Jennifer Hillebrand

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Evidence-based practices background, concepts
and EMCDDA activities

• Jennifer Hillebrand

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Outline of this presentation

• Origin of evidence-based medicine
• What is evidence based medicine/evidence-based
  practices?
• Evidence-based practices and drug addiction
• Challenges research-practice gap,
  research-policy gap
• Evidence-based practices, the EMCDDA- EU Action
  Plan
• Conclusions

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Pierre Louis (1787-1872)Inventor of the numeric
method and the method of observation
Found that, on average, patients who were bled
did worse than those who were not.
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What is evidence?
Etymology Medieval Latin evidentia (-ae,
f),-illustration. Encyclopédie ou dictionnaire
raisonne des sciences, des art et des lettres (M.
Diderot et M. DAlambert, 2nd half of 18th
century) a certainty which is so clear and so
manifest by itself that our minds cannot refuse
it Facts, documentation or testimony used to
strengthen a claim or reach conclusion. (Oxford
dictionary)
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What is evidence-based medicine?

• The conscious, explicit and judicious use of the
• best current evidence in making decisions
• about the individual patients.
• Sackett et al., 1996

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What are evidence-based practices?
Interventions that show consistent scientific
evidence of being related to preferred client
outcomes.
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Assumptions of evidence-based practices

• Not all evidence is equivalent
• There is a hierarchy of study design
• External evidence can inform but can never
  replace individual clinical expertise (Sackett et
  al., 1996)
• Starting from the best external evidence and work
  from there.

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Evidence pyramid
Retrospective
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Randomised controlled trials (RCTs)

• Often referred to as the gold standard
• Clients are randomly assigned to a treatment
  group and to a control group.
• Does the treatment cause an improvement on the
  outcome measures that is independent of other
  possible causal agents?
• RCTs that eliminate purposely the confounding
  effects of context are not sufficient to study
  addictive behaviour change

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Randomised controlled trials (RCTs) and addiction
research

• RCTs have established several drug treatments as
  being efficacious.
• RCT designs cannot always investigate key aspects
  of addictive behaviour change processes
• Multivariate models may help further
  investigations.

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Efficacy vs effectiveness

• Efficacy The extent to which a specific
  intervention produces the intended results under
  ideal conditions.
• Effectiveness The extent to which a specific
  intervention when deployed in the field does what
  it is intended to do for a defined population.

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The Trade-offs
Efficacy. Maximizes internal validity, i.e.,
the degree to which one can conclude
with confidence that the intervention caused the
result. Effectiveness. Maximizes external
validity, i.e., the degree to which one can
generalize from the test to other times, places,
or populations. Threat External validity gets
little attention in the final recommendation of
best practices but which is in particular
important when social and psychological factors
are involved.
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Model for evidence-based decisions, Haynes et al.
1996
Clinical expertise
Research evidence
Clients preferences
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Challenges - The research-practice gap
Research Evidence
Practice
Diffusion /Adoption Information
overload Application to other populations Lack
of consideration of local practitioners,
community groups, agencies and governments role
and needs Cultural factors Economic
factors Social factors

Green, 2001, American Journal for Health Behaviour
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Challenges The research-policy gap
Research Evidence
Policy making
Service level
National policy level
Social, financial reasons Strategic development
of services Terms and conditions of
employers Dismissal because research comes from a
different sector or speciality Lack of
consensus Other types of competing evidence
experience, opinions, beliefs
Experiential evidence Ideology Electoral
considerationsValue judgments Finance Political
expediency Intellectual fashion
Black, 2001, BMJ
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Example Effects of Media Health Campaigns on
Behaviour

• Mediated health campaigns in the US have
• small effect sizes in short-term (Snyder et
• al.2004)
• ES .15 seat belts
• ES .13 oral health
• ES .09 alcohol
• ES .05 heart disease prevention
• ES .05 smoking
• ES .04 -sexual behaviours

A Meta-Analysis of the Effect of Mediated Health
Communication Campaigns on Behavior Change in
the United States Journal of Health
Communication, Volume 9, Issue S1 2004 , pages 71
- 96
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American National Youth Anti-drug Media Campaign

• planned by the National Drug Control Policy
  (ONDCP)
• funded in 1997 by the United States Congress with
  1,2 billion dollars
• Aim To prevent the initiation of or curtail the
  use of drugs among the nations youths
• alcohol and tobacco were omitted from the main
  focus of the campaign
• focused mainly on minimizing illegal drug use
  among young adolescents who have not yet become
  regular users of illegal substances
• televised anti-drug public service announcements
  broadcasted 1998-2004
• 2002-2004 Focus on marijuana use

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American National Youth Anti-drug Media Campaign

• Evaluation by Westats
• Recall of campaign advertisement increase over
  time among youth and parents.
• Beliefs about talking about drug use with their
  children among parents changed.
• Parents monitoring of their children's behaviour
  was not changed
• Parental change in attitudes did not lead to
  changes in youth attitudes or behaviour towards
  drug use.
• No effect on disapproval of drugs among youths.
• Past month use of marijuana appeared
  significantly increased by 2.5 among 14-18 years
  (Orwin 2006).
• Post-2002 results statistically significant
  increase in rates of marijuana use initiation
  among youth who were prior nonusers (2000 to 2004
  change 2.1)

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The EMCDDA and best practices
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Rationale for the EMCDDA focus on best-based
practice

• Objective 7 of the EU Action Plan on Drugs
  2005-2008 states the need to improve coverage of,
  access to, quality and evaluation of drug demand
  reduction programmes and to ensure effective
  dissemination of evaluated best practices.
• The provision of information on best practices in
  the Member States and the facilitation of
  exchange of such practices is a task of the
  EMCDDA (recast of the EMCDDA regulation)
• The Centre recognises that it is important to
  place the descriptive data in the context of
  identifying and sharing information on best
  practices.

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EMCDDA best practice portal Main objective and
target groups
To provide an overview on the latest evidence on
what works in demand reduction field. It will
also present tools and standards aimed at
improving the quality of interventions, as well
as highlighting best-practice examples from the
field. It is primarily aimed at professionals,
policy-makers and researchers in the drugs field.
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Why best practice portal and not science-based
practice portal?

• Corresponds better to the recast of the EMCDDA
  regulation
• Inclusion of "best practices" not yet fully
  investigated by scientific methods (e.g.
  innovative best practices in the field).

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Best-practice portal
glossary
Evidence of what works (and gaps?)
Overview on latest systematic reviews on efficacy
of Interventions Summary of conclusions on what
works/or does not work across latest systematic
reviews and information on how the reviews
arrived at the conclusions (methodology)
Tools to evaluate practices
Evaluation Guidelines
Prevention Evaluation resource kit (PERK)
Evaluation Instrument Bank
Standards and guidelines for practices
Guidelines, quality standards for practices
developed in different MS
Evaluated DDR projectsin MS
EDDRA inclusion of quality levels in EDDRA
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Conclusion-1 evidence-based practices

• Further analytical development to integrate
  theory and findings about contextual,
  psychological and other influences on behaviour
  over time.
• Evidentiary pluralism better than evidentiary
  dogmatism -Interdisciplinary approach
• Diffusion of evidence is not a linear process.
• Logos AND pathos AND ethos
• Consensus conference combine evidence with
  human judgement
• Inclusion of various types of evidence in our
  decisions

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No magic bullet but Best practices for the
process of planning for most appropriate
interventions for the setting and population
Results from self-monitoring
Clinical expertise
Diagnosis and analysis of context Place, setting
and culture (complementary research)
Research evidence
Clients needs
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Conclusions - EMCDDA

• Increased focus and promotion of quality (EDDRA
  quality levels)
• Need to foster effectiveness studies and theory
  based evaluation
• Portal will be a reference point for best
  practices only that can not guarantee
  implementation of evidence-based practices

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Thank you for your attention.Jennifer.hillebrand
_at_emcdda.europa.eu