A groundbreaking research collaboration

The fields of medicine and addiction treatment are both moving toward evidence-based practice. This approach is focused on determining what interventions work best for whom under what conditions, in order to improve treatment effectiveness and efficiency. In accordance with this approach, in 2007 the Hanley Center in West Palm Beach, Fla., embarked on a five-year collaborative clinical research program. The Hanley Center serves as the lead agency for this effort.

The Hanley Center is a private nonprofit 82-bed residential substance abuse treatment facility. It has gender-specific and age-separate treatment programs for men, women, boomers and older adults. Comprehensive assessment and services are provided based on an eclectic model including medical, 12-Step, cognitive-behavioral and spiritual approaches delivered in individual, family and small-group modalities.

The three collaborative partners are the Comprehensive Drug Research Center of the University of Miami Miller School of Medicine Department of Epidemiology and Public Health; the Palm Beach County Health Department, a public entity focusing on health and disease prevention; and the Scripps Research Institute-Florida, a private nonprofit research center focusing on biomedical research. The collaboration came about through the confluence of individuals and groups within each institution who were interested in advancing the knowledge base on substance abuse treatment.

The long-term vision of the project is to create a pioneering consortium of public and private institutions that seeks to position itself as an innovator, incubator and proving ground for promising new protocols and treatments. The focus will be on implementing long-term outcome research that validates treatment effectiveness. The specific aims of the collaborative are to:

• Establish an ongoing recovery consortium of key stakeholders organized to conduct ongoing outcome research;

• Validate new protocols and treatments;

• Identify promising new areas for research;

• Serve as an incubator for promising approaches to advance addiction treatment and medicine;

• Have a synergistic effect on regional and national policy development by involving all key recovery stakeholders;

• Validate local and regional pilot programs; and

• Serve as a “go-to” resource for outcome research.

The five-year plan addresses the following research objectives:

1. Define recovery and its associated outcomes.

2. Describe and analyze gender-specific and older adult-specific interventions utilized at the Hanley Center.

3. Determine the effectiveness of treatment delivered at the Hanley Center.

4. Explore the influence of hormonal shifts on treatment success and survival.

5. Explore the role of chronic pain, where goals of abstinence and harm reduction intersect.

To date, objectives 1 and 2 have been achieved; these and each of the others are briefly described below.

Defining recovery

As a first step in the research process it was necessary to develop an operational definition of “recovery” to be used in the subsequent treatment effectiveness studies. Even though existing literature strives to define recovery, there is no one clear industry standard. Thus, the primary objective of this first leg of the Hanley Center's journey was to articulate clearly the domains that comprise the construct of chemical dependency recovery.

This was done through use of a grounded theory, participatory research design to inductively construct a definition of recovery from the perspectives of addiction treatment professionals. There were 10 participants in this process. Seven were managers of their respective disciplines at the Hanley Center (medicine, psychiatry, psychology, clinical therapy, social/emotional wellness, family/community and spirituality). Additionally, three researchers with expertise in addiction, research methodology and neuroscience lent their empirically centered guidance to the process. Some of these participants were in recovery themselves. Participants included both men and women, all had a master's or doctorate degree in their discipline, and most had worked in the substance abuse field for more than 10 years.

The participants convened in panel discussions at the Hanley Center over a period of one year to review literature, review the instruments used to collect data from Hanley clients, discuss practice observations and experiences, and derive findings in a prioritization process to define recovery and to select measures to indicate the attainment of recovery. The researchers encouraged the practitioners to inductively construct domains from the ground up to represent dimensions of recovery. Their responses were then merged with the existing literature to determine overlaps of concepts and to reconcile differences in order to formulate a collective operational definition of recovery and to select instruments that measure it.

The panel review process led to the conclusion that a single industry-wide definition of recovery did not exist and that the multiple definitions that did exist were usually subjective and open for interpretation, often appearing more ideological than scientific. As a result, the panel inductively constructed seven domains that represent aspects, and are sensitive to status, of recovery: medical, bio-marker, chemical dependency, psychological, psychiatric, family/social, and spiritual. The panel further identified measurable indicators for each domain, including psychometric, biological and spiritual measures.

Describing interventions

The first attempt to do this occurred empirically through factor analysis, a statistical procedure that identifies commonalities among items. This in fact revealed that there were no correlations among the 1,250 interventions. In other words, each intervention was used on an individual case-by-case basis; interventions were not used in a “packaged” format. This validated the Hanley Center's philosophical approach of applying individualized treatment for each client.

Since the interventions were not statistically correlated, they were grouped conceptually. This was done by having two researchers review each intervention and identify a larger category to which it belonged. This process resulted in the identification and classification of 15 therapeutic categories, such as cognitive-behavioral, 12-Step, social skills training, family therapy, and so forth. Analysis of these categories across the different treatment units at Hanley (i.e., men's, women's and older adults), indicating differential use of the therapeutic methods, validated Hanley's philosophical approach of gender-specific and age-specific treatment.

The remaining objectives

The next step in the collaborative research agenda will be to evaluate the Hanley model of recovery. Patient assessments and outcome measures are being collected over time as patients proceed through the continuum of care. Data are collected at admission, 30 days, 90 days, 180 days, 270 days and 360 days using the instruments identified earlier as indicators of recovery. A relational database that contains intervention and treatment outcome data for each client has been developed. The ultimate outcome of this process will be to identify which patient characteristics and intervention categories are predictive of successful treatment outcome.

Regarding the issue of hormonal shifts, anecdotal evidence indicates that substance abuse relapse may be triggered by shifts in levels of hormones such as estrogen and progesterone in women, testosterone in men, and cortisol in both genders. The Hanley Center is collecting hormonal data and will examine whether there is an empirical association between these variables and treatment outcome.

Finally, on the subject of pain management, the fine line between effective pain management and prescription medication addiction has been underexplored to date. This is a particularly salient issue among older patients. The Hanley Center collaborative will address relevant issues such as the following: What are the treatment protocols to address chronic pain as a co-occurring condition with substance abuse? How can these issues be integrated to produce recovery? What treatments might bridge the dichotomy between abstinence and harm reduction theories of intervention?

Implications for practice

The Hanley Center's research collaborative bears two primary implications for practitioners and programs elsewhere. First, this collaborative can serve as a model for other institutions that wish to incorporate an evidence-based perspective into their treatment approach.

Second, the forthcoming findings from this research program will contribute to the ongoing effort to identify effective, targeted interventions for the diverse population of individuals with substance use problems.