In Issue 16 of Drugnet Ireland we looked briefly at the concept of evidence-based medicine (EBM).  This article will examine some of the issues around finding reliable evidence on substance abuse treatment and prevention and will review some of the recent literature on this subject.

EBM and addiction

Reimer1 points out that the efficacy of the evidence-based approach to clinical practice is by no means universally accepted.  Criticism focuses on the narrow range of reliable research methods accepted by the approach and difficulties in interpreting and applying the results of meta-analysis and systematic reviews.  The fields of substance use treatment and prevention are not immune to the debates surrounding the appropriateness of EBM.  However, a number of factors not directly related to the application of evidence-based treatments in the clinical setting have contributed to EBM’s increasing relevance in the addictions field.  Reimer identifies these factors as:

·          an increasing emphasis on accountability and evidence of effectiveness from governments and funding agencies, particularly since the early 1990s

·          the importance to healthcare policy of standardised treatment procedures, cost-effectiveness and outcomes

·          the recognition, by those delivering services in the community, of the importance of delivering empirically supported therapies as funding sources increasingly emphasise best-practice guidelines.

Despite this supportive environment, the body of evidence available to practitioners wishing to pursue an evidence-based approach to treatment and prevention is small.  Lacroix2 explains that the dominance of the disease model of addiction meant that the introduction of non-medical therapies occurred relatively recently.  Addiction medicine developed rapidly as a separate discipline in the US in the immediate post-war period. But it was not until the 1980s that a more complex understanding of the nature of addiction emerged and psychologists and counsellors began to apply different models of treatment.  Therefore, the study of addiction has not yet produced a body of evidence-based knowledge comparable with that of other branches of medicine and health science.

Sources of evidence

The number of systematic reviews and practice guidelines developed for non-medical treatments is very small.  The Cochrane Database of Systematic Reviews is divided into a number of thematic review groups.  The Drug and Alcohol Group and the Tobacco Addiction Group are the review groups of most interest to those studying addiction treatments.  Of a total of 31 completed systematic reviews published in the current issue (2, 2006) by the Drug and Alcohol Group, only seven dealt primarily with psychosocial or other non-pharmaco-therapy interventions.  There were no such reviews in Issue 4, 2001, so interest is increasing.  However, in many of the recent studies the outcome was inconclusive because of inadequate or incomplete research. 

The Medline database is the main source of bibliographic information on medical literature and it is possible to select literature for evidence-based decision making from it.  By limiting publication types to meta-analysis, practice guidelines or randomised controlled trials, it is possible to estimate the volume of literature dealing with evidence-based approaches to treatment for addiction and substance use disorders.  Only about 2% of the total number of articles in this category deals primarily with non-medical or psychosocial interventions.  It would be necessary to consult a number of sources to carry out a useful literature review in this area.  Other databases which might produce relevant material include PsycINFO, the database of the American Psychological Association; ETOH, the Alcohol and Alcohol Problems Science Database (not updated since 2004 but still a valuable source of literature in this area); and DrugData, maintained by the library of DrugScope in the UK. 

Several medical organisations in the US publish practice guidelines on substance use treatment, many of which are available online through the National Guidelines Clearing House database (www.guidelines.gov). Finney3 explains the difficulty in developing comprehensive, useful practice guidelines for behavioural and psychosocial approaches to treatment.  Such guidelines do exist, but they are not as easy to locate as medical guidelines.  Finding appropriate ones may involve a detailed literature search and an examination of the publications produced by relevant research centres and well-known researchers in the field. 

Recent publications

A number of recent publications reviewing literature in the addiction field are useful for identifying high-quality research.  Stockwell et al.4 provide a summary of recent research on aspects of prevention work and assess the effectiveness of various intervention strategies described in the available research.  Linford-Hughes et al.5 wrote a very useful review of recent research on pharmacological management of problem drug use.  They argue that, while quality research is scarce, a wealth of clinical experience can be drawn on to increase the effectiveness of treatment.  In an American study, McGovern et al.6 examine the process by which treatment professionals use an evidence-based approach to select appropriate interventions.

Research transfer

Summarising the literature on the research-to-practice exchange, Reimer1 identifies three prerequisites for effective research transfer:

·          relationships need to be developed between researchers, practitioners and policy makers

·          research evidence and practice guidelines must be combined with individual instruction, incentives and active learning strategies

·          research organisations need to devote an equal amount of funding to research studies and to research transfer

Research on addiction and substance use cannot, of course, match that in the medical field in terms of funding or infrastructural support.  Researchers and information professionals have an important role in drawing attention to the evidence that does exist and ensuring that it is used to establish a sound evidence base for programmes and policy in the field.

1. Remier B (2003) Strengthening evidence-based addictions programs:a policy discussion paper.  Ottowa: Canadian Centre on Substance Abuse. http://www.ccsa.ca/Eng/Pages/Home.aspx

2. Lacroix SI  (2002) Evidence-based and best-practice addiction treatment resources: a primer for librarians. Behavioral & Social Sciences Librarian, 21(1): 61–71.

3. Finney JW (2000) Limitations in using existing alcohol treatment trials to develop practice guidelines.  Addiction, 95(10): 1491–1500.

4. Stockwell T, Gruenewald P J, Toumbourou J W and Loxley W (eds) (2005) Preventing harmful substance use: the evidence base for policy and practice. Chichester: John Wiley.

5. Lingford-Hughes AR, Welch S and Nutt DJ (2004) Evidence-based guidelines for the pharmacological management of substance misuse, addiction and comorbidity: recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology, 18(3): 293–335.

6.  McGovern MP, Fox TS, Xie H and Drake RE (2006) A survey of clinical practices and readiness to adopt evidence-based practices: dissemination research in an addiction treatment system. Journal of Substance Abuse Treatment, 26(4): 305–312.