Q&A with Dr. McCarty: Envisioning a Chronic Care Model for Addiction Treatment

Dr. McCartyDennis McCarty, PhD, Professor, Department of Public Health & Preventive Medicine, is head of the department's Division of Health Services Research. With over 35 years in the field, Dr. McCarty is a visionary in addictions treatment research. Through collaboration with colleagues in the department, policy makers in state and local government, and practitioners in community treatment programs, Dr. McCarty seeks to increase support for the treatment of alcohol and drug abuse, improve the quality of treatment services, and link policy, practice, and research.

Recently, Dr. McCarty answered questions about the challenges and hopes associated with his research.

Q&A with Dr. McCarty

In addition to working with state and local policy makers to improve the quality of services and the use of data on substance abuse treatment, what is involved in your role with addiction treatment?

Dr. McCarty: Addiction treatment is more than patients and counselors and 12 step groups. It’s the organization, financing, structure and delivery of treatment services. My job is to understand the context for addiction treatment, in order to improve patient care and outcomes. Additionally, my work is directed toward helping addiction treatment systems do a better job with patients the first time they enter care. I want to make care more accessible, attractive and effective. That’s the goal.

Why do you think people take a long time to be ready to quit abusing drugs and alcohol? Does it have anything to do with their treatment options?

Dr. McCarty: The simple answer is because they are addicted—their brain chemistry changes. A longer, more complex answer is that treatment services wait for patients to be ready rather than helping patients become ready.

How does substance addiction compare to a chronic disease like diabetes?

Dr. McCarty: Diabetes is a good example of a chronic disease that can be treated effectively but also requires lifestyle changes. If a diabetic stops exercising, dieting and monitoring insulin levels, they get sick. Doctors make lots of money treating diabetics for preventable illness. But as you note they continue to treat them. One strategy we need in addiction treatment is a system of chronic disease management. Currently the system provides acute care rather than chronic care.

What does the future of addiction treatment look like?

Dr. McCarty: Substantial system change is required. This includes evaluating how counselors work, as well as the roles of people in recovery. We anticipate greater integration with primary care and a shift of care from specialty clinics to medical homes that include continuing treatment for alcohol and drug disorders. It probably includes ongoing contact and leaving medical records open like physicians do. Also, it requires different systems of reimbursement and contracting.

What barriers do drug counselors face in delivering the type of treatment that would be most effective?

Dr. McCarty: Health care reform and the Affordable Care Act have created many opportunities for changing systems of care. Unfortunately, counselor barriers remain. Training is the first on the list. Only about half of the US addiction counselor workforce has a graduate degree. This means that individuals without graduate training are working as counselors. Reimbursement and salary are other obstacles that must be overcome. They are contributors to a high counselor workforce turnover rate, which is at 25 percent annually. Finally, a lack of evidence-based practices, including counselors trained in this field, is another challenge that must be met.

Your team is also involved in scientific research, is it not?

Dr. McCarty: Yes. We participate in the National Drug Abuse Treatment Clinical Trials Network and test pharmacological and behavioral therapies in community-based addiction treatment programs like CODA, ChangePoint, and NARA (addiction treatment centers in Portland). Nationally, we work closely with the Network for the Improvement of Addiction Treatment (NIATx) to help treatment centers learn and use process improvement to bring patients into care more quickly and retain patients in care longer.

What are your thoughts on methadone clinics? People are concerned about them. Are they safe in neighborhoods?

Dr. McCarty: The problem is not the medication; it is the quality of the treatment service. Opioids and nicotine are probably the two hardest drugs to stop using. The best treatments for both are agonist (replacement) medications. Most opioid users return to opioid use following treatment. And if you are using heroin or pharmacological opioids you are likely to be supporting your use with illegal activity. Patients using an agonist medication like methadone or buprenorphine have more stable outcomes, reduced criminal involvement, more employment, and better health. What’s bad about that? Of course it’s more complex but that is the goal.

With crime and drug use being closely related, how does treatment for drug addiction in prison help inmates upon release?

Dr. McCarty: The link between crime and drugs is astounding. Individuals who receive treatment in prison are less likely to use when they return to the community. Those who continue in treatment when they return to the community have the lowest re-incarceration rate. Incarceration is not treatment.

It doesn’t sound like any of this is simple.

Dr. McCarty: Yes. The complexity becomes compelling. The outcome measure varies depending on your perspective. Another anecdote: if I am taking a medication for high blood pressure and my blood pressure is normal, the drug works. But if I stop taking the medication and my blood pressure is too high no one claims the medication does not work. They say I should be taking my medication. But if someone stops alcohol and drug use while in treatment and relapses to drug use when they leave treatment, treatment is said to have failed. It’s not fair. In both cases treatment should continue at levels required to support behavior change. This brings us back to a chronic care model for addiction treatment.

Which is what methadone clinics are for, right? What is the chronic care model for alcohol addiction?

Dr. McCarty: Absolutely. Methadone is a chronic care model. The problem with methadone again is the way it’s delivered not the medication. One chronic care model for alcoholism is AA. The question is can we invent additional models?

Can we invent additional models?

Dr. McCarty: Sure. Let’s pay for internet counseling. Let’s use text messages and cell phones to support ongoing recovery. Let’s invent other strategies. Barriers are just problems that need to be solved. The solutions are often in inventing new systems of care or new rules for care.

Where do you see addictions treatment in the U.S. in 20 years?

Dr. McCarty: The addictions treatment system as we know it today may not exist. Addiction treatment should be more fully integrated into health care. However, the addiction treatment system exists because health care does not want to address addiction and addicts so the separate specialty system may persist. Hopefully, the system is using more evidence-based practices, using chronic care strategies for those who need chronic care, and relying on medications to more fully address changes in the neurochemistry. Treatment for alcohol and drug use disorders will begin earlier in the course of addiction, continue for those who need ongoing support, and, in general, be of better quality and greater effectiveness.

Q&A by Gloria Harrison , Department of Public Health and Preventive Medicine