In this occasional series in conjunction with the SSA’s journal Addiction, we record the views and personal experiences of people who have especially contributed to the evolution of ideas in the journal’s field of interest. Dennis McCarty is Professor Emeritus at Oregon Health and Science University’s School of Public Health. His contributions to health services research related to alcohol and drug use disorders have embraced four broad themes: 1) assessments of managed behavioural healthcare and healthcare reforms, 2) collaborative research within the structure of the National Drug Abuse Treatment Clinical Trials Network (CTN), 3) studies to improve the quality of care, and 4) strategies to address opioid use, opioid overdose, and treatments for opioid use disorder. He has received the Lifetime Achievement Award from the American Public Health Association and an International Award for Excellence in Mentoring from the International Program within the National Institute on Drug Abuse.
This interview took place on 16 April 2019.
Below is an edited text version of the interview. A video recording of the full conversation can be seen above.
Addiction (A): Welcome to another edition of Addiction Lives. My name is Keith Humphreys, I’m the regional editor for the Americas for the journal Addiction, published by the Society for the Study of Addiction. For many decades we’ve had the privilege to interview leaders in the field, looking back on their careers, contributions and their experiences, for the benefits of subsequent generations. We have got a terrific opportunity to do that today with Dr Dennis McCarty of Oregon Health Sciences University. Dennis welcome to Addiction Lives.
Dennis McCarty (DM): Thank you Keith, I’m honoured to be here, I hadn’t expected this. I look forward to the interview.
A: We’re glad to have you. Let’s begin at the beginning, I know you were born in Chicago, which many people who watch these interviews would know, but then you moved and you moved to Kentucky. So, what was Kentucky like in those days, what do you recall?
DM: We relocated to Kentucky when I was ten years old, it was 1959. The exciting thing about Louisville, Kentucky was that’s where the Kentucky Derby was, that’s about all we knew about Kentucky. So, I grew up in an Irish Catholic neighbourhood, it was about 40% Irish Catholic. Our Parish was a good strong Irish Catholic community with plenty of good Irish alcoholic drinking. I grew up in that environment.
A: Did you go to Catholic Schools?
DM: I did, both great schools, “St Francis of Assisi” and St Xavior High School, a boy’s school.
A: And do you remember the first time you got interested in science, math, was it through your own curiosity, or was it a teacher who got you interested?
DM: I think I was a freshman in high school biology and then later in chemistry. They showed us how to table results and that was so fascinating that you could actually see the data and it made sense to me.
A: And clearly appealed to you since that’s how you made your career. And you went to university in Kentucky, in psychology. So when, do you remember when you decided you wanted to major in psychology?
DM: Well I initially started college as a biology major. I had taken advanced biology at St X and I thought that was my career path, until we had to do faecal analysis. I decided it was time for another major and jumped into psychology.
A: All the other fields you could have taken, why psychology, what drew you?
DM: Again, the science appealed to me. I had taken some introductory classes and had mastered fairly quickly. This was the second semester of my junior year, so I had to do a lot of catch up real quick and took a lot of credit hours. I was able to finish and then stayed in Kentucky for graduate work.
A: And once you received a doctorate, you became engaged in the addiction field, how did that come about?
DM: It was as a graduate student, I had a choice, I could either teach for $3000, teach statistics to undergraduates, or I could work on a research project for $6000. It wasn’t a hard decision at that moment in time! I was interested in the research, I didn’t know anything about alcohol and drugs at that point in time. I really had to learn a lot to contribute that study.
A: And do you remember what that study was about?
DM: It was looking at the effectiveness of outpatient counselling for treatment of alcohol use disorders. It was a comparison of a social work therapy, to a peer therapist and to a self-help group that was modelled after AA, but it really wasn’t AA.
A: So, this was new for you, you hadn’t had this interest … What was it like for you to just see for the first time what alcohol, well I guess we’ll call it alcoholics treatment.
DM: I saw it mostly from the data side. I wasn’t in the room with the counsellors, with the group. But I was comfortable there. I had been around people who had had alcohol problems all my life, so it wasn’t an uncomfortable environment, or a stigmatised environment for me. It was an opportunity to really drill down and to learn the tools. As a research associate, I had to figure out what was this quantity, frequency variability measure and why were we measuring that and what are we going to do with all of this data. It was an opportunity to do some introductory work and get into the field.
A: And what was your dissertation about?
DM: Nothing to do with alcohol or drugs.
A: Oh is that right.
DM: Yeah, it was on testing the Fishbein and Ajzen Model of Behaviour Change, now called the Theory of Planned Behaviour. I was looking at the use of contraceptives for men and women among college students. It turns out that it was an early study on the use of men using condoms. It became an important study in the HIV literature.
A: Right where you later contributed.
DM: Yeah, yeah.
A: It’s interesting how life knits together that way. And you went then to the University of North Carolina in Chapel Hill, to do a Postdoc with John Ewing and Ken Mills, is that right?
A: What did you work on there?
DM: John was the Executive Director of the North Carolina Alcoholism Research Authority. The [Authority had] a [budget] from the legislature I think about $200,000 a year. So, the Authority funded my first proposal for $16,000, it was looking at misattribution of intoxication. I gave some people a placebo and gave some people alcohol. Did they attribute the effects to the pill or not? I subsequently did a follow-up study where we did a double blind study where people were told they were drinking alcohol, but weren’t, people were told they weren’t drinking alcohol but were, and that led to looking at how they attributed the feelings. Were they attributing the feelings to the pictures we showed them, which were beautiful men and beautiful women, or was did they attribute [their feelings] to the drink. We found that in fact those who did not know they were drinking, rated the pictures more attractive than those who knew they were drinking.
A: Fascinating. Social psychology, that kind of framework that you were trained in. So even though you ended up working a lot on treatment, your came at it from a different discipline in a clinical perspective.
DM: Correct, Also while at North Carolina, NIAAA [National Institute on Alcohol Abuse and Alcoholism] came out with an RFA [Request for Applications) for prevention replication models. They had a model at college level, they had one at high school and one at grade school levels. We wrote a proposal to replicate the University of Massachusetts prevention model and we did that with [the University’s Dean of Students, a team of students, and with the state alcohol authority. I think the money had to run through the state authority actually. It was a pretty successful study.
A: Then after that you made, in some ways maybe the most momentous decision in your career, is you might have gone and become a professor directly and instead you went to Massachusetts and you started working closely with the state government and I’m sure that was a big decision for you, how did you make that decision?
DM: I was a trailing spouse at that point, my wife had a position at Tufts New England Medical Centre. Before we left from North Carolina, I got a phone call from a friend of a friend, who said he had a job and would I like to interview for it. That was Milton Argeriou and that began a long time collaboration with Milt. Milt had a contract with the Massachusetts Department of Public Health, to wrap up a study on drunk driving. Massachusetts had passed a new legislation to change the way drunk driving was addressed and we pulled arrest records and looked at re-arrests and found that the drunk driving programmes reduced the occurrence of re-arrests.
A: So paint a picture, what area is this now?
DM: This is 1980. Excuse me, is that right, yes this is 1980. The alcohol safety action programmes had been recently funded. We weren’t looking exactly at alcohol action safety programmes, but Milt had some experience with them. Milt had also built an early information system for the Division of Alcoholism and we were analysing those data as well. The Division of Alcoholism was part of public health, but was in a separate building and they operated pretty autonomously. Ed Blacker did a wonderful job building that system. He was the Director of Alcoholism [he built a system of care using private, non-profit corporations, mostly men and women in recovery. That started in the early 1960’s. Massachusetts was building a system of care well before most states were. [The Division] extended our contract. We then helped them build a new information system, one that was easier for the clinicians to use, easier for us to analyse and that became a basis, a foundation for much of my work. I was doing health services research on alcohol use disorders, without knowing anything about health services research, I was following the data.
A: And you then started having responsibility for substance use services in Massachusetts to try to change those services and improve the quality of those services. Just tell us a little about some of the things you did to try and make the system better for the people of Massachusetts.
DM: Sure. I worked with Milt for seven years, as part of a group we called Alcohol and Health Research. The Division of Alcoholism and the Division of Drug Rehabilitation [merged] and became the Bureau of Substance Abuse Services. Dave Mulligan was appointed the Director of the Bureau of Substance Abuse Services. He invited me to join him as his deputy director. That’s when I moved from a contract relationship to an employee relationship and my responsibilities changed. I was no longer an external evaluator. I was now evaluating internally and using data to help make decisions. Our first initiative was looking at services for homeless alcoholics. We knew we had a lot of homeless men and women in our system, because we had the information system. I met with shelter providers and with some more traditional treatment providers and we worked out a relationship where the shelters opened in the daytime, to provide safe environments for people in early recovery. We compared that to the traditional treatment services and found that they were equally effective. That was my first NIAAA award as principle investigator. It helped established the value of services for individuals who were homeless. That led to a second study also using the information system, it was done in collaboration with the state Medicaid authority. We had received a waiver from what’s called the Institute for Mental Disease Exclusion [so that] we could treat pregnant and parenting women in residential care. We showed that it was cost effective and it reduced subsequent arrests and led to stable recovery and lower birth weights, or better birth weights in babies.
A: Yes, really focused on the most vulnerable citizens.
A: You then interacted with someone who became a quite prominent politician, your State Governor, Michael Dukakis who had a long interest in addiction issues and became the nominee of the Democratic Party for the presidency of the United States in 1988.
A: And so what was your interaction with him and how did that affect your career?
DM: My interaction was more indirect than direct. My colleague David Mulligan worked more closely with the Governor. As the Director of the Bureau of Substance Abuse Services, Dave had a good relationship with Dukakis. During the campaign, he was advising the campaign. The campaign said we want to offer treatment on demand, we want to say Massachusetts has treatment on demand. We said we can’t say that; here’s what we can do. We can, create an outpatient benefit for Medicaid, because Medicaid did not cover outpatient substance abuse treatment at the time. We can say we have treatment on demand for pregnant women and for people with HIV, because those [individuals] were [categorically eligible for] Medicaid. So, we changed the Medicaid regulations, we made outpatient services a benefit. We worked out a deal with Medicaid that [the outpatient services] were licensed as a class, not as a practitioner, so the agencies could bill directly. That really began opening up other doors for the treatment providers and for the patients. Subsequently Medicaid introduced the first behavioural health carve out in the country and we worked with and advised the carve out company.
A: Maybe you should explain for anyone that may not know what a behavioural health carve out is.
DM: Medicaid, traditional Medicaid has a fee for service system where they cover medical care, mental health care, substance abuse care. With experience people were finding that if you specialise in behavioural health you do a better job in managing those cases. So, they created a Medicaid managed care for medical care and then they carved out the mental health and substance abuse benefits under a separate management contract. So that’s the carve out, you’re carving it out from the medical care. I said nobody stays in outpatient very long, don’t worry about pre-authorisation and I showed them the data that the average stay was two visits. We said use the publicly funded detoxes, not the hospitals, they did, and ultimately in the first year saved something like 12 million dollars and served more people. I began to see that managed care was an effective tool, it wasn’t a bad thing. If you managed it right it improves care.
A: And a lot of what you’re describing the role of Medicaid, moving more care to an outpatient setting, um non-medical detox, or social detox, are things that are now done throughout the United States.
A: That had to be at least among the first States to do that.
DM: It was.
A: Yeah it must be very satisfying to look at how the system has progressed you know building on things you did back then.
DM: Well I was taking advantage of the opportunity. The Governor’s office needed some help for the campaign, we were able to take advantage of that. The behavioural health carve out company needed some help. They didn’t know what they were doing either. It was brand new. There were no publicly funded carve outs prior to that. Also, the big players were apprehensive, they didn’t know what the risk was. We were able to do this pretty autonomously, so that was an advantage. Then there was an opening, the Commissioner of Public Health resigned and Governor Dukakis appointed David as Commissioner of Public Health and I became Director of Substance Abuse Services.
A: And you then had an experience that everyone in Government has at some time or the other, but it’s a different side of the fun, which is there was a recession economically in the 1990s and you had on your plate to figure out what to do about swinging budget cuts to your agency. So what did you learn, I mean everyone in Government has to deal with this? I’m just curious how did you make those decisions and what did you learn doing it?
DM: Well there was a 40% reduction in the State appropriation, so a pretty substantial reduction. I talked to Dave and said “What do I do?” He said, “I don’t know, talk to the providers.” (Laughs.) So that was good advice, because we met, we had a series of meetings with providers, talked to them about what our priorities were, set those priorities together, talked about options, identified better options and then used the data that we have been collecting on who they were serving and how they were serving them, to make the budget decisions. Detoxes got cut more because they were Medicaid reimbursable, go get the money from Medicaid. Outpatient was cut more because they were Medicaid reimbursable. Halfway houses and residential programming was cut less, because they were not Medicaid reimbursable. They were a more vulnerable piece of the population because they didn’t have alternative sources of income. And, we looked at those serving injection drug users, people of colour and protected those agencies more. I don’t think the providers were happy, but they accepted the solution and then that situation that is much better than people going to the legislature complaining about how much you’ve hurt me.
A: Right. So, you kept a connection with the people who were going to take the pain of the cuts and you figured out you’re not going to be able to do as much, so what do you care about the most.
A: As well it sounded like a strategy of figuring out other resource streams that you could bring to bear or that could cover costs. You managed to do that, I’m sure it was no fun at all. It goes with the territory. So then surely after that, or I guess a few years after that the mid-90s you make another momentous career change, maybe back more to familiar haunts, but you leave the role inside the Government and move into academia. How did you make that decision?
DM: It was clear that I didn’t have the skill-set to advance in Government. I didn’t have David’s political skills. I didn’t have his personal skills. I could watch him do it, I could be amazed by how he did it, but I couldn’t do it. I was at a point that if I stayed longer, I would be locked into a state retirement plan and I also wasn’t looking forward to that. When I had an opportunity to transition to Brandeis University, I took advantage of it.
A: And there you formally started doing what people now call Addiction Health Services Research and that became a hot topic at NIH [National Institutes on Health] and within the field. So, what was it then and what was the role in launching Addiction Health Services Research?
DM: Yeah there was a change in the authorisation language for NIAAA and then NIDA [National Institute on Drug Abuse] and NIMH [National Institute on Mental Health]. They were moved out of the Alcohol Drug Abuse and Mental Health Administration, into NIH. There were concerns that the kinds of services, research they did would no longer be supported. Congress in its wisdom created a requirement that 15% of their budget had to be spent on services research. Both NIAAA and NIDA started planning processes, what should be in our portfolio, what does services research consider? I was part of the NIAAA effort to define services research. You’re right that gave me insights, I didn’t know that what I was doing had a name, I just thought I was doing data analysis.
A: And were there many people like you who would actually run health services systems or was it more round the table, full time, life-time academic researchers?
DM: I think most of them were probably researchers.
A: So did you, I’m curious what that experiences was like, did the way they look at it make sense to you, or did you ever find yourself saying, come on I’ve actually run a system and this is, the actual things we need to know about are different to what you need to work with?
DM: Frankly I’m not recalling those conversations in detail. What I did for NIAAA was to write a history of the role of the State in addressing alcohol use disorders. In order to do that, I had to do the history of federal court decisions state legislation and the role of Senator Harold Hughes. It was an informative process for me, because now I had more of the history.
A: Okay so you talked about managed care earlier, as a practitioner and as a leader in the service system, around this point in your career you also start doing a lot of research on managed care and working also with the Institute of Medicine on managed care, so tell us a bit about that. What were the questions you were pursuing and what did you conclude about managed care, or substance use disorders.
DM: Two weeks after I went to Brandeis, the National Institute on Drug Abuse issued an RFA, for services research. It was broad. Brandeis had experience with Medicaid managed care, they had done the evaluation of the Massachusetts carve out. We began thinking about well how do we study managed care. I was assigned the responsibility of preparing the proposal. This is a P50 proposal, it includes an administrative core and four RO1 type research applications. For the next ten weeks, that is what I was working on, just putting that together. My particular study was using state information systems from Maine, Ohio and Massachusetts, working with investigators with access to those systems. We wanted to see what’s the impact of managed care on publicly funded addiction treatment services. Other studies in the proposal were looking at the health economics of addiction and addiction treatment. Richard Frank was leading that and Connie Horrigan was leading an analysis of behavioural health carve-outs from the employer perspective. The debate was that managed care was ruining addiction treatment services, because they were reducing lengths of stay from the traditional 30 days at the Lake, to only 14 days for some.
A: Sorry, did you agree with that that it was ruining it, because before you were more optimistic about it?
DM: Well, as an investigator, I’m dispassionate, I want to know what the results are. There was a lot of advocacy in the field that the residential treatment system was being dismantled and in fact a lot of programmes closed. But from a data perspective we saw more people getting care, we saw services surviving, we saw savings in money and savings in people, because more people were getting into care. I think if it’s managed right it can be a benefit for everyone.
A: And can you just give a little bit more detail about the, so the Institute of Medicine (IOM) and the Center for Substance Abuse Treatment within the Substance Abuse and Mental Health Administration came calling. You worked with them on a report that I think most people consider a landmark in the field. What was that experience like?
DM: That was my first IOM committee. It was an exciting moment. I was bringing in the State perspective. The Study Manager found me f at the last minute and got permission to add me to her committee. I brought in that State perspective. I was explaining to people how the State public funded systems worked. A lot of the committee members were not familiar with that, they were from other industries or other perspectives, I think primarily from employer based health plans and Margo Edmunds who was the Study Director, let me go at it. She gave me a lot of latitude to write and to help frame the report. I enjoyed that.
A: And what do you think the impact of that report was?
DM: As far as I can tell almost nothing. (Laughing.) The advocates didn’t like it because we didn’t come to the conclusion they wanted, which was managed care was bad. I think it was a useful report, it just wasn’t useful the way that the advocates hoped it would be.
A: it’s quite a stark assessment, no impact, so do you regret doing it, did you regret at the time?
A: So why not?
DM: Well I think we set the record straight. Managed care had a bad reputation. Mental health advocates were especially dismayed, SAMHSA had funded the study, to appeal to the mental health advocates. They were disappointed that we didn’t come up with the answer that they wanted.
A: But you feel like you got the right answer in doing it.
A: So we’ve talked a lot about Medicaid and you know as a public insurer, but of course not long after this, people started focusing finally on what can private insurance do for people with mental health and addiction problems. One of those lived out and what’s called US parity legislation. President Clinton’s administration gave people who worked for the federal government behavioural health parity [equal benefits for treatment for alcohol, drug and mental health disorders compared to benefits for medical conditions] that became the battleground for which people argued about should we do this for the entire country. Which Congress did do in 2008. But first they had to figure out what happened in that period and you were key to that effort. Tell a bit about that sort of very policy relevant research experience.
DM: Well let me say I was tangentially involved, not key.
A: You’re a humble guy, I already kind of knew that.
DM: Richard Frank and Howard Goldman were the PI’s on the evaluation [of the Federal parity initiative.] I had worked with Howard and Richard earlier in my career, in a different topic, but they invited me to be part of their technical advisory group. So, I sat on the side lines, watched what they did, blessed what they did and encouraged them to do it. The net result was that they found very little increase in the cost of care, which was the important question: is this going to force the cost of care way up? They found no effects. Subsequently I may be jumping ahead of you a little bit, so let me pause for a minute. What else did you?
A: No that’s fine, because I observed, I worked with Richard Frank in fact and I saw that research to be very influential and I wonder if you share that perception in terms of the debate that occurred in the Congress later, 2008?
DM: Yes I think that research was key, you’re right it was very important research. It was now databased and they could say no this won’t affect your bottom line.
A: Yeah so that’s a nicer experience I guess than the IOM reported … So you then move here, where we are today in Oregon, so what drew you out to the pacific west?
DM: Well, that was the second IOM committee I was part of. It was commissioned specifically to address the gap between services and research in the treatment of alcohol and drug use disorders. It was funded by both NIDA and SAMSHA. Mitch Greenlick chaired the committee. My role in that committee was to describe what the real treatment services look like, and the reality of the chaos in the treatment environment. Treatment environments do not select the patients they care for, they care for everyone that comes, at least in the public sector. So, the carefully controlled study you did around cocaine and people with jobs, is not going to be very applicable in the public sector of the community. So again, I ended up having a lead role on writing that report. Mitch Greenlick gave me lots of latitude and the very first recommendation suggested that NIDA should fund a clinical trials network on drug abuse treatment, so that providers would have more confidence in the results that were applicable to them.
A: And these were a network where real world, community programmes treating real world patients would be partnered with scientists in trials that would apply more traditional…
DM: Correct. That was the vision. I had talked briefly with Alan Leshner at another meeting and asked Alan what are you looking for? He said give me something useful. I guess that recommendation struck him as useful. The RFA came out in 1998 and Brandeis was part of an application team that put together a proposal. It did not win, Mitch Greenlick went back to Oregon and began working with providers and put together a strong proposal. Mitch was one of the five founding PI’s of Nodes of the [National Drug Abuse Treatment Clinical Trials Network (CTN)]. Mitch had said while I was working on the Institute of Medicine report on Bridging the Gap between Research and Practicethat if I ever wanted to relocate and work in Oregon, he would be glad to have a position for me. Sarah had wanted to return to the northwest, she grew up in Boise, so this was an opportunity to better align my personal life and my research. We moved to Portland in 2000.
A: And you if I remember right, edited a special issue of the Journal of Substance Treatment… looking at the clinical trials network on its decade anniversary. So I’m sure you spent a fair amount of time thinking about what were the successes of this and what were the disappointments, or what were the areas where you are need more work … What are those, say what would you say that CTN [Clincial Trials Network] accomplished and what does it still need to accomplish?
DM: At the tenth anniversary what the CTN had accomplished was to document that buprenorphine was safe when used with typical clients. That treatment programmes could use it safely. Phoenix House for example participated in the CTN. Phoenix House had been opposed to the use of opioid agonist therapy. [After participating in the study], they said “These patients came through treatment, came through detox much more quickly, are much happier, we can work with them more quickly”, Phoenix House began using buprenorphine as part of its therapy. The same thing happened in the commercial sector, Kaiser Permamente in Portland Oregon began using buprenorphine and never looked back. [The CTN studies facilitated the adoption of buprenorphine.
CTN also tested at a very large scale the contingency management strategies and tested a lower cost contingency management. When contingency management first came out they were paying sums like $2000 dollars if a patient was abstinent from cocaine. Well, that is not affordable in a publicly funded service system. The CTN tested a lower cost contingency management strategy. The cost was about $200 a patient and treatment centers can make that cost by better retention, so it becomes affordable, it becomes realistic.
The CTN again found that motivational interview was effective, more effective with alcohol than with drugs. A replication of what was found in more controlled studies. And that was the first group of trials.
There was one on should you do a slow taper or a quick taper on buprenorphine. They both led to relapses and the quicker one was probably the less expensive one. That was the first decade of CTN, or part of the first decade. We also did a census of the treatment providers, who are the programmes on the CTN and who’s their workforce and I think that’s the best workforce survey to date, as far as I know. It had 70% response rate and we had good coverage throughout the, across the nation.
A: So quite a few achievements then.
A: And what about things that, either disappointments, or just territory, not explored at the CTN, you want to pursue in the future?
DM: Well I’ve just agreed to co-edit with Dennis Donovan and issue for the 20thanniversary of the CTN. We are expecting a lot of thoughts about the future, a lot of reflections on the past. A big change for the clinical trials network was that Nora Volkow wanted to move out of the specialty addiction programmes into medical care settings. I think that was the next appropriate step. We found that we could work effectively with public sector programmes, could we now move this platform into primary care settings, or more broadly in medical care settings. And for the past ten years or so the CTN has been working in that environment. It has had to learn how to do that, it’s a different environment, it’s a more complex environment in some ways, because physician time is tightly scheduled.
A: It’s a multi-mission healthcare system that works on addiction.
DM: So we benefited there. It’s now doing a scale up study on the use of buprenorphine in emergency care and it’s got several other big studies in the hopper. [The CTN will] continue to document the value of better integration of primary care and treatment for drug and alcohol use disorder as a chronic illness. Every time you come in, your physician should be asking “Keith how’s your drinking doing? Are you still sober? Do you want some help? Here’s some naltrexone to help reduce your urges to drink.
A: Like they would if I had diabetes.
DM: Correct, exactly.
A: In Oregon you were, I will say, central, maybe you’ll tell me that you were tangential, to a major effort to help treatment programmes improve the quality of their care, which is NIATx and also in a follow on initative called Advancing Recovery. Presuming you’re willing to acknowledge that you were more than tangential, how did that come about, what was the purpose of the work?
DM: The back story is that in Massachusetts as State Director, we’d started a quality improvement collaborative. Commissioner Mulligan came under the influence of Don Berwick, brought him down for a [a discussion of quality of care and how to improve it]. We were all committed to improving the quality of public health services in Massachusetts. Simultaneously SAMHSA [Substance Abuse and Mental Health Services Administration] issued requirements that States had to review and audit its programmes. We used that as an opportunity to test practice improvement strategies. One of the providers was Victor Capoccia, he ran one of the larger treatment programmes. He asked Marriott Hotels to help him with his quality improvement. Marriott is a leader in the application of process improvement strategies to service delivery.. Skip ahead a few years, Victor is accepts a position with Robert Wood Johnson Foundation to direct their drug abuse policy, prevention and treatment portfolio. Victor wanted to address quality of care. That was his first initiative. We had some background conversations. What is the problem? It’s retention and care, it’s a long wait to get into care. My thinking on, quality improvement had evolved and developed over that time period as well. Victor was also talking with Dave Gustafson at the University of Wisconsin. Dave has done a lot of work on quality of healthcare, but no work on substance abuse treatment and said he really wasn’t the person to do that. He had a staff person who had a daughter who was using heroin. She said “Dave you need to do this.” Dave’s method is to do a walkthrough. If he’s looking at a medical procedure, he wants to walk through the patient experience. So, he did that with substance abuse. He called the County Detox. He had to call every day for a month before they gave him a bed. He walked in, went through the strip search, spent the night there, heard people in agony because they weren’t getting opioid agonist therapy. He came back and told his staff person, “I have to do this.” The University of Wisconsin, under Dave’s leadership, became the National Programme Office, Robert Wood Johnson Foundation put out a call for proposals for a national evaluation. I was led the Oregon Health and Science University application and secured that national evaluation award. I became a partner with Dave.
I believe that evaluation is most useful when it’s linked to programming, not separate from programming. I want to be involved in programming, I want my information to be back in the programming. Dave was open to that. We built data systems together, we were able to demonstrate that programmes reduced their time to treatment by 20%, they improved their retention by 20% and we were able to replicate that in a second cohort. We also received NIDA funding to look at it in more detail. The model expanded into Advancing Recovery, which worked with the state authority, the payer, the state or county payer and the treatment providers. Involving the payer made the process improvement strategies more effective. More people were inducted onto buprenorphine. More people were inducted onto Naltrexone for alcohol treatment. In addition, programmes were improving retention and care using psychosocial interventions.
Between those two interventions, the NIATx enterprise was growing. The next study was NIATx 200. It enrolled 200 treatment programmes in five States to see if NIATx scaled up. We had scaled it with Robert Wood Johnson and CSAT awards and had worked with about 35 programmes. They were getting $100,000 a year to participate. In the NIATx, 200 programmes volunteered to participate and got nothing except the services that we provided and the coaching, the telephone calls and things of that nature. Again, in NIATx 200 we found that days to treatment declined, retention in care improved a little bit and admissions increased because were using their capacity more efficiently. We also discovered that intensive learning communities, the face to face meetings were not making the difference, the coaching was what was making the difference. We could focus energy more on coaching, rather than on hosting meetings. More than 1000 programmes have been trained in NIATx and it’s going strong, it’s a strong enterprise.
A: Very impressive, very impressive. I just wanted before we close to ask you a couple of questions that occurred to me as I was looking over your career as a whole.
A: One is you are a contemporary of Tom McLellan. Another person who has had a big impact on addiction treatments and like you has never seen a patient. It’s interesting most people who study treatment at some point have provided it and you’ve not. So what do you, what do you think that has done to your perspective and in what way was it may be an advantage to not be a clinician and in what ways was it may be a limit?
DM: Yeah when I speak in public I have to say I’m not a licensed clinician, I’m not qualified to treat or to diagnose. I think that limits my credibility somewhat. On the other hand, I’m the external evaluator. I was able to bring people to the table, I was able to build partnerships with treatment providers. I think that’s something that investigators have not done in the past, or have not done as well as they could have done. I think that is the strength of the work I brought to the table this was all done in partnership with providers directly or indirectly.
A: I want to ask you about technology, I mean part of, when we understand and NIATx and Advanced Recovery, it’s … just teaching good business practice to a sector that hasn’t really had it and you’ve also had a lot of interest in making better use of all sorts of technologies to improve addiction treatment. What do you think are the key technologies that people who take care of people who have addictions could take advantage of more and help more people?
DM: Clearly, science has developed effective medications, pharmacotherapy that facilitates recovery and the treatment field has been very resistant to adopting those technologies. Quite a bit of my work in the past 20 years has been focused on what can we do to facilitate the adoption of these technologies – it’s implementation science. It’s one area where implementation science really began to work. The electronic health record is another technology. We don’t do enough with electronic health records. Many treatment programmes don’t have electronic health records.
A: It’s still paper and pencil.
DM: Yes. They are expensive. But it’s now a cost of doing business, something that’s expected. We’ve got to link those electronic health records with the medical record. In Oregon I’ve been advocating to add questions on cannabis use to the medical record, because it’s legal in Oregon, we know patients are using. We know which smoke cigarettes, but we don’t know what form of cannabis they are using. We don’t know what the THC levels are. We could be doing so much more prospectively to talk about the acute and chronic effects of cannabis use and yet the medical side of the house is resistant to doing that. They don’t want more questions, they don’t want more burden in the medical record. We’re looking at the medical record to see what can we say about cannabis use, given the data that’s there, what is the quality of the data, how useful are they, or are they not.
A: So I wanted to shift to another part of your career and ask a question, you know being one of the first people to do addiction research, you won the prize of having to review an enormous amount of grants, I think you chaired the health services committee at some point. As you know, the grant process is criticised a lot of being unreliable or capricious and so on,. What would you say to people who are dubious of whether our grant review process does a good job of picking out the right studies, or not, or maybe you share those doubts, I don’t know?
DM: I think the grant review process is a fair process. Reviewers have a good sense of what’s a good application, what’s a weak application. Occasionally there are disagreements on a specific application, but usually, if you discuss the application, reviewers come to consensus on what are the strengths, what are the weaknesses. As a reviewer I learned a lot about writing grants. I could see bad applications, I could see good applications. I could take advantage of learning to write more effectively within that situation. Not every one of my applications has been funded, but those were weaker applications. I learned from the reviewer comments, I learned how to write more effective applications. So, I think it’s about a good a process as we can get.
A: So just last question, because you have worked on the administration, you’ve run systems, you’ve also worked in policy and you’ve been an academic. Lots of academics aspire to influence those other places where they wished their work was used by treatment providers, they wished their work affected the people, or a state, you know a substance use treatment centre, they wished that politicians paid attention to their work and they are frustrated that it’s not the case. What advice would you give to that probably significant contingent in our field about what is it that academics need to start doing to have those kinds of impacts that they don’t have?
DM: The first step is to get involved. Don’t be afraid of getting your hands dirty. I think that’s one of the admirable things about Tom McLellan. He worked in a lab for many years and decided to get his hands dirty and moved into the policy arena. Here in Oregon, I served on the Oregon Alcohol and Drug Policy Commission. Its goal is to revamp the addictions treatment system in Oregon. They haven’t done the job yet, they may never be able to do the job and it’s frustrating to know that things can be better, but to not have control over how the state authority is organised and managed. But at the same time if we are not in the arena, we have no influence at all. So, I’ve been fortunate that I’ve been able to play in the arena, I’ve been fortunate that I’ve been able to work closely with providers and gain the experiences that they have taught me.
A: It’s a terrific note to end on. Dennis McCarty, thank you so much for telling us about your amazing career.
Dennis McCarty was in conversation with Keith Humphreys.
This interview is licensed under CC BY-NC-ND.
The interviewee has provided an annotated bibliography of his work, available here
The opinions expressed in this commentary reflect the views of the author(s) and do not necessarily represent the opinions or official positions of the Society for the Study of Addiction.