Volume 1, Issue 2

 

Heather GothamResponse 3: Progress has been Made, But We Can Learn From Other Systems’ Experiences
By Heather J. Gotham

Dr. Roman’s essay challenges us to think about how organizational influences have shaped the field of substance use disorder treatment writ large, and also hints at how they have influenced the push toward evidence-based practices (EBPs) and technology transfer. In some ways the struggle for legitimization of the substance use disorder treatment field was caused by its growing up outside other behavioral health fields such as clinical psychology and social work, but also from the non-medical nature of the treatments. The field of mental health has also struggled to gain legitimacy and keep pace with the medical field. Issues of technology transfer and evidence-based practices have had similarly rough roads on the mental health side, and to some extent the substance use disorder treatment field has lagged further behind mental health, but fought similar battles. The field of substance use disorder treatment may benefit from the struggles within mental health and not have to pay the same “dumb tax.” Here I outline several positive implications of and several challenges (vis a vis mental health; Gotham, 2006) based on Roman’s points regarding the dominance and influence of federal and state governments on substance use disorder treatment and the pressure, in part resulting from NIDA’s and NIAAA’s entry into NIH, to medicalize substance use disorder treatment.

Implications:

The past 20 years have seen a large increase in quality research on psychosocial therapies for substance use disorders, which has led to further legitimization of the substance use disorder treatment field. Research advances have included the use of more controlled study designs, including randomized controlled trials, fidelity measurement, treatment manuals and advanced statistical techniques that allow for more reliable and valid cause and effect statements to be made about the efficacy and effectiveness of treatments. Miller, Zweben, and Johnson (2005) recently published a synthesis of 10 reviews of evidence-based treatments for substance use disorders, finding that seven treatments were endorsed by at least half of the reviews. Dennis (2005) has talked about the “current renaissance in adolescent [substance use disorder] treatment research” describing that there were only 16 adolescent substance use disorder treatment studies published and publicly available between 1930-1997, but between 1997 and 2005 there were over 200 studies, including quite a few randomized controlled trials and studies that used treatment manuals. In fact, NIDA and NIAAA have increased their support for the development of psycho-social treatments by endorsing a three-stage model of treatment research that funds early development and later effectiveness (in community settings) studies as well as randomized controlled trials (Rounsaville, Carroll, & Onken, 2001). These advances in research and development of evidence-based practices are likely due in large part to direct and indirect support and funding from NIH, perhaps disadvantaging less-easily studied forms of treatment. However, the ability to point to research evidence supporting psycho-social substance use disorder treatments has allowed the field to become more legitimate in the eyes of the public.

Federal attention to and responsibility for substance use disorder treatment has gone hand-in-hand with federal efforts at technology transfer to disseminate evidence-based practices into the field. Brown and Flynn (2002) outline a number of federal policy efforts that have helped to increase the quality and effectiveness of substance use disorder treatment. NIDA’s Research Monograph Series, the Addiction Science and Clinical Practice journal, and Clinical Trials Network, as well as NIAAA’s Project MATCH and COMBINE manuals and clinical guidelines, have all focused on bridging the gap between research and practice. However, SAMHSA’s Center for Substance Abuse Treatment has taken the federal lead on technology transfer with the Treatment Improvement Protocol series, Technical Assistance Publication series, National Registry of Effective Programs and Practices, and the Addiction Technology Transfer Center Network. Although NIMH and SAMHSA’s Center for Mental Health Services provide somewhat similar technology transfer functions, their role within the mental health field is smaller. We should take advantage of the federal role in subsidizing much of substance use disorder treatment and press for more assistance for treatment providers in the field who are implementing evidence-based practices (e.g., in-depth technical assistance, coaching, clinical supervisor training, fidelity and performance monitoring).

Challenges:

Substance use disorder treatment provider organizations need to take a strong stance toward EBPs. In the early 1990s, the American Psychological Association (APA) took a leadership role in the movement toward evidence-based practices with the Division 12 (Clinical Psychology) Task Force on the Promotion and Dissemination of Psychological Procedures (APA, 1995). The first report outlined criteria for categorizing treatments as empirically-validated or probably efficacious, and provided lists of treatments that met the criteria. However, after that first report, the APA retreated from the issue. The Task Force’s second report and later updates were published under the individual members’ names (e.g., Chambless et al., 1998). Also, in early 2000, the APA website had a large section devoted to the description of mental health problems and specific EBPs, but that section was removed until just recently. Clearly, the issue of EBPs arouses strong feelings from proponents and critics, which goes along with the changing emphasis that the APA has placed on the EBP movement. However, by not providing a leadership role, this critical voice for psychology was relatively silent, amidst a medicalization of mental illness (including the huge increase in prescriptions for depression and anxiety being provided by primary care doctors) and major debates on issues such as mental health parity. Federal agencies, the American Psychiatric Association, and private organizations took the lead in promoting the implementation of EBPs, rather than the national organization of providers who use EBPs. It would benefit the field of substance use disorder treatment to take a stronger lead in the movement toward evidence-based practices, to highlight the essential role of psychosocial therapies in conjunction with medications and to reduce the stigma of the field from continued beliefs that treatment doesn’t work.

In light of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), substance use disorder treatment providers should work cooperatively with health insurance plans and managed care organizations. Typically, managed care organizations are seen to limit behavioral healthcare (Mechanic, 2003), and within mental health a focus of debate has been that having EBPs that specify numbers of sessions will provide further reasons for managed care organizations to limit sessions. However, might it be better if managed care organizations determine session caps or authorization practices based on EBPs and guidelines provided from within the field? For example, the depression care guidelines for United Behavioral Health are based on the American Psychiatric Association and AHRQ guidelines (Azocar, Cuffel, Goldman, & McCarter, 2003), rather than on guidelines developed from within the clinical psychology or social work aspects of mental health. Managed care organizations have a responsibility to look to effective psycho-social treatments when developing guidelines, but again, the field of mental health should have forced itself to be at the table. There are opportunities for increased coverage for behavioral health treatments if EBPs include specific recommendations for insurers and policymakers (see Asarnow et al., 2005 for examples). Again, the field of substance use disorder treatment can help to shape the outcome of the MHPAEA by proactively working with health insurance and managed care organizations. National and state provider organizations can influence the ways in which MHPAEA is implemented and assist the development of standards of care that are in keeping with evidence-based practices for substance use disorders.

References:

American Psychological Association. (1995). Training in and dissemination of empirically-validated psychological treatments: Report and recommendations. The Clinical Psychologist, 48, 3-23.

Asarnow, J. R., Jaycox, L. H., Duan, N., LaBorde, A. P., Rea, M. M., Murray, P., et al. (2005). Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: A randomized controlled trial. JAMA: Journal of the American Medical Association, 293, 411-319.

Azocar, F., Cuffel, B., Goldman, W., & McCarter, L. (2003). The impact of evidence-based guideline dissemination for the assessment and treatment of major depression in a managed behavioral health care organization. Journal of Behavioral Health Services and Research, 30, 109-118.

Brown, Barry S. and Flynn, Patrick M. (2002). The federal role in drug abuse technology transfer: A history and perspective. Journal of Substance Abuse Treatment, 22(4), 245-257.

Chambless, D. L., Baker, M. J., Baucom, D. H., Beutler, L. E., Calhoun, K. S., Crits-Christoph, P., et al. (1998). Update on empirically validated therapies II. The Clinical Psychologist, 51, 3-21.

Dennis, M. R. (2005, November). State of the art of treating adolescent substance use disorders:  Course, treatment system, and evidence based practices. Presentation at the 2005 State Adolescent Coordinators (SAC) Grantee Orientation Meeting, Baltimore, MD.

Gotham, H. J. (2006). Advancing the implementation of EBPs into clinical practice: How do we get there from here? Professional Psychology: Research and Practice, 37, 606-613.

Mechanic, D. (2003). Managing behavioral health in Medicaid. New England Journal of Medicine, 348, 1914-1916.

Miller, W. R., Zweben, J., Johnson, W. R. (2005). Evidence-based treatment: Why, what, where, when, and how? Journal of Substance Abuse Treatment, 29, 267-276.

Onken, L. S., Blaine, J. D., & Battjes, R. J. (1997). Behavioral therapy research: A conceptualization of a process. In S. W. Henggeler & A. B. Santos (Eds.), Innovative approaches for difficult-to-treat populations (pp. 477-485). Washington, DC: American Psychiatric Press.



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