Category: Change

Research-into-practice: US drugs expert talks in Ballyfermot

program changer


“You can get much farther with a kind word and a gun than you can with a kind word alone.”
Al Capone in the Untouchables (1987)
It’s Friday afternoon, July 6th, and a dozen of eager addiction professionals wait seated in a circle. Some of them come to the Cherry Orchard Hospital each last Friday of the month. It’s the time of their regular journal club. One of them leisurely raises and picks up a slide clicker lying on the desk in front of the room. It’s Professor Dennis McCarty, an expert who dropped by the hospital while on his holidays in Ireland.
Dennis McCarty is a Professor in the Department of Public Health and Preventive Medicine at Oregon Health & Science University in Portland, Oregon ( He is the Co-Principal Investigator for the Western States Node of the National Drug Abuse Treatment Clinical Trials Network (CTN). The CTN tests the implementation of research findings in community treatment programs. Dr McCarty also leads the national evaluation for the Network for Improvement of Addiction Treatment (NIATx); a Robert Wood Johnson Foundation and Centre for Substance Abuse Treatment initiative designed to improve access and retention in alcohol and drug abuse treatment using process and quality improvement techniques. His experience combines policymaking and research. Between 1989 and 1995, Dr McCarty directed the Massachusetts Bureau of Substance Abuse Services for the Massachusetts Department of Public Health. He has a PhD in Social Psychology from the University of Kentucky.
Among the many interesting topics that Dr McCarty covered in his talk was the integration of addiction related care into general practice systems. To change the poor-performing systems, and to provide a better integrated care, NIATX uses a powerful process improvement tool – PDSA ( The Plan-Do-Study-Act model allows changes to be implemented over short time periods, which can improve the success of the implemented projects (1). As part of the PDSA process, organisations ‘set improvement goals, pilot test changes, and assess outcomes using demonstrated performance measurement tools’ (2, 3). A figure of the Plan-Do-Study-Act rapid change cycles is shown below.
Figure 1 PDSA model
© 2009 G. Duffy, J. Moran, and W. Riley
An example of a successful implementation project, realised by the Oregon group, is the SBIRT primary care residency initiative ( SBIRT stands for Screening, Brief Intervention, and Referral to treatment, and is successfully applied in the area of managing problem alcohol use in primary care settings across US. An Irish group led by Prof Walter Cullen (University of Limerick) was inspired by this initiative and started research collaboration with Dr McCarty on a newly funded project in Ireland. The project, which starts in 2013, aims to determine whether SBIRT-modelled intervention can reduce the proportion of people with problem alcohol use among people who are also addicted to other substances and attend primary care.
Among problem drug users, previous work conducted by members of this team, highlighted that: (a) problem alcohol use is common, (b) that primary care has an important role in its identification / treatment, (c) that brief interventions are feasible, and (d) that comprehensive, many-sided interventions may enable screening & brief interventions for problem alcohol use. The trial will be conducted in two regions with very deprived areas, Dublin South West and the Midwest region and will involve distributing best practice guidelines to GPs, practice visits and training of practitioners. The project will be overseen by experts responsible for research, planning and delivery of addiction treatment/ primary care in Ireland with collaborators in the UK and US.
Dr McCarty finished his talk with a famous quote by Al Capone, printed above; noting that a successful change sometimes requires powerful mechanisms to get the reformative message across. The staff who attended this CME-accredited (continued medical education) event was psychiatrists, registrars, addiction counsellors and nurses. It wouldn’t be possible to organise this meeting without the support from Dr Eamon Keenan (Clinical Director, HSE Addiction services Mid Leinster) and Ms Catherine Blake who helped with the organisation and catering.

Trust: the usual suspect in the addiction story

Believe me, or not, trust is something that has been emphasized in addiction treatment for many years. One can hardly argue that it has become one of the usual suspects in the life stories of most recovering drug users.

In this post, I write about two main findings of my latest research published in the current issue of the Czech academic journal Adiktologie (Addictiology). Although they may not be the key findings, which I discovered, this blog gives me an opportunity to illuminate what I feel people should take away from this paper.



This comes with no surprise – trust is key for building or restoring relationships of all people. No matter if they have drug problems, or not. In this way, my research confirmed what common sense tells us without any special knowledge of research. Re-prioritisation of relationships during treatment was facilitated by the experience of help, support and restoration of trust in relationships.

Because I was able to look at the pre-recovery years of drug users lives, when they actively used drugs, I could go with the trust issue a little further. Changes in relationship priority during active drug use occurred on the basis of barriers (e.g. the need to obtain drugs, stigma), which restrained active drug users from engaging in and maintaining the social relationships.


This research has further deepened my understanding of how problem drug users function and indeed how similar they are to people who don’t have drug problems. Some readers may not like this, but they may be less different to ‘us’ than we thought. The key factors that keep them function in a way that is hardly acceptable  by the main-stream population are drug-related barriers. These barriers prevent them from engaging in the usual social life pleasures, such as keeping in touch with non-drug-using friends, visiting parents etc. My research highlighted that they don’t do these things because they have different priorities, which are not compatible with them (See Figure 1 below).

Saying that they are not bothered with relationships or that they’ve no interest in them is too simplistic, and as suggested by this research, not true. Other research showed that people with drug problems do engage in social relationships, pro-social activities, social relationships, raising children – they just don’t do it in a way that ‘we’ are willing to accept. The question that remains to be answered by future research is what would happen if the barriers of engaging in culturally-acceptable social activities were removed? Would ‘they’ be more like ‘us’? The first signals supporting this question come from the opioid agonist treatment. People maintained on pharmaceutical opioids, substituting their illicit drug use, lead more stable lives, commit less crime and have better chances of being employed than people without these substitutes.

Original abstract:
Background: interpersonal problems among drug users (DU) are frequent, are related to other problems, and improve during the addiction treatment.
Aims: to better understand changes in relationships which occur in the course of drug use and drug treatment, as well as their subjective appraisal by ex-drug users, using retrospective methodology.
Method: semi-structured interviews with DUs in a therapeutic community (TC) were analysed with descriptive-interpretive method. The coding of interview transcripts into categories was performed in two phases using qualitative software NVivo 7. Five interviews were coded in the pilot phase, followed by an audit by an external psychologist and progressive coding of the rest of the transcripts, with data saturation being reached in the second phase.
Participants: nine male and one female client, aged 18-36 years (mean: 25.9), participated in the study and the length of their stay in the TC was 2-35 months (mean: 9.9). The approximate mean age of drug use onset was 15.6 years (12-28).
Results: the analysis provided 21 categories which were divided into three domains based on chronological order. Changes in relationship priority during active drug use occurred on the basis of barriers (such as the need to obtain drugs and stigma), which restrained active DUs from engaging in and maintaining their social relationships. Re-prioritisation of relationships during treatment was facilitated by the experience of help, support and the restoration of trust in relationships.
Conclusions: this study builds on the previous work exploring the broad issue of social consequences of drug use and offers clients’ perspective on this topic.
Cite as: Klimas, J. (2012) Interpersonal relationships during drug use and treatment from the perspective of clients in a therapeutic community. [Interpersonálne vzťahy v priebehu užívania drog a liečby závislosti z pohľadu klientov/iek v terapeutickej komunite.]. Adiktologie (12)1, 36-45
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Figure 1. Evolution of relationships during drug use, addiction and treatment