EvidenceBased Research Findings on Substance Use Disorders

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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

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Goals

• 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

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Substance Abuse TreatmentFinding Good Care
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What do we need to know to improve care?
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Clinician 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 dont comply
  with our exacting program requirements?
• Should we discharge them if they drink/use?

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Clinician 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?

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Important 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.

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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.

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Evidence-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.)

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Policies 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

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Evidence-Based PracticesKey Issues in the Debate
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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.

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Random Assignment Controlled Trials (RCTs)

• 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)

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Are RCTs Over-rated?
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RCT
QUERI
Mark Willenbring MD (ASAM 2006)
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Issues with RCTs

• 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?

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Important 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)

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IMPLEMENTATION ISSUES
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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

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• Can we assume that interventions with documented
  efficacy will be effective in the community if we
  only implement them correctly?

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Important Questions to Ask

• What are the characteristics of interventions
  that can
• Reach large numbers of people, especially those
  who can most benefit
• Be broadly adopted by different settings
• Be consistently implemented by different staff
  with moderate training and expertise
• Produce replicable and long lasting effects (with
  minimal negative impact) at reasonable costs.
• (Glasgow et al, AJPH, 2003)

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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)

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Key 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)

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Specific Treatment Issues Approaches
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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.

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Pitfalls 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

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Pitfalls 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

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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

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Goals 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

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Stages of Change

• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Prochaska , DiClementi, and Norcross (1992)

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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

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Organizing 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.

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Organizing 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

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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)

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Family Treatments (Adolescents)

• Well defined, family-focused engagement
  strategies outperform other, more standard
  engagement strategies.
• Retention is better.
• We dont know much about how or for whom they
  work.
• Definitions and outcomes vary widely.
• Much more research is needed.
• (Rorbach and Shoham, 2006)

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Limitations

• Small pool of family therapists
• Smaller pool with substance abuse expertise
• Training for some approaches is very expensive
• No studies of homeless families (exclusively)

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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)

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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

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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.

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Acknowledgements

• 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.

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RESOURCES

• Download slides from www.ebcrp.org
• (go to Presentations)
• Order TIPS and Matrix Manuals from
• www.ncadi.samhsa.org