough, what about the wishes of treatment clients, their families, and their significant others? While huge sums are invested in educating about the adverse effects of drug and alcohol use, close to nothing is invested in education about treatment. Again, we have more than enough documentation that people who seem to need SUD treatment will not use it, but this is blamed on "stigma" or the unavailability of care. Is treatment attractive? Is it credible? When clients do eventually get to treatment, are they adequately educated to ask for what specialists call EBPs? Will they accept a treatment that they do not understand? Will they accept using a substance to deal with the substance that got them into trouble in the first place? These are core questions, and only those with expertise in SUD research and treatment are equipped to address them, but again this key issue receives no attention from the WG.

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