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J Summary of Interviews with Minnesota State Alcoholism-Addiction Leaders Cindy Turnure, Ph.D. Single State Agency Chief Patricia Harrison, Ph.D. Chief of Alcoholism/Addictions Research/Evaluation POSITIVE STRATEGIES AND CONTRIBUTIONS OF RESEARCH TO COMMUNITY PROGRAMS 1. Research studies (especially treatment outcome studies) have produced a few major findings, discernible largely through meta-analyses, that do guide state-level planners (although may not yet affect community programs and private health organizations). These are as follows: virtually any kind of treatment helps (message: look for the low cost treatment); brief but frequent contacts with patients work better than intensive but short-term contacts; and treatment should be for the long-term, with the expectation that many patients will surface repeatedly in treatment over a lifetime. 2. Nationwide data on addiction have not been particularly helpful. States and communities vary too greatly. More specific data on similar states and communities have been helpful. NONPRODUCTIVE STRATEGIES AND PROBLEMS OF RESEARCH IN RELATION TO COMMUNITY PROGRAMS 1. They discern a growing "research gap" that is, the field has more and more findings that are less and less used in community settings.
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2. Dissemination of research results to practitioners in the community: expensive to get information to community practitioners; they do not read the newsletters often produced by research centers or federal agencies; application of some research results requires additional staff training; there are no funds to pay for this; some research findings would require considerably increased staff time and/or staff credentials to bring these findings to the patient; these cannot be implemented in a time of declining state and private budgets for addiction services; some research findings require sophisticated resources, additional financing, etc., to apply; such findings have low-to-nil utility in the community (e.g., much "matching" research). 3. The highly selective criteria for many research protocols bias the research towards atypical rather than typical patient-subjects. For example, most research appears to involve "proactive" patients, urban patients, patients who have transportation to a center where research is conducted, can get referred into a research program, or come across the "right" gate keepers. These traits do not apply to most patients in community settings. 4. Much of the research appears to be based on models or concepts that clearly have not worked in this field. Examples, include research strategies that have approached patients as though addiction were an "acute care" disorder, rather than a chronic relapsing disorder in which recovery (even if it does occur) continues over years rather than weeks. Another flawed approach has been the search for a psychosocial or biomedical "silver bullet," in which one acute or subacute treatment method will "cure" addiction. RECOMMENDATIONS FOR FUTURE RESEARCH FUNDING 1. More clinicians (or at least clinicians who are active applied researchers) should be appointed to committees charged with funding research. 2. Research goals should have as a criterion the applicability of any anticipated research findings to patients in community settings. 3. Research models should reflect the realities of addictive disorders (e.g., chronic, often recurrent disorders; associated psychosocial and biomedical problems; requiring years for recovery-maintenance-management). 4. Is there a way that public policy (on state as well as national levels)
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can be tied to research findings? Currently, research findings do not seem to influence public policy. 5. Is there a way that research findings can inform public perceptions and opinions? Currently, public opinion leaders (e.g., mass media, heads of managed health care organizations, elected officials, health professionals, educational system, etc.) hold opinions counter to research findings (e.g., treatment for addiction does not work, treatment is more expensive than "supply reduction"). 6. State planners would like to have research findings that address the following issues facing community programs: How "brief" can brief contacts be and still be effective? One hour, half hour, fifteen minutes, five minutes? How much do interventions cost in terms of assessment, total costs (including training, consultation, administrative costs, cost efficacy, cost offsets) ? Where should treatment be best provided? Medical center? Home? Workplace? What about telephone contacts? 1. Any research findings, to be utilized at a community level, must be simple to apply (KISS principle). Interventions requiring special interviews (e.g., ASI), or costly psychological evaluation, or special assessments of staff members (e.g., personality types) are not used. 2. More research should be conducted in community settings. Much research now is conducted in large university or VA medical centers. 3. Community personnel, programs, and planners need algorithms to help in guiding patients through treatment. Examples include patients who are failing in treatment, special demographic groups, those with associated biomedical or psychosocial problems. 4. Managed care has become an integral part of health care. How can managed care methods be brought to the service of addicted patients? What are reasonable criteria for the involvement of managed care organizations and personnel in the care of addicted patients? 5. The distinction between private and public patients is fading fast in the addiction field. Previously "private" programs are taking public patients, as private programs no longer pay for addiction services. In addition, employed addicted persons either cannot get health insurance nowadays or lose private insurance coverage more readily than in the past. How can these "mixed" patients be best managed in the same system? What kind of case manager (or what kind of case management) should apply to either or both systems? How much does such case management cost? Case managers currently seem to add to treatment costs, rather than decrease costs. In addition, the cost efficacy of case management is far from obvious.
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6. The model of paying for addiction services varies from community to community. Research might address whether "carve in" administration/ funding is better than, worse than, or the same as "carve out" administration/funding. There are many theoretical advantages and disadvantages to both, or to perhaps some combination of both. Research is needed to assess the influence of these different approaches on addiction treatment. 7. The distinction between prevention (especially early intervention at the point of heavy use or early prediagnostic problematic use) and treatment are less relevant in the addictions than they may be in infectious disease, cardiovascular disease, cancer, etc. Currently, the "prevention" people receive different funding streams and do not address "early case" or "precase" finding. Likewise, clinicians do encounter early cases and heavy users, but cannot be funded to provide care if the person does not meet diagnostic severity or if their social impairment is still minimal. This is especially apropros of adolescents, who often do not meet diagnostic criteria, but are vulnerable to an addictive career. Can research address the special dimensions of prevention in the addiction field? 8. Research regarding addiction services under welfare reform is urgently needed. These reforms are cutting off payments to addicted persons. Most people at the community level believe that this may have serious social effects, but are not agreed on what is apt to occur. States and communities would like information about the consequences of welfare reform on addicted persons, along with how best to manage this. 9. More quasi-experimental designs would be appreciated, since these seem to provide more practical information than highly controlled (but also highly biased and nonapplicable controlled, random assignment studies). For example, the results from policies and strategies employed in the fifty different states should be informative. Could such data be collected, compared, and analyzed? 10. Long-term studies and longitudinal studies (over at least one year, and sometimes several years or a few decades) are needed. Community agencies provide services for years and even decades in many, perhaps most cases. 11. Cocaine abusers are going to prison in large numbers, relative to alcohol, cannabis, opiate, etc. abusers. Overlapping this is the fact that Afro-American patients are using cocaine more and going to prison more often. Community people would like to find ways of keeping cocaine patients and Afro-American patients in treatment rather than in prison. Can research help address this issue? Understanding of the complexities involved might also help (e.g., organic brain damage from cocaine, reversible vs. irreversible effects, ethnic differences in the acceptance of cocaine, community approaches to getting cocaine out of the community). 12. Can research tell us how best to detect and treat patients with
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comorbid psychiatric disorders in community settings? What is the best way to provide combined addiction and mental health services in the community, especially in a time of dwindling resources? 13. At a community level, much resources continue to be devoted to patients whose benefit or outcomes from treatment are poor or nil. How can we identify when to reduce services to such patients? How should treatment of chronic, relapsing patients be managed? Should they have special assessments to ascertain whether a treatable condition exists? How much would this cost. Who would do this and where should it be done? What ethical, legal, and socially acceptable alternatives can be brought to bear (e.g., case management, asylum, methods of managing their money, or other resources)? 14. The research "turn around time" needs to be faster. Much research now being published was conceived several years or a decade ago, when a much different system was in place. Research funding should support more exploratory, quasi-experimental, clinically relevant studies. Secondary analyses and meta-analyses of state agency data might reveal useful trends or information. 15. Federal "on-site" visits/reviews and technical assistance to states and communities should be expanded. Perhaps these could include researchers who have conducted community-applicable research. Those who have a national or cross-state perspective can tell community, state, and regional people what is being tried and what has been successful in similar settings. Community and state program leaders and planners have found these contacts helpful. 16. Providing care to addicted persons in rural areas is a growing problem. More drug use now occurs in rural areas; it is no longer "contained" in urban settings. All aspects of care are multiplied: access to care; support over time back in the community; special help for people with special needs (e.g., solo mothers, adolescents, elderly). We need new models of care such as more use of primary care, telemedicine, and mobile treatment teams. Conducted by Joseph Westermeyer July 1997
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