EvidenceBased Practices in Addiction Treatment: An Overview

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Evidence-Based Practices in Addiction Treatment
An Overview

• Suzette Glasner-Edwards, Ph.D.
• UCLA Integrated Substance Abuse Programs
• September 10th, 2009 Burbank, CA
• September 21st, 2009 Sacramento, CA

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Overview

• Defining Evidence-Based Practices (EBPs)
• EBP Alphabet Soup
• Controversies surrounding implementation
• Problems with EBP Lists
• Recommendations for dissemination

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What can be gained from using EBPs?

• In theory
• Increased treatment effectiveness
• Consistency in practice
• Accountability of providers to funding sources
• Improved quality of treatment services
• The problem lack of consensus about what
  constitutes EBP

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Working definition of EBP

• Institute of Medicine (2001)
• the integration of best research evidence with
  clinical expertise and patient values (p.71).
• Dilemmas within the definitions components
• Best research evidence
• What sources to use?
• How much evidence is sufficient?
• Clinical expertise
• Training standards for counselors vs. regulations
  for sufficient expertise to provide services

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Graded sources of research evidence

• Level 1 Experimental Designs or Syntheses of
  Experimental Studies
• Randomized Controlled Trials (Double Blind,
  Single Blind, or Unblinded)
• RCTs ideally by more than one research team
• Systematic Reviews
• Meta-analyses
• Level 2 Quasi-Experimental Designs
• Non-randomized Controlled Trials
• Use of matched controls
• Multiple time series studies
• Cohort comparisons between groups receiving tx
  vs. no tx
• Correlational studies with systematic
  observation across cases/programs

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Graded sources of research evidence (contd)

• Level 3 Expert Consensus/Opinion
• Single Case Reports/Observational studies
• Consensus opinions of clinically experienced
  experts
• Expert committee recommendations
• Best practice guidelines assembled by expert
  consensus
• Level 4 Personal Communication

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EBP Lists

• No consensus has been reached for evidence
  standards, but there are many federal and state
  initiatives emphasizing EBP implementation (e.g.,
  NOMS, Oregons Senate Bill 267)
• Correspondingly, several lists have been
  developed to inform which txs meet sufficient
  evidence standards to be considered EBPs.

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Criteria for EBP Designation Four Sources

• American Psychological Association, Division 12
  (Clinical Psychology)
• Oregon Addictions and Mental Health Division
• National Registry of Evidence-Based Programs and
  Practices (NREPP)
• University of Washington Alcohol and Drug Abuse
  Institute

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Criteria for EBP Designation

• American Psychological Association
• The approach has demonstrated efficacy in gt2
  randomized controlled trials (RCTs) (i.e.,
  through demonstrated equivalence to an already
  established treatment or superiority to another
  treatment) OR a large series (gt9) of single-case
  design experiments
• Efficacy has been confirmed by gt2 independent
  investigation teams
• If (a) and (b) are not met, an approach with
  demonstrated efficacy in gt1 investigation is
  designated possibly efficacious (vs.
  well-established)
• Clear descriptions of the approach in the form of
  manuals or other materials are used
• Sample characteristics are specified

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Criteria for EBP Designation

• Oregon Addictions and Mental Health Division
• The approach is consistently supported by RCTs or
  rigorously conducted and designed evaluations
  (minimum gt2 studies in peer-reviewed journals).
• The elements of the approach are standardized and
  replicable
• If an approach or element(s) of an approach
  established through RCTs or other studies is
  tested in a setting or with a population that is
  difficult to study using a rigorous design, the
  research must be published in a peer-reviewed
  journal.

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Criteria for EBP Designation

• National Registry of Evidence Based Programs and
  Practices (NREPP)
• The approach has demonstrated positive outcomes
  (p lt 0.05) in gt1 studies
• The results of the research have been published
  in a peer-reviewed journal or documented in a
  comprehensive evaluation report
• Sufficient documentation exists in the form of
  manuals, training materials, etc. to facilitate
  dissemination of the approach

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Criteria for EBP Designation

• University of Washington Alcohol and Drug Abuse
  Institute
• The approach has been scientifically studied (no
  study design requirement) and may or may not have
  been published in a peer-reviewed journal
• The approach has demonstrated benefits in
  relation to treatment goals
• The approach has been standardized to facilitate
  replication
• The approach has been studied in gt1 setting with
  consistent results
• A fidelity measure either exists or could be
  developed from available information

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Taking a Closer Look at the Sources

• General considerations
• Each criteria set is developed by a professional
  group (e.g., APA is psychologists) and
  applicability is therefore limited
• Some lists are easier to qualify for than
  others (e.g., NREPP)
• Must consider real-world barriers which
  approaches are best for your particular
  population/community, taking local resources into
  consideration?

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Downsides of EBP Lists

• Concerns include
• EBPs may be used incorrectly or with insufficient
  fidelity
• Use of manualized EBPs will result in less
  individualized treatment
• EBPs may be used for political purposes
• De-emphasis on the therapist-client relationship

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Treatment Fidelity

• Transfer of EBPs into clinical settings can be
  problematic when implementation is nonstandard.
• Accurate implementation of EBP protocols is
  associated with positive clinical outcomes.
  (McHugo et al., 1999 Jerrell Ridgley, 1999)
• Providers may overestimate the extent to which
  they utilize EBPs when surveyed.
  (Miller Meyers, 1995)
• Ongoing clinical supervision and fidelity
  monitoring are critical components of successful
  EBP implementation.

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Clinical Expertise

• Significance
• Individual therapist effects predict outcomes
• (Norcross, 2001 McKay et al., 2006)
• Clinicians interpersonal skill can influence pt
  motivation for therapeutic change
• (Moyers et al., 2005)
• What is necessary for EBP delivery? Vs. required?
• Depends what we ask of clinicians
• Present requirements do not support skills to
  review and understand research evidence (Kerwin
  et al., 2006)
• Working within workforce constraints, can focus
  on a limited set of core change principles with
  corresponding skill sets that can be widely
  applied to clinicians with varying levels of
  experience (Carroll Rounsaville, 2006)
• (e.g., Skills to establish and maintain
  therapeutic alliance)

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EBP Alphabet Soup

• Practice Guidelines
• (incl. protocols, standards, or algorithms)
• Purpose to help clinicians make empirically
  informed tx decisions.
• Not based on a single theoretical framework
• Widely vary in terms of guidance to inform
  implementation
• Examples
• NIDA Principles of Effective Treatment, defined
  as
• a set of overarching principles that
  characterize the most effective drug abuse and
  addiction treatments and their implementation.
• (NIDA, 2000)
• American Psychiatric Association Practice
  Guidelines for Addiction Treatment (APA, 2006)

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EBP Alphabet Soup

• Best Practices
• Purpose to guide tx program planning and
  development of processes for EBP dissemination.
• Not clinicians guide
• Includes
• Recommended scope of services
• Considerations for tx of special populations
• Specific types of intervention techniques
• Examples
• Center for Substance Abuse Treatment (CSAT)
  Treatment Improvement Protocols (TIPs)
• Best Practices in Addiction Treatment (ATTC,
  2007)

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Which Evidence-Based Practices can be transferred
into community addiction treatment settings now?
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Realistic Dissemination Strategies

• Goal Provide clinicians with training in core
  evidence-based skills that tangibly influence
  their practice. (Carroll Rounsaville, 2006)
• Why skills and not manualized treatments?
• Current tx system not well-suited for immediate
  implementation of manualized EBPs.
• Clinicians report that skills that can be rapidly
  learned and put into practice are more appealing
  than those that require large-scale system change
  (Torrey et al., 2001).
• Use of these skills is expected to improve
  measurable clinical outcomes.

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Which skills?

• Therapeutic skills that promote 3 therapeutic
  goals
• Improving impulse control
• Reducing craving
• Promoting an adaptive social environment
• Approaches to achieve these goals include
• Motivational Interviewing/Brief Intervention
• Contingency Management
• Cognitive-Behavioral Coping Skills Training
• Couples and Family Counseling

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Motivational Interviewing Definition

• Motivational interviewing is a client-centered
  style of interaction aimed at helping people
  explore their ambivalence about their substance
  use and begin to make positive behavioral and
  psychological changes.

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Five Principles of Motivational Interviewing

• Express empathy through reflective listening.
• Develop discrepancy between patients goals or
  values and their current behaviors.
• Avoid argument and direct confrontation.
• Adjust to client resistance.
• Support self-efficacy and optimism.

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Summary of M.I.

• Understanding a substance users level of
  motivation can guide a clinicians first
  intervention.
• Goal is to enhance motivation to change behavior
  and elicit self-motivational statements using a
  supportive, non-confrontational style.
• This can be accomplished in 5-10 minutes once
  diagnostic information has been acquired.
• The 5 principles of M.I. are
• Express empathy
• Develop discrepancy
• Avoid argument
• Roll with resistance
• Support self-efficacy

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Contingency Management

• Basic Assumptions
• Drug and alcohol use behavior can be controlled
  using operant reinforcement procedures
• Vouchers can be used for money or goods
• Vouchers should be redeemed for items
  incompatible with drug use
• Escalating the value of the voucher for
  consecutive weeks of abstinence promotes better
  performance
• Counseling/therapy may or may not be required in
  conjunction with CM procedure

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Principles of CBT

• CBT is used to teach, encourage, and support
  individuals about how to reduce / stop their
  harmful drug use.
• CBT provides skills that are valuable in
  assisting people to achieve initial abstinence
  from drugs (or to reduce their drug use).
• CBT also provides skills to help people sustain
  abstinence (relapse prevention).

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Principles of Relapse Prevention

• Relapse Prevention (RP) is a cognitive-behavioral
  treatment (CBT) with two main goals
• To prevent the occurrence of initial slips or
  lapses after a commitment to change has been
  made and
• To prevent any lapse that does occur from
  escalating into a full-blown relapse.

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Cognitive CBT Concepts

• As CBT treatment continues into later phases of
  recovery, more emphasis is given to the
  cognitive part of CBT. This includes
• Psychoeducation regarding addiction
• Teaching clients about triggers and cravings
• Teaching clients cognitive skills (e.g., thought
  stopping and urge surfing)
• Identifying red flag thoughts

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Conclusions

• Training clinicians to use evidence-based skills
  is a reasonable place to start to transport EBPs
  into clinical practice.
• Target skills include contingency management
  principles, cognitive-behavioral and relapse
  prevention techniques, motivational interviewing,
  and couples and family counseling.
• Supervision and fidelity monitoring are key
  components of introducing and maintaining the use
  of evidence-based skills.
• Useful resources include implementation toolkit
  from the National Implementing Evidence-Based
  Practices project (Mueser et al.,
  2003)
• Combining toolkits with in-service training and
  consultation may optimize outcomes.

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References

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Thank you!Suzette Glasner-Edwards,
Ph.D.sglasner_at_ucla.edu310-267-5206