Marcie Bough
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What is the most effective way to treat substance-abuse disorders? Until last December, one guess was as good as another.
That was when the National Quality Forum (NQF) published a set of seven evidence-based treatment practices it found effective
in treating substance-use disorders, or SUDs. The NQF document also lists common barriers to the adoption of evidence-based
treatment practices.
The NQF recommendations grew out of a December 2004 conference. "It is good for pharmacists to learn more about substance-abuse
disorders and treatments that work," said Marcie Bough, Pharm.D., senior manager, practice development & research, American
Pharmacists Association (APhA). "It is part of the movement toward the greater utilization of evidence-based care, which will
improve the overall quality of treatment for patients."
The key word is implementing. "Many pharmacists don't have a clue about substance-abuse disorders or their treatment," said addiction specialist Merrill
Norton, R.Ph., counselor at the Metro Atlanta Recovery Residence, a treatment program in Atlanta. "Best practices are a step
in the right direction, but pharmacy is a very conservative profession. It's going to take concerted effort from APhA and
ASHP to put this on the front burner."
NQF is busy highlighting best practices. The expert panel found evidence to back three high-priority treatment practices for
SUDs, concluding that effective treatment should take place within a continuum of care that includes screening, diagnosis,
and assessment; active treatment (stabilization, early recovery treatment and management of comorbidities such as mental illness);
and continuing engagement as part of a longer-term chronic care plan. NQF is "very much moving in the right direction," Norton said. "But many states are cutting treatment funding and treatment
days, making effective treatment even more difficult." NQF noted that only a fraction of the spectrum of SUD treatment is
validated or supported by rigorous evidence in the current medical literature. But the panel was able to identify seven practices
with enough scientific support to merit widespread adoption:
- Screening for alcohol misuse should take place for all patients in both general and mental healthcare settings (including
primary care, urgent care, and emergency care). The evidence to support routine screening for misuse of other drugs is less
extensive and less compelling.
- All patients with a positive screen should receive a brief intervention by a healthcare practitioner trained in this intervention.
- Every patient assessed and diagnosed with SUDs should receive a written "dosing recommendation" explicitly prescribing the
specific services, the initial duration, and quantity of each service for the patient.
- All patients referred to specialty care treatment of SUDs should receive evidence-based psychosocial interventions. Effective
interventions include motivational interviewing, motivational enhancement therapy, cognitive behavioral therapy, structured
family and couples therapy, contingency management, community reinforcement therapy, and 12-step facilitation therapy. All
of these therapies must be used by trained clinicians.
- Addiction-focused pharmacotherapy should be considered for all patients diagnosed with alcohol and/or opioid dependence. Drug
therapy should be provided in addition to and directly linked with psychosocial treatment.
- Providers should systematically promote patient engagement to improve retention in SUD treatment programs.
- Patients treated for SUDs should be engaged in the long-term, ongoing management of their care.
"Comorbidities are a real issue in substance-abuse treatment," Norton said. For example, sleep problems, common during SUD
treatment, are often associated with anxiety disorder or obsessive compulsive disorder. Many physicians prescribe a sleep
aid such as Ambien (zolpidem, Sanofi Aventis) without recognizing the potential to create a dynamic that leads the patient
toward relapse. "We don't lack information," Norton said. "We just have a lot of misinformation. That's the real value of
evidence-based treatment." The panel also found a list of treatments that do not work and should not be routinely provided.
Treatments to avoid include:
- The use of acupuncture, relaxation therapy, didactic group education, or biological monitoring of substance use as a stand-alone
treatment
- Detoxification as a stand-alone treatment for dependence
- Individual psychodynamic therapy
- Unstructured group therapy
- Confrontation as a principal approach to treatment
- Discharge from treatment in response to relapse.
A best practices summary can be found at http://www.qualityforum.org/txSUDforweb.pdf.
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