Evidence-Based Research Findings on Substance Use Disorders

Evidence-Based Research Findings on Substance Use Disorders

Homeless Families – February 8, 2007

Joan E. Zweben, Ph.D.Executive Director

The 14th Street Clinic & EBCRPHealth Sciences Clinical Professor of Psychiatry,

University of California, San Francisco

GoalsGoals 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

Substance Abuse Treatment:Finding Good Care

What do we need to know to improve care?

Clinician Questions IClinician Questions I 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 IIClinician Questions II

Should we require them to attend 12-step programs?

Do recovering counselors do better/worse than others?

Do harm reduction goals produce greater public health and safety benefits than abstinence goals?

Important DistinctionsImportant Distinctions Evidence-based principles and

practices guide system development 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

Evidence Based Principles & Practices vs Evidence Based Treatment Interventions

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 PrinciplesEvidence-Based Principles 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 ResearchPolicies and Practices Not Supported by Research 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 StudiesEfficacy StudiesSpecific 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)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?

Are RCT’s Over-rated?

QUERIQUERI

Mark Willenbring MD (ASAM 2006)

Issues with RCT’s Is the research question an

appropriate question? 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 HierarchyImportant to Extend the Evidence Hierarchy

RCT designs have limitations and are not always best for investigating key aspects of behavior change process: 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 ISSUESIMPLEMENTATION ISSUES

Barrier: Resource AllocationBarrier: 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 AskImportant Questions to Ask

What are the characteristics of interventions that can:

1. Reach large numbers of people, especially those who can most benefit

2. Be broadly adopted by different settings3. Be consistently implemented by different

staff with moderate training and expertise

4. Produce replicable and long lasting effects (with minimal negative impact) at reasonable costs.(Glasgow et al, AJPH, 2003)

Ineffective Implementation StrategiesIneffective 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 IngredientsKey Ingredients 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 & ApproachesSpecific Treatment Issues & Approaches

Abstinence-Oriented Treatment & Harm Reduction 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 TreatmentPitfalls of Abstinence-Oriented Treatment 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 ApproachPitfalls of Harm Reduction Approach

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

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 BenefitsGoals and Benefits 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 ChangeStages of Change

Precontemplation Contemplation Preparation Action Maintenance

Prochaska , DiClementi, and Norcross (1992)

The Matrix ModelRichard Rawson, Ph.D., Jeanne Obert, MFT & Colleagues (Los Angeles)

The Matrix ModelRichard 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 IOrganizing Principals I

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 IIOrganizing Principles II 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

Evidence-Based Family Treatment in Substance Abuse

Behavioral strategic family therapy (BSFT)

Behavioral marital therapy Multidimensional family therapy for

adolescents Multisystemic therapy (MST) Family consultation approach

(FAMCON)

Family Treatments (Adolescents)Family Treatments (Adolescents) 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)

LimitationsLimitations

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

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

EBCRP Family Oriented Treatment for Methamphetamine Users II

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…..Some Final Points….. 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.

AcknowledgementsAcknowledgements 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.

RESOURCESRESOURCES

Download slides from: www.ebcrp.org(go to Presentations)

Order TIPS and Matrix Manuals from: www.ncadi.samhsa.org