Read an Excerpt
Evidence-Based Addiction Treatment
Academic PressCopyright © 2009 Elsevier Inc.
All right reserved.
Chapter OneWhat Is Evidence-Based Treatment? James L. Sorensen, Jennifer E. Hettema, and Sandra Larios University of California, San Francisco
I am a firm believer in the people. If given the truth, they can be depended upon to meet any national crisis. The great point is to bring them the real facts.
"Evidence based" has been defined in many ways; however, most definitions include components that emphasize the importance of the scientific method and the cumulative evidence base derived from research. This chapter defines evidence-based treatment as a treatment that has been scientifically tested and subjected to clinical judgment and determined to be appropriate for the treatment of a given individual, population, or problem area.
Methodological issues may arise when evaluating evidence. Several factors important to consider when evaluating methodological quality include group allocation (were subjects randomly assigned to conditions), inclusion of collaterals, objective verification, treatment completion rates, generalizability, and the fidelity of the intervention.
Examples of evidence-based treatment interventions have been divided into different types and include randomized clinical trials, effectiveness trials, reviews, and National Registration of Effective Programs and Practices.
Specific interventions include cognitive behavioral therapy, motivational interviewing, brief interventions, relapse prevention, behavioral marital therapy, community reinforcement and contingency management, and adjunctive pharmacotherapy.
Imagine that you are approached by a close friend or family member who has developed an addiction to alcohol or another substance and wants to pursue treatment. This person asks you to visit a few treatment programs to help evaluate which offers the best treatment. What sort of questions would you want to ask the treatment program? What kind of answers would you find compelling? Would you be likely to choose a treatment option because the person explaining it to you had a salient and emotional story about how that treatment had helped a specific individual, perhaps even him or her, or would you want to know other things, such as how many people had been through the treatment program and what percentage have shown improvement? Perhaps you might even question how similar these people are to your loved one or how information on improvement rates was gathered and measured. This latter approach represents an evidence-based approach to treatment, and many of the questions that you may ask in this area are the same questions that scientists, policy makers, and treatment providers are beginning to ask regarding substance abuse interventions.
The substance abuse field is experiencing a transition from reliance on personal evidence and subjective testimony to a more objective, evidence-based approach. While testimony before public commissions about substance abuse treatment and policy has tended to use storytelling about the success or failure of a specific individual more than scientific evidence (Sorensen, Masson, Clark, & Morin, 1998), recent years have witnessed a growing emphasis on substance abuse treatments that have a strong scientific base. For example, the state of Oregon has implemented a policy requiring that 75% of state funds for substance abuse treatment go to support evidence-based practices by the 2009–2011 budget period (Oregon Department of Human Services, 2008). Across the country, there is increasing pressure for programs to justify their outcomes against competing approaches so that they can collect insurance reimbursement. Increasingly, treatment programs need hard scientific evidence to maintain their existence.
The emphasis on research is somewhat new to the field of substance abuse treatment. For a large part of the 20th century, treatment of addiction was conducted separately from mainstream medical or scientific establishments. Because of this, treatment grew from a movement of dedicated nonprofessionals, whose personal experience led to their involvement in the field (Lamb, Greenlick, & McCarty, 1998). These compassionate peers built a system of care that was relatively independent of the medical and scientific communities. For these treatment staff, personal experiences were regarded as much more valuable evidence than the findings of science. Although substance abuse treatment is becoming increasingly integrated into scientific and medical communities, there is still an emphasis on personal experience and distrust of scientific evidence among many treatment providers. Yet there is increasing scrutiny of substance abuse treatment programs, which need data to justify their place in financially strapped health care systems. Fortunately, a set of treatments is emerging that is "evidence based."
This chapter focuses on evidence-based interventions in the treatment of addiction. Several definitions of the term "evidence based" will be provided, and the readers will learn about the different types of evidence that are available when making treatment decisions. The chapter also focuses on the skills necessary to critically evaluate and weigh information regarding the effectiveness of a given intervention. Several key studies that have dramatically informed the field of substance abuse are highlighted. Finally, a list of widely accepted evidence-based practices is introduced, and the future of evidence-based practice is explored.
WHAT DOES "EVIDENCE BASED" MEAN?
While on the surface we may all agree about the importance of using evidence-based practice, defining the term "evidence based" is not a simple task. In fact, many different definitions have been put forward. Some definitions focus solely on the status of the intervention within the available scientific literature base. For example, Drake et al. define evidence-based practices as "interventions for which there is consistent scientific evidence showing that they improve client outcomes" (Drake et al., 2001, p. 180). Other definitions emphasize the important role the individual clinician plays in searching for, evaluating, and applying knowledge derived from the scientific evidence base. For example, the Center for Evidence Based Medicine points out that the literature base itself requires interpretation, which highlights the importance of clinical expertise when interpreting the findings of research (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). Finally, other definitions focus on the importance of patient values in determining what constitutes evidence-based practice. For example, the Institute of Medicine (2001, p. 147) calls attention to the importance of scientific evidence, clinical judgment, and "the unique preferences, concerns, and values that each patient brings to a clinical encounter." Even more clinical judgment is necessary to apply the literature base to a specific treatment-seeking individual with a unique background and characteristics. For the purposes of this chapter, all of these important factors are taken into consideration, and evidence-based treatment is defined as a treatment that has been scientifically tested and subjected to clinical judgment and determined to be appropriate for the treatment of a given individual, population, or problem area.
Future sections of the chapter emphasize the importance of the scientific method and cumulative evidence base, but also highlight that the interpretation of evidence is rarely a straightforward task and typically requires subjective decision-making. This chapter describes several methods for identifying and evaluating the evidence base, describes several landmark studies that have informed the field, and identifies treatments that are widely considered to be evidence based.
EVALUATING THE EVIDENCE
A clinician interested in providing evidence-based treatment may turn to the literature in search of research articles that focus on the disorder, population, or intervention of interest. Some types of evidence, however, are more prone to bias than others, and several systems have been developed to help researchers and clinicians organize their thinking about types of research. Several important terms used when evaluating evidence-based treatments can be found in Table 1.1.
Evaluating evidence through clinical trials
In behavioral research, randomized controlled trials, or efficacy trials, have historically been the gold standards against which to evaluate interventions. As the name suggests, randomized controlled trials randomly allocate participants to treatment condition and control for extraneous factors that could confound interpretations of causality. However, recent critics have begun to question whether the findings achieved under such tightly controlled studies will translate into routine clinical practice. Instead, many researchers are suggesting effectiveness trials, which test interventions in real-world settings, with the patients and therapists likely to be using the intervention. This design choice consequently limits intervention studies to those that can be realistically administered given staff preferences, time, and resources (Hunsley & Lee, 2007).
Excerpted from Evidence-Based Addiction Treatment Copyright © 2009 by Elsevier Inc.. Excerpted by permission of Academic Press. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.