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BRIDGING THE GAP BETWEEN PRACTICE AND RESEARCH Forging Partnerships with Community-Based Drug and Alcohol Treatment Sara Lamb, Merwyn R. Greenlick, and Dennis McCarty, Editors Committee on Community-Based Drug Treatment Division of Neuroscience and Behavioral Health INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1998
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NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. This study was supported under Contract No. 270-96-0008 from the Substance Abuse and Mental Health Service Administration's Center for Substance Abuse Treatment and the National Institute on Drug Abuse. Library of Congress Cataloging-in-Publication Data Bridging the gap between practice and research : forging partnerships with community-based drug and alcohol treatment / Sara Lamb, Merwyn R. Greenlick and Dennis McCarty, editors. p. cm. Includes bibliographical references and index. ISBN 0-309-06565-8 (cloth) 1. Drug abuse—Treatment—Research—United States. 2. Alcoholism—Treatment—Research—United States. 3. Drug abuse—Research—United States. 4. Alcoholism—Research—United States. I. Lamb, Sara. II. Greenlick, Merwyn R. III. McCarty, Dennis, Ph. D. RC564.65 .B75 1998 362.29'.0973—ddc21 98-25418 Copyright 1998 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.
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COMMITTEE ON COMMUNITY-BASED DRUG TREATMENT MERWYN R. GREENLICK (Chair),* Professor and Chair, Department of Public Health and Preventive Medicine, Oregon Health Sciences University, Portland, Oregon GAURDIA E. BANISTER (since July 1997), Director of Behavioral Health Services, Providence Hospital, Washington, District of Columbia BENJAMIN P. BOWSER, Professor, Department of Sociology and Social Services, California State University at Hayward, Hayward, California KATHLEEN T. BRADY, Associate Professor, Department of Psychiatry, Center for Drug and Alcohol Programs, Medical University of South Carolina, Charleston, South Carolina VICTOR A. CAPOCCIA, President, CAB Health and Recovery Services, Inc., Salem, Massachusetts THOMAS J. CROWLEY, Professor, Department of Psychiatry and Executive Director, Addiction Research and Treatment Service, University of Colorado School of Medicine, Denver, Colorado EMILY JEAN HAUENSTEIN, Associate Professor of Nursing, University of Virginia School of Nursing, Charlottesville, Virginia DENNIS McCARTY, Director, Substance Abuse Group, Institute for Health Policy, Heller Graduate School for Advanced Studies in Social Welfare, Brandeis University, Waltham, Massachusetts A. THOMAS McLELLAN, Professor of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania STEVEN M. MIRIN, Medical Director, American Psychiatric Association, Washington, District of Columbia LISA NAN MOJER-TORRES, Attorney, Lawrenceville, New Jersey DAVID L. ROSENBLOOM, Project Director, Join Together and Associate Professor of Public Health, Boston University School of Public Health, Boston, Massachusetts JAMES L. SORENSEN, Professor, Department of Psychiatry, University of California at San Francisco, San Francisco, California JOSEPH WESTERMEYER, Professor, Department of Psychiatry, and Adjunct Professor, Department of Anthropology, University of Minnesota and Clinical Chief of Psychiatry, Minneapolis VA Medical Center, Minneapolis, Minnesota * Institute of Medicine member.
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Institute of Medicine Staff SARA LAMB, Study Director CARRIE E. INGALLS, Research Associate (until August 1997) THOMAS J. WETTERHAN, Research Assistant AMELIA B. MATHIS, Project Assistant CHERYL MITCHELL, Administrative Assistant CONSTANCE M. PECHURA, Director, Division of Neuroscience and Behavioral Health
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Preface There are several aspects of this study that contribute to its specific character. The first is that the study was sponsored by both the Center for Substance Abuse Treatment (CSAT) and the National Institute on Drug Abuse (NIDA). The joint sponsorship was particularly apposite because the study's mission was predicated on the concept that there is value in enhancing collaborative relationships between the drug abuse research community and the world of community-based treatment programs. The symbolism of this collaboration between two, sometimes disparate, elements of the federal government responsible for supporting the respective communities facilitated the development of a collaborative perspective from the beginning of the study. Consequently, this was not a search for villains. The process of the study was as collaborative as possible and the report is offered with the message that working together can help all of us in the field achieve individual objectives and serve the public good more effectively. The second feature that influenced this study is that it is one in a series of outstanding Institute of Medicine (IOM) studies of drug abuse issues conducted recently by study committees of the IOM's Division of Neuroscience and Behavioral Health. During the same period there have been a series of landmark reports and studies in the area by CSAT, NIDA, and other Substance Abuse and Mental Health Services Administration (SAMHSA) and National Institutes of Health (NIH) agencies. Chapter 1 reviews some of these studies and places this one in the context of the work of the last decade. The committee worked hard to keep focused on its charge and to avoid plowing ground
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that had been so well cultivated by the work of others. Many times this required an act of will, as the issues in this field are so compelling. The result of this discipline is that readers will need to look in one or another of the studies referenced in this report for more complete discussion of some topics. An important study, funded by SAMHSA and carried out by the Mathematica organization, was released in March after the committee concluded its deliberations. The study assessed the costs and effects of requiring parity for mental health and substance abuse treatment within health insurance. This study is relevant to the report because of our recommendation that purchasers of care should take research findings into account in making purchasing decisions (see Recommendation 7). An identified barrier to the implementation of this recommendation was the different treatment of substance abuse services from other medical care services under health insurance, a difference that would be eliminated by achieving parity. This study was particularly timely because the Mental Health Parity Act was passed by Congress and became effective January 1, 1998. Parity bills were also introduced in 37 states last year, some of which included substance abuse services. The Mathematica study indicates that full parity for mental health and substance abuse services would only increase health insurance premiums an average of 3.6 percent—in a group of health plans that reflect nationwide coverage. Most important for this study, it was estimated that substance abuse treatment contributes only .02 percent of the increase. The Mathematica study also reported that state parity laws on the books to date have had only small effects on premiums and that employers have not attempted to avoid parity laws by becoming self-insured. The Mathematica findings are consistent with testimony before the committee that insufficient funding for treatment is a major obstacle to the integration of knowledge from treatment research into clinical practice. Because of the financial constraints of the field, many of those we talked with in the treatment community were extremely frustrated with research that provided evidence of effectiveness of treatments they would be unable to adopt because of limited treatment budgets. The committee was also taken with the observation the drug abuse field included policy barriers deriving from an ideological or political perspective that prevented the free flow of some kinds of research knowledge into treatment programs. For example, the committee noted that treatment programs (and even treatment research) funded from or organized within the criminal justice system had a restricted set of options available. Consequently, in some instances it was not possible to integrate less expensive treatments that were of proven effectiveness. The specific charge to the committee is discussed in Chapter 1 and is
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included in its entirety as Appendix A. As Chair, I proposed early in the process that we guide our task by testing three assumptions, beyond the basic assumption that the ultimate purpose of the study was to improve the effectiveness and efficiency of the treatment of addictive disorders in the United States: 1. drug abuse research will be improved and the knowledge creation process will be aided by the two-way communication and long-term collaboration between community-based treatment program staff and researchers; 2. community-based treatment programs will benefit, in a number of ways, from participating in drug abuse research; and 3. research findings exist that are not being universally used within treatment and the treatment programs (and their patients/clients) would benefit if these findings were appropriately implemented. It is important to note that the committee and the treatment providers who participated in this study readily agreed that their definition of critical drug abuse research included the full research spectrum—from clinical research, through services research and sociobehavioral research, to program evaluation and quality improvement activities. Basic biological research was out of the scope of our charge and therefore isn't discussed in our report. The report includes two distinctly different kinds of recommendations. The first kind of recommendations are formal policy and technical recommendations that could be (in our view) adopted directly by CSAT, NIDA, and other federal or state agencies. The second kind are normative recommendations to the two other audiences to which the report is being addressed—the treatment community and the research community. While the former are the recommendations most sought by the sponsors of the study, committee members recognized the many cultural barriers to the integration of research activities into community-based treatment programs, and these barriers exist in the subcultures of both the research and the treatment community. Because the strong subcultures have, at their heart, a critical set of beliefs and values we believe the cultures can only be changed by a change in some of their beliefs and values. The normative recommendations are focused on changing those elements of the cultures.* There are so many acknowledgments that must be recorded. The first acknowledgment is to the wonderful committee members who were my * These normative recommendations are put forward in the text under Recommendations 1 and 2, as well as the text of Chapters 4 and 5.
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colleagues for this study. Drug abuse is not my substantive area, so I relied heavily on the committee members for their knowledge of the drug abuse field. All committee members had a hands-on role in the preparation of this report. That the committee's expertise is wide and deep is obvious to all in the field and that expertise guided the substance of this report. But of equal importance to the study was the spirit that emerged during the committee process. The interaction among the study director, the committee chair, and the committee members is as critical to the product as it is to the process. And this process was as fruitful and harmonious as any I have observed in serving on IOM committees over the past 25 years. Of special note is the work of an executive writing group that was formed comprising myself, Victor Capoccia, Dennis McCarty, James Sorensen, from the committee membership, and Sara Lamb, the study director, and Constance Pechura, who was the Director of the IOM Division of Neuroscience and Behavioral Health during the life of the study. Drs. Sorensen, Capoccia, and McCarty were primarily responsible, with their own writing groups, for the first drafts of Chapters 2, 3, 4, and 5. They were wonderfully collaborative and constructive colleagues. Dr. McCarty, in addition to taking primary responsibility for Chapter 5, contributed creatively and substantially to the overall writing and is recognized as a coeditor of the report. Dr. Pechura was extremely supportive throughout this process. She attended our meetings, piloted us through difficult technical, scientific, and political waters, and provided inspiration to us during difficult times. She was our friend and counselor. The study was supported by a talented staff. Amelia Mathis was extremely professional as she staffed the committee. She always had the process under control with a firm, but friendly hand. She mothered us when we needed mothering and was unflappable in times of stress. She was always ready to go the extra step when that was needed. Research Associate Carrie Ingalls provided exceptional research and organizing skills, as well as support team management for the first half of the study. Thomas Wetterhan provided excellent administrative and technical support to the project and also assumed responsibility for providing research assistance in the last half of the study. His extensive knowledge of the systems, procedures, and resources of the IOM served the project well through the final challenging months of coordinating writing group activities, report preparation, and report review. Finally, while the committee owns the findings and the recommendations, the ultimate responsibility for any IOM study always rests with the study director. This study was the first undertaken by study director Sara Lamb and she took over a study that was already behind schedule. She did
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an excellent job, learning both the substance of the field and the complexities of the process. My task as chair was made so much easier because she was such an able, competent, and staunch partner. Merwyn R. Greenlick, Ph.D., Chair Committee on Community-Based Drug Treatment
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Acknowledgments The Committee on Community-Based Drug Treatment and the study staff are grateful for the assistance received from many individuals and organizations over the course of the study. The names of those who participated in our workshop and roundtable discussions are listed in Appendix B. The opportunities for knowledge exchange provided by these interactive discussions were crucial to the deliberations of the committee and to the shaping of its subsequent recommendations. A number of individuals made special contributions to the committee's work and served as consultants in a variety of important ways: Joseph Brady, Deborah Haller, Constance Horgan, Arnold Kaluzny, Harold Perl, Everett Rogers, and H.R. (Rick) Sampson. The contributions of Constance Horgan, Arnold Kaluzny, and Everett Rogers are specifically referenced in the report. The committee would like to recognize the individuals who helped identify and recruit a diverse and articulate group of participants for our public workshops: Douglas Anglin, UCLA Drug Abuse Research Center; Linda Kaplan, National Association of Alcoholism and Drug Abuse Counselors; Luceille Fleming, Ohio Department of Alcohol and Drug Addiction Services; Linda Grant, Washington Association of Alcoholism and Addiction Programs; Judge Richard Knolls, Second Judicial District, Bernalillo County, New Mexico; Phillip May, Center for Alcohol, Substance Abuse and Addictions (CASAA) at the University of New Mexico; Gwen Rubinstein, Legal Action Center; and Linda R.Wolfe-Jones, Therapeutic Communities of America. The committee is greatly indebted to Phillip May and his staff at
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CASAA, particularly Phyllis Trujillo, for making it possible for us to hold a workshop at the University of New Mexico; and to Dr. May and Lynn Brady, Executive Director of the Behavioral Health Services Division of the New Mexico Department of Health, for providing the committee with an overview of the community-based drug treatment system in New Mexico. A number of persons contributed to this report by meeting with individual committee and staff members in their home states and sharing their information with the committee. The committee thanks the following state officials who gave us the benefit of their experience: Barbara Cimaglio, Office of Alcohol and Drug Abuse Programs, Oregon Department of Human Resources; and Cynthia Turnure and Patricia Harrison, Chemical Dependency Program Division, Minnesota Department of Human Resources; as well as the treatment providers who generously invited us to visit their programs: Dale Adams, Resada Alcohol and Drug Abuse Program, Las Animas, CO; Nancy Jo Archer, Hogares, Inc., Albuquerque, NM; Gaurdia Banister, Seton House of Providence Hospital, Washington, DC; Jane Spence and Bradley Anderson, Recovery Resources, Kaiser Permanente, Portland, OR; Ann Uhler, Comprehensive Options for Drug Abusers (CODA), Portland, OR; and Fredi Walker and Michel Lilly, Boston Detoxification Center, Boston, MA. The committee is especially grateful to those individuals who allowed their stories to be used in this report: Michael Kirby, Chilo Madrid, Selbert Wood, Carol Leonard, Richard Suchinsky, and those who chose to remain anonymous. The perspective of the committee was broadened by many individuals, particularly by the contributions of two who were appointed to the committee, but were unable to continue because of conflicts in their teaching and research commitments. Spero Manson and Robert Fullilove both continued to be available to committee and staff. Robert Fullilove participated in both public workshops and served as the host for the provider panel for the first workshop. The committee and staff also appreciate the assistance and support provided by our project officers, Mady Chalk at the Center for Substance Abuse Treatment and Gerald Soucy at the National Institute on Drug Abuse. Too numerous to mention are the many staff at the IOM who provided expert support at various stages of the project. The committee staff, however, wishes to particularly acknowledge Susan Fourt and Patricia Kaiser for library services throughout the study and Claudia Carl for piloting this report through review. The report was improved by the copy editing of Paul Phelps, as well as the assistance of two staff members from the Kaiser Permanente Center for Health Research: senior editor Gary Miranda and library services coordinator Nancy Hunt. This report has been reviewed by individuals chosen for their diverse perspectives and technical expertise, in accordance with the procedures
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approved by the National Research Council's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the authors and the IOM in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The content of the review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their participation in the review of this report: James W. Curran, Emory University; Arthur J. Schut, Iowa Substance Abuse Directors' Association; Anderson Spickard, Vanderbilt University; Donald M. Steinwachs, Johns Hopkins University School of Hygiene and Public Health; Cynthia Turnure, Minnesota Department of Human Services; and Joan Ellen Zweben, 14th Street Clinic and East Bay Community Recovery Project. While the individuals listed above have provided many constructive comments and suggestions, responsibility for the final content of this report rests solely with the authoring committee and the IOM.
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Contents EXECUTIVE SUMMARY 1 1 INTRODUCTION 16 The Study Process and Report Organization, 19 Historical Background, 21 Definitions and Current Context, 23 Summary, 25 2 THE GAPS BETWEEN RESEARCH, TREATMENT, AND POLICY 27 Overview, 29 Evidence for the Gaps, 30 Barriers to Closing the Gaps, 40 Summary, 51 3 APPROACHES TO CLOSING THE GAPS 56 Overview, 56 Technology Transfer Models, 57 Organizational Change Models, 59 Practice Guidelines and Scorecards in Addictions Treatment, 61 Consensus Conferences and Evidence-Based Reviews, 63 Top-Down Incentives Models, 64 Models that Incorporate Trust-Building Experiences, 66 Summary, 69
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4 BENEFITS AND CHALLENGES OF RESEARCH COLLABORATION FOR COMMUNITY-BASED TREATMENT PROVIDERS 73 Overview, 75 Benefits and Challenges of Research/Practice Collaborations, 75 Factors Affecting Linkage Between Practice and Research, 78 Summary, 86 5 BENEFITS AND CHALLENGES OF COMMUNITY-BASED COLLABORATION FOR RESEARCHERS 89 Overview, 90 Historical Approaches to Collaboration for Research, 90 Models for Collaboration, 95 Lessons from Demonstration Initiatives, 102 Guidance for Grant Review, 106 Summary, 107 6 FINDINGS AND RECOMMENDATIONS 111 Strategies for Linking Research and Practice, 111 Strategies for Linking Research Findings, Policy Development, and Treatment Implementation, 114 Strategies for Knowledge Development, 116 Strategies for Dissemination and Knowledge Transfer, 116 Strategies for Consumer Participation, 118 Training Strategies for Community-Based Research Collaboration, 119 APPENDIXES A Statement of Task 123 B Workshops and Roundtable: Agendas and Participants 125 C Commissioned Paper: Drug Treatment Programs and Research: The Challenge of Bidirectionality Benjamin P. Bowser 135 D Commissioned Paper: The Treatment of Addiction: What Can Research Offer Practice? A. Thomas McLellan and James R. McKay 147 E Commissioned Paper: The Substance Abuse Treatment System: What Does It Look Like and Whom Does It Serve? Preliminary Findings from the Alcohol and Drug Services Study Constance M. Horgan and Helen J. Levine 186 F National Institutes of Health Consensus Development Statement on Effective Medical Treatment of Heroin Addiction 198 G Useful Internet Resources—Examples 226
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HList of Currently Available CSAT Treatment Improvement Protocols (TIPs) 233 IOpportunities for Collaboration Joseph Westermeyer 235 JSummary of Interviews with Minnesota State Alcoholism-Addiction Leaders Cindy Turnure and Patricia Harrison 246 INDEX 251
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Acronyms AA Alcoholics Anonymous ADSS Alcohol and Drug Services Survey, sponsored by the Substance Abuse and Mental Health Services Administration AHCPR Agency for Health Care Policy Research CASAA Center on Alcohol, Substance Abuse, and Addictions at the University of New Mexico CBO community-based organization—in this report used to refer to community-based drug and alcohol treatment organizations CCOP Community Clinical Oncology Program of the National Cancer Institute CME continuing medical education CSAT Center for Substance Abuse Treatment DATOS Drug Abuse Treatment Outcome Study, sponsored by the Substance Abuse and Mental Health Services Administration DSM-IV Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition EAP employee assistance program
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HEDIS Health Plan Employer Data and Information Set, developed by the National Committee on Quality Assurance HIV human immunodeficiency virus HMO health maintenance organization IRB Institutional Review Board, implements Title 45, Part 46 of the Code of Federal Regulations, Protection of Human Subjects, NIH Office of Protection from Research Risks JCAHO Joint Commission on Accreditation of Healthcare Organizations LAAM levo-alpha-acetylmethadol or levomethadyl acetate, trade name: Orlaam® NASADAD National Association of State Alcohol and Drug Abuse Directors NIAAA National Institute on Alcohol Abuse and Addiction NIDA National Institute on Drug Abuse NIH National Institutes of Health ONDCP Office of National Drug Control Policy SAMHSA Substance Abuse and Mental Health Services Administration TIE Treatment Improvement Exchange, sponsored by the Substance Abuse and Mental Health Services Administration TIP Treatment Improvement Protocols, maintained by the Substance Abuse and Mental Health Services Administration
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BRIDGING THE GAP BETWEEN PRACTICE AND RESEARCH
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In our scientific culture, knowledge is generally what can be known through science. But science understands some relationships by excluding others, including many that concern practice. Science rests on the power of abstraction. Wisdom may entail appreciation of contextuality. Ann Lennarson Greer in ''The shape of resistance ... the shapers of change."