Slogging through another LinkedIn discussion on the claim that “90% of treatment centers do not use Evidence Based Practices (EBPs)”…

I’m skeptical about the claim because without exception the centers I’ve worked with over the past few years (6 of them, in 4 states) all used EBPs. It might be true that 90% do not use EBPs exclusively, but use other interventions beside them. Which to me makes perfect sense because some of the most helpful resources for any treatment professional– fellowships like the 12 Step movement and others–  aren’t considered EBPs. Or for that matter, treatment at all. They’re supports for recovery. And a whole lot of recovering folks rely on them.

I’m reminded that ‘EBP’ simply means an approach or treatment has a basis in well-designed, well-conducted research– research that found it useful versus no treatment. Of course, it’s true that something that appears to work in the structured, supportive environment of a university research project may not be best approach for an outpatient clinic in Opa-Locka. This is why we take the trouble to differentiate between ‘efficacy’ in research and ‘effectiveness’ in practice.

In practical terms, when a clinician uses an EBP, she’s reassuring herself that it’s likely to be more helpful than if she sat on her hands and did nothing. Nice to know, but a long way from a guarantee of success.

As an aside, I’ve also read that fewer than half the treatments used by doctors in all fields of medicine would qualify as ‘evidence-based’. Instead, they reflect the doctor’s beliefs, training, and experience. And most of them are helpful, which is why physicians tend to keep using them.

David Sackett, who’s written extensively on the subject of EBPs in medicine, said this:

“Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannized by external evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best external evidence, practice risks becoming rapidly out of date, to the detriment of patients. “

He was addressing perinatology (maternal-fetal medicine), but the lesson holds.

I’m also advised that more than 900,000 medical research studies were done last year. Such a vast volume that I’m not sure how we could reliably separate good from less good from (quite frankly) not good at all. John Ioannidis used a complex mathematical formula of his devising to assert that about half of these studies are bound to be wrong. That’s not helped by the advent of easy-to-access Internet science journals that skip the traditional peer-review process. No wonder we feel deluged with questionable, often contradictory findings.

Not surprisingly to me, the loudest critics of conventional addiction treatment are pushing more reliance on medication-assisted approaches. Those range from opioid substitutes like methadone and buprenorphine to naltrexone injections or implants and on to anti-craving meds and even disulfiram. They’re all evidence-based and since the entire healthcare field is designed to rely on medications to treat disorders, it naturally looks in that direction for addiction treatment, too. After all, addiction is a disease and doctors are trained to treat diseases, so it seems like a natural fit, until you realize that the track record of the medical profession with addiction is not so good. For instance, the reason we are suffering through a prescription drug epidemic is because doctors became convinced (wrongly) that more potent opioid meds were not as dangerous as they turned out to be. All along other doctors who were experienced with addictions warned them of their mistake, but they didn’t listen.

Lots of them don’t listen now, either, when they’re warned about Suboxone or methadone.