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Practice Guidelines in the Addictions: Recent Developments

Although practice guidelines have been in use for over 50 years to assist physicians in making efficacious decisions, the last decade has seen physician and other professional organizations become increasingly involved in the development of specific practice guidelines. In 1990, 26 physician organizations were responsible for creating more than 700 guidelines; by 1992, 45 organizations had created approximately 1,500 guidelines. More recent efforts to develop guidelines for the treatment of substance abuse and related disorders are consistent with these trends to provide increasing support of standardization in health care service delivery. Because professionals and laypersons have increasingly recognized the ubiquity of substance abuse disorders and their consequences, there has become a wider perceived need to systematize treatments for addictive disorders.

The authors of this 1995 article list several other reasons for continued development of substance abuse treatment-specific guidelines: (1) Considerable uncertainty prevails regarding the selection of appropriate treatments for substance-dependent patients with different clinical presentations; (2) current treatment practices are varied-some that are particularly effective are rarely used, and some that are not effective are in widespread use; (3) there is much debate about basic clinical determinations (e.g., optimal treatment settings and modalities or combinations thereof for different patient subpopulations); and (4) there is a growing impetus to match specific and appropriate treatments to patients' specific clinical presentations and individual needs. The authors describe the addiction treatment guidelines available as of 1995 as varied in scope and quality, with many narrow in focus and poorly operationalized. Most of the published guidelines for treating substance abuse at that time were not consensus products.

The authors review some of the major institutional and disciplinary efforts to develop guidelines for treating addictive disorders that incorporate data derived from extensive literature reviews and perspectives of expert panels and reviewers, describe related consensus-building activities, and discuss the potential effects of practice guidelines and consensus-building activities. In their research for this article, the authors collected information through personal interviews and computerized bibliographic literature searches; approximately 16 key terms/phrases were used in the literature search. The authors examined 200 of the resulting citations. Specific reviews of developed guidelines, guidelines in progress, and related consensus-building activities are given for the following organizations: the American Psychiatric Association (APA), the American Society of Addiction Medicine (ASAM), the American Psychological Association, the American Nurses Association (ANA), the National Organization of Social Workers (NASW), and the Center for Substance Abuse Treatment (CSAT). Also briefly described are some international efforts to develop addictions treatment guidelines. For APA, the authors provide a detailed description of the organization's substance dependence treatment guideline, which was being developed using a protocol similar to the one used for APA's eating disorders and depression guidelines. In addition, the authors describe a lengthy report of the APA's Task Force on Psychiatric Services for Addicted Patients and efforts to develop admission, continued stay, and discharge criteria for use in evaluating acute, rehabilitation, and partial hospitalization levels of care treatment recommendations for patients with substance abuse disorders. For ASAM, the authors describe the organization's 1991 publication Patient Placement Criteria for the Treatment of Psychoactive Substance Use Disorders. Although the American Psychological Association had not as of 1995 developed specific substance dependence treatment guidelines, the authors mention the practice guidelines developed by the Committee on Alcoholism, Substance Abuse, and Other Addictions of the New York State Psychological Association, which at that time was the American Psychological Association's de facto practice guideline. As the authors state, the utility of this guideline is "diminished by the poorly operationalized and empirically unsupported nature of the diagnostic and treatment recommendations." Several nursing standards for the treatment and aftercare of substance-dependent patients produced by the ANA are reviewed and critiqued. The authors briefly mention the NASW's efforts to pilot addiction treatment training modules for distribution to U.S. graduate schools of social work. CSAT's Treatment Improvement Protocols (TIPs) are listed, and the TIPS process is described. The authors advise that, because guidelines are unlikely to change treatment practices and improve patient outcomes unless they are adequately disseminated, research should be performed to assess the extent to which providers are aware of, and implement, the TIPs.

Because contemporary health care policy and research have become increasingly concerned with assessment and accountability in the service of improved patient outcomes, the authors devote a section to clinical performance and outcomes assessment (what has been described as the "third revolution" in medical care). In this section, alcohol and drug outcomes assessment modules developed by the Center for Mental Healthcare Research of the University of Arkansas for Medical Sciences, in association with the Health Outcomes Institutes (Bloomington, Minnesota), are briefly reviewed. In conclusion, the authors list and discuss many of the pros and cons of practice guidelines in general and comment on the development of practice guidelines for the treatment of addictions in particular; they also recommend ongoing efforts to evaluate the effects of practice guidelines on patient's outcomes. The article's reference list contains 91 citations.

Proper citation:

Walker RD; Howard MO; Walker PS; Lambert MD; and Suchinsky R. Practice guidelines in the addictions: recent developments. Journal of Substance Abuse Treatment 12(2):63-73;1995.

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Last Updated 11-7-02