By Holly Hagle, National SBIRT ATTC
For me, this topic provides a useful segue from the previous issue of The Bridge in which we commented on the 2012 NIDA Workgroup report on the need for dissemination research to enhance the adoption of evidence-based treatment (NIDA, 2012).
One of the points that the NIDA workgroup report makes is that "availability of medications is key to accelerate the medicalization of Screening Brief Intervention and Referral to Treatment (SBIRT) procedures," both topics of interest for me.
As the Director of the National SBIRT Addiction Technology Transfer Center, the emphasis on SBIRT is important. Second, the connection with medication-assisted treatment (MAT) is relevant to advancing SBIRT to increase access to addiction treatment. So I have to ask, "What stands in the way of broader acceptance and use of SBIRT and MAT?" Unfortunately it seems like there is currently neither a demand for nor an acceptance of pharmacotherapies for substance use disorders. The NIDA workgroup defined addiction treatments to include medication and screening and assessment; both of these topics have particular relevance to the work we conduct every day in SUD treatment.
The pharmacotherapies have great potential. Pettinati et al. (2006) highlighted the growth and progress made in the last decade in understanding the neurobiology of addiction and the extent to which this has led to the development of pharmacotherapies that "target the neural pathways involved in the brain's reward center" (Pettinati et. al., 2006). These promising pharmacotherapies added to counseling or other psychosocial treatments can add to stabilizing an individual and helping to decrease relapse rates.
In reviewing research literature I found a report that looked at the market barriers to the development of pharmacotherapies for the treatment of cocaine (Goodman, et al., 1997). This is not a peer-reviewed study and was not produced by the National Institute on Drug Abuse, but was apparently developed by the U. S. Department of Health and Human Services through a contract to better understand this issue, with the report commissioned at the government's top management level.
Although the report is dated, it is a unique resource in examining barriers to the use of pharmacotherapies from a marketing perspective. The purpose of the report and the barriers that it examined has relevance to the topic at hand—consumer attitudes toward pharmacotherapies. The report characterizes the market for substance abuse pharmacotherapies; identifies real and perceived market barriers; reviews case studies of pharmaceutical companies that have developed and marketed substance abuse pharmacotherapies such as LAAM and naltrexone and reports the industry's perception of the readiness of the science base.
Goodman, et al., (1997) somewhat pessimistically concluded that there were three critical market barriers to the effective marketing of pharmacotherapy. These three market barriers were: a small and uncertain market of cocaine addicts entering treatment; the substance abuse treatment system that limits access to this market; and limited and uncertain payment for pharmacotherapy. These conclusions obviously still ring true today even though this report was issued 16 years ago.
What can be done? Counselor education can also play a key role in the dissemination of information about treatment modalities, especially new innovations in treatment (Abraham, et. al., 2009). A study conducted by Abraham, et al., (2009) found that counselors were not trained in understanding pharmacotherapies. They concluded that where counselors receive medication-specific training and indirect observation of the pharmacotherapy's use, this increased the diffusion of information about the pharmacotherapies. They also determined that counselors' acceptance of the pharmacotherapy and perceptions of its effectiveness was associated with medication-specific training.
The NIDA workgroup report (2012) recommended exploring ways to promote and develop medication or medication-assisted treatment (MAT) for substance use disorders in general medical settings.
The workgroup sited the following as barriers to the uptake of MAT:
Therefore the workgroup concluded that there is a need for strategic planning for adoption of future approved medications and innovative behavioral treatments within addiction treatment services.
McGovern, et al. (2004) surveyed addiction treatment providers to assess clinical practices and readiness to adopt certain EBPs (such as pharmacotherapies). They found that the addiction treatment providers in their study were more motivated to adopt "certain" EBPs such as cognitive behavioral therapy or motivational interviewing as compared to their readiness to adopt pharmacotherapies.
When considering the relationship between the demand for and acceptance of pharmacotherapies to facilitate recovery from addiction, I personally feel that anything that facilitates stabilizing individuals and improving their quality of life is important and worthy of consideration. However, we can come to increase our understanding of the lack of use when we consider the barriers such as the substance abuse treatment system's limited access to this market, limited and uncertain payment for pharmacotherapy, and addictions counselors' limited training and knowledge. However, only if we begin to address these barriers can we make the necessary innovation to the addiction treatment system so that people can get the best treatment available.