Volume 1, Issue 2

Rejoinder: The Respondents Suggest Many New Avenues to Explore in Technology Transfer
By Paul Roman

My colleagues have produced outstanding essays, each following a different track of thinking.  The respondents worked independently from one another, and it is quite remarkable that there is essentially no repetition of points across their essays.

Hannah Knudsen taps into a very important idea that, to my knowledge, receives very little attention in writings that discuss the processes of technology transfer.   The image that typically prevails is that a new practice develops from research, goes through multiple modifications, and finally is the subject of multiple clinical trials.  At the very best, these multiple trials suggest the nature of the clinical sub-populations where the practice will have different degrees of effectiveness.  Nonetheless, the final step in technology transfer is for potential adopters to test out the practice in their own setting, compared to “treatment as usual.”  We don’t talk a whole lot about “treatment as usual,” but it can easily be re-labeled as “treatment that this provider believes to work.”  Thus "treatment as usual" is the natural competitor for any new practice that might be introduced as its full or partial replacement.  As Dr. Knudsen argues, only by making this comparison will a treatment program be able to fully accept a new practice.  This suggests that some form of evaluation must occur at the program level.  It also suggests a critical “piece” in the process of implementation of a new practice.

Mike Boyle correctly points out that the influence of NIH agencies on the adoption of new practices is indirect at best.   In my mini-history of events, it is important to note that beginning in the 1970s and through the early 1980s, both NIAAA and NIDA included miniature versions of what is now SAMHSA.  In other words, the research review and funding, and the funding of demonstration projects and block grants all occurred under one roof.  If we conceive of social distances and the absence of routine communication and interaction as barriers to technology transfer, then such an arrangement would seem to have been ideal.  Most observers at the time believe that this organizational change was motivated much more by complex political factors than by a belief that the creation of a new organization would enhance technology transfer.  The chance to conduct a “clinical trial” to see which model was more effective has long passed.  While it is clear today that SAMHSA works closely with NIAAA/NIDA, these are different organizations with different cultures and goals, and possible problems in these partnerships are rarely considered. 

How do state leaders make decisions about what they want to buy?  There may be implications for Mike Boyle’s observations from a recent study from Australia that examined the sources of information used by state-level substance use disorder administrators in considering treatment efficacy.  The researchers found that scientific journals were used minimally or not at all, and that administrators were likely to rely on news articles and simple reports rather than evaluating the science (need citation).   In my own experiences at conferences and in other interactions with substance use disorder treatment leaders, I am quite amazed by “the power of the anecdote” in convincing them that a practice or a medication is not effective or of very limited application. 

Furthermore, Mike Boyle offers what is to me a unique and outstanding suggestion that other branches of medicine can learn from substance use disorder treatment about the value of using psychosocial interventions to support medication impact and utilization.  Likely no one in our field would argue against this principle.  However, from the perspective of science, this combination needs to be carefully measured in clinical trials to assure that we can ascertain the extent to which combinations and “dosages” of these very different approaches maximizes treatment impact.

Heather Gotham very effectively summarizes the tremendous progress that has been made in recent decades in generating organizational and programmatic infrastructures to support both the development of EBPs and their transfer into substance use disorder treatment practice.  She points out how we have neglected to learn from the experiences of mental health systems in dealing with some of the very same issues, once again confirming the observation about the common “silo-ing” of substance use disorders relative to other areas of practice.  There is a bit of irony here, for once upon a time, the alcohol and drug abuse “desks” were inside the National Institute of Mental Health.  After NIAAA and NIDA became separate institutes, they were, in organizational terms, “cheek and jowl” with NIMH within the ADAMHA structure.  While many things have changed since those days, including the advancement of behavioral-problem treatment technology across the board, my recollections from “being around” at that time suggest that sharing the same corridors, cafeteria and conference rooms did not seem to facilitate any interaction between NIAAA/NIDA and NIMH.  In fact, for a considerable period of time, there was almost no interaction between NIAAA and NIDA.

The critical roles of state agencies in facilitating or demanding the use of EBPs raises the perennial question of which practices belong on “the list.”  It is very clear that the evidence base for some practices is much broader and deeper than for others.  Heather Gotham’s description of the Miller et al. “meta-review” can be seen as either a glass half-full or a glass half-empty given that while there were a significant number of studies that did not support the EBPs,  the majority were supportive.  The comparison of the approaches to EBPs of Delaware and Oregon is also relevant.  In Delaware, focus was perhaps more appropriately on treatment outcome at the provider level whereas Oregon adopted an extensive list of recommended treatments regarded as EBPs with minimal guidance or technical assistance available for choosing EBPs or implementing them.

Finally, Dr. Gotham lays down the gauntlet for the role EBPs will play in the success of  the implementation of parity.  This is a complex, and potentially scary, issue.  She suggests that we begin to dialog more effectively with managed care organizations, and likely with other insurers as well.  How will this be accomplished?  What are the mechanisms for those interactions?  How can the substance use disorder field move toward speaking with a single voice at this critical juncture?

Dennis McCarty, a pioneer in the EBP movement in substance use disorders, spells out the foundations for the movement in very clear and compelling terms.  As all of the respondents point out, there can be no question that, as a whole, the field of substance use disorder treatment practice does not come close to fully utilizing the substance use disorder treatment evidence base.  In order for full utilization to occur, we need to add more tools to our technology transfer toolbox. 
First, we need to define evidence-based practices more broadly than just treatment practices.  The national Network for the Improvement of Addiction Treatment (NIATx) has shown that managerial practices in substance use disorder treatment are of great importance for successful programs, and that they can be changed through some participative implementation strategies.  Participation in these clear-cut processes of managerial change may be a “gateway” experience to further adoption of EBPs in treatment. 

Second, we need to develop evidence-based technology transfer processes.  NIATx is demonstrating a strategy of implementation that is gaining a strong evidence base.  More such research is badly needed, yet relatively little is underway.  It is unlikely that successful full-scale implementation of EBPs is going to occur according to any simple formula, applicable across the board.  Developing evidence for a variety of models that work looks very much like the next frontier in our field.


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