This assessment of 49 states' implementation of evidence-based practices for substance abuse treatment reveals widespread articulation of support for EBPs among state substance abuse authorities (SSAs) but considerable variation in actual adoption of individual strategies. Each state has a unique approach to service delivery and funding of substance abuse treatment services. Therefore, to provide a framework for discussions with each of the SSAs, this comprehensive semi-structured interview protocol was based primarily on the NQF's practices and strategies.12
Of four EBP adoption strategies endorsed by the NQF, SSAs reported the highest emphasis on employing infrastructure and development, as well as education and training to promote all EBPs for substance abuse treatment. Regulations and accreditation strategies were reportedly used more for encouraging wraparound services and aftercare and recovery management than screening and brief intervention, proven psychosocial interventions, or access to medications. Importantly, SSAs also reported relatively low strategic emphasis on financial incentives and mechanisms, as well as regulations and accreditations. Problems with financial support options and accreditation could play a role in variation in actual adoption of EBPs.
The finding that financial incentives and mechanisms were used least of the five NQF strategies mirrors a study by Finnerty and colleagues ranking health-related barriers and strategies as (in descending order) money, engagement, training/consult, attitude, mandate, policies, credential, understanding, plan enacting, plan sustaining.47
More recently, Koch and colleagues examined a partnership formed in Virginia to stimulate dissemination of EBPs for adolescents with co-occurring disorders.31
They also found barriers to implementation that included financing concerns (e.g., unavailable or expensive training, individual clinicians disinterest in new treatment models, and treatment models being too expensive or too restrictive).31
In terms of legislative action, Oregon remains the only state with a statute that financially requires treatment expenditures on substance abuse EBPs. North Carolina's mental health system reform law incorporates EBP promotion within available resources. Alaska's EBP legislation was passed without funds appropriated. Other SSA representatives reported active movement toward legislation or other higher authority support, such as strategic plans or governor's commissions. Interestingly, some SSA representatives reported that EBP legislation was unlikely, either due to the SSA's relative autonomy in substance abuse treatment matters or political issues within the legislature. Thus, it appears that support for legislative mandates is highly variable.
In contrast to the lack of legislation, the majority of SSA representatives reported use of treatment EBPs as a criterion in contract agreements with or grants to treatment providers. Of those, some require specific EBPs as part of their contracting criteria (e.g., motivational interviewing, cognitive behavioral therapy, Matrix model). Additionally, even states without EBP contracting criteria indicated concrete efforts toward, at minimum, encouraging EBP use. However, one overall theme included defining what constitutes an evidence-based practice for such contracts. In some states, there is no specific definition of EBPs or list of practices to use in provider contracts because they are still debating what qualifies as an EBP. It should be noted that some SSAs contract indirectly with providers, through county (or other local) contracts or managed care entities, and may not control contracting language.
In addition to state contracts or grants awarded through requests for proposals (RFPs), state funding can be tied to EBP use through federal block grant requirements. For example, SAMHSA's Center for Mental Health Services promotes IDDT as an EBP for individuals with co-occurring mental health and substance abuse disorders.28
Moreover, there is a combined effort from several federal programs including the NIDA Clinical Trials Network and the Center for Substance Abuse Treatment (CSAT) Blending initiatives, SAMSHA's NREPP work, and CSAT's Treatment Improvement Protocols to establish substance abuse treatment EBPs. This conjoint effort links to the federal block grant funding, but the range of EBPs varies depending on the level of care. Additionally, a few SSA representatives noted that Medicaid funding does not allow billing of substance abuse treatment services. Other states have undertaken broad Medicaid reform to address financing issues.20,21,30
Several SSA representatives noted that there is a need for a greater number of best practices for specific populations such as pregnant women, women with children, and diverse populations. Generally, issues related to the lack of evidence for diverse populations are concerning, and some SSA representatives noted conflicting ideas about how to address the lack of EBPs for specific populations.
A majority of SSA representatives reported use of regulations and accreditation to promote implementation of EBPs. However the interview question, “Are there regulations or accreditation strategies in place that support the use of EBPs?,” did not specify agency-level regulations (licensure standards, rules of practice) versus provider-level regulations (counselor credentialing). Additionally some SSA representatives interpreted the question as a duplicate of the contracting question, “Is the use of EBPs a criterion in contracting with providers?” Mixed interpretations of these two interview items complicated attempts to compare qualitative responses to related state activities. In interview protocol design, the regulations question was intended to capture both agency- and provider-level data. Phase 2 will address regulations and accreditations in more detailed interviews.
Promisingly, almost all of the SSA representatives reported additional activities designed to facilitate EBP adoption. The most commonly reported activites were provider training, workshops, federal and private grants, and data system updates. Some SSAs are actively pursuing EBP implementation despite not having sufficient resources (funding or staff). This advocacy for EBPs in substance abuse treatment is key to successful adoption and fidelity.48,49
Indeed, a particularly important barrier to the implementation of EBPs are unsupportive state, local, and federal mental health authority administrative practices and policies.15
The most prevalent examples are lack of a long-term vision, lack of agreement on desired outcomes, lack of penalties for non-evidenced-based practices, short-term horizons for policy planning, political mandates on competing public-sector priorities, resource limitations, and uncertainty associated with change and untoward events.50
Phase 2 of this project will identify SSA-specific barriers to EBP implementation.
Overall, the current findings indicate that leadership plays a crucial role in effective implementation of EBPs at the SSA level. Leaders have multiple means to communicate the commitment to EBPs, including a commitment of resources, mission statements, and internal and external collaborations. 19,51,52
Various methods SSA policymakers can use to promulgate their expectations include state-provider contracts, design of RFPs and grant funding decisions, licensing regulations, quality improvement plans, and media dissemination (e.g., newsletters, reports, press releases, and presentations).15,52
Of course, these efforts are dependent on appropriate financial support. Therefore, state effort and strategies to increase adoption of EBPs are encouraging, but without attention to key issues such as financing, implementation possibilities may be minimized.
The current project's preliminary data collection format, which primarily inquired about the five EBP adoption strategies endorsed by the National Quality forum, provided a useful structure for discussion of this topic. However, it is possible that additional information on related but separate implementation efforts was not obtained. Phase 2 of this study will compliment this report with a broad spectrum of in-depth qualitative data, including additional description of multiple activities employed in states representative of more intensive efforts aimed at adopting and implementing EBPs. Documentation of actual state efforts and review of legislative mandates, contract language, and SSA websites will provide additional material to augment the reports of those interviewed for the project. Additionally, it should be noted that each response in this study is one person's report and the job title/description of respondents did vary. However, each respondent's role included the professional capability to represent the state substance abuse authority regarding the state's promotion of EBPs. Due to different job descriptions and titles, as well as varied hierarchical arrangements for each state office, in some cases, the SSA director or deputy director was best suited to address these issues; in other states, a program manager for treatment services was most knowledgeable about EBPs. Therefore, responses reflected the current organizational leadership's approach to EBPs within the confines of available resources. Finally, while this initial project phase provides a snapshot of SSA approaches to adopting EBPs for substance abuse treatment, commentary on the perceived value or effectiveness of a given EBP for substance abuse treatment or respective approaches to adoption are addressed in phase 2.
Implications for Behavioral Health
While specific strategies differ, reports from representatives of state substance abuse authorities (SSAs) offer an entry point into state efforts toward implementing EBPs for substance abuse treatment. Data and qualitative comments indicated that every state in the study is either (a) implementing steps toward policy (e.g., through workgroups, incorporating licensure standards, and planning system change), (b) requiring EBP use in some special program contracts including prevention but not in treatment, (c) utilizing contracts or department policies to encourage EBP use in treatment, or (d) requiring EBP use in contract language. These results offer the opportunity to track the number of states engaged in NQF-supported practices and changes in state contracting and EBP acceleration efforts over time. State agencies, substance abuse treatment providers, and policymakers can benefit from knowing how other states nationwide have responded to the call for increased substance abuse treatment EBP adoption and fidelity. Knowledge of SSA implementation strategies should facilitate opportunities for states seeking to increase their EBP adoption efforts. Such assistance supports prioritization of research-based, client-focused practices for substance abuse treatment.