Too often, wide gaps separate substance abuse researchers, policymakers, and treatment providers, said Mady Chalk, Ph.D., director of the Office of Managed Care at the federal Center for Substance Abuse Treatment (CSAT).

"Either treatment research is not relevant to practitioner needs or research findings are simply not being implemented," Chalk observed at a conference sponsored by CSAT’s Advisory Council last month in Bethesda, Md.

"We’ve finished working on the general-principles level," agreed Alan Leshner, Ph.D., director of the National Institute on Drug Abuse, speaking specifically about substance abuse prevention. He noted, however, that his remarks applied to treatment research as well.

"Now we have to see what works for whom under what circumstances. The local context must be assessed and then programs modified to fit," he said.

Typically, said Chalk, community-based groups have to tell researchers that the kind of research they are proposing to do with, or for, the providers does not meet their needs. "This is one problem we as a field have not solved."

As an example, Chalk cited the case of clinicians in New York State who are seeking "best practices" for retaining patients in treatment programs. A federal official told them that research on retention was "inadequate." This, said the providers, was exactly the point—that the research they needed to solve their problem did not exist.

In an effort to bridge this gap, late in 1999 the Office of Managed Care funded a series of nine practice research collaboratives (PRCs). Their goal, said Chalk, is to create an infrastructure for community-based treatment research studies that are relevant to local provider needs. The grant program grew out of an Institute of Medicine report, "Partnerships for a Changing Environment," for which CSAT was the prime funder and which Chalk directed.

"The idea," said Chalk, "was to motivate local providers by asking research questions they’re interested in."

Nine one-year grants were awarded: one each in Iowa, California, Louisiana, Georgia, New York, Florida, and Arizona and two in Portland, Ore., one of which will be specifically focused on Native Americans. The initial grants will serve to establish networks, assess needs, set knowledge development and application agendas, study how to apply and disseminate knowledge, and devise a three-year implementation plan. The implementation grants will be limited to the existing grantees, said Frances Cotter, a social science analyst with the Office of Managed Care.

The research agenda will thus originate from the ground up, said Chalk, not the top down. The program will help these treatment providers define their organizational and clinical research needs, then develop these ideas so they can be full partners in conducting the research. In subsequent stages of the program, the PRCs will develop additional sources of funds to adapt evidence-based findings and test them so they can be incorporated into treatment programs.

"We’re looking at local collaborations between researchers and providers and their stakeholders, to develop their own agendas," she said. It will not be an overnight process. "Five years will just be a beginning."

The PRC program has only just begun, but the collaboratives are holding stakeholder meetings to establish the range and priority of questions they feel need to be addressed in their regions. For instance, a statewide PRC in Oregon wants to assess strategies for staff training that affect the relationship between staff and client turnover. They want to compare chronic versus acute episodic models of care, and ways of maintaining relationships with clients and continuity of care following discharge. They also want to compare single with multiple modalities in treatment. Each PRC must also develop means to disseminate the results of the research.

At the same time, said Leshner, NIDA research was continuing on the national level in several areas of ultimate interest to treatment providers.

"We’ve come a long way in replacing ideology with science," he said.

NIDA-funded researchers are looking at how genes and environment interact in addiction to nicotine, cocaine, heroin, and codeine. Population genetic studies are under way to identify which genes render people more susceptible to addiction but not, he emphasized, to see whether some people are genetically more vulnerable.

Others were looking at biochemical mechanisms—like dopamine D2 receptors in the striatum region of the brain—which might make people more or less prone to addiction. For instance, one team noted a different response in PET scans of the brains of people who found pleasure in methylphenidate (a mild stimulant) compared with those who found it unpleasant.

Leshner noted an area of direct application to the treatment community lay in the undefined boundary area between being a drug user and being an addict. "This is clearly a qualitatively different state behaviorally," he said. "We don’t know if it is continuous or discontinuous, but if we could understand it, we could intervene at that stage and avoid many problems."

The real-world relationship between drug abuse and infectious diseases also worries Leshner. "We know a lot about the long-term use of alcohol but not much about the long-term medical consequences of drug abuse, especially when combined with infectious diseases—AIDS, hepatitis C, or tuberculosis," he said. "What happens to the body over that time? What happens when a patient is taking prescription medications and is on heroin?"

Finally, he noted that primate research has shown that the effects on cognate functions of "club drugs" linger for months after use is stopped, and the effect on dopamine transporters may last as long as two years. There are ongoing Phase II/III trials for four new drugs designed to counter methamphetamine.