Volume 1, Issue 2

 

Paul Roman

Large Scale Organizational Processes and the Emergence of the Emphasis on Technology Transfer in the Substance Use Disorder Treatment Field
By Paul Roman

The goal of The Bridge is to be a sounding board for ideas, some of which are based in practical experience, with others coming from a broader look at the social context of the substance use disorder treatment field. Our basic concern is technology transfer. Seemingly simple, that concept actually covers a huge amount of intellectual and practical territory.

In this issue, I address one set of forces affecting the emergence of the evidence-based practice movement within the substance use disorder treatment field, and the subsequent importance of technology transfer. This is only a partial overview, and does not include discussion of the role of managed care, and the effects of the occupational and professional makeup of the substance use disorder treatment field, both of which are important factors in this larger picture, and which will be discussed in later issues.

This initial essay is intended to raise some controversial questions, and members of The Bridge’s Editorial Board have written responses to the essay. I then offer concluding remarks. The Editorial Board invites and welcomes further comments from our readers for possible publication in future issues.

The first issue of The Bridge was dedicated to setting a context for thinking critically about technology transfer. We looked back in history at the big ideas of “progress” and “innovation” as guideposts to “better” ways of living and better ways of delivering services. An important message from the first issue of The Bridge was the very broad context of technology transfer. The substance use disorder treatment specialty is participating in what might well be called a major social movement - beginning in industrial development, moving on to agriculture, and most recently impacting the practice of medicine and principles of workplace management.

We can perhaps summarize the roots of that movement in the fact that leaders of organizations are often under steady pressure to try to improve organizational performances. Some leaders are very curious and experimental, and in their organizations change may be the norm. Other leaders may have peaceful periods of normalcy and routine within their organizations and then be unpredictably challenged by a “reorganization” of the configuration of opportunities and resources in the external environment. These changes are almost always brought about in the name of improvement.

Thus, whether the impetus comes from internal or external forces, organizations are regularly experiencing processes of change. This is a unique feature of our modern world, very different from centuries of our ancestors’ human experience in which tradition and the perpetuation of “sameness” were the macro-level social goals. It ties directly into our capitalistic economy where entrepreneurs’ goals can only be served by change, cloaked in a vision of “improvement” that is usually consistent with the norms on “progress” embedded in the broader culture.

The evidence-based practice movement became prominent in the substance use disorder treatment field at the end of the 20th century. In order to better understand this movement, it is necessary to review the substantial growth the field has undergone over the past 50 years, especially in regard to Federal bureaucratic infrastructure.

Since the 1960s, the Federal government has had a proactive policy and resource allocation role in dealing with the nation’s substance use and mental health problems. This history is a bit complicated, but is symbolically important for understanding the emergence of the emphasis placed on change within treatment delivery organizations through the adoption of evidence-based practices.

The National Institute of Mental Health (NIMH) was initially established in 1946 within the National Institutes of Health (NIH), but in the 1960s was separated from it. Shortly thereafter, NIMH “spawned” both the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in 1970 and the National Institute on Drug Abuse (NIDA) in 1973.

Following a complicated transitional period, these three institutes were brought under a new parent structure, the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA). The seeds for change in Federal roles were planted in the early 1980s with the withdrawal of the authority for direct funding of treatment and demonstration projects from the alcohol, drug and mental health research institutes. These organizations were reshaped over the 1980s and eventually merged into the National Institutes of Health (NIH). Meanwhile, ADAMHA became the Substance Abuse and Mental Health Services Administration (SAMHSA), which does provide support and funding for direct services. Thus, while previously both research and programmatic interests in alcohol, drugs, and mental health had been “housed” together, presumably leading to rapid translation of research into program practice, in the 1980s research was split from practice at the Federal level, making this rapid translation more difficult.

What is important about this bureaucratic history?

First, if we were writing about technology transfer in the fields of cardiac care or diabetes management, the Federal government would not be front and center. There is a massive amount of research on both of these substantive fields within the NIH, but policy about the organization of cardiac or diabetic treatment is not set at the Federal level, with the exception of standards embedded within the reimbursement policies of Medicare.

By contrast, substance use disorder treatment is indirectly influenced by policy at the Federal level, and directly influenced by Federal dollars that are transfigured into state dollars through what were initially known as Federal “formula” grants and more recently as “block” grants. The “formula” concept stemmed from an actual calculation of estimated levels of substance use disorders in the respective states. While the “block” concept continues to follow a formula, the emphasis has shifted to the states’ autonomy in allocating the funds that are received from Washington.

The bottom line is that federal funding for substance use disorders to the states comes with strings attached, including a raft of rules and accountability. Thus, with the exception of substance use disorder treatment organizations that are totally independent of any infusion of public money through grants, contracts, or Medicaid/Medicare payments, the field can in fact be seen as a form of partially socialized medicine. The influence of Federal and state funding carries with it legitimized efforts to control, manage and alter a very large proportion of the practice of substance use disorder treatment. Therefore, since the need for evidence-based practice and technology transfer are now central parts of Federal and state efforts, those treatment organizations receiving public money must pay close attention to those efforts as well or risk losing funding.

Secondly, the bureaucratic history described above is also important when we consider the entry of NIAAA and NIDA into NIH. NIH is a multi-billion dollar organization that recently adopted the brand as “The Nation’s Medical Research Agency.” It is made up of largely disease-specific institutes, which partially compete with each other for allocations of funding, but which also may have their own Congressional mandates and support systems.

Being a part of NIH is certainly a means for legitimizing the status of “true” medical conditions. Looking back at the decades during which the constituency of recovering alcoholics and their friends fought for the recognition of “alcoholism as a disease like any other,” the move to NIH was a significant accomplishment. As it happened, the move was more of a bureaucratic maneuver than a response to a demand for this recognition. Nevertheless, since the Institute representatives all sit at the same table, substance use disorder research emphases become notably visible to the research leadership in other medical specialties, certainly far more than they were when these institutes were outside NIH. Thus, placement within NIH is a legitimizing process in terms of being part of the medical community, but at the same time such placement demands new forms of behavior that much more closely resemble a medical specialty. If the substance use disorder agencies are going to be part of the Federal medical research enterprise, then they have to conform to the imagery and norms of that larger enterprise.

I would contend that more than anything else, the placement of these Institutes within NIH was the source of the movement toward the diffusion and adoption of evidence-based practices in substance use disorder treatment.

Integrating NIAAA, NIMH and NIDA into the NIH has led to even stronger biological emphases in substance use disorder research than was previously the case. Genetic research flourishes as never before. The assertion that addiction is a brain disease is made repeatedly, with the unstated implication that it is not a bad habit or a moral failing. Equally welcome is the repeated rhetoric that addiction is a chronic disease, despite the clear possibility that such labeling may produce some undesirable backlash in terms of creating barriers to social reintegration during the recovery process.

The treatment of disease is based on scientific theory and statistical evidence, not on folklore or cherished beliefs. Diseases are treated in hospitals and clinics, not in church basements. Diseases are treated with medications, not with talk therapy. Thus the pressure to develop new treatments that may thoroughly medicalize substance dependence is consistent with the NIH culture, and this in turn has become a vector in cultural change within the substance use disorder treatment specialty.

Further, evidence-based practice emphases have been well underway in the broader field of medicine for well over 15 years. Thus creating these emphases within substance use disorder treatment was another means for conformity and image management within NIH.

To summarize, I have explored organizational processes that support the emergence of evidence-based practice as a key theme in the management of substance use disorder treatment. First, the dominance and influence of Federal and state governments on the substance use disorder treatment field, in fairly sharp contrast to other areas of medical practice, createsthe perceived need for control and accountability. The use of evidence-based practices in substance use disorder treatment helps meet this need. Second, the integration of the substance use and mental health disorder research organizations into the NIH umbrella increased the pressure within those agencies to fully medicalize substance use disorder treatment, and to do so through the adoption of evidence-based practices in a manner paralleling that of other medical specialties.



Return to Top | Back to Home