This paper systematically reviewed the last decade of scientific research addressing attitudes towards, adoption of, and implementation of EBTs within the field of substance abuse treatment. Based upon this review significant progress has been made, especially with regard to the advancement of the fields’ knowledge about attitudes toward EBTs and the extent to which specific EBTs are adopted in practice. However, in contrast to the 25 studies on attitudes toward EBT and the 31 research studies on EBT adoption, only nine research studies were found to have examined implementation of EBTs, which suggests the substance abuse treatment field is still in the early stages of development and knowledge regarding implementation of EBTs. Certainly numerous reasons exist for the disparate number of research studies on EBT implementation, and future research on identifying such barriers is clearly warranted. Seemingly, one of the most significant barriers to implementation research may be the lack of objective criteria for what determines when EBT implementation has or has not occurred in practice. For instance, according to Fixsen et al. (2005)
implementation is defined as “a specified set of activities designed to put into practice an activity or program of known dimensions.” Importantly, both the activity/program being implemented and specified set of activities are supposed to be described in enough detail to allow independent observers to assess the presence and strength of each. Although EBTs generally have associated manuals and/or treatment fidelity measures, there is typically little guidance on the extent to which modifications (desirable or undesirable) can be made and still allow the EBT to be considered implemented as planned by the treatment model developers (i.e., level of implementation tested and shown to be effective as part of randomized clinical trials). Given such modifications or “re-invention” as labeled by Rogers (2003)
is generally the rule rather than the exception in implementation efforts, it would seem to behoove the field as a whole to work towards the development of implementation criteria that would aid future studies of EBT implementation.
Considerable research to date has examined attitudes towards EBTs with the majority of studies having addressed attitudes toward pharmacological EBTs. Interestingly, the literature seems to suggest generally more positive attitudes are held towards the use of psychosocial EBTs, relative to pharmacological EBTs. In fact, a recent study by Thomas and Miller (2007)
found 65% of the 84 counselors and administrators surveyed agreed pharmacologic interventions work best only if accompanied by psychosocial interventions. What appears to be one of the primary reasons why staff have less positive attitudes toward pharmacological EBTs is simply lack of knowledge about pharmacological EBTs relative to psychosocial EBTs. That is, unfortunately education and/or training about pharmacological EBTs are not provided to community-based substance abuse treatment staff and which is reflected in the fact that Knudsen et al. (2004)
found 1,972 of the 2,298 (86%) substance abuse treatment counselors surveyed to report not knowing about the effectiveness of Buprenorphine. Thus, in order to improve attitudes toward pharmacological EBTs it is imperative that future initiatives target increasing counselors’ knowledge about the effectiveness of available EBTs, both psychosocial and pharmacological. Fortunately, as has been shown by McCarty and colleagues (2004)
staff attitudes toward pharmacological EBTs can be improved by providing trainings on the potential benefits of using such practices.
Almost half of studies identified as part of the current review focused on adoption of EBTs with the majority of these studies focused on adoption of pharmacological EBTs such as naltrexone or buprenorphine. Despite the large number of studies conducted it was not easy to determine a single estimate of the rates of adoption, given estimates varied considerably depending on the sample surveyed and the year the survey was conducted. As noted previously, Knudsen, Ducharme, & Roman (2007a)
appear to have provided the best current estimate of the rate of naltrexone adoption within US substance abuse treatment centers at 21%, which is based upon data from 766 treatment centers surveyed between 2002 and 2004. However, given less than two percent of the 194,001 Veteran Affairs outpatients diagnosed with alcoholism between October 2000 and March 2001 were prescribed naltrexone (Petrakis, Leslie, & Rosenheck, 2003) suggests that simply because a center has “adopted” a EBT does not guarantee all who may benefit from the treatment will receive it. Nevertheless, rates of naltrexone adoption do appear to be higher than the rates of buprenorphine adoption, which based upon available estimates ranges between 5.5% (Koch et al., 2006
) and 14% (Knudsen, Ducharme, & Roman, 2006
). Perhaps due to the wider range of available EBTs or possible the generally more positive attitudes held towards them, considerably less research to date has examined adoption of psychosocial EBTs. However, among the studies that have provide rates of adoption for psychosocial EBTs one of the highest rate of adoption was found for CRA at 49% (Knudsen et al., 2003
Only nine of the 65 research studies (14%) identified in this review focused on implementation of an EBT. As noted above, this relative paucity of implementation research suggests the substance abuse treatment field is ripe for further research in this area. In addition to the previously noted recommendation to develop more objective implementation criteria six strategies to help encourage better EBT implementation were given by Guydish et al. (2007)
with a common theme among several of these strategies being related to “training” (e.g., training senior staff how to deliver the EBT, using a regional training model, and bring EBT training back to the clinic). Two good examples of the types of implementation research studies which are needed to significantly enhance the field have been provided by Andrzejewski et al. (2001)
and Liddle et al. (2006)
. However, this is not to say that these studies were not without their limitations. For instance, the study by Andrzejewski and colleagues was based upon a very small sample of only ten counselors, which limits the generalizability of the findings. An important limitation of Liddle and colleagues study was the high degree of staff turnover. Given only one of the five social workers participated during all of the study phases it is not possible to conclude whether the improvements found during the implementation phase of the Liddle et al study are attributed to the training intervention or simply to having hired more competent staff. Nevertheless, this study is notable for being the only study to have examined longer-term implementation (i.e., sustainability).
Although not a primary focus of the current review, it does seem relevant to note that for the most part research studies did appropriately apply the various terminology, which represents a significant advancement within the field given previous reviews have noted the varied and inconsistent usage of terms (Gotham, 2004
; Fixsen et al., 2005
). Additionally, it seems relevant to note that the term “implementation science,” which was defined by Perl (2006)
as “the study of principles and methods to promote the systematic adoption and implementation of scientific advances into real-world practice” was not found to be used in any of the studies identified. Indeed, using implementation science as a keyword in Psychinfo and Medline searches resulted in only 10 articles, none of which were related to substance abuse treatment. Similarly, substance abuse as keyword search in Implementation Science, which is an online journal published by BioMed Central, resulted in only six articles – none of which met inclusion criteria for the current study. Rather, it appears most common for researchers to discuss specific stages, such as adoption or implementation, or the general process of “technology transfer”, which as noted by Gotham (2004)
also is sometimes referred to as diffusion of innovations. Given the theoretical basis for many conceptual frameworks is actually based upon Rogers’ (1962
) diffusion of innovation theory, it may be appropriate to begin referring to the study of how innovations spread (planned or unplanned) as “diffusology.” Although, adoption, implementation, and sustainability should still be used to be more specific about which stage of the diffusion process is being examined, this broader term would be more consistent with how fields of study are typically labeled. For instance, the study of the origin and spread of diseases is referred to as epidemiology, not disease transfer.
Primary limitations of the current review are that it only includes research studies conducted within the U.S. substance abuse treatment field and published after 1998. Although beyond the scope of the current review, diffusion of EBTs is of considerable interest in other fields of research. As this is particularly true of mental health treatment (e.g., Aarons, 2004
, Gotham, 2004
; Henggeler, Melton, Brondino, Scherer, & Hanley, 1997
; Schoenwald, Sheidow, Letourneau, & Liao, 2003
) it behooves substance abuse treatment researchers and clinicians to familiarize themselves with these types of related research. Additional limitations of the findings of the current review include use of cross-sectional survey methods, low survey response rates, and heavy reliance on respondent self reports.
4.2 General conclusion and future directions
As discussed previously, significant progress has been made in the advancement of knowledge regarding EBT diffusion research within substance abuse treatment. Nonetheless, there remains considerable opportunity for further study. In particular, there is a need for more experimental or quasi-experimental studies which test different methods of improving the adoption and/or implementation of EBTs. One of the best examples to date, which was previously reviewed in Walters and colleagues (2005)
systematic review of the effectiveness of workshop training for psychosocial addiction treatment, was a study by Miller et al. (2004)
. Using a randomized design, Miller and colleagues tested four methods to help therapists learn Motivational Interviewing (MI). These conditions included 1) workshop only, 2) workshop plus practice feedback, 3) workshop plus individual coaching, and 4) workshop, feedback, and coaching. Overall, results of their study indicated only clinicians in the full training condition (i.e., workshop, feedback, and coaching) showed significantly better client responses compared to baseline.
Related to the need for more controlled studies on methods to improve the diffusion of EBTs is the need for better measures of adoption and implementation. To date, diffusion research has relied heavily on “yes” or “no” self-reported responses, with little, if any, external verification of the validity of such reports. Although reliance on self-report remains far from perfect, such methods are at least much more suited for studies of EBT adoption than they are for studies of EBT implementation given the latter generally require more information about the extent of and/or quality of implementation (i.e., implementation fidelity). Indeed, among the studies included in this review, only a couple (Henggeler et al., 2008; Liddle et al., 2006
) used an implementation measure to collect this type of information. Thus, in sum it is concluded that in order for the field of substance abuse treatment to further advance its knowledge about how to best diffuse EBTs, future research needs to develop psychometrically sound measures of adoption and implementation, and more importantly use these measures to develop and experimentally test different diffusion interventions. Additionally, future researchers are encouraged to employ mixed methods (integration of both quantitative and qualitative method), which also has been recommended by others (Dennis, Fetterman, & Sechrest, 1994
; Dennis, Perl, Huebner, & McLellan, 2000
). Use of methodologically rigorous experimental or quasi-experimental design, psychometrically sound instruments, and integration of quantitative and qualitative data collection should hopefully lead one day to the field having not only EBTs, but evidence-based diffusion practices.