Addiction Lives: Paul Roman [Annotated Bibliography]
Key reading from Paul Roman’s body of work and to accompany his Addiction Lives interview. Annotated by the author.
1.Roman, P. M. (2014). Alcohol Studies and Science: Trapped In the Velvet Cage of Medical Research? An Editorial. Journal of Studies on Alcohol and Drugs, Supplement 17: 125-132.
Published as an “editorial” written by someone who was not and never had been on the journal’s Editorial Board, this invited piece proved troublesome in the gatekeeping process but partly made it through because of this supposedly neutralizing label. I took the opportunity to express a number of dissatisfactions with the alcohol field as well as the broader addictions enterprise. Included among these concerns, which I of course still see as legitimate, are the absence of any kind of central authority that prioritizes a broad range of research that will improve treatment. An example is used of the absence of detailed studies as to where clinicians, particularly in primary care, should and should not be using medication-assisted treatment. As a bit of a fluke, this manuscript is in the “Supplement” series of the Journal, which for complicated reasons seems to result in its content articles becoming to a degree scholarly orphans, since the publication is neither a book/monograph or a journal.
- Fields, D., Knudsen, H. K., & Roman, P. M. (2015). Implementation of Network for the Improvement of Addiction Treatment (NIATX) Processes in Substance Use Disorder Treatment Centers.. The Journal of Behavioral Health Services & Research. Doi:10.1007/S11414-015-9466-7
One of the streams of research that I pursued was examination of the management of substance use disorder treatment as a central part of health services research. This particular analysis focuses on a uniquely important set of strategies developed by Dave Gustafson and his team at the University of Wisconsin. Use of these strategies took most treatment centers into new arenas of understanding where they could see how their management practices and procedures were major pitfalls to treatment success, totally independent of clinical excellence or intensity of care. Importantly, these researchers are based in industrial engineering, not management research. A similar thread of promoting the involvement of I/O psychology and organizational behavior to “addiction health services research” was pursued by NIDA’s Tom Hilton, but breaking the barriers into previously uninvolved research specialties has proven very difficult. Research on management of substance abuse treatment remains to be meaningfully developed.
3a. Knudsen, H. K., & Roman, P. M. (2014). The Transition to Medication Adoption In Publicly Funded Substance Use Disorder Treatment Programs: Organizational Structure, Culture, And Resources. Journal of Studies on Alcohol and Drugs, 75(3), 476-485.
3b. Knudsen, H. K., & Roman, P. M. (2016). Service Delivery and Pharmacotherapy for Alcohol Use Disorder in the Era of Health Reform: Data from a National Sample of Treatment Organizations. Substance Abuse, 37(1), 230-237. Doi:10.1080/08897077.2015.102869
A large part of our research emphasis had been on the adoption and implementation of medication assisted treatment (MAT). This was an ideal context for studying an organizational innovation because was distinctive and required other organizational changes. The findings seem to be sustained over time, namely that roughly 40 percent of substance use disorder treatment programs will adopt and consistently utilize MAT. This seems to be a “plateau” figure and of course varies by the definition of adoption and use that is applied. From the perspective of the research evidence that we accumulated, it is unfortunate that it is now normative to “condemn” programs that do not use MAT, or do not use it broadly. Caricaturing such programs are primitive or locked in some kind of blind tradition is simply wrong. Our data indicated that centers had their own clear reasons for not using MAT, much of which centered around employing adequate medical personnel, and equally strongly, being committed to a certain organizational culture of treatment. These cultures are not identical such that one can easily describe an MAT and a non-MAT culture. Some proponents of MAT ignore the data about MAT effectiveness, and come close to claiming that refusing to offer it is malpractice. Also unfortunate is the publicity which views MAT as a uniform, single entity when in fact the applications and actions of the medications are very different. This of course is not meant to deny the efficacy of MAT and the impact it has had on many who might not have otherwise recovered, but from the experience of talking to a great many program administrators, it is not the magic bullet that some seem to imagine.
- Edmond, M. B., Aletraris, L., Paino, M., & Roman, P. M. (2015). Treatment Strategy Profiles in Substance Use Disorder Treatment Programs: A Latent Class Analysis. Drug and Alcohol Dependence, 153, 109-115. Doi:10.1016/J.Drugalcdep.2015.05.047
I look back with pleasure on this piece because of the process that went into its development. I was privileged to be working with these three outstanding young scholars. Our goal was to put into perspective the incredibly publicized but shop-worn belief that most treatment for substance use disorders was based on 12-step programming. The findings here show how 12-step concepts are woven into treatment strategies rather than driving them, demonstrating creativity and high clinical sensitivity within many treatment programs rather than some kind of blind lock-step conformity to 12-step principles. We made a mistake in not highlighting that theme in the title of the article, as we had planned to pursue these exciting findings in further papers that are yet to be written.
5a. Dye, M. H., Ducharme, L. J., Johnson, J. A., Knudsen, H. K., & Roman, P. M. (2009). Modified Therapeutic Communities and Adherence to Traditional Elements. Journal of Psychoactive Drugs, 41(3), 275-283.
5b. Dye, M. H., Roman, P. M., Knudsen, H. K., & Johnson, J. A. (2012). The Availability of Integrated Care in a National Sample of Therapeutic Communities. The Journal of Behavioral Health Services & Research, 39, 17-27.
In about 2000, I received an in-depth exposure to the current state of therapeutic communities in the US. At a conference, I overheard a comment, “TCs have really just come out of the closet.” Their image bears a heavy burden with the well-known stories of the scandals of Synanon, and some of TC terminology has multiple and confusing definitions. The TC intervention logic is particularly compelling when linked with clients who have failed in other treatments and are motivated toward a different form of life. We were fortunate to be funded to study a national sample of self-defined TCs, and found that the “classic” model associated with George DeLeon’s textbook had been altered in all sorts of directions. The main source came from efforts by TCs to “mainstream” and become qualified for public monies as well as health insurance payments. This led to “professionalism” which had a mainly negative effect on preserving TC traditions, as well as introducing elements which do not fit. Sadly, some noted “experts” misused these traditions to mock TCs and promote their own alternatives. Similar attempts to stabilize TC caseloads and income through referral connections with the criminal justice system have had equally problematic effects by introducing clients under compulsion with no particular motivation to actively participate in the program.
6a. Abraham, A. J., Knudsen, H. K., & Roman, P. M. (2014). The Relationship between Clinical Trial Network Protocol Involvement and Quality of Substance Use Disorder Treatment. Journal of Substance Abuse Treatment, 46(2), 232-237. Doi:10.1016/J.Jsat.2013.08.021
6b. Roman, P. M., Abraham, A., Laschober, T. C., & Knudsen, H. K. (2010). A Longitudinal Study Of Organizational Formation, Innovation Adoption, And Dissemination Activities Within The Clinical Trials Network Of The National Institute On Drug Abuse. Journal Of Substance Abuse Treatment, 38(Suppl. 1), S44-S52.
I was fortunate to receive 10 years of funding from NIDA to conduct a study of the Clinical Trials Network (CTN) that NIDA had formed to use RCTs to jump-start and then sustain the development of new evidence-based treatment practices as well as refining established practices. Since there are no comparable networks addressing other behavior disorders, it is difficult to measure the success of this effort. Our study’s basic aim was to compare the implementation of evidence-based practices among treatment centers inside and outside the network, and indeed CTN membership was clearly associated with greater adoption behavior, although the differences were not as dramatic as one might expect. Two observations that became clearly formed over time were, first, the benefits that accrued to treatment programs through CTN membership that brought them into both a strong community as well as into CTN sub-communities that enhanced overall morale considerably. Our national surveys of treatment programs have repeatedly shown their isolation from each other and the general sense of “normlessness” exacerbated by high counselor turnover and funding insecurities. These result in turn from an external organizational environment riddled with unpredictable and often irrational changes in funding and procedures, in turn resulting from the political and non-professional penetration into US treatment rule-making and resource distribution. CTN membership and participation (the former did not assure the latter) buffered these morale-grinding features of working in substance use disorder treatment. The second observation was observing the failure of “democratic science” that was attempted in the CTN through an initial declaration that researchers and treatment providers would be almost rigidly equal in determining which clinical trials would be launched. While themes of such “participatory democracy” seem to prevail in many quarters of healthcare today, the CTN experience suggests that there needs to be more attention to stubborn impediments that evolve when diversity and equity issues become the pivots for decision-making, invariably blocking compromise with conflict.
- Roman, P. M. (1981). From Employee Alcoholism to Employee Assistance: De-Emphasis on Prevention and Alcohol Problems in Work Based Programs. Journal of Studies on Alcohol, 42, 244-272.
I worked long and hard through several revisions of this piece while alone through a winter sabbatical in a North Carolina beach house. It turned out to be more prescient than I had expected in that I essentially predicted the loss of alcohol problem emphasis within EAPs. One of the themes, which would be seen as almost totally obscure today, was that effectively implemented EAPs had the potential for truly “early” intervention in the process of alcohol addiction, and that such practices could sharply eliminate the extent of need for treatment. This harked back to my 1968 piece (see below) suggesting the potential adverse effects of workplace treatment utilization. This thinking was against the grain of those in the EAP occupation who saw EAPs as a way to increase treatment utilization, and possibly improve the quality of treatment through the influence of expectations of hard-nosed workplace-based clinicians. Further, there is no doubt that the engine behind NIAAA’s early promotion of EAPs was to increase treatment utilization.
- Trice, H. M. & Roman, P. M. (1970). Delabeling, Relabeling, and Alcoholics Anonymous. Social Problems, 17, 538-546.
Another old piece which has been influential as a frequent inclusion in discussions of labeling theory, this was drafted when I was still a grad student, and I regret a bit that Harry Trice ended up as first author on the basis of a coin toss. While the subject of a huge number of publications, labeling theory has no single authoritative articulation upon which an evaluation of evidence can be carried out. In this paper we were looking at the “end point” of the theory’s proposed sequential process, namely where culturally-charged labels are permanent and may “ruin” one’s life. AA seems an example of capitalizing on labeling rather than avoiding it. Whereas many if not most treatments emphasize one’s essential “normality” as the process begins, AA emphasizes one’s essential difference, albeit a single difference of not being able to drink in a controlled fashion like others. Moving through the Steps is a sequential building of a new label, once being recovered alcoholic and now being “recovering” (and more stigmatized) alcoholic. This “re-label” replaces (or revises) the prior label of active alcoholic and through image management by both AA and the individual, the new label may have positive and even status-enhancing features.
- Roman, P. M., & Trice, H. M. (1968). The Sick Role, Labeling Theory, and the Deviant Drinker. International Journal of Social Psychiatry, 14, 245-251.
This very old paper was written while I was a grad student very much enamored by “labeling theory” (and still believe in its explanatory power if it is measured properly). At the time, Harry Trice and I really were thinking of workplace programs as true “secondary prevention” rather than their being part of a pipeline to treatment. The basic idea is that job-based intervention and the implied threat of job security can create a personal crisis for a chronic heavy drinker and lead to behavior change without treatment. Treatment is viewed negatively in this piece and as a possible avenue to what sociologist Edwin Lemert called secondary deviance, where any form of socially-defined aberrant behavior can come to be driven primarily by one’s self concept rather than by external etiological forces. This was written well before the founding of NIAAA, and it is evident that the workplace intervention campaign never took the direction that is suggested here because its major intent was to “grow” alcoholism treatment.