Will EBP Evidence Based Practices, hurt or help the treatment or advancements of Substance Problems?

What Evidence Based Practices means in simple terms, what is the most effective treatment for a diagnosed disorder, and the “payer” will then only pay for the treatment that is defined as being the most effective treatment for the problem. On a fast first glance it makes complete sense, common sense tells us, do what works on a proven basis. However, that is if you only look at the surface.

The problems become, who supplied the list of “most effective”, was it really unbiased, and will that allow for parallel treatments. (MOC) or Method of Coverage, seen below as “managed care” becomes the deciding factor, will the therapist, professional, or treatment facility get paid if an (EBP) is not used, in the treatment of a client that did not respond to the approved lists deemed “most effective?” One very disturbing factor mostly overlooked is the approval process, who funded the research for the “most effective” can determine its outcome. If a researcher is funded by a company, will the evidence be impartial? That would depend on the researcher, do they like being paid and are they looking for more funding, is it self-serving? One thing most do not consider, in the world of “research papers” getting published, in this field, can become the driver for more research dollars being made available.

“Tainted research,” does the researcher have a motive beyond research, who supplied the funding is a valid question. What happens if the researcher is on the payroll of the company funding the findings? Do they bite the hand that feeds them? Is the research then independently validated?

Will it come as a surprise to you this argument is based on “payers”, a nice way to say insurance companies? In an article written by APA’s president elect in June 2004 Dr. The Empirically-Validated Treatments Movement: A Practitioner Perspective:

“The empirically-validated treatments movement has had quite an impact on practitioners. It provided ammunition to managed care and insurance companies to use in their efforts to control costs by restricting the practice of psychological health care (Seligman & Levant, 1998).” -Ronald F. Levant, Ed.D., J.D. (President-Elect, American Psychological Association)

What does this mean to the men and women seeking treatment with a substance problem in the United States?

The largest inhibitor to treating substance problems for men and women in America is they simply cannot afford it. In the recently released 2009 annual report from the U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Office of Applied Studies tells us the reasons people ages 12 and up do not receive treatment, thirty-six percent (36.8%) stated cost, they simply could not afford it or did not have insurance coverage. Another eight percent (8.8%) said their healthcare did not cover it. This tells us out of the 22.9 million people needing treatment, forty-five percent (45.6%) or 10.4 million people of the 22.9 can’t afford to “quit.”

This should bring chills down your spine, if you have a substance problem, can you afford the treatment it needs and will it be the treatment you actually needed?

So where does EBP fit in this story? If nearly half the addicted population cannot afford treatment, where does the “payer” fit in this scenario? And can you see why the “self-help groups” is the largest treatment sector in the treatment of substance dependence or misuse problems, it does not matter the chemical substance, whether it be alcohol or drugs, or both. The cost of receiving treatment is going to get “worse before it gets better.” And in the life and death of chemical dependence, we cannot afford to get any worst.

If the treatment professionals working in the industry cannot be paid, that could create a treatment environment that ceases to exist, a paid recovery profession. While altruism is a nice concept, working for free, is for the rich. Which is exactly what the government is telling us in their report, the largest sector in “recovery” is the self-help group. While this may sound disturbing, the actual size of the self-help recovery networks is even more disturbing. There are an estimated two million (2.5M) going to self-help groups, which comprises the largest “treatment” sector for substance abuse or dependence problems in the USA. Treatment now belongs to the non-professional.

Looking at the numbers, twenty two million people have an alcohol or drug abuse or dependence problem or both, out of that number, two and a half million people (2.5 million) are going to non-professionals for help. The reasoning is simple, it is based on money, and self-help is cheap but not as effective as professional help.

Out of the twenty two million in trouble, only one million men and women (1.2M) actually, go to inpatient treatment.

Now, EBP, what is that really? And where did it come from and the reasons it came to pass. Evidence Based Practices, what does that mean really?

Let us first take a look at different treatments from the professional community. Before you can look at the solution you must understand that a diagnosis is needed before a medical treatment plan can be prescribed.

If the logical scenario of a substance problem starts with a medical detoxification process, immediately costs are incurred. The average cost of a detox unit is $ 1,500.00 per day. The average “detox” ranges from three to seven days. The numbers start to add up quickly. Here we see the “lucky” person if they only require three days of medical detox, and paying out $ 4,500.00 but the longer the detox, the higher the cost, seven days lands on $ 10,500.00.

Treatment has not yet started; detox is not treatment, simply a medical process to remove any toxins out of a person’s body safely. A person could find themselves in debt upwards of ten thousand dollars (!) It is during this time frame that a medical diagnosis is happening based on the criterion of substance abuse, or dependence found in a medical bible of sorts called the DSM-IV-TR.

The problem is self created, by the very people that created the criterion.

The American Psychiatric Association, printed the Diagnostic Disorder Manual, called the Diagnostic and Statistical Manual of Mental Disorders, the “DSM” each revision gets its own number, DSM III moved to DSM IV, currently the “text revision” is in its fourth revised/edition, the treatment medical community is waiting for the newly revised “V” or fifth edition to be released soon. So we end up with the DSM-IV-TR. This manual has a competitor called the International Classification of Diseases (ICD). ICD 10, created by the World Health Organization (WHO) their manual contains all medical conditions are assigned a code, and the two, the DSM and ICD, are trying to meet in the middle. The DSM is strictly used for “Mental disorders” while the ICD, lists all diseases and medical disorders.

This is needed for charting purposes and creating a medical treatment plan. And the pictures start to reveal themselves. If a person is “alcoholic” what is the most effective treatment for alcoholism? If a person is substance dependent to cocaine, what is the most effective treatment for cocaine addiction? The problems start to add up, what if that same person, was dependent to both substances alcohol and cocaine, and suffered from a manic disorder? Here we have three disorders, what is the best practice for each, what is the one the “payer” will approve for payment.

Then we enter the medical skills training challenge versus costs, if the approved therapy is Cognitive Behavioral Therapy (CBT) based, for example DBT, Dialectic Behavior Therapy, a flavor of CBT was determined as “best”. The problem becomes the shoehorn effect. We will make that shoe fit, even if it’s not working or, what happens with the high amount of turnover in the recovery industry, what if the facility does not have a certified DBT therapist? The failure to “pay” for treatment, which was difficult before now becomes even more difficult. The added paperwork, takes the diagnosis out of the field of professionals to the hands of what will be covered by the insurance payer. To get the right treatment, may turn the professional to “game” the system which is nice way to avoid using the terms “insurance fraud.” Do they risk their professional license for an addict?