“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 (www.ohsu.edu). 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 (www.NIATx.net). 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.
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| 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 (www.sbirtoregon.org). 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.
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