New Partnerships for a Changing Environment: Why Drug and Alcohol Treatment Providers and Researchers Need to Collaborate (1999)

The program director of a 50-patient drug and alcohol abuse treatment facility was thinking about collaborating with researchers at a local university on a project of special interest to him. He had observed informally that about one in five of the program’s patients “makes it” to a consistently abstinent life, and he wanted to be able to predict which patients were more likely to be the successful ones and to develop more effective treatments for the others. The program director had 25 years of clinical experience, but no research training or research experience.

Research participation, he reasoned, might be good for the program and good for staff morale because of what they would learn, but it also would mean more work. While it would bring in new funds, the project might not cover all costs, and it was likely to face opposition from the board of directors, which was made up primarily of men and women who were not generally supportive of change.

After careful thought, the program director decided that the benefits of research collaboration could outweigh the risks. He recognized that it would be a challenge to develop a successful research collaboration given the numerous barriers he faced.

This scenario is happening across the United States in community-based treatment organizations. Treatment providers and researchers are beginning to court each other, but still have many questions. This brochure illustrates the gaps between providers and researchers and suggests ways to bridge them. It is based on a report of the Institute of Medicine’s Committee on Community-Based Drug Treatment Research, which stresses the value of decreasing barriers and enhancing relationships between community-based treatment programs and the drug and alcohol abuse research community. The report also provides practical suggestions for how this can be achieved.

Less than 20 percent of the nation’s 9.4 million drug-addicted and dependent individuals receive treatment each year. In spite of great strides made in research on the science and treatment of addiction, there are still many barriers to linking research findings with policy development and treatment implementation. Critical to improving treatment is closing the gap between community-based treatment organizations and researchers.

Across the country, treatment providers talked with the committee about their needs for improved treatment. Consistently, providers expressed their need for research to help them determine efficacy and cost-effectiveness of treatments. Despite this need, relatively few researchers work closely with community-based treatment organizations, and even fewer providers actively participate in research. This is not to assign blame, but rather to explain why the gap exists and to find ways to bridge it.

The universe of community-based treatment providers is large—there are more than 8,000 such facilities in the United States—and they account for the bulk of drug and alcohol treatment. The broad range of treatment programs includes therapeutic communities, freestanding outpatient clinics and programs based in health departments, hospitals, academic medical centers and managed care organizations. Self-help programs are included in most of these treatment settings.

There is a gap between knowledge gained from clinical experience and knowledge gained from basic science and applied treatment research. The IOM study addresses this gap with the goal of enhancing collaborative relationships between providers and researchers to improve the effectiveness and efficiency of the treatment of addictive disorders in the United States.

Bridging this gap will:

• facilitate collaborative research to address the needs of community-based treatment organizations;

• encourage the adoption of proven research findings into treatment practice; and

• broaden the tools available to community-based treatment organizations by enhancing their ability to develop more targeted interventions. See recommendations, pp. 8–9.

Substance abuse among young women has set new challenges before the treatment community and presents a research opportunity for providers. The rapid development of women’s programs, which has occurred with little systematic evaluation of the processes and outcomes of treatment, provides researchers and clinicians with the chance to study new treatment modalities through all stages of development and implementation. Evidence-based treatment for women presents an opportunity for providers and researchers to set a collaborative research agenda and study new treatment approaches from concept through development and implementation.

Providers recognize that one of the first challenges they face in collaborating with researchers is the nature of the population they treat. People in drug and alcohol treatment have a significant incidence of relapse and high levels of co-existing psychiatric and other medical problems. Problems such as homelessness and lack of income also limit their ability to comply with treatment regimens. This population often does not fit easily into clinical trials. However, there is important research to be done in order to improve the targeting of clinical interventions and demonstration of their effectiveness to health care purchasers, policymakers and the population at risk.

Through collaborative research, treatment providers can help develop better treatment interventions and improve outcomes for their patients.

Community-based drug and alcohol programs operate in a rapidly changing environment. Drug use has increased, and so has the incidence of HIV/AIDS, tuberculosis, hepatitis and other infectious diseases among individuals in treatment. In spite of increasing needs, length and intensity of treatment and service mix seem to have decreased. The advent of managed care has created new challenges for community-based treatment programs.

To survive in this uncertain environment, treatment providers must have new tools, new skills and new partnerships to demonstrate which treatments are cost-effective.

Community treatment programs are supported primarily by public funds through federal block grants and state and local funding. This money, as well as public and private health insurance, comes with some strings attached. For example, residential care often depends on availability of federal block grant funds because other payers limit such care.

Locally funded treatment facilities must be responsive to community priorities and opinions. Some communities do not want treatments that might be viewed as controversial. Often, public opinion is more likely to support prison terms even for nonviolent drug users rather than treatment, so treatment providers may be cautious about offering new services.

Collaborating with researchers and state and local policymakers could provide community-based treatment programs with opportunities to help develop a scientific basis for distinguishing among treatment alternatives in a political environment.

Stigma is a special problem for the drug and alcohol abuse treatment field. Despite growing recognition of drug and alcohol addiction as chronic, relapsing medical conditions, addiction is still often seen as a social or moral problem, rather than a medical problem. No one argues about providing care for chronic conditions that have similar relapse rates, such as hypertension, diabetes or asthma, but there is still much debate about supporting substance abuse treatment on a par with chronic medical problems. As a result, publicly funded drug and alcohol treatment programs often have inadequate resources and long waiting lists.

Another stigmatizing factor is job status. The addiction treatment field has large numbers of clinicians at all levels who have, themselves, experienced drug and/or alcohol problems. Recovering clinicians may be effective counselors and many seek certification; however, credentialing requirements of states and some payer organizations tend to discourage the use of experientially trained staff.

Research participation from the full spectrum of treatment programs and their staff will facilitate the study of important problems that are currently underresearched.

Faced with the many challenges of providing services, community-based treatment organizations are often frustrated by an apparent failure of research to provide practical and relevant answers to important clinical and programmatic questions.

Researchers are frustrated because many research-developed innovations that can improve treatment outcomes are not widely used. While collaborating with providers can help put more findings into practice, getting funding for and conducting research in community clinical settings is not easy, and some researchers hesitate to develop alliances with community-based treatment providers.

Given these perspectives about research—and a common goal of improving treatment—the IOM study recommendations seek to provide incentives for clinicians and researchers to work together.

Solid research findings are underused by treatment programs for a variety of reasons. For example, incorporating effective medication into treatment protocols is often resisted or not commonly practiced in some communities. The cost of adopting proven research findings has been little studied. Although clinical trials have consistently shown that methadone maintenance is effective for heroin addiction only when methadone is given in adequate doses, low-dosage treatment persists because of financial barriers, lack of current information or ambivalence about using medications to treat drug addiction.

Naltrexone is not widely used in alcohol treatment outside of medical centers and specialized treatment centers, even though it has long been shown to be effective in the treatment of alcohol dependence and was approved for this use in 1994 by the Food and Drug Administration. Barriers to the use of naltrexone may include lack of appropriate medical expertise in treatment programs, financial constraints and poor dissemination of information about the cost-effectiveness of this treatment.

Increasing treatment compliance through the use of behavioral incentives such as reward vouchers is another established research finding not widely used in community programs. Studies show that using behavioral incentives can improve treatment outcomes for cocaine users. Reasons for not using a voucher system include lack of information about the efficacy of the strategy, ideological resistance to paying people to stay drug-free and difficulty in financing vouchers in addition to other treatment costs.

There are many barriers to the spread of knowledge in this field, and the IOM study includes recommendations to address them. Treatment providers can also learn about new research findings and research opportunities in substance abuse treatment through the Internet. See Logging onto the Internet, p. 11.

One reason researchers may be reluctant to study treatments in community-based programs is that they may not be knowledgeable about these programs or what goes on in the clinical environment. Few researchers study therapeutic communities, and research in this area tends to focus on assessing overall effectiveness rather than understanding how the communities work, why, for whom and at what cost. Outpatient treatment accounts for about half of all drug treatment, so it is also an important site for research. However, there is insufficient research taking place in outpatient treatment settings.

Treatment organizations can help establish the research agenda by clarifying the issues most in need of investigation.

Collaborations between providers and researchers often are hampered because each group may have a different understanding of what is meant by “research.”

• Researchers prefer a clearly defined study question with diagnostic and demographic variations of the study population as narrow as possible in order to achieve statistically significant results. This methodological rigor has done much to advance the credibility of clinical research in alcohol and drug treatment. However, findings from these studies are often too restrictive to be applicable to general patient populations.

• Treatment providers want a study question to reflect more closely the complexity and multidimensional nature of the population they serve. Providers are in the best position to know what research is important for treatment organizations and to help develop research that will answer questions that are relevant for community-based treatment.

One important ingredient of a successful relationship between providers and researchers is compatibility of goals. Researchers must be willing to explore and understand the theory and context that guide treatment in different settings, and providers must be willing to share their experience to create testable hypotheses for research.

What should a treatment provider do when a researcher wants to collaborate with his or her organization? One experienced program director speaking to the committee suggested 10 questions that providers should ask themselves as well as researchers. These are issues that researchers should be willing to discuss when seeking a treatment partner.

1. What funds are available for clinical services?

   Do all of the grant or contract funds go to research?

2. Are the researchers sensitive to cultural issues in your organization?

3. Does the study address questions that are applicable to your organization, or are the research questions unrelated to your work?

4. Are the research questions practical? Have the underlying hypotheses and the purpose of the investigation been explained fully to you?

5. How will your treatment program benefit from the research?

   What technical assistance or treatment benefits are provided?

6. Will the research help your clients or put them at risk?

7. What will be the long-term benefits for your program and for research theory?

8. Does the investigator express genuine concern for your program and its clients?

9. How much choice will you have in selecting the researcher with whom you will work?

10. If there is to be an evaluation, does your organization have a say in who is chosen to be evaluator?

Source: Chilo Madrid, Aliviane, Inc., El Paso, Texas

As the introductory scenario illustrates, providers have good reason to have second thoughts about moving ahead into uncharted territory. Why should treatment programs embark on research projects, introducing uncertainty and risk that can be destablizing for their organizations?

Working with the right research partner, community-based treatment programs can enhance their organization in several ways:

• Programs benefit by using the research findings to help treat patients.

• Staff gains knowledge on emerging clinical issues and treatments.

• Research partnerships have the potential for on-the-job training for staff in research techniques, data collection, data analysis and program evaluation.

• Opportunities may exist for continuing education about addiction treatment—for example, exploring tuition credits and other learning opportunities for staff working on funded collaborative research.

• Research collaboration can help providers adopt demonstrated “best practices” and bring new ideas into their organization.

There also are some financial benefits. The IOM study recommends that costs of research participation be covered by research funds and providers be reimbursed for related overhead expenses. So, for example, programs with limited access to capital may benefit from new equipment purchased for research purposes or from sharing overhead expenses.

For community-based treatment organizations that want to “test the water” before jumping into a research partnership, initial steps may include contributing to surveys, sharing databases or facilitating access of researchers to patients.

A more active role in research requires a greater commitment of staff and agency resources. Clinicians will need to spend time working with researchers to define the research questions and data collection methods; management, too, will have to allocate time to advise studies and review reports. Some treatment providers may have researchers on staff and have the capacity to serve as principal investigators of projects. This is more likely to be the case with providers that have developed a relationship with an academic or other research institution. As research staff and experience grow, providers may want to become the applicant agency for research grants.

Substance abuse treatment programs are not the only corporate entities struggling for survival. Demands for change affect large and small organizations in all settings. For the past decade, chief executive officers and managers have found guidance for corporate change in Peter Senge’s concept of the learning organization, as described in The Fifth Discipline: The Art & Practice of the Learning Organization (1990). Senge defines learning in organizations as “the continuous testing of experience, and the transfomation of that experience into knowledge—accessible to the whole organization and relevant to its core purpose.” The testing of experience is the essence of the experimental method. Treatment programs that follow this model will be comfortable linking research and practice.

There is no single best approach to promoting collaboration between treatment providers and researchers. What works for one group may not work for another; strategies vary depending on the issues and policies of interest, the available resources and the participants. Whatever the approach, the core of any collaboration is building a relationship based on trust and open dialogue. The following are examples of collaboration for building infrastructure, supporting research and establishing research partnerships.

This program began in 1976 as an alcohol detoxification program and halfway house service for Arapahoe County, Colorado, and grew into the largest drug and alcohol abuse treatment program in the state. Beginning its research collaboration more than 16 years ago, it currently participates in research with investigators from the University of Denver and the University of Colorado Medical School. Working as a team, Arapahoe House and its research collaborators identify and design research on treatment interventions most likely to be implemented. Clinicians and researchers have recognized that their collaboration is stronger because of the complementary strengths and abilities each brings to the team. Not every treatment program will have the capacity to emulate Arapahoe House, but many may find that participation in research can help them reach their goals.

This state consortium includes substance abuse treatment programs, investigators from four Iowa universities and policymakers from the state agencies responsible for corrections, education, Medicaid, public safety and public health. The goal of the consortium is to provide a forum to promote the collection of data and use of research in policy formation and clinical practice. Because the consortium encourages treatment providers to participate in the design of research projects and to request support for staff working on research projects, it has become a vehicle for collaborative research with community-based treatment agencies.

CCOP involves treating cancer rather than substance abuse. It is presented here as a successful model for supporting research within a network of community-based treatment programs. CCOP brings state-of-the-art cancer treatment research to local communities, provides a blueprint for community practitioners to participate in clinical trials and provides support for the infrastructure needed for such participation.

CCOP links community-based oncologists and primary care physicians in National Cancer Institute (NCI)-approved clinical trials. Regional centers develop protocols, analyze data and provide quality assurance; and local community practitioners are able to enroll and treat patients according to the most recent research protocols. As part of CCOP’s ripple effect, patients treated by any physician in a participating community are now more likely to receive the appropriate therapies.

The IOM report recognizes that support is needed to implement a research effort in community-based substance abuse treatment programs. Accordingly, the first recommendation is that the National Institute on Drug Abuse and the Center for Substance Abuse Treatment support development of an infrastructure for a network of treatment providers similar to the CCOP network.

The gap between practice and research in drug and alcohol abuse is real, but treatment programs and researchers can help to bridge it.

Here are five action steps treatment programs may want to take:

• Look for potential research partners.

• Develop a strategic plan for making research collaboration a part of your organization.

• Learn more about federal, state and local funding opportunities for substance abuse treatment research.

• Seek opportunities to participate in developing a policy research agenda in your state, and get your professional associations and potential advocacy allies involved in this process.

• Form partnerships with research organizations and other treatment providers.

With the goal of improving clinical practice and enhancing the value of drug and alcohol treatment research to clinicians, investigators, policymakers, patients and the general public, the IOM Committee on Community-Based Drug Treatment Research made recommendations for strategies in six areas: linking research and practice; linking research findings with policy development and treatment implementation; knowledge development; dissemination and knowledge transfer; consumer participation; and community-based research collaboration.

1. The National Institute on Drug Abuse (NIDA) and the Center for Substance Abuse Treatment (CSAT) 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.

2. NIDA and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) should develop research initiatives to foster studies that include community-based treatment programs as full partners.

3. State authorities should provide financial incentives for collaborative investigations between community-based organizations (CBOs) and academically oriented research centers, and should support structures to foster broad participation among researchers, practitioners, consumers and payers in the development of a treatment research agenda, including studies to measure outcomes and program operations.

4. CSAT and the states need to cooperate in the development of financial incentives that encourage the inclusion of proven treatment approaches into community-based treatment programs. This approach should include making additional funds available for implementing targeted treatment approaches.

5. CSAT and NIDA should develop mechanisms to enable state policymakers to monitor service delivery in community-based treatment programs, to determine if consumers receive services empirically demonstrated as effective and to ascertain if the treatment dosage and intensity are sufficient to be effective.

6. NIDA and NIAAA should continue to support “real world” services research and cost-effectiveness studies and include the development of services research in their strategic plans.

7. CSAT, NIDA, NIAAA and the Agency for Health Care Policy and Research (AHCPR) are the federal agencies that should develop formal collaborations, where appropriate, to synthesize research, reduce the barriers to knowledge transfer and provide updated information about drug and alcohol treatment strategies to purchasers of health care.

8. CSAT, in collaboration with state substance abuse authorities, professional organizations and consumer organizations in the addiction field, should continue the development of evidence-based treatment recommendations for use by clinicians of all disciplines involved in the treatment of drug and alcohol use disorders.

9. CSAT and NIDA, in collaboration with state substance abuse authorities, should develop public awareness programs to encourage consumers and their families to recognize high-quality treatment programs so they will begin to demand that treatment programs include research-proven treatment approaches within their treatment models.

10. NIDA and other research funding agencies should support predoctoral and postdoctoral research training programs that provide experience in drug abuse treatment research and health services research within community-based treatment programs. Programs funded should have the full and active participation of community-based treatment programs and should include resources to fund the costs of participation for the treatment programs.

11. University training programs in the health professions should:

• enhance exposure of students to didactic teaching about substance abuse and dependence;

• require didactic teaching as well as supervised clinical experiences in community-based treatment settings;

• teach students to interpret substance abuse treatment research and apply research findings in their clinical practices;

• work with professional organizations to enhance continuing education about the addictions within the residency training curriculum of the various health professions; and

• support researchers seeking to enhance collaborative relationships with treatment programs by offering tuition credit for CBO staff involved in funded collaborative research.

12. NIDA, CSAT and other appropriate funding agencies should create research training programs for staff members of community-based treatment programs to strengthen the ability of the treatment programs to include research activities and to adopt the findings of research into their treatment approaches. Training programs should promote research training for clinical staff through fellowships and tuition remission, and incentives for attending professional meetings.

MERWYN R. GREENLICK (Chair),

Professor and Chair, Department of Public Health and Preventive Medicine, Oregon Health Sciences University, Portland, Oregon

GAURDIA E. BANISTER, 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

SARA LAMB, IOM Study Director

This study was supported by the Substance Abuse and Mental Health Service Administration’s Center for Substance Abuse Treatment and the National Institute on Drug Abuse. The views presented in this report are those of the Committee on Community-Based Drug Treatment and are not necessarily those of the funding organizations.

These Web sites for selected organizations will lead you to many more.

GOVERNMENT

• Center for Substance Abuse Treatment (CSAT)

  http://www.samhsa.gov/csat

• National Clearinghouse for Alcohol and Drug Information

  http://www.health.org

• National Institute of Drug Abuse (NIDA)

  http://www.nida.nih.gov

• National Institute on Alcohol Abuse and Alcoholism (NIAAA)

  http://www.niaaa.nih.gov

• Treatment Improvement Exchange (TIE)

  http://www.treatment.org

  ASSOCIATIONS/ADVOCACY

• Join Together

  http://www.jointogether.org

• National Association of Alcohol and Drug Abuse Counselors (NAADAC)

  http://www.naadac.org

• National Association of State Alcohol and Drug Abuse Directors (NASADAD)

  http://www.nasadad.org

  RESEARCH AND EDUCATION

• Center for Substance Abuse Research (CESAR)

  http://www.bsos.umd.edu/cesar/cesar.html

• National Center on Addiction and Substance Abuse (CASA)

  http://www.casacolumbia.org

• UCLA Drug Abuse Research Center (DARC)

  http://www.medsch.ucla.edu/som/npi/DARC