A drugs worker told me a few years back that he would never refer a patient to a recovery service on the basis that he would not be following the evidence base. I did ask him at the time ‘but what if that’s not what the client wants?’ It seemed the evidence base came first. In any case, there is evidence around recovery – it has gaps because few are doing the research work – but it is there as the Scottish Government commissioned Research for Recovery publication showed. We know quite a bit already, though we need to know more.
I read a paper in the British Medical Journal this week about the potential shortcomings of practising evidence-based medicine (EBM). Some are saying that there is a ‘serious crisis.’ On one hand, the benefits are well known and documented across a range of conditions, but the challenges of EBM are not generally much discussed. In the article they are listed as:
- Vested interests using EBV for their advantage (think Big Pharma who invent ‘new diseases’ then ‘evidence’ drugs that help and go on to make profits. Or who heavily market drugs that may have little clinical impact. Pharmaceutical companies may hide poor results. One study looking at trials of antidepressants found that 37 out of 38 with positive findings were published, but only 14 out of 36 with negative findings found their way to journals.
- Too much evidence. Those working in clinical services are drowning in guidelines.
- Marginal gains. How a significant improvement shown in a trial translates into everyday life for a patient is variable.
- Overemphasis on following rules and algorithms.
- Poor fit for those with multiple health problems
Evidence based tail wagging the clinical dog
What came to mind immediately for me were the benefits and deficiencies of opioid replacement therapy. As a population approach, there is good evidence for widespread use of methadone and buprenorphine to reduce harms. There is less evidence that they help clients achieve their goals on an individual level – especially when those goals are abstinence based.
In the BMJ paper, using statins as an example the authors make a powerful point:
The 74 year old who is put on a high dose statin because the clinician applies a fragment of a guideline uncritically and who, as a result, develops muscle pains that interfere with her hobbies and ability to exercise, is a good example of the evidence based tail wagging the clinical dog.
Following guidelines in a non-nuanced way may miss what’s important to the person:
In such scenarios, the focus of clinical care shifts insidiously from the patient (this 74 year old woman) to the population subgroup (women aged 70 to 75) and from ends (what is the goal of investigation or treatment in this patient?) to means (how can we ensure that everyone in a defined denominator population is taking statins?)
One of the main criticisms of following treatment rigidly for opiate dependence is that individual needs and goals may not be addressed appropriately. Trying to reduce or moderate deaths through ORT prescribing is a population approach. The more people in treatment on therapeutic doses, the fewer deaths we would hope to see; though at the moment that is an aspiration in Scotland as deaths are not falling, though the reasons for this are complex.
Tensions arise when the individual wants both to avoid death and not lose their gains but wants also to move on from opioid replacement. I know that most practitioners are person centred and will listen carefully to the client’s wishes, but aspiration can undoubtedly be low at times. Again and again clients in these situations report being dissuaded from reducing their prescription on the basis that it would not be safe and they might lose what they have achieved. I’ve certainly been in that position. There are good grounds for caution, but there are also ways to try to moderate risk.
The authors of this paper have some suggestions which might help us loosen up a bit in addiction treatment settings without putting clients in danger. I’ve selected and paraphrased some of these below. You can see the full list here.
Real Evidence Based Medicine
- Demands individualised evidence in a format that clinicians and patients can understand
- Is characterised by expert judgement rather than just following rules mechanically
- Shares decisions with patients through meaningful conversations
- Builds on a strong clinician-patient relationship and the human aspects of care
Delivering on this
- Patients must demand better evidence, better presented, better explained, and applied in a more personalised way
- There should be joint decision making
- The research agenda must become broader and more interdisciplinary, embracing the experience of illness, the psychology of evidence interpretation, the negotiation and sharing of evidence by clinicians and patients, and how to prevent harm from overdiagnosis
I’ve written many times on the importance of informed consent; that clients understand what the evidence says and what ORT does and what it doesn’t do. It’s harder to practise evidence-based interventions that are personalised and nuanced than it is to simply follow guidance that is based on large scale trial evidence and has relatively little room for flexing. I actually don’t think that is what is generally happening, but like Greenhalgh and colleagues, I think we could do better. The BMJ is clear what is needed:
It involves finding out what matters to the patient—what is at stake for them—and making judicious use of professional knowledge and status (to what extent, and in what ways, does this person want to be “empowered”?) and introducing research evidence in a way that informs a dialogue about what best to do, how, and why.
Greenhalgh T, Howick J, Maskrey N, & Evidence Based Medicine Renaissance Group (2014). Evidence based medicine: a movement in crisis? BMJ (Clinical research ed.), 348 PMID: 24927763