Seven core principles can help substance use treatment systems focus on high-level goals

Lead study author Brian Rush, Ph.D., Scientist Emeritus at the Centre for Addiction and Mental Health in Toronto, says that, over the last 10 to 15 years, he has often been invited to do a system-wide review and to let those responsible for the overall network of services know how it is performing with respect to substance abuse: Is the system meeting the needs of the population? Are there gaps in the programs being offered? Are they evidence based?

"It's obviously different from a program review, which is for one particular organization," says Rush. "We're looking at the whole community network of services."

The seven principles are meant to serve as a template for system analysis, and they provide such recommendations as "a range of systems supports are needed to support and facilitate the effective delivery of services" and "attention to diversity and social-structural disadvantages is crucial to ensuring effective and equitable system design and service delivery."

Rush highlights two principles that stand out to him as most crucial. The first is the need for collaboration between the different sectors that are stakeholders in the process, including mental health services, addiction medicine doctors, primary care physicians, corrections, education -- all under the umbrella term of "a whole government response" or "whole of society."

"The biggest takeaway here is that the need in the population for alcohol and drug services is so high that the specialized alcohol and drug services alone cannot meet that need," says Rush. "They need a strong collaborative partnership with the other sectors."

He also points to the principle of the population-level approach.

"Many people with alcohol and drug problems have very serious problems, such as opioid or substance abuse combined with schizophrenia or depression, and this is a segment of the population that experiences quite serious challenges," says Rush. "But there's a larger percentage of the population who are just beginning to experience these challenges. If we don't also provide some services to these people, then they may be on a trajectory that's a far more serious and more expensive problem to help resolve. Policymakers funding programs are often responding to a crisis: Who's in the emergency room? Who's taking up hospital beds? But the fewest people at the top of the population health pyramid are the ones who cost the most. They came from somewhere, and they didn't wake up overnight as an addict in the hospital."

Rush says that although treatment system planners and funders are often looking to improve, sometimes it's hard for them to make the big decisions.

"The addiction field, more so than many other areas of health, is dominated by very strong opinions," says Rush. "It's also a marketplace for private enterprise versus public services, as well as a place where people have very strong personal experience with addiction. Depending on who that person is, they can have a very strong influence on policymakers. A principles-based methodology levels the playing field for people advocating for resources and asks them to take a very evidence-based approach in reviewing systems and making recommendations."

Rush says that although the researchers and some of the reviews are based in Canada, the findings are universal.

"We have a lot of experience with the World Health Organization and other important organizations involved in setting substance abuse treatment standards and guidelines, and a large percentage of the research we have drawn upon has been published by U.S. researchers," says Rush. "The principles draw upon our experience in consultation around the world."