Evidence Based Practices Gaps in Substance Use Treatment Presented by: Rhonda G. Patrick, LCSW, MPA

Evidence Based Practices What is it? “The integration of best research evidence with clinical expertise and patient values.” Treatment based on the best available science Respect for the expertise of the clinician Acknowledgement and incorporation of patient values Institute of Medicine, 2001

Evidence Based Practices What is it? “EBP is a process in which the practitioner combines well researched interventions with clinical experience, ethics, client preferences, and culture to guide and inform the delivery of treatments and services.” National Association of Social Workers

Evidence Based Practices Why EBP? Concerns related to cost and effectiveness of substance abuse treatment. Delineation of a rational approach to allocation of scarce resources. Mitigation against a system in which treatment practices are based solely on practice wisdom. Finding the “best” available treatment or policy that reduces the harm and costs of substance abuse. 18.3 billion cost of treatment. Majority funded with public dollars.

Research & Knowledge What do we know? We have validated measurement tools We have replicable biopsychosocial predictors of substance related events and outcomes We have a number of efficacious treatments of varying intensity and duration that produce benefits across a range of problem severity.

Research & Knowledge What do we don’t know? Much treatment research has proceeded without the benefit of theory, the mechanisms of action of many efficacious treatments are poorly understood. Patterns of substance use, abuse, remission and relapse are highly variable over time between and across individuals in treated and untreated samples. We do not have an understanding of the influence of contextual factors.

Research & Knowledge What do we don’t know? The reach and impact of efficacious treatments into the affected population remains suboptimal. Most people with substance use disorder do not seek professional care, a subset recover on their own, and most available treatments target the majority with more serious problems. Talk about statistical data from 2009 regarding use trends and diagnostics.

Research & Knowledge What do we know about Hispanic substance users? Younger users of alcohol and drug have more serious social problems as they age. Consequences are greater the younger you start. Cultural dissonance is occurring, especially for immigrated families. The closer you are to the routes of trade the higher your risk. Most will not and do not seek assistance through formal networks of care. There are regional substance use differences, however across the board alcohol and marijuana abuse impact a significant portion of the Latino community. There are differences in subpopulations of the Latino group in substance use severity, retention and outcome. Talk about statistical data from 2009 regarding use trends and diagnostics.

Research & Knowledge What do we don’t know about Hispanic substance users? What are the circumstances of Hispanics in their own communities (i.e., community context); What service delivery models are tailored to Hispanics’ circumstances and special needs; What are the client, provider, and system barriers to utilization of substance abuse services; How do we establish links between drug abuse services, social services, and other service sectors to optimize treatment outcomes. Talk about statistical data from 2009 regarding use trends and diagnostics.

Bridging the Gap: Community Characterize the local Hispanic community in terms of structure, cultural composition, and relations with the larger non- Hispanic community. Consider the role of community unemployment, residential segregation, proximity to centers of drug trade, and numbers of retail alcohol outlets in communities were Hispanics live as risk factors. Understand community factors that might prevent or promote use of alcohol or drugs. Develop community research partnerships can help elucidate how services need to be adapted for a particular community group or segment (e.g., Hispanic gang-involved youth, outreach) and identify how feasible and acceptable are the planned community interventions. Utilize a community participatory research framework: involve local community members and community-based organizations in community-based research. This research involves capacity building in intervention, services research for community leaders; learning about community needs and structure for researchers; and exploring the potential for alternative, community-based models of care to enhance service delivery by addressing local needs.

Bridging the Gap: Service Delivery Test the effectiveness of community-based therapeutic approaches that take advantage of natural supports (religious organizations) and of those that bring evidence-based treatments to non-clinical environments (e.g., academic community-partnerships). Evaluate and test collaborative research partnerships with Hispanic community members that identify new and innovative approaches to drug abuse treatment services. Test community-level interventions that facilitate recovery and reintegration of drug users within their Hispanic communities.

Bridging the Gaps: Barriers Test the effects of improved communication between caregivers and Hispanic clientele and its impact on retention in pharmacologic and cognitive substance abuse treatments. Assess programs on Latino’s health literacy for entry and engagement in care and decision-making in substance abuse treatments. Evaluate the impact of insurance coverage on access to substance abuse services, sustained attendance in drug treatments and relapse recovery. Test system interventions to redesign complicated admissions systems, improve patient engagement at intake, accommodate flexible scheduling, and reduced provider burden.

Bridging the Gap: Linkages Generate information that can be used to develop and test a workable model of community-based delivery in Hispanic communities, including research that identifies untapped, informal Hispanic community-based resources. Develop and evaluate best practices that focus on the integration of social, health and drug abuse services and that can optimize treatment outcomes for Hispanic service users.

Bridging the Gap: Other Issues Speaking a Common Language How we define the problem How we define the outcome How we define the measurement Documenting Effectiveness Informal Publications Formal Publications Increasing Funding for Research and Services Making Addiction a Priority Economic Costs Social Costs

Evidence Based Substance Use Treatment: Where do we find them? National Registry of Evidence-Based Programs and Practices Created in 2007 List SAMSHA Model Treatment Programs Defines EBP as “approaches t prevention or treatment based in theory and have undergone scientific evaluation.” Submissions are “reviewed” by experts with doctorial degrees, evaluation research experience and clinical experience. Many more prevention/intervention programs. Searchable by target population needs

Evidence Based Substance Use Treatment: Where do we find them? Agency for Healthcare Research and Quality National Guidelines Clearinghouse Search by topic area. Can compare multiple guidelines across variety of criteria and classifications. Can download information to PDA’s. Rigorous selection and review process Can only be developed by professional organization, developed in last 5 years and most recent version, comprehensive literture review using peer reviewed journals, provide recommendation from lietrture.

Evidence Based Substance Use Treatment: Where do we find them? Co-Occurring Disorder Center for Excellence Foster infusion and adoption of evidence and consensus based treatment and program innovation into clinical and organization practice. Created in 2003 Intended for the co-occurring disorder service system Provides descriptions of interventions Describes intervention implementation References related to EBPs Can only be developed by professional organization, developed in last 5 years and most recent version, comprehensive literture review using peer reviewed journals, provide recommendation from lietrture.

Evidence Based Substance Use Treatment: Where do we find them? Technology Transfer Centers 14 Regionally based addiction technology transfer centers Bridging the gap between science and practice Addiction Science Made Easy Program Intended for addiction treatment professionals Provides descriptions of interventions Describes intervention implementation References related to EBPs Can only be developed by professional organization, developed in last 5 years and most recent version, comprehensive literture review using peer reviewed journals, provide recommendation from lietrture.

Evidence Based Substance Use Treatment: Where do we find them? National Drug Abuse Treatment Clinical Trials Network The CTN provides an enterprise in which the National Institute on Drug Abuse, treatment researchers, and community-based service providers cooperatively develop, validate, refine, and deliver new treatment options to patients in community-level clinical practice. This unique partnership between community treatment providers and academic research leaders aims to achieve the following objectives: Conducting studies of behavioral, pharmacological, and integrated behavioral and pharmacological treatment interventions of therapeutic effect in rigorous, multi-site clinical trials to determine effectiveness across a broad range of community-based treatment settings and diversified patient populations; and Ensuring the transfer of research results to physicians, clinicians, providers, and patients. Regional “Nodes” Service providers attached to various regional nodes Evaluating pharmacotherapy, methadone, motivational interviewing, computer assisted treatment.

Discussion