Imagine that your beloved dog, Rocky, became ill suddenly and required a visit to the animal ER. He received a thorough assessment of his medical history and his current condition. After a few moments, the vet turned to you and said, “Rocky’s life is at risk due to this very serious illness, but I don’t pay much attention to current research. I don’t have time to read journals and the research isn’t very relevant to what we do here. I can treat him with the methods I learned in school three decades ago, but I’m not certain that he will return to good health.” Would you find another vet to care for Rocky?
Now imagine that we are talking about an ill family member or loved one—your parent, child, spouse, sibling, or best friend. Wouldn’t you expect the highest standard of care for them? Don’t you want them to receive treatment that favors the best odds for success?
In the treatment of substance use disorders, we know that there are varying degrees of success based on treatment modalities and techniques, the clinical complexities of patients, the treatment environment, and patients’ social support networks, among other considerations in the treatment equation. When we talk about providing “quality treatment,” one way to support quality is to tie it to outcomes. Given that research has offered evidence of what works best for whom and under what circumstances, don’t we owe it to our patients to offer the highest-quality treatment?
Evidence-based practices (EBPs) are grounded in sound research that demonstrates a greater likelihood of yielding more positive clinical outcomes for patients over other practices. External scientific evidence (i.e., research) plus expert consensus are utilized often in determining whether a treatment practice qualifies as evidence-based. There has been a growing literature in the past 10 to 15 years about use of EBPs in substance use disorder treatment as well as in the treatment of mental illness.
EBPs are typically manualized to increase standardization in their execution and to maintain fidelity across practitioners and programs. This assists providers in conducting outcomes research, as many practices build in some type of measurement component. As more providers evaluate outcomes of EBPs and share their results, the practices' evidence is strengthened. Another emerging benefit is that, particularly when financial resources are scarce, funders may choose to reimburse providers who include EBPs in treatment and may limit financial support to providers who do not.
Evidence-based practice’s opponents, however, are quick to cite the expense of implementation. EBPs can be expensive in both time and money depending upon training requirements and costs of materials. Since many practices are manualized and some are copyrighted, it is likely that original manuals and supporting materials will need to be purchased, if not for each practitioner then for every program. Training fees can vary based on who trains staff. The EBP’s developer is often available to provide training, or the developer may have a staff of approved trainers available at a reduced cost. These trainings can last a few days, but full implementation may require ongoing paid booster or consulting sessions. If a provider organization is not structured with internal program evaluation capabilities, an additional outside consulting fee may be warranted to monitor and maintain EBP fidelity.
Choosing an evidence-based practice should be a multifaceted endeavor. At Gateway Rehabilitation Center, our selection and implementation process was thoughtful, strategic and enduring. We attempted to leave no stone unturned during our planning phase. Simply stated, we did our homework.
We concentrated on finding an EBP that was consistent with our treatment philosophy. While we wanted to stay true to the heart and soul of Gateway, we also sought to implement a practice that would allow us to integrate state-of-the-art treatment adjuncts (in our case, a new medication-assisted treatment program). We searched EBPs through the Substance Abuse and Mental Health Services Administration’s (SAMHSA's) National Registry of Evidence-Based Programs and Practices (NREPP), hoping to find a few with outcome variables congruent with our routine outcome evaluation.
Also, since we maintain that addiction is a disease, we hoped to consider a few practices that address the biological, psychological, social and spiritual aspects of addiction, treatment and recovery. We concluded that Twelve Step Facilitation (TSF; www.nrepp.samhsa.gov/ViewIntervention.aspx?id=358) offered the best fit for our organization.
Our decision to adopt TSF as a core practice was not made hastily—it took us approximately one year. Basing the decision on our background research with NREPP, we followed the Addiction Technology Transfer Centers' (ATTCs') The Change Book: A Blueprint for Change1 to guide us through the process. We acknowledged at the outset that any EBP adoption would be a heavy undertaking, but we never lost sight of our goal.
Training more than 200 clinicians across two states in four divisions comprising 20 locations would not be an easy task. The opening of a new Research and Training Institute gave Gateway the entity it needed to focus on TSF, while managing the day-to-day practicalities of implementation such as training trainers and coordinating training sessions.