- Email: [email protected]
Dancing with strangers
Addictive Behaviors 27 (2002) 941 – 949
Dancing with strangers: Will U.S. substance abuse practice and research organizations build mutually productive relationships? Richard A. Rawson*, Patricia Marinelli-Casey, Walter Ling UCLA Integrated Substance Abuse Programs (ISAP), 11075 Santa Monica Boulevard, No. 200, Los Angeles, CA 90025, USA
Abstract The scientific knowledge gained from research has not been extensively integrated into the U.S. substance abuse treatment system. A clear call to arms has been issued by the U.S. federal treatment and research agencies to bring research and practice together to create a better treatment system and a more responsive research agenda. The current federally sponsored initiatives to ‘‘close the gap’’ between research and practice are large and well funded. The field appears ready to change and realize the mutual benefits that can be achieved from the increased ‘‘blending’’ of research and practice. However, while the music has started and the partners seem willing, there are still many obstacles to a successful dance. D 2002 Elsevier Science Ltd. All rights reserved. Keywords: Research-practice gap; Treatment
A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it. (Max Planck, 1858 –1947)
1. The challenge of integrating research and practice An increasingly important theme in the substance abuse field in the United States goes by a number of names. These include ‘‘science to practice,’’ ‘‘research to application,’’ ‘‘bench * Corresponding author. Tel.: +1-310-312-0500x511; fax: +1-310-312-0538. E-mail address: [email protected] (R.A. Rawson). 0306-4603/02/$ – see front matter D 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 3 0 6 - 4 6 0 3 ( 0 2 ) 0 0 2 9 2 - 7
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to trench,’’ ‘‘technology transfer,’’ or some variation of the above. Regardless of the specific terms selected, the basic premise is the same: Substance abuse services should increasingly employ approaches that are grounded in empirical support and developed with sound scientific methods. As recently noted by Dr. Alan Leshner, former director of the National Institute on Drug Abuse (NIDA), the challenge of integrating science-based substance abuse treatment practices into clinical care is best conceptualized as a ‘‘blending’’ of research and practice as opposed to the ‘‘replacement’’ of current/traditional practices with those with scientific support (Leshner, 2001). These efforts to blend research and practice attempt to influence the basic conceptualization of substance use disorders, the clinical approaches used in prevention and treatment programs, and the techniques used to evaluate the effectiveness of these programs. The goal, over time, is for science to serve as the foundation for the field. The report from an Institute of Medicine (IOM) committee titled Bridging the Gap Between Practice and Research: Forging Partnerships With Community-Based Drug and Alcohol Treatment (IOM, 1998) signaled the movement of this issue into national prominence. For the past 25 years, most attempts to ‘‘blend’’ research and practice have been hindered by a variety of issues. The IOM committee was charged with investigating various domains related to barriers between research and practice. Committee members held discussions with providers, researchers, and policymakers, and they made site visits to obtain input from a variety of stakeholders. The report generated by the committee is now seen as the benchmark resource publication on the research–practice relationship. Even with the best intentions and leadership from U.S. federal agencies, it is unlikely that the shift of the substance abuse treatment system from a foundation of personal ideologies (i.e., treatments based on individuals’ experience of substance abuse and recovery) to one of empirical evidence will be smooth and effortless. In fact, there is a good deal of experience that indicates that there are many obstacles to shifting to a science-based treatment system. The purpose of this article is to describe some of the reasons for and examples of the substance abuse research–practice gap in the United States. In addition, the article presents some of the obstacles to closing this gap and some of the U.S. initiatives to close this gap.
2. Evidence of a gap between research and practice The esteemed U.S. television journalist, Bill Moyers, produced a five-part documentary (‘‘Moyers on Addiction: Close to Home’’) that premiered March 29, 1998, on the American perspective on substance abuse (Public Broadcasting Service, 1998). This Public Broadcasting Service documentary provided a superb illustration of the chasm between the worlds of substance abuse research and treatment in the United States in the late 1990s. In the report, Moyers describes, with great enthusiasm, the tremendous advancements made during the 1980s and 1990s in understanding the biobehavioral underpinnings of the causes and course of addictive disease from use to abuse to dependence. He interviews numerous scientists who have documented genetic-based vulnerabilities to developing substance use disorders; he
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shows with sophisticated PET scan technology vivid pictures of how substance use changes the brain and how it is now possible to ‘‘see’’ the areas of the brain that are involved when an addicted person craves a drug; he interviews Dr. Alan Leshner, who describes addiction as a ‘‘brain disease.’’ After this first segment, one is left with the impression that we are on the verge of a scientific revolution in how we can help individuals with addiction disorders. Much of the rest of the Moyers series describes the mainstream treatments used throughout the United States for people with substance use disorders. Amazingly, when the U.S. treatment service delivery system in 1998 is described, it is virtually indistinguishable from the system that was in place in 1975. It might be argued that the reason there has been little change in the ‘‘traditional’’ approaches to treating substance abusers is that the existing treatments produce universal success. However, even the most loyal defender of the existing treatment approaches would be reluctant to take this position. Few programs conduct any form of treatment outcome assessment; however, most program directors acknowledge that a substantial percentage, if not the majority, of treatment program graduates relapse at some time following their completion of treatment, and, in real-world treatment programs, there is currently no assurance that the treatment activities employed have any evidence to support their usefulness. Maintaining the status quo in the substance abuse service delivery system puts continued public support and public funding for substance abuse treatment services into a very tenuous position. Within the past decade, the U.S. federal agencies responsible for substance abuse treatment and research have received budget increases (especially NIDA, whose budget has nearly doubled in the past 5 years). These increases are predicated on the public trust in the fact that these funding increases will allow the treatment system to improve care for individuals with drug and alcohol problems. There is an increasing number of requests by funders for treatment service organizations to demonstrate their value with outcome data (Carise & Gurel, in press; Crevecoeur & Rawson, in press). The public wants to know what it is getting for its investment in substance abuse treatment. As these evaluation efforts and others come to fruition and document the performance of substance abuse treatment activities, it is extremely likely that the ‘‘successes’’ of treatment will receive less attention than the ‘‘failures.’’ If (when) the public becomes aware of the fact that billions of dollars have been spent on research to improve treatment, but that service providers have chosen to ignore this information and conduct ‘‘business as usual,’’ it is probable that there will be unpleasant consequences. It is incumbent that practitioners demonstrate their efforts to improve their outcomes, and it will be similarly important that researchers demonstrate that the investment in research produces something other than academic research articles. Evidence to support the existence of a chasm between research and practice is readily available. The minimal use of the pharmacotherapies, LAAM (levo-alpha-acetyl-methadol) for heroin addiction and naltrexone for heroin addiction and alcoholism, both of which have clear empirical support for their effectiveness, is indicative of the difficulty of introducing new medication treatments (Callahan, Rawson, Glazer, McCleave, & Arias, 1976; Cornish et al., 1997; Hough, Washton, & Resnick, 1983; Ling, Charuvastra, Kaim, & Klett, 1976; Ling, Huber, & Rawson, 2001; O’Brien, Volpicelli, & Volpicelli, 1996; O’Malley et al., 1992;
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Volpicelli, Alterman, Hayashida, & O’Brien, 1992). The minimal application of behavioral strategies such as contingency management (the offer of rewards for specific behavioral changes), which has very strong empirical support in the treatment of stimulant dependence and alcohol-use disorders, further emphasizes the distance between the ‘‘science’’ of addiction treatment and the ‘‘practice’’ of this care (Higgins & Petry, 1999). Few challenge the contention that there is a great disconnection between research findings on substance abuse and the services used to address these problems in the ‘‘real world.’’
3. Standard practices versus new technologies In other areas of health care, it is a foregone conclusion that when treatment methods are developed and determined, with research data, to be superior to old methods, the new methods are adopted. Consider the speed with which cardiac care procedures such as bypass surgery and angioplasty have been adopted and how rapidly the new ‘‘statin’’ medications have been applied to the treatment of high cholesterol. Similarly, the embracing of contact lenses and laser surgery has substantially reduced the number of individuals wearing glasses. Virtually the entire field of treatment for serious mental health disorders has been transformed by new medications in the past 15 years. And, PET scan and MRI technologies have created tremendous paradigm changes in the treatment of many forms of illness. Certainly from the scientist’s perspective, it seems clear that techniques with sound scientific support should be moved into standard application as a logical result of their demonstrated empirical validity. Surely, no one can argue with the wisdom of basing health care interventions on scientifically derived strategies. Science has taken humans to the moon, it has given us the Salk vaccine and protease inhibitors, and it guides the evolution of medicine in virtually all areas. Although the movement toward science-based practice in the health care field may seem inevitable to some, the words of Max Planck offer an important cautionary observation. The substance abuse field now has a substantial set of scientifically supported advancements that are not being used. It is incumbent that we ask: ‘‘Why is this new technology not routinely moved into mainstream use?’’
4. Researchers and practitioners: understanding the other’s perspective As noted above by Max Planck, new knowledge does not guarantee new practice, and this is due in large part to the human element. What people believe about a new technology significantly affects what they will do with the new information. Furthermore, the relationship between those proposing the innovation and those responsible for implementing the innovation is critical. Backer, David, and Soucy (1995) note that there are more than 10,000 citations of literature on technology transfer. Many of the research-to-practice problems in the substance abuse field are common to challenges faced in other fields when implementing new technologies.
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In the substance abuse field, a main factor contributing to the gap between research and practice is the lack of cooperation between researchers and practitioners. The two groups have made little effort to understand and learn how to use one another’s knowledge. Practitioners and researchers view the world differently. They have different missions, cultures, histories, and information needs, and they assess, formulate, process, and disseminate information in their own way. Although the two groups interact at times, constructive communication has been missing. Examples of the obstacles faced in blending research and practice are as follows: 1. Researcher and practitioner philosophies. The ‘‘culture and ethical values’’ of substance abuse researchers and practitioners could hardly be more different. Researchers worship at the altar of science. Data are the lifeblood of a researcher’s world. The ‘‘products’’ of the research are the data, whether positive or negative. Practitioners frequently have little understanding or appreciation of the role of science in the delivery of care. For many treatment delivery personnel, the ‘‘product’’ of their work is the ‘‘conversion’’ of a substance user into a person ‘‘in recovery.’’ In addition, historically, there has been little mutual respect between researchers and practitioners. Many researchers view the clinical practices currently used to be quasi-religious, ideological propaganda. Some researchers view practitioners as poorly educated, naı¨ve, and ignorant of the most basic appreciation of empirical principles. Practitioners commonly view the scientific agenda as esoteric, sterile, and lacking in empathy for real-world substance users grappling with psychological, social, emotional, and economic challenges. They often express the belief that researchers are only concerned about publishing articles and not about helping people with addictions. 2. Policies and regulations. The substance abuse service delivery system is one of the most regulated areas of health care. Specifically, the delivery of opiate pharmacotherapies, including methadone and LAAM, are among the most highly regulated services in all of medicine (IOM, 1998). Not only are medications closely regulated, but in many locations, effective behavioral strategies such as contingency management techniques are infeasible because there is no mechanism for reimbursement for this nontraditional treatment. 3. Funding. In many parts of the United States, the impact of managed care and related funding policies has stripped the treatment delivery system of much of its flexibility. Treatment service providers may, in fact, desire to hire staff with professional degrees to implement new treatments, but the treatment reimbursement levels are barely adequate to attract staff willing to work for minimum wage. Many treatment organization directors face a choice between using relatively inexpensive traditional methods, believed in by the staff, or new approaches requiring substantial training costs that are viewed with skepticism by program staff. 4. Consumers. Consumers and their families are increasingly taking a more active role in their health care. They are no longer passive recipients of recommendations made by their physicians. Growing dissatisfaction with the treatments offered by substance abuse services has increased consumer demand for more treatment options. Books published in the popular press, access to the internet, and multimedia advertising have allowed
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individuals to learn about new health care technologies and medications that may help treat their illnesses. Substance abuse treatment providers for the first time face questions from knowledgeable consumers about availability of new treatments. It will become increasingly important for service providers to be at least as aware of new treatments as the public they serve. The IOM report prompted two U.S. federal agencies (NIDA and the Center for Substance Abuse Treatment [CSAT]) to release funding initiatives that encourage both researchers and practitioners to collaborate to ‘‘bridge the gap.’’ The challenge of integrating research and practice appears to be taking center stage as a major focus for the substance abuse field in the next decade.
5. National efforts to blend research and practice The first recommendation of the IOM report states, ‘‘The National Institute on Drug Abuse and the Center for Substance Abuse Treatment should support the development of an infrastructure to facilitate research within a network of community-based treatment programs, similar to the National Cancer Institute’s Community Clinical Oncology Program (CCOP) networks’’ (IOM, 1998). To date, both NIDA and CSAT have developed initiatives in accordance with this recommendation and published documents that aim to reduce the research–practice gap. 5.1. NIDA initiatives and publications
NIDA’s Clinical Trials Network (CTN). In January 1999, NIDA began building the CTN, which was designed to build collaborations between regional research and training centers and community treatment programs, known collectively as regional nodes. Each of the 14 nodes has a university-based research and training center responsible for conducting multisite clinical trials in partnership with their affiliated community treatment programs. Participation in the network requires researchers and practitioners to work collaboratively to determine the direction of the research and the scope of the projects. Through the CTN initiative, NIDA is attempting to foster collaboration between substance abuse practitioners and researchers and create the necessary infrastructure to design scientifically sound research protocols and conduct multisite trials in community-based settings. The NIDA CTN website is at www.nidactn.org. The NIDA Clinical Toolbox: Science-Based Materials for Drug Abuse Treatment Providers. In an effort to disseminate science-based information about substance abuse and its treatment, NIDA has distributed a compilation of publications on effective drug treatment approaches and strategies entitled, the ‘‘NIDA Clinical Toolbox: Science-Based Materials for Drug Abuse Treatment Providers.’’ Nearly 12,000 drug treatment programs nationwide have received this set of materials. For more information about The NIDA Clinical Toolbox, visit http://165.112.78.61/TB/Clinical/ClinicalToolbox.html.
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5.2. CSAT’s initiatives and publications Under the leadership of Dr. Westley Clark, CSAT has taken the lead in disseminating empirically based treatment materials and promoting multiple strategies for improving substance abuse treatment by more closely linking science and service.
The Addiction Technology Transfer Centers (ATTCs). The centerpiece of the CSAT effort is a system of 14 training centers located throughout the United States that have as their goal the improvement of substance abuse treatment by increasing the use of treatments with empirical support. This network of training centers has created a new array of training activities and materials never before available for substance abuse service personnel. The ATTCs have created documents to promote organizational change (e.g., The Change Book: A Blueprint for Technology Transfer, available online at http://www.nattc.org/resPubs/ cbResources.html#cb), developed online training courses and video training programs that facilitate training to rural providers and providers in areas with few training opportunities, and promoted the development of clear and objective standards for the training and certification of counselors. The national ATTC website is at www.nattc.org. CSAT’s Community-Based Practice Improvement Collaboratives (PICs). In 1999, CSAT released its own initiative aimed at improving the quality of substance abuse treatment by increasing the interaction and knowledge exchange among key community stakeholders. This initiative created 14 geographically dispersed PICs that bring together treatment providers, organizations providing support services to substance abusers, researchers, and policymakers, including health plan managers and purchasers of services. The PICs are intended to create the necessary environment to ensure that research agendas are relevant to the needs of the treatment community and that new, effective approaches are implemented in treatment programs. More information about PIC is located at www.samhsa.gov/centers/csat/content/pic/contact.html. CSAT Methamphetamine Treatment Project (MTP). Although CSAT has sponsored a number of multisite evaluations of specific new treatments, one of the most ambitious is the MTP (Anglin & Rawson, 2000). The MTP is an eight-site randomized clinical trial designed to compare an empirically based model of treatment (known as the Matrix Model) with ‘‘treatment as usual’’ for methamphetamine dependent individuals. The eight sites are encountering diverse challenges in moving a science-based treatment into community settings. One of these challenges involves the differing perspectives, and the tensions created by those differences, between researchers and practitioners in areas such as boundary issues, clinical approaches, and the viewing of participants as clients versus data sources (Rawson, McCann, Huber, Marinelli-Casey, & Williams, 2000; Zweben, Cohen, Obert, Vandersloot, & Marinelli-Casey, 2000). CSAT’s Treatment Improvement Protocols (TIPs). CSAT has published 38 TIPs. These best-practice guidelines offer information and recommendations from expert panels of researchers, clinicians, and administrators on a wide variety of topics including: treatment drug courts, substance abuse among older adults, naltrexone and alcoholism treatment, stimulant abuse treatment, and pregnant substance-using women. Because research
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frequently lags behind treatment innovations, a major goal of the TIPs is to convey ‘‘frontline’’ information quickly and responsibly. Relevant research is included when it is available. CSAT TIPs are accessible online through http://www.samhsa.gov/centers/ csat2002/publications.html (after clicking on ‘‘Treatment Improvement Protocols,’’ click on ‘‘Contents’’ on the National Library of Medicine HSTAT website).
6. Integrating research and practice—2002: where do we stand? The IOM Bridging the Gap report has spurred the allocation of tens of millions of dollars by NIDA, CSAT, and the National Institute on Alcohol Abuse and Alcoholism on an extensive set of activities designed to better link substance abuse treatment and research in the United States. Many leaders in the substance abuse field are promoting the idea as critical to the future of the field itself. There appears to be little organized resistance to the concept that research and practice should be made increasingly synergistic. No one is marching in the streets to oppose this idea. Is it safe to say that ‘‘bridging the gap’’ is an idea whose time has come? Perhaps. It is clear that researchers and practitioners are beginning to dance together, but it is unclear if the dance will look like a waltz or like the ‘‘funky chicken.’’ Bringing researchers and practitioners together to discuss issues, conducting research projects in community clinics, and producing materials for staff training are a start, but they are not sufficient preconditions to change the system. It will take policy changes by treatment funders requiring the use of treatments with empirical support. A tremendous amount of training will be needed to initiate and maintain new practices. Staff in treatment programs will require considerably more formal education than is currently the case. Political will and money are going to be necessary to push this agenda forward. While the atmosphere in 2002 for blending science and practice is the most encouraging in the history of substance abuse treatment, it is far from a ‘‘done deal.’’ At present, cautious optimism is warranted.
References Anglin, M. D., Rawson, R. A. (Eds.) (2000). The CSAT Methamphetamine treatment project: moving research into the ‘‘real world’’. Journal of Psychoactive Drugs, 32, 133 – 238. Backer, T. E., David, S. L., & Soucy, G. (1995). Introduction. In T. E. Backer, S. L. David, & G. Soucy (Eds.), Reviewing the behavioral science knowledge base on technology transfer. NIDA Research Monograph, vol. 155 (pp. 1 – 20). Bethesda, MD: National Institute on Drug Abuse. Callahan, E. J., Rawson, R. A., Glazer, M., McCleave, B., & Arias, R. (1976). Comparison of two naltrexone treatment programs: naltrexone alone versus naltrexone plus behavior therapy. Narcotic antagonists: naltrexone progress report. NIDA Research Monograph, vol. 9 (pp. 150 – 157). Bethesda, MD: National Institute on Drug Abuse. Carise, D., & Gurel, O. (in press). Integrating assessment technology with treatment—the DENS Project. In J. L. Sorensen, R. Rawson, J. Guydish, & J. Zweben (Eds.), Research to practice, practice to research: promoting scientific – clinical interchange in drug abuse treatment. Washington, DC: American Psychological Association. Cornish, J. W., Metzger, D., Woody, G. E., Wilson, D., McLellan, A. T., Vandergrift, B., & O’Brien, C. P. (1997).
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Naltrexone pharmacotherapy for opioid dependent federal probationers. Journal of Substance Abuse Treatment, 14, 529 – 534. Crevecoeur, D., & Rawson, R. (in press). Los Angeles County Evaluation System (LACES): bringing accountability to alcohol and drug abuse treatment through a collaboration between providers, payers, and researchers. Journal of Drug Issues. Higgins, S. T., & Petry, N. M. (1999). Contingency management. Incentives for sobriety. Alcohol Research and Health, 23, 122 – 127. Hough, G., Washton, A. M., & Resnick, R. B. (1983). Addressing the diversion of take home methadone: LAAM as the sole treatment choice for patients seeking maintenance therapy. In L. S. Harris (Ed.), Problems of drug dependence, 1982. Proceedings of the 44th annual scientific meeting, the Committee on Problems of Drug Dependence. NIDA Research Monograph, vol. 43 (pp. 302 – 306). Bethesda, MD: National Institute on Drug Abuse. Institute of Medicine (1998). Lamb S., Greenlick M. R., & McCarty D. (Eds.), Bridging the gap between practice and research: forging partnerships with community-based drug and alcohol treatment. Washington, DC: National Academy Press. Leshner, A. (2001, June). Blending research and practice—the time has come. Presented at the annual meeting of the College on Problems of Drug Dependence, Scottsdale, AZ. Ling, W., Charuvastra, C., Kaim, S. C., & Klett, C. J. (1976). Methadyl acetate and methadone as maintenance treatment for heroin addicts. Archives of General Psychiatry, 33, 709 – 720. Ling, W., Huber, A., & Rawson, R. A. (2001). New trends in opiate pharmacotherapy. Drug and Alcohol Review, 20, 79 – 94. O’Brien, C. P., Volpicelli, L. A., & Volpicelli, J. R. (1996). Naltrexone in the treatment of alcoholism: a clinical review. Alcohol, 13, 35 – 39. O’Malley, S. S., Jaffe, A. J., Chang, G., Schottenfeld, R. S., Meyer, R. E., & Rounsaville, B. (1992). Naltrexone and coping skills therapy for alcohol dependence: a controlled study. Archives of General Psychiatry, 49, 881 – 887. Public Broadcasting Service. (1998). Moyers on addiction: close to home. Available at: http://www.pbs.org/wnet/ closetohome/home.html. Retrieved June 4, 2001. Rawson, R. A., McCann, M. J., Huber, A., Marinelli Casey, P., & Williams, L. (2000). Moving research into community settings in the CSAT Methamphetamine Treatment Project: the coordinating center perspective. Journal of Psychoactive Drugs, 32, 201 – 208. Volpicelli, J. R., Alterman, A. I., Hayashida, M., & O’Brien, C. P. (1992). Naltrexone in the treatment of alcohol dependence. Archives of General Psychiatry, 49, 876 – 880. Zweben, J. E., Cohen, J. B., Obert, J., Vandersloot, D., & Marinelli Casey, P. (2000). Conducting trials in community settings: the provider perspective. Journal of Psychoactive Drugs, 32, 193 – 200.
Dancing with strangers: Will U.S. substance abuse practice and research organizations build mutually productive relationships? Richard A. Rawson*, Patricia Marinelli-Casey, Walter Ling UCLA Integrated Substance Abuse Programs (ISAP), 11075 Santa Monica Boulevard, No. 200, Los Angeles, CA 90025, USA
Abstract The scientific knowledge gained from research has not been extensively integrated into the U.S. substance abuse treatment system. A clear call to arms has been issued by the U.S. federal treatment and research agencies to bring research and practice together to create a better treatment system and a more responsive research agenda. The current federally sponsored initiatives to ‘‘close the gap’’ between research and practice are large and well funded. The field appears ready to change and realize the mutual benefits that can be achieved from the increased ‘‘blending’’ of research and practice. However, while the music has started and the partners seem willing, there are still many obstacles to a successful dance. D 2002 Elsevier Science Ltd. All rights reserved. Keywords: Research-practice gap; Treatment
A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it. (Max Planck, 1858 –1947)
1. The challenge of integrating research and practice An increasingly important theme in the substance abuse field in the United States goes by a number of names. These include ‘‘science to practice,’’ ‘‘research to application,’’ ‘‘bench * Corresponding author. Tel.: +1-310-312-0500x511; fax: +1-310-312-0538. E-mail address: [email protected] (R.A. Rawson). 0306-4603/02/$ – see front matter D 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 3 0 6 - 4 6 0 3 ( 0 2 ) 0 0 2 9 2 - 7
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to trench,’’ ‘‘technology transfer,’’ or some variation of the above. Regardless of the specific terms selected, the basic premise is the same: Substance abuse services should increasingly employ approaches that are grounded in empirical support and developed with sound scientific methods. As recently noted by Dr. Alan Leshner, former director of the National Institute on Drug Abuse (NIDA), the challenge of integrating science-based substance abuse treatment practices into clinical care is best conceptualized as a ‘‘blending’’ of research and practice as opposed to the ‘‘replacement’’ of current/traditional practices with those with scientific support (Leshner, 2001). These efforts to blend research and practice attempt to influence the basic conceptualization of substance use disorders, the clinical approaches used in prevention and treatment programs, and the techniques used to evaluate the effectiveness of these programs. The goal, over time, is for science to serve as the foundation for the field. The report from an Institute of Medicine (IOM) committee titled Bridging the Gap Between Practice and Research: Forging Partnerships With Community-Based Drug and Alcohol Treatment (IOM, 1998) signaled the movement of this issue into national prominence. For the past 25 years, most attempts to ‘‘blend’’ research and practice have been hindered by a variety of issues. The IOM committee was charged with investigating various domains related to barriers between research and practice. Committee members held discussions with providers, researchers, and policymakers, and they made site visits to obtain input from a variety of stakeholders. The report generated by the committee is now seen as the benchmark resource publication on the research–practice relationship. Even with the best intentions and leadership from U.S. federal agencies, it is unlikely that the shift of the substance abuse treatment system from a foundation of personal ideologies (i.e., treatments based on individuals’ experience of substance abuse and recovery) to one of empirical evidence will be smooth and effortless. In fact, there is a good deal of experience that indicates that there are many obstacles to shifting to a science-based treatment system. The purpose of this article is to describe some of the reasons for and examples of the substance abuse research–practice gap in the United States. In addition, the article presents some of the obstacles to closing this gap and some of the U.S. initiatives to close this gap.
2. Evidence of a gap between research and practice The esteemed U.S. television journalist, Bill Moyers, produced a five-part documentary (‘‘Moyers on Addiction: Close to Home’’) that premiered March 29, 1998, on the American perspective on substance abuse (Public Broadcasting Service, 1998). This Public Broadcasting Service documentary provided a superb illustration of the chasm between the worlds of substance abuse research and treatment in the United States in the late 1990s. In the report, Moyers describes, with great enthusiasm, the tremendous advancements made during the 1980s and 1990s in understanding the biobehavioral underpinnings of the causes and course of addictive disease from use to abuse to dependence. He interviews numerous scientists who have documented genetic-based vulnerabilities to developing substance use disorders; he
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shows with sophisticated PET scan technology vivid pictures of how substance use changes the brain and how it is now possible to ‘‘see’’ the areas of the brain that are involved when an addicted person craves a drug; he interviews Dr. Alan Leshner, who describes addiction as a ‘‘brain disease.’’ After this first segment, one is left with the impression that we are on the verge of a scientific revolution in how we can help individuals with addiction disorders. Much of the rest of the Moyers series describes the mainstream treatments used throughout the United States for people with substance use disorders. Amazingly, when the U.S. treatment service delivery system in 1998 is described, it is virtually indistinguishable from the system that was in place in 1975. It might be argued that the reason there has been little change in the ‘‘traditional’’ approaches to treating substance abusers is that the existing treatments produce universal success. However, even the most loyal defender of the existing treatment approaches would be reluctant to take this position. Few programs conduct any form of treatment outcome assessment; however, most program directors acknowledge that a substantial percentage, if not the majority, of treatment program graduates relapse at some time following their completion of treatment, and, in real-world treatment programs, there is currently no assurance that the treatment activities employed have any evidence to support their usefulness. Maintaining the status quo in the substance abuse service delivery system puts continued public support and public funding for substance abuse treatment services into a very tenuous position. Within the past decade, the U.S. federal agencies responsible for substance abuse treatment and research have received budget increases (especially NIDA, whose budget has nearly doubled in the past 5 years). These increases are predicated on the public trust in the fact that these funding increases will allow the treatment system to improve care for individuals with drug and alcohol problems. There is an increasing number of requests by funders for treatment service organizations to demonstrate their value with outcome data (Carise & Gurel, in press; Crevecoeur & Rawson, in press). The public wants to know what it is getting for its investment in substance abuse treatment. As these evaluation efforts and others come to fruition and document the performance of substance abuse treatment activities, it is extremely likely that the ‘‘successes’’ of treatment will receive less attention than the ‘‘failures.’’ If (when) the public becomes aware of the fact that billions of dollars have been spent on research to improve treatment, but that service providers have chosen to ignore this information and conduct ‘‘business as usual,’’ it is probable that there will be unpleasant consequences. It is incumbent that practitioners demonstrate their efforts to improve their outcomes, and it will be similarly important that researchers demonstrate that the investment in research produces something other than academic research articles. Evidence to support the existence of a chasm between research and practice is readily available. The minimal use of the pharmacotherapies, LAAM (levo-alpha-acetyl-methadol) for heroin addiction and naltrexone for heroin addiction and alcoholism, both of which have clear empirical support for their effectiveness, is indicative of the difficulty of introducing new medication treatments (Callahan, Rawson, Glazer, McCleave, & Arias, 1976; Cornish et al., 1997; Hough, Washton, & Resnick, 1983; Ling, Charuvastra, Kaim, & Klett, 1976; Ling, Huber, & Rawson, 2001; O’Brien, Volpicelli, & Volpicelli, 1996; O’Malley et al., 1992;
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Volpicelli, Alterman, Hayashida, & O’Brien, 1992). The minimal application of behavioral strategies such as contingency management (the offer of rewards for specific behavioral changes), which has very strong empirical support in the treatment of stimulant dependence and alcohol-use disorders, further emphasizes the distance between the ‘‘science’’ of addiction treatment and the ‘‘practice’’ of this care (Higgins & Petry, 1999). Few challenge the contention that there is a great disconnection between research findings on substance abuse and the services used to address these problems in the ‘‘real world.’’
3. Standard practices versus new technologies In other areas of health care, it is a foregone conclusion that when treatment methods are developed and determined, with research data, to be superior to old methods, the new methods are adopted. Consider the speed with which cardiac care procedures such as bypass surgery and angioplasty have been adopted and how rapidly the new ‘‘statin’’ medications have been applied to the treatment of high cholesterol. Similarly, the embracing of contact lenses and laser surgery has substantially reduced the number of individuals wearing glasses. Virtually the entire field of treatment for serious mental health disorders has been transformed by new medications in the past 15 years. And, PET scan and MRI technologies have created tremendous paradigm changes in the treatment of many forms of illness. Certainly from the scientist’s perspective, it seems clear that techniques with sound scientific support should be moved into standard application as a logical result of their demonstrated empirical validity. Surely, no one can argue with the wisdom of basing health care interventions on scientifically derived strategies. Science has taken humans to the moon, it has given us the Salk vaccine and protease inhibitors, and it guides the evolution of medicine in virtually all areas. Although the movement toward science-based practice in the health care field may seem inevitable to some, the words of Max Planck offer an important cautionary observation. The substance abuse field now has a substantial set of scientifically supported advancements that are not being used. It is incumbent that we ask: ‘‘Why is this new technology not routinely moved into mainstream use?’’
4. Researchers and practitioners: understanding the other’s perspective As noted above by Max Planck, new knowledge does not guarantee new practice, and this is due in large part to the human element. What people believe about a new technology significantly affects what they will do with the new information. Furthermore, the relationship between those proposing the innovation and those responsible for implementing the innovation is critical. Backer, David, and Soucy (1995) note that there are more than 10,000 citations of literature on technology transfer. Many of the research-to-practice problems in the substance abuse field are common to challenges faced in other fields when implementing new technologies.
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In the substance abuse field, a main factor contributing to the gap between research and practice is the lack of cooperation between researchers and practitioners. The two groups have made little effort to understand and learn how to use one another’s knowledge. Practitioners and researchers view the world differently. They have different missions, cultures, histories, and information needs, and they assess, formulate, process, and disseminate information in their own way. Although the two groups interact at times, constructive communication has been missing. Examples of the obstacles faced in blending research and practice are as follows: 1. Researcher and practitioner philosophies. The ‘‘culture and ethical values’’ of substance abuse researchers and practitioners could hardly be more different. Researchers worship at the altar of science. Data are the lifeblood of a researcher’s world. The ‘‘products’’ of the research are the data, whether positive or negative. Practitioners frequently have little understanding or appreciation of the role of science in the delivery of care. For many treatment delivery personnel, the ‘‘product’’ of their work is the ‘‘conversion’’ of a substance user into a person ‘‘in recovery.’’ In addition, historically, there has been little mutual respect between researchers and practitioners. Many researchers view the clinical practices currently used to be quasi-religious, ideological propaganda. Some researchers view practitioners as poorly educated, naı¨ve, and ignorant of the most basic appreciation of empirical principles. Practitioners commonly view the scientific agenda as esoteric, sterile, and lacking in empathy for real-world substance users grappling with psychological, social, emotional, and economic challenges. They often express the belief that researchers are only concerned about publishing articles and not about helping people with addictions. 2. Policies and regulations. The substance abuse service delivery system is one of the most regulated areas of health care. Specifically, the delivery of opiate pharmacotherapies, including methadone and LAAM, are among the most highly regulated services in all of medicine (IOM, 1998). Not only are medications closely regulated, but in many locations, effective behavioral strategies such as contingency management techniques are infeasible because there is no mechanism for reimbursement for this nontraditional treatment. 3. Funding. In many parts of the United States, the impact of managed care and related funding policies has stripped the treatment delivery system of much of its flexibility. Treatment service providers may, in fact, desire to hire staff with professional degrees to implement new treatments, but the treatment reimbursement levels are barely adequate to attract staff willing to work for minimum wage. Many treatment organization directors face a choice between using relatively inexpensive traditional methods, believed in by the staff, or new approaches requiring substantial training costs that are viewed with skepticism by program staff. 4. Consumers. Consumers and their families are increasingly taking a more active role in their health care. They are no longer passive recipients of recommendations made by their physicians. Growing dissatisfaction with the treatments offered by substance abuse services has increased consumer demand for more treatment options. Books published in the popular press, access to the internet, and multimedia advertising have allowed
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individuals to learn about new health care technologies and medications that may help treat their illnesses. Substance abuse treatment providers for the first time face questions from knowledgeable consumers about availability of new treatments. It will become increasingly important for service providers to be at least as aware of new treatments as the public they serve. The IOM report prompted two U.S. federal agencies (NIDA and the Center for Substance Abuse Treatment [CSAT]) to release funding initiatives that encourage both researchers and practitioners to collaborate to ‘‘bridge the gap.’’ The challenge of integrating research and practice appears to be taking center stage as a major focus for the substance abuse field in the next decade.
5. National efforts to blend research and practice The first recommendation of the IOM report states, ‘‘The National Institute on Drug Abuse and the Center for Substance Abuse Treatment should support the development of an infrastructure to facilitate research within a network of community-based treatment programs, similar to the National Cancer Institute’s Community Clinical Oncology Program (CCOP) networks’’ (IOM, 1998). To date, both NIDA and CSAT have developed initiatives in accordance with this recommendation and published documents that aim to reduce the research–practice gap. 5.1. NIDA initiatives and publications
NIDA’s Clinical Trials Network (CTN). In January 1999, NIDA began building the CTN, which was designed to build collaborations between regional research and training centers and community treatment programs, known collectively as regional nodes. Each of the 14 nodes has a university-based research and training center responsible for conducting multisite clinical trials in partnership with their affiliated community treatment programs. Participation in the network requires researchers and practitioners to work collaboratively to determine the direction of the research and the scope of the projects. Through the CTN initiative, NIDA is attempting to foster collaboration between substance abuse practitioners and researchers and create the necessary infrastructure to design scientifically sound research protocols and conduct multisite trials in community-based settings. The NIDA CTN website is at www.nidactn.org. The NIDA Clinical Toolbox: Science-Based Materials for Drug Abuse Treatment Providers. In an effort to disseminate science-based information about substance abuse and its treatment, NIDA has distributed a compilation of publications on effective drug treatment approaches and strategies entitled, the ‘‘NIDA Clinical Toolbox: Science-Based Materials for Drug Abuse Treatment Providers.’’ Nearly 12,000 drug treatment programs nationwide have received this set of materials. For more information about The NIDA Clinical Toolbox, visit http://165.112.78.61/TB/Clinical/ClinicalToolbox.html.
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5.2. CSAT’s initiatives and publications Under the leadership of Dr. Westley Clark, CSAT has taken the lead in disseminating empirically based treatment materials and promoting multiple strategies for improving substance abuse treatment by more closely linking science and service.
The Addiction Technology Transfer Centers (ATTCs). The centerpiece of the CSAT effort is a system of 14 training centers located throughout the United States that have as their goal the improvement of substance abuse treatment by increasing the use of treatments with empirical support. This network of training centers has created a new array of training activities and materials never before available for substance abuse service personnel. The ATTCs have created documents to promote organizational change (e.g., The Change Book: A Blueprint for Technology Transfer, available online at http://www.nattc.org/resPubs/ cbResources.html#cb), developed online training courses and video training programs that facilitate training to rural providers and providers in areas with few training opportunities, and promoted the development of clear and objective standards for the training and certification of counselors. The national ATTC website is at www.nattc.org. CSAT’s Community-Based Practice Improvement Collaboratives (PICs). In 1999, CSAT released its own initiative aimed at improving the quality of substance abuse treatment by increasing the interaction and knowledge exchange among key community stakeholders. This initiative created 14 geographically dispersed PICs that bring together treatment providers, organizations providing support services to substance abusers, researchers, and policymakers, including health plan managers and purchasers of services. The PICs are intended to create the necessary environment to ensure that research agendas are relevant to the needs of the treatment community and that new, effective approaches are implemented in treatment programs. More information about PIC is located at www.samhsa.gov/centers/csat/content/pic/contact.html. CSAT Methamphetamine Treatment Project (MTP). Although CSAT has sponsored a number of multisite evaluations of specific new treatments, one of the most ambitious is the MTP (Anglin & Rawson, 2000). The MTP is an eight-site randomized clinical trial designed to compare an empirically based model of treatment (known as the Matrix Model) with ‘‘treatment as usual’’ for methamphetamine dependent individuals. The eight sites are encountering diverse challenges in moving a science-based treatment into community settings. One of these challenges involves the differing perspectives, and the tensions created by those differences, between researchers and practitioners in areas such as boundary issues, clinical approaches, and the viewing of participants as clients versus data sources (Rawson, McCann, Huber, Marinelli-Casey, & Williams, 2000; Zweben, Cohen, Obert, Vandersloot, & Marinelli-Casey, 2000). CSAT’s Treatment Improvement Protocols (TIPs). CSAT has published 38 TIPs. These best-practice guidelines offer information and recommendations from expert panels of researchers, clinicians, and administrators on a wide variety of topics including: treatment drug courts, substance abuse among older adults, naltrexone and alcoholism treatment, stimulant abuse treatment, and pregnant substance-using women. Because research
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frequently lags behind treatment innovations, a major goal of the TIPs is to convey ‘‘frontline’’ information quickly and responsibly. Relevant research is included when it is available. CSAT TIPs are accessible online through http://www.samhsa.gov/centers/ csat2002/publications.html (after clicking on ‘‘Treatment Improvement Protocols,’’ click on ‘‘Contents’’ on the National Library of Medicine HSTAT website).
6. Integrating research and practice—2002: where do we stand? The IOM Bridging the Gap report has spurred the allocation of tens of millions of dollars by NIDA, CSAT, and the National Institute on Alcohol Abuse and Alcoholism on an extensive set of activities designed to better link substance abuse treatment and research in the United States. Many leaders in the substance abuse field are promoting the idea as critical to the future of the field itself. There appears to be little organized resistance to the concept that research and practice should be made increasingly synergistic. No one is marching in the streets to oppose this idea. Is it safe to say that ‘‘bridging the gap’’ is an idea whose time has come? Perhaps. It is clear that researchers and practitioners are beginning to dance together, but it is unclear if the dance will look like a waltz or like the ‘‘funky chicken.’’ Bringing researchers and practitioners together to discuss issues, conducting research projects in community clinics, and producing materials for staff training are a start, but they are not sufficient preconditions to change the system. It will take policy changes by treatment funders requiring the use of treatments with empirical support. A tremendous amount of training will be needed to initiate and maintain new practices. Staff in treatment programs will require considerably more formal education than is currently the case. Political will and money are going to be necessary to push this agenda forward. While the atmosphere in 2002 for blending science and practice is the most encouraging in the history of substance abuse treatment, it is far from a ‘‘done deal.’’ At present, cautious optimism is warranted.
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