Evidence-Based Treatment: What Does It Really Mean?

Evidence-based medicine rose to prominence about 20 years ago as a way to improve quality of care and patient outcomes. Today, evidence-based medicine explicitly integrates clinical expertise with the best available evidence from high-quality, systematic research and patient values.¹ Guidelines for treatment are based on evidence that promotes the use of specific approaches for particular groups of patients.

Evidence-Based Treatment

The concept of evidence-based treatment is newer to addiction medicine than to some other fields, just as addiction medicine itself is a newer discipline in mental health. Medication use and clinical trials have long been part of the treatment of depression and anxiety, for instance, but aside from buprenorphine and naltrexone, few drugs have been tested in randomized clinical trials for use in addiction. Certain forms of psychotherapy for addiction, such as cognitive behavioral therapy and 12-step programs, have been validated in large studies that have demonstrated their effectiveness and utility. However, in some instances, their qualitative nature makes it harder to tease out what specifically works and what does not.

The concept of evidence-based treatment informs the Positive Sobriety handbook, which serves as a primer for patients, staff and trainees. As part of our commitment to using proven treatments, the handbook includes extensive references so that anyone, even a family member, can understand how research literature supports what we do. Families can read studies that underpin our use of medication-assisted treatment, 12-step programs and therapeutic communities.

As part of our commitment, we continue conducting research that expands the knowledge base for addiction treatment. Currently, we are studying personality traits to determine how personality variables can guide treatment planning and affect the success of therapeutic approaches.²

The current study builds on research conducted by the National Institute on Drug Abuse and spearheaded by its director, Nora Volkow, MD. That work indicates there are genetic subtypes that make individuals more vulnerable to addiction. Dr. Volkow and colleagues found that high scores on the characteristics of positive emotionality/extraversion and constraint appear to be protective factors, while their opposites, negative emotionality/neuroticism and constraint-disinhibition, appear to increase vulnerability to addiction.³

Among those diagnosed with a substance use disorder, we are trying to determine if those subtypes correspond to a greater or lesser risk of relapse.

We test individuals when they first arrive at Positive Sobriety and then before patients leave to see whether their personality traits change during the course of treatment. Someone who has, for instance, high scores on neuroticism, extroversion and openness at the beginning of treatment will tend to be moodier, more depressed, less conscientious and more disorganized. Generally, they experience more difficulty achieving their goals. According to literature, these patients have the highest risk for addiction. If we work with these individuals to reduce anxiety, relieve depression and increase conscientiousness, these patients will also develop greater resiliency and a better ability to reach their goals. Does that individualized therapy reduce their risk of relapse? Preliminary evidence indicates it does.

Individuals high in conscientiousness, but low in agreeableness, tend to have trouble getting along with others. They will need different kinds of support in therapy to improve their likelihood of a lasting recovery.

Each person exhibits a unique set of personality traits, just like a thumbprint. Based on how patients score, we target their weaknesses and build on their strengths. After six weeks, some will test a bit more positively, showing greater resilience and goal achievement. Others will stay the same and we will know that addressing the constraining personality traits will be a long-term project. Separating the two tests by six weeks also allows us to determine how much withdrawal and addiction affected the initial state of mind and how much is core personality trait or set point.

We are excited about participating in this research and its potential to help us further refine treatment and improve outcomes for individuals with addictions. We may be at the start of a new age in addiction treatment similar to the breakthrough that occurred when oncology recognized multiple subtypes of cancer and began to develop targeted therapeutics.

REFERENCES:

Evidence-Based Medicine Tutorial. Florida State University College of Medicine. 2016.
Angres DH. The Temperament and Character Inventory in Addiction Treatment. Focus. Spring 2010;VIII:187-198.
Belcher AM, et al. Personality traits and vulnerability or resilience to substance use disorders. Trends Cogn Sci 2014 April;18:211-217.