On October 9, 2010, I had the privilege of sitting down with Dennis McCarty, PhD to discuss drug and alcohol addiction treatment in the US. I have the great fortune of working with Dennis, mostly by turning his printouts into PDFs and booking the conference room for him, and I’ve always been fascinated and heartened by the work he and his team does; I’ve secretly always thought of him as a bit of an unsung superhero – out there fighting the good fight. After reading some posts about drugs, addictions, and treatment here on TNB in recent months, I asked Dennis to share his thoughts on all of it from the angle of policy. Here’s what he had to say.
GH: Hi Dennis!
DM: Hi Gloria.
Thank you for taking the time to answer some questions. Don’t hold back too much! Let it flow, Dennis! Be lyrical and stuff. This is a literary site after all.
As best I can for an old guy.
Okay, to start: I see from your faculty profile that you are the Director of the Substance Abuse Policy Center in the Oregon Health Policy Institute and that you work with state and local policy makers to improve the quality of services and the use of data on substance abuse treatment. What does that mean?
And you want me to be lyrical?
Yes. Make sure you write an a-b rhyme – like The Lorax, only about drugs.
I will try. Addiction treatment is more than patients and counselors and 12 step groups. It’s the organization and financing, structure and delivery of treatment services. My job is to understand the context for addiction treatment.
To what end?
To improve patient care and outcomes. I will tell a story: I was flying from Kansas City to Saint Louis. The last passenger to board took the empty middle seat next to me and announced, “I am a nervous flyer, I need to talk.” I ignored her and she turned to Mr. Window seat. When she exhausted him she turned to me. “I see you are reading medical papers. What do you do?” I responded ‘I study the organization and financing of addiction treatment services.’ That is usually sufficient to inhibit conversation. Not this time. She needed to talk. I proceeded to discuss addiction treatment. As we began to land in St. Louis, Mr. Window seat leaned across and dropped a coin in my hand and said, “I wanted you to know.” It was his sobriety medallion. A number 2 was on the back — two years of sobriety. Mr. Window Seat explained that he had entered treatment 6 years ago but was not ready to stop drinking. His story is not uncommon. But why should we and he blame himself. “I was not ready.” I believe that the treatment program was not ready for Mr. Window Seat. So my work is directed to helping addiction treatment systems do a better job with patients the first time they enter care. Let’s 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? Do you think it has anything to do with their treatment options? I know that there are many factors in a person’s willingness to get sober – psychological, sociological, etc.
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.
But, you know, if you have diabetes, you can go get treated – get some insulin and voila! Better. It’s not like that with addiction, which is also a disease, isn’t it?
Diabetes is a good example of a chronic disease that can be treated effectively but also requires lifestyle changes. If a diabetic stops exercising and dieting and monitoring their 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 would that look like?
We don’t know actually because the system has not been invented.
You’re a visionary, Dennis! Imagine the future!
It probably includes ongoing contact and leaving medical records open like physicians do. It requires different systems of reimbursement and contracting. Lots of systems changes. Also changes in the type of work for counselors and people in recovery.
So, basically, a reform of the medical system in general, which has been an ongoing discussion and debate. What barriers do drug counselors face in delivering the type of treatment that would be most effective?
Yes. Health care reform and the Affordable Health Care Act create many opportunities for changing systems of care. Counselor barriers are many. Training is the first. Only about half of the US counselor workforce has a graduate degree. Should we allow individuals without graduate training to work as counselors? Reimbursement and salary are another. The counselor workforce has a 25% annual turnover rate. Lack of evidence-based practices is another challenge and counselors who are not trained in the practices that are evidence based.
What do you mean by evidence based?
Evidence-based is based on scientific research.
Your team is also involved in some of that scientific research, is it not?
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).
Which leads me to my next question: as you know, I asked a few fellow TNB writers what they’d like to ask you, and one question that was repeated several times involved methadone clinics. People are concerned about them. Are they safe in my neighborhood? Why should we let junkies use our social service dollars to get drugs? Etc. What can you say about that?
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 medications (replacement medications). Most opioid users relapse 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 methadone 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.
Sure. Let me segue now. The second most asked question was: What alternatives to god-based recovery do we have here in the U.S.? I think one barrier to drinkers quitting drinking is that AA looms large as the only game in town for support and it turns the less religious among us off, I think.
I sense a bias in the question. AA is only 75 years old or so. The whole field dates to the mid 1930s and existed without federal or state support until the late 1960s. Addiction treatment is a young science. But about the god thing – AA in the Netherlands does not discuss god and do not include prayers in meetings. AA need not be about god. People seeking recovery can find god-less groups and alternatives to AA.
Is it still called Alcoholics Anonymous in Holland?
Yes, it’s still called AA. But the Dutch are relatively godless.
Can you name some other American-based support systems that are not AA and don’t discuss God or a higher power in their approach?
SMART Recovery is probably the most visible of the alternatives.
Speaking of the Dutch – when I think of the Dutch, I think of three things: windmills, tulips, and marijuana. So, let’s talk about pot for a second. Something that I’ve heard asked many times in my life by many people is: Why is pot illegal and alcohol legal? Can you help answer that question?
It’s the devil’s weed. Being silly. I don’t know if there is a good answer. Technically, marijuana is prohibited because international treaties declare that it has no valid medical use.
Many states disagree. Oregon, for example.
There is scientific debate. But until the international drug control conventions are revised, marijuana is an illegal substance and member nations are required to make marijuana use illicit and to prosecute offenders. The tension between state and federal government does not change federal law where marijuana is illegal.
As I sit here and type, there is an advertisement for Concerta going on in the background. That’s an ADHD medication that uses methamphetamines in its ingredients. And pain is often treated with opioids. I thought it was a widely held understanding that those drugs that are illegal are also used legally.
Yes, drug control policies are an amusing set of contradictions. Legal drugs can be used illegally but illegal drugs cannot be used legally (under federal law).
It sounds like this isn’t just federal (US) law. It sounds like what you’re saying is that our country’s drug laws are also regulated by some sort of international body. Is that right?
Yes. The United Nations now functions in that capacity. Of course, the US tends to have a disproportionate influence. The international conventions (treaties) are marvels of ambiguity so that the Dutch can do their interpretation and the US can have a different opinion.
Why does the US have a greater influence?
Because we have the biggest purse and are the most dogmatic. Dogmatism is a function of US policy. The Regan Bush Bush administration catered to white southern Christians who feared that marijuana was stealing their children.
I see. For the record – for all of posterity, Dennis, where do you stand on the legalization of marijuana?
I am ambivalent. The biggest drugs of abuse are all legal: tobacco, alcohol, prescription opioids and marijuana (which is quasi-legal in many states). From a public health perspective, I think that legalization would increase problems with marijuana. At the same time, I recognize that too many people are in prisons and jails.
What types of problems would it cause?
Drugged driving, neglect of children, health problems.
I’m glad you brought up prisons. As I mentioned, some TNBers sent me some questions they’d like to ask you. Sean Beaudoin asked some really incredible questions, and I think each would be its own essay. In one of his questions, he mentions “…the usage of the penal system to handle addicts, particularly addicts of specific drugs (massive percentage crack), as well as that approach’s colossal failure and the opportunities to institute genuine rehabilitation within the penal system that are missed…” What can you say about the way the US uses the penal system to deal with addictions? I mean, it seems like that’s our real addictions treatment system.
Historically, the US relies on corrections to address addictions. In the 1950s, the county work farm was the primary treatment for alcoholics. Today incarceration is the primary treatment system for heroin, cocaine, and marijuana. The Department of Justice screens arrestees for drug use in 10 communities across the US (Portland is one of the cities) about two thirds of the offenders are positive for drug use at the time of their arrest. The link between crime and drugs is astounding.
Do you have any numbers on how many people go back to using after they’re released from prison?
It’s high. I can find numbers but I guess it’s at least 50% if not 75 to 90%.
So, then, it sounds like the incarceration model of treatment is a colossal failure.
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 reincarceration rate. Incarceration is not treatment.
Andrew Nondetti wants to know: What constitutes a “rehabilitative success”? Complete non-recidivism? A reduction in usage to “social levels”? Not seeking further treatment?
Neither a simple question nor a simple answer.
It doesn’t sound like any of this is simple, actually. Probably why you’ve dedicated 35 years of your life to it and still haven’t ironed it all out!
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, it seems, is sort of what methadone clinics are for, yeah? What is the chronic care model for alcohol addiction?
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? Not is it within the realm of possibility, but more are the barriers in place to allow for that so prohibitive that it will never occur?
Sure. Let’s pay for internet counseling. Let’s use text messages and cell phones to support ongoing recovery. Let’s invent other strategies.
Ooh, those are awesome solutions.
Barriers are just problems that need to be solved.
Ha! I love you; you’re so optimistic.
The solutions are often in inventing new systems of care or new rules for care — New rule we pay for chronic care. Just looking at the opposite side of the coin or the glass half full.
Because it seems like the barriers are not just on a local level – but international too.
Yes international, national, state, local, and individual.
Where do you see addictions treatment in the US in 20 years?
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.
Why doesn’t healthcare want to address addiction and addicts?
Addicts are disruptive pains that don’t have real health care problems.
Medical professionals believe this?
Physicians and the healthcare system currently have little to offer addiction.
Isn’t it widely accepted that addiction is a disease?
They believe it. Addiction is a disease but most people still believe that it’s a result of weak will.
Even health care providers?
What do you believe?
I believe addicts are a pain for the health care system. I also believe that they are real people struggling with an illness and need compassionate care. They deserve better than they are currently given.
Let’s talk about willpower for a second. Where does an addict find the willpower to seek treatment? What can we do differently to see to it that people who are born with the disease of addiction don’t get to a place where they’re addicted in the first place?
Good treatment programs offer hope. Women and men struggling with alcohol and drug problems need confidence in their ability to recover. Good treatment provides hope and structure to guide recovery. Addiction has both genetic and environmental causes. We have more opportunity to create environments that discourage use and support recovery than we have in changing the genetics. Strong policy that supports prevention and treatment is a good strategy.
I would love to talk about the national policy on prevention. I know that the national approach in the 80s was to increase the policing of borders and prosecution of drug traffickers. Is that right? What is it now?
Yes, the Regan Bush Bush regime emphasized supply reduction. The Obama administration is placing more stress on demand reduction — treating addiction.
That sounds like the correct order of things in my opinion. Didn’t DARE come out of the 80s?
DARE is a good example of practice driving policy without the guidance of science. DARE came out of LA in the late 80s as a way to get police involved with schools.
Why do you think DARE is the wrong approach?
Research shows it does not reduce drug use.
I see. Well, I think that’s it. Any final thoughts?
I wasn’t even lyrical in rhyme or song. Thanks for your interest in the issues of treatment and addiction:
The conversation can continue to unfold.
Who knows what stories are yet to be told
During the long walk from infant to old.
Sorry, that’s the best I can do.
It’s perfect. Thank you for your time, Dennis.
Dennis McCarty is head of the Health Services Division of Public Health and Preventive Medicine at Oregon Health and Science University. He’s invested over 35 years into studying addictions and addictions treatment. He works about 34 hours a day, 12 days a week, but does take a few weeks off every year to go bird watching with his wife Sarah in a remote area of the world.