Volume 1, Issue 2

Mike BoyleResponse 2: The States are the Key Factor in Successful EBP Adoption and Technology Transfer
By Mike Boyle

The location of NIAAA and NIDA within the National Institutes of Health promotes research on substance use disorders, predominantly by academic institutions. The funding of such research does not necessarily lead to adoption of positive outcomes from these studies within the addiction treatment field. The gap remains between treatments that have demonstrated efficacy and the implementation of these findings in treatment settings. A promising effort to bridge this gap is the establishment of the NIDA Clinical Trials Network that combines research institutions with treatment programs in different modes of collaboration. Especially valuable are the Blending Conferences where the results of CTN research are shared with providers.

Dr. Roman discusses the accountability that results from the provision of Federal financing. Within NIDA and NIAAA, the accountability rests on the institutions doing the research to implement the objectives and plans contained in their funding proposals. This accountability does not impact States or treatment providers directly.

In SAMHSA targeted initiatives, the accountability is directed to the recipients of their funding of specific services, but the bulk of the SAMHSA funding has been distributed to the States as a block grant with few strings attached. Historically, many states have not even reported encounter data to the SAMHSA Treatment Encounter Data Set. This may change with the new requirements for reporting on the National Outcomes Measures (NOMS), but it remains to be seen if there will be sanctions or incentives based on performance of the states on these process and outcome measures.

The SAMHSA block grant allows each state to decide what services to purchase. Similarly, substance use disorder treatment is optional under Medicaid and each state can decide whether they wish to use this funding mechanism and what services they wish to cover. Another source of state funding is their own general revenue funds, which is also optional. However, once state contributions to treatment are established, CSAT requires that the level of state funding be maintained in order for the state to receive its full allocation of the block grant. The majority of addiction treatment in the United States is purchased through these state funding mechanisms. Thus, it is the states, not NIAAA or NIDA, that have the greatest control over what treatment services are provided.

A premise is that organizational behavior is driven by what is purchased. If states want more effective addiction treatment services delivered, they have to change their purchasing strategies to require evidence based practices. While there are outstanding examples of organizations embracing and implementing evidence based practices (EBPs), a large percentage of treatment providers have retained the “peaceful periods of normalcy” identified by Dr. Roman in his essay, sometimes lasting for decades. Significant and rapid change may only occur if the equilibrium is disrupted by external factors. States could provide this external incentive for change. They control and manage substance use disorder treatment. The question is whether they wish to alter the practice. The choice is theirs.

A promising example of a state using their purchasing influence is occurring in Delaware. The performance contracts are structured to allow providers to earn less or more state funding depending on their results on established measures. While the initial focus has been on access, retention and continuation across levels of care, some providers are adopting EBPs to achieve the objectives that earn additional revenues.

As another example, 2002-2003 legislation passed in Oregon mandated a graduated increase in the use of evidence-based practices in both addiction and mental health treatment. Currently, 50% of the treatment funded by the State requires the use of approved EBPs. This percentage will increase to 75% for years 2009-2011. No provider specific financial incentives or consequences have been implemented.

The greatest impact of the location of NIDA and NIAAA within the NIH will probably be on the identification of the various biological processes of addictions and the development of effective addiction medications. Several of these medications are now approved by the FDA for the treatment of alcoholism and opiate addiction, yet are infrequently used by treatment organizations. Dozens more are in research and development efforts for a variety of abused substances. Dr. Roman noted that “diseases are treated by medications not with talk therapy”. The combination of both approaches is needed, not only in substance use disorder treatment but in other medical care as well. In fact, the way primary care addresses chronic disorders such as diabetes and hypertension could benefit from more behavioral training on lifestyle changes that would impact the medical conditions. However, the fee-for-service funding of brief encounters within primary care does not allow for such psycho-social interventions.

Conversely, addiction treatment funding allows for extensive psycho-social treatments. With the exception of methadone, the use of medications has not been part of the dominant treatment equation. Could we imagine a primary care system for the treatment of hypertension that did not inform patients that effective medications were available that could help control their disease? Yet, that is exactly what occurs in most substance use disorder treatment programs. When will the first lawsuits be filed against providers for failure to inform individuals of the availability and options to include medications in the treatment regime?

Continue reading Response 3: Progress has been Made, But We Can
Learn From Other Systems’ Experiences



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