Transcript Implementing Evidence-Based Practices: Challenges & Perils

Evidence-Based Research
Findings on Substance Use
Disorders
Homeless Families – February 8, 2007
Joan E. Zweben, Ph.D.
Executive Director
The 14th Street Clinic & EBCRP
Health Sciences Clinical Professor of Psychiatry,
University of California, San Francisco
Goals
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Alert you to issues in the EBP debate
that may affect you soon
Give basic overview of evidence-based
principles and practices
Introduce two widely used models for
engagement and treatment of
substance use problems
Describe family program for
methamphetamine users at EBCRP
Substance Abuse Treatment:
Finding Good Care
What do we need to
know to improve care?
Clinician Questions I
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Should we admit people who are still drinking
and using?
Should they see a psychiatrist while they are
still drinking/using?
Should we discharge them if they don’t
comply with our exacting program
requirements?
Should we discharge them if they drink/use?
Clinician Questions II
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Should we require them to attend 12step programs?
Do recovering counselors do
better/worse than others?
Do harm reduction goals produce
greater public health and safety
benefits than abstinence goals?
Important Distinctions
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Evidence-based principles and
practices guide system development
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Example: care that is appropriately
comprehensive and continuous over time
will produce better outcomes
Evidence-based treatment
interventions are important elements
in the overall picture. They are not a
substitute for overall adequate care.
Evidence Based Principles & Practices vs
Evidence Based Treatment Interventions
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Principles and practices are derived
from different types of research.
Rigor often trumps relevance in
determining what type of research is
valued.
Policy makers must be educated on
these issues.
Evidence-Based Principles
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Retention improves outcomes; we need to
engage people, not discharge them
prematurely.
Addicts/alcoholics are a heterogeneous
population, not a particular personality type.
Addiction behaves like other chronic disorders
Harm reduction approaches yield benefits for
public health and safety.
Problem-service matching strategies improve
outcomes. (Other matching strategies
disappointing.)
Policies and Practices Not
Supported by Research
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Requiring abstinence as a condition of access
to substance abuse or mental health
treatment
Denying access to AOD treatment programs
for people on prescribed medications
Arbitrary prohibitions against the use of
certain prescribed medications
Discharging clients for alcohol/drug use
Evidence-Based Practices:
Key Issues in the Debate
Efficacy Studies
Specific psychosocial interventions are
usually investigated in random
assignment studies using manualized
treatments in carefully controlled trials.
Samples and settings are homogeneous
and treatment is standardized. Specific
procedures assure fidelity to the model.
Random Assignment
Controlled Trials (RCT’s)
Gold standard for pharmacological and many
psychosocial interventions
Examples with strong efficacy:
 Cognitive behavioral therapy
 Motivational enhancement therapy
 Behavioral marital therapy
 Community reinforcement approach
 Relapse prevention
 Social skills training
(see Miller et al, 2005)
Are RCT’s Over-rated?
QUERI
Mark Willenbring MD
(ASAM 2006)
Issues with RCT’s
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Is the research question an appropriate
question?
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Example: CBT A compared with CBT B, vs
CBT A compared with TAU
Are the treatment effects modest or
robust?
What is the cost to achieve and
maintain the intervention? Are the
results worth it?
Important to Extend the
Evidence Hierarchy
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RCT designs have limitations and are
not always best for investigating key
aspects of behavior change process:
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What influences people to seek and
engage in treatment?
How do these self-selection processes and
contextual influences contribute to the
change process?
(Tucker & Roth, Addiction, 2006)
IMPLEMENTATION
ISSUES
Barrier: Resource Allocation
99% = Investment in Intervention
Research to develop solutions ($95
billion/yr)
1% = Investment in Implementation
Research to make effective use of
those solutions (Up from ¼% in
1977) ($1.8 Trillion/yr on service)
Dean Fixsen, 2006
Can we assume that
interventions with
documented efficacy will be
effective in the community if
we only implement them
correctly?
Important Questions to Ask
What are the characteristics of interventions
that can:
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Reach large numbers of people, especially
those who can most benefit
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Be broadly adopted by different settings
3.
Be consistently implemented by different
staff with moderate training and expertise
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Produce replicable and long lasting effects
(with minimal negative impact) at
reasonable costs.
(Glasgow et al, AJPH, 2003)
Ineffective Implementation
Strategies
“…experimental studies indicate that
dissemination of information does not
result in positive implementation
outcomes (changes in practitioner
behavior) or intervention outcomes
(benefits to consumers)”
(Fixsen et al, 2005)
Key Ingredients
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Presenting information; instructions
Demonstrations (live or taped)
Practice key skills; behavior rehearsal
Feedback on Practice
Other reinforcing strategies; peer and
organizational support
(Fixsen et al, 2005)
Specific Treatment
Issues & Approaches
Abstinence-Oriented
Treatment & Harm Reduction
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Polarization unnecessary and misleading
Those who succeed quickly do not
remain in specialty treatment. We are
working with people who have trouble
establishing and maintaining
abstinence.
Go beyond the rhetoric and look at
what people/programs actually do.
Pitfalls of Abstinence-Oriented
Treatment
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Failure to assess motivation level before
pushing abstinence commitment
Failure to understand factors promoting
continued use
Unrealistic timetables
Power struggle vs clinical approach
Failure to recognize fluctuating motivation
Inappropriate termination of treatment
Pitfalls of Harm Reduction
Approach
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Inappropriately low expectations for
what client can achieve
Difficulty setting clear goals
Reluctance to ask client to abstain
completely
Underestimate risks/lethality
Clinician alcohol and/or illicit drug use
Motivational Enhancement
Strategies
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Widely adopted
Principles widely applicable outside
substance abuse treatment
TIP 33: Enhancing Motivation for
Change in Substance Abuse Treatment order from: www.ncadi.samhsa.org
Goals and Benefits
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Inspiring motivation to change
Preparing clients to enter treatment
Engaging and retaining clients in treatment
Increasing participation and involvement
Improving treatment outcomes
Encouraging a rapid return to treatment if
symptoms recur
Stages of Change
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Precontemplation
Contemplation
Preparation
Action
Maintenance
Prochaska , DiClementi, and Norcross (1992)
The Matrix Model
Richard Rawson, Ph.D., Jeanne Obert, MFT &
Colleagues (Los Angeles)
It is many treatments in one:
 Components based on scientific literature
promoting behavior change.
 Emphasis on collaborative relationship with
client.
 Teaches early recovery and relapse
prevention skills
 Facilitates participation in 12-step meetings
Organizing Principals I
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Non-confrontational, non-judgmental
relationship between therapist and
client creates positive bond that
promotes participation.
Positive reinforcement, incentives and
contingencies used extensively to
promote treatment engagement and
retention.
Organizing Principles II
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Accurate, understandable scientific
information used to educate the client and
family members
Cognitive behavioral strategies used to
promote drug cessation and relapse
prevention
Family therapy interventions used to engage
families in the recovery process
Social support activities provided to help
maintain abstinence
Evidence-Based Family
Treatment in Substance Abuse
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Behavioral strategic family therapy
(BSFT)
Behavioral marital therapy
Multidimensional family therapy for
adolescents
Multisystemic therapy (MST)
Family consultation approach (FAMCON)
Family Treatments
(Adolescents)
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Well defined, family-focused engagement
strategies outperform other, more standard
engagement strategies.
Retention is better.
We don’t know much about how or for whom
they work.
Definitions and outcomes vary widely.
Much more research is needed.
(Rorbach and Shoham, 2006)
Limitations
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Small pool of family therapists
Smaller pool with substance abuse
expertise
Training for some approaches is very
expensive
No studies of homeless families
(exclusively)
EBCRP Family Oriented Treatment for
Methamphetamine Users I
SPECIFIC FAMILY ELEMENTS
 Couples and family counseling to address
relationship issues
 Supportive family therapy – for parents and
young children; facilitate bonding and
address other issues
 Family education groups – 16 wk group to
address the basics of addiction and recovery,
using “family in recovery” model (Matrix)
EBCRP Family Oriented Treatment for
Methamphetamine Users II
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Parenting support groups – to increase
parenting skills as well as provide
support and feedback for parents in
recovery
Multi-family groups – to explore
changes in family structure that occur
when a family is in recovery
Some Final Points…..
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Learn about research so you can
educate your funders
Most substance abuse treatment is a
blend of evidence-based practices and
activities that have not been well
studied
Find community partners who will work
to meet the needs of your clients.
Acknowledgements
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Center for Substance Abuse Treatment, for
treatment funding (since 1990) that
encouraged innovation and supported our
ability to do comprehensive, evidence-based
care.
Clinical Trials Network, National Institute on
Drug Abuse for providing arena (since 2002)
for collaboration that greatly fostered mutual
understanding to bridge the gap between
treatment and research.
RESOURCES
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Download slides from: www.ebcrp.org
(go to Presentations)
Order TIPS and Matrix Manuals from:
www.ncadi.samhsa.org