The Evidence Based Medicine Manifesto (EBM manifesto) has been launched to improve the implementation of evidence based interventions by pulling together a clear set of achievable goals, and a strong overview of the strategies that work best, to help deliver change better and faster.
In some areas, such as the treatment of illicit drugs related problems, evidence based medicine struggles to be firm. Ideologies, political views, and advocacy agendas complicate the picture. In this area some suggestions from the manifesto also help to address other difficult areas like mental health, obesity, and behavioural-related health problems.
In the treatment of illicit drugs related problems, the EBM approach is taking time to be accepted and implemented. Some of the lessons learnt can contribute to the EBM manifesto.
The evidence base has been formalised through the creation of the Cochrane Drugs and Alcohol Group in 1998 (Davoli 2000). Today using the evidence base has become a requirement in many drugs policy documents at both European and national levels (Ferri and Bo, 2012). This is particularly important in a field where most of the patients in need of publicly financed treatment have a low socioeconomic status and may not be able to demand effective treatments and quality interventions (Galea and Vlahov, 2002).
However, the extensive use of the term: “evidence base” creates potential “side effects,” which are of interest for the EBM manifesto.
Many people from a variety of backgrounds use “evidence base” to mean different things. Evidence is used to justify decisions. Rather than identifying a question, searching for the evidence, and then taking decisions, the process is inverted. First comes the decision, followed by the opportunistic choice of supporting evidence (“cherry picking”).
More commonly there is misunderstanding on what a systematic review actually is. For example, rather than being based on systematic reviews of studies—in agreement with standards set by the Cochrane and Campbell collaborations—recommendations are based on a much simpler narrative synthesis of published reviews. These “reviews of reviews” combine the conclusions of several primary reviews, often irrespective of their quality. In addition, the primary reviews may be based on the same sets of individual studies, resulting in artificially inflated conclusions.
The common confusion between lack of evidence and evidence of non-effectiveness exacerbates defensive rejections of EBM, rather than encouraging advocacy for more investment in research.
Professionals and decision makers are uncertain on how to implement and monitor evidence-based interventions and can be tempted by simplistic approaches.
What change do we want to achieve?
We need a shared understanding of what evidence-based medicine is and how to apply it in everyone’s daily life. We must encourage greater participation of actors: front-line carers, patients, and their families should become EBM knowledge brokers for their peers. This is particularly vital for marginalised patients and for conditions with low research investment. I recommend that projects like the James Lind Alliance should be piloted in more European countries; and projects like Sense the Science should be implemented in all schools in order to increase the numbers of those able to advocate for evidence-based interventions.
What actions are currently underway to achieve this change?
Avoiding research waste by enhancing the availability of timely systematic reviews and targeting research priorities is crucial. We should make these activities and results available across all health conditions and geographical settings. Examples of gap analysis using systematic reviews to engage carers, patients, and families should be replicated (Ferri, 2013).
What new actions do you think would achieve this outcome better?
We need investment in promoting partnerships among decision-makers, health professionals, patients and families in order to identify both knowledge needs and strategies for the dissemination and implementation of evidence.
In the illicit drugs related problems area we should implement a three-step participatory exercise:
- Join resources to carry out an evidence gap analysis;
- Identify feasible research methods (well-conducted observational studies of implementation aspects) and promote it;
- Train the trainers to reproduce successful interventions in different local contexts.
How would we know we had succeeded?
Drug strategies are adopted at European and national level. They typically include the principles that inspire both the policy and the actors involved. In addition they include action plans for implementation.
These documents might be complemented by an interventions matrix where each objective should correspond to a quantitative indicator of success including the independent source of data from where the indicator should come. In case of an evidence gap, the matrix should indicate what action is expected (commissioning research or fostering participation in European Funded initiatives). These matrices could be used to identify progress over the years and to trigger quantifiable change.
Marica Ferri is currently the Head of Sector in best practice, knowledge transfer and economic issues at the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). She is a member of the Cochrane Collaboration and author of a number of systematic reviews. She is also a panellist in the development of evidence-based guidelines and quality standards for the improvement of interventions. She is interested in evidence base developments including methods and implementation studies.
Marica is contributing to this blog in her personal capacity. The ideas here expressed do not necessarily represent the view of the EMCDDA.
Follow Marica on twitter: @marica.ferri
Thank you to Marie-Christine Ashby for her editorial support.
References:
The EBM Manifesto: http://evidencelive.org/manifesto/
Amato L, Mitrova Z, Davoli M; Cochrane Drugs and Alcohol Group (2013)Cochrane systematic reviews in the field of addiction: past and future. J Evid Based Med. 2013 Nov;6(4):221-8. doi: 10.1111/jebm.12067.
Davoli M, Ferri M. The Drugs and Alcohol Cochrane Review Group. Addiction 2000; 95(10): 1473-4
Ferri M, Bo A. Best practice promotion in Europe: A web-based tool for the dissemination of evidence-based demand reduction interventions. Drugs: Education, Prevention and Policy 2013;20(4):331
Ferri M, Davoli M, D’Amico R. Involving patients in setting the research agenda in drug addiction. BMJ. 2013 Jul 16;347:f4513. doi: 10.1136/bmj.f4513. PubMed PMID: 23861429.
Galea S, Vlahov D. Social determinants and the health of drug users: socioeconomic status, homelessness, and incarceration. Public Health Reports. 2002;117(Suppl 1):S135-S145.