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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