Volume 1, Issue 2

Dennis McCartyResponse 4: The Realities of Evidence-Based Practices for Addiction Treatment
By Dennis McCarty

Capitalism, not socialism, drives the interest in evidence-based practices in medicine and in treatment for alcohol and drug disorders.  Thomas Friedman’s (2000) analysis of globalization, The Lexus and the Olive Tree, reiterates economist Joseph Schumpeter’s observation that “the essence of capitalism is the process of ‘creative destruction’ – the perpetual cycle of destroying the old and less efficient product or services and replacing it with new, more efficient ones” (p. 11).  Medicine and addiction treatment have a relentless need to develop more effective and more efficient treatments. 

Regional variation in rates of medical procedures like tonsillectomy and Caesarean-section births, for example, suggests that practitioner interests, rather than patient needs, often affect the care provided.  Unnecessary care increases economic costs and exposes patients to increased risks of morbidity and mortality.  Evidence-based medicine is not a government conspiracy.  It is a necessary response to inefficient and haphazard care.

The Institute of Medicine’s Crossing the Quality Chasm reports on American health care describe a distressingly inefficient and ineffective system for providing health care where medical error leads to needless mortality and morbidity and where too often the care provided does not reflect current research on more effective interventions (Institute of Medicine, 1998; Institute of Medicine, 2000).  Substandard treatment is especially common among individuals with alcohol and drug disorders.  Chart reviews found that only 10% of the patients identified with an alcohol disorder received recommended care (McGlynn et al., 2003). 

The Crossing the Quality Chasm reports advocate for health care that meets six standards for quality: safe, effective, patient-centered, timely, efficient, and equitable (Institute of Medicine, 2001).  Health care systems, moreover, must strive for a) continuous healing relationships, b) customized care based on patient needs and values, c) patient controlled care, d) freely shared information, e) evidence-based decision making, f) a priority on patient safety, g) transparent information on quality and effectiveness, h) anticipation of patient needs, i) elimination of waste, and j) cooperation among practitioners (Institute of Medicine, 2001).  These recommendations are also applicable to treatments for mental health and substance use conditions (Institute of Medicine, 2006).

The emphasis on effectiveness and the use of evidence-based decisions requires the adoption of evidence-based practice.  The IOM committee used a definition of evidence-based practice that recognizes the need to temper science with clinical feasibility and expertise:

Evidence-based practice is the integration of best research evidence with clinical expertise and patient values.  Best research evidence refers to clinically relevant research … Clinical expertise means the ability to use clinical skills and past experience … Patient values refers to the unique preferences, concerns and expectations that each patient brings to a clinical encounter … (p.  147) (Institute of Medicine, 2001).

The exact words used to describe the practices may vary.  The term “evidence-based practice” is relatively generic and in widespread use (APA Presidential Task Force on Evidence-Based Practice, 2006).  Others prefer the term “empirically supported treatments” (O'Donohue et al., 2000) or “empirically supported therapies” (Chambless & Hollon, 1998) to emphasize the research base.  “Evidence-based practice” reflects a broad perspective that incorporates personal experience and judgment with the application of science-based interventions.

The application of evidence-based practice, however, is controversial especially for psycho-social treatments and behavioral therapies.  Critics contend that the empirical evidence may be biased or incomplete because only areas amenable to simplistic studies are investigated and specification of best practices may constrain practitioner and patient choice (Nathan, 1998; Wampold & Bhati, 2004).  Others are concerned with a focus on brief manualized treatments, limited generalizability to diverse patient populations, and the emphasis on specific factors (the manualized intervention) rather than common treatment factors (APA Presidential Task Force on Evidence-Based Practice, 2006). 

Advocates for greater use of evidence-based practices challenge its critics noting that when practice is not based on evidence it seems to be driven by anecdote and instinct (McCabe, 2004).  The net result is that the field continues to promote greater use of evidence-based practices.  Professional organizations (APA Presidential Task Force on Evidence-Based Practice, 2006) and trade groups are reviewing the science and developing guidelines to assist practitioners in the identification and use of evidence-based practices.  

One of the more ambitious efforts provides guidance for the health care systems and purchasers that belong to the National Quality Forum (NQF).  With support from the Robert Wood Johnson Foundation, the NQF has published consensus standards for the treatment of alcohol, tobacco, and drug use disorders.  The practice standards require evidence-based practices for four domains: 1) identification of substance use conditions (systematic screening for alcohol, tobacco and drug use and diagnosis and assessment for individuals who screen positive), 2) initiation and engagement in treatment (brief interventions for excessive alcohol use, support for participation in treatment, and pharmacotherapy for withdrawal management), 3) therapeutic interventions to treat substance use illness (empirically validated psychosocial treatments and pharmacotherapy for alcohol, tobacco, and drug use), and 4) continuing care management of substance use illness (long-term coordinated care with care management and ongoing monitoring) (National Quality Forum, 2007).  The consensus standards are expected to

“provide guidance on how to achieve desired outcomes of treatment in the practice domains, provide useful information to providers who adopt processes to improve outcomes, to purchasers in making reimbursement and coverage policies, and to consumers and purchasers in making decisions about treatment services, and serve as the basis for the development of quality measures that can be used for public accountability” (p. 4) (National Quality Forum, 2007). 

Evidence-based practice is the contemporary standard of care.  The challenge is to develop implementation strategies that facilitate rather than frustrate consistent and efficient use of evidence-based practices for treatment of alcohol and drug disorders.  Economic survival is at the core of the need to develop and implement service improvements for addiction treatment.

Conclude reading Rejoinder: The Respondents Suggest Many New
Avenues to Explore in Technology Transfer

Resources:

APA Presidential Task Force on Evidence-Based Practice (2006). Evidence-based practice in psychology. American Psychologist, 61, 271-285.

Chambless, D. L. & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66, 7-18.

Friedman, T.L. (1999, 2000) The Lexus and the Olive Tree.  Anchor Books: New York.

Institute of Medicine (1998). Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, DC: National Academy Press.

Institute of Medicine (2000). To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press.

Institute of Medicine (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press.

Institute of Medicine (2006). Improving the Quality of Health Care for Mental and Substance-Use Disorders: Quality Chasm Series. Washington, DC: National Academy Press.

McCabe, O. L. (2004). Crossing the quality chasm in behavioral health care: The role of evidnece-based practice. Professional Psychology: Research and Practice, 35, 571-579.

McGlynn, E. A., Asch, S. M., Adams, J., Keesey, J., Hicks, J., DeCristofaro, A. et al. (2003). The quality of health care delivered to adults in the United States. New England Journal of Medicine, 348, 2635-2645.

Nathan, P. E. (1998). Practice guidelines: Not yet ideal. American Psychologist, 53, 290-299.

National Quality Forum (2007). National Voluntary Consensus Standards for the Treatment of Substance Use Conditions: Evidence-Based Treatment Practices. Washington, DC: National Quality Forum.

O'Donohue, W., Buchanan, J. A., & Fisher, J. E. (2000). Characteristics of empirically supported treatments. Journal of Psychotherapy Practice and Research, 9, 69-74.

Wampold, B. E. & Bhati, K. S. (2004). Attending to the omissions: A historical examination of evidence-based practice movements. Professional Psychology: Research and Practice, 35, 563-570.



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