The Evidence Gap in the Field of Substance Abuse Treatment

The Evidence Gap in the Field of Substance Abuse Treatment


A recent article published in the New York Times talks about the “evidence gap” in the field of substance abuse treatment. What they are referring to is the fact that there is very little evidence and follow-up that shows that any of the treatments out there for addiction are working at all. There is currently a push in some states (such as Oregon) to switch the industry over to “evidence-based practices.”

What are “evidence-based practices?” Essentially, this is when you switch over to a more scientific, medical approach with an emphasis on tracking and measuring so that you can better determine what works and what doesn’t. It seems to include an emphasis on using medications to control cravings or to treat addicts, and also the possibility of mandating certain approaches such as cognitive-behavioral therapy. It also might require additional training for all of the therapists and counselors out there who already attempt to work with addicts.

Another example might be a follow up program where the recovering addicts return to treatment every week after leaving and do urine drug screens and talk with a counselor. The idea is to measure outcomes so that we can know what is working and what is not.

Unfortunately, it’s all about money

Most of the therapists and counselors that work in the treatment industry are upset by this movement towards evidence-based practices. Here’s why:

1) They are being told how to do their job – if this gets mandated, basically state money to help run rehab facilities will be withheld unless the treatment center complies. Most therapists are in recovery themselves and have overcome their own addictions, so they know what works for them and attempt to pass that knowledge on to clients. But if the state steps in and says “use these evidence-based practices,” then they therapists are forced to teach or use a different style of therapy then what they are used to.

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2) It will be expensive to implement – most treatment centers cannot afford the new training that will be needed to implement these new evidence-based practices. They are already stretched thin and doing the best they can. Additional money for extra training is just not there. The potential emphasis on using medication requires a doctor on staff – meaning even more money.

3) They are being forced to measure their results – No one wants to have to prove that they are doing a good job, and this puts the therapists in the impossible position of having to produce miracles in a field where success rates are traditionally very low.

The article goes further, mentioning a study done by an author who interviewed recovering addicts with at least 5 years clean and sober, determining that “a standard program might not help at all.” In other words, the study indicated that many found sobriety outside of the traditional treatment model through other means.

It all seems to add up to one thing: insurance companies and state governments that pay big money to treatment centers want to start seeing documentation that their money is actually producing decent results. In my opinion, this is not going to happen given the current situation because decent results do not really exist; it is a tough industry and very few who enter treatment will find success in sobriety. If they do, many will have to attend several treatment centers before they actually “get it.”

Now the therapists and counselors who work in the field and are recovering themselves argue back that “treatment works.” Many of them found sobriety through treatment and they have of course worked with clients and seen some direct evidence that their efforts are paying off. But the vast majority will still relapse and so the evidence gap still exists. The people who are funding treatment are saying “show us the results.” The therapists and counselors are saying “we are doing the best we can.”

So where is the middle ground here? What should happen with the evidence gap? Should the treatment industry be forced to change?

My personal philosophy

My thoughts on this is that it’s probably going to happen anyway, as budgets tighten up the states are going to keep pushing for this until evidence-based practices become mandatory. The treatment industry should do their best to embrace the changes. It might be expensive and difficult to implement but I doubt that doing so could actually make outcomes any worse. Any change would be welcome at this point because even though “treatment works” for some, the vast majority still relapse within a very short time of leaving treatment. In my opinion our current success rates are still unacceptably low and I think the industry should be scrambling to find better methods. Instead it seems to have embraced a recovery model that consistently produces poor results.

I agree with the article in that standard programs (such as the 12 step model) are not the ideal treatment for everyone. I see direct evidence of this as I work in a 12 step based treatment center myself. My own personal philosophy (the creative theory of recovery) is a push away from traditional recovery models and more towards individualization and a more customized recovery program. In other words, people have to “find their own path” and there is less emphasis on networking with others as you progress in recovery.

I’m not so sure that the creative theory could be molded into a one-size-fits-all program in the same way that the 12 step program is. There is too great a need for customization. I personally think this is a large part of why the 12 step model fails for so many people – because we are trying to fit square pegs in round holes. We take every addict and alcoholic, even though they might be completely different and with completely different needs, and try to force them into the same 12 step model of recovery. We have essentially said to the struggling addicts and alcoholics: “this is the solution. Take it or leave it.”

That’s not good enough for me and I personally welcome any mandated changes that might shake things up and get us to experiment with new therapies and techniques. What we are doing has not been working. It’s time for a change and unfortunately it looks like that change is going to be based on economics. But in the end I think it has the potential to benefit everyone as a whole.

If they mandate evidence-based practices, some treatment centers might struggle with this and fold, but others will adapt and good things may come of it. If nothing else, the change will produce a mountain of data that can guide us in forming new therapies and strategies for recovery. I am a marketer at heart and believe that we should start measuring. If we close our eyes and refuse to measure then we are just fooling ourselves.

Just my 2 cents….what does everyone else think about this?


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