How to Make Addiction Care Routine | Jennifer McNeely, MD

Despite affecting more Americans than diabetes, substance use is often left out of routine medical care. In this episode, NYU Langone Health’s Jennifer McNeely, MD—a clinician investigator, primary care and addiction medicine physician—explains why that must change. From the surprising history behind addiction’s exclusion from mainstream medicine to the innovative screening tools shaping the future of care, this conversation is a must-listen for anyone interested in addiction care and healthcare policy.

Jennifer McNeely, MD, is an Associate Professor of Medicine and Population Health at NYU Grossman School of Medicine and co-director of the Section on Tobacco, Alcohol, and Drug Use.

🔍 Topics Covered:

00:00 – Introduction
01:15 – Why addiction hasn’t been part of traditional medical care
05:00 – What medications can primary care providers actually prescribe?
07:00 – Why lifting legal barriers isn’t enough
08:00 – Making substance use screening part of routine care
11:50 – The power of self-report screening tools
13:30 – What primary care physicians can actually do after screening
16:10 – Real-world clinical impact of identifying substance use
18:00 – Overcoming stigma and “we don’t do that here” culture
22:17 – Can AI help with screening and care prioritization?

📚 Related Resources:

Jennifer McNeely, MD
Addiction Treatment at NYU Langone
NIDA’s Resources for Clinicians
Substance Use Screening Tools (NIDA)

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Executive Producer: Jon Earle

Transcript

DR. THEA GALLAGHER: Welcome to the Insights on Psychiatry podcast. I'm Dr. Thea Gallagher, and I'm excited to be talking to Dr. Jennifer McNeely today. She's an Associate Professor of Medicine and Population Health at NYU Grossman School of Medicine, also the Co-Director of the Section on Tobacco, Alcohol, and Drug Abuse, primary care and addiction medicine physician at Bellevue Hospital as well. Thank you so much for being with us today. 

DR. JENNIFER MCNEELY: Thanks for having me. 

DR. THEA GALLAGHER: So can you just tell us a little bit about the overview of the work you're doing right now? 

DR. JENNIFER MCNEELY: Sure. So I'm a general internal medicine physician, an addiction medicine physician, who is mostly clinically very oriented to primary care and I think the whole thrust of my work in general has been around trying to do better with how we address substance use in medical settings. So I do work kind of across the general medical settings but most of it is focused in primary care, but also research in hospitals and EDs, but really trying to have substance use, addressing substance use prevention and treatment, become part of regular medical care because I think that's where it belongs.

DR. THEA GALLAGHER: Why do you think it hasn't been there? 

DR. JENNIFER MCNEELY: Lots of reasons. It has been not part of the culture of medicine. And sort of stemming from that it hasn't been taught generally as part of medical education. There aren't examples, a lot of role models for doing it. So it goes all the way through. But I think in the US we have an interesting history here that way back with the early drug prohibition laws, there was a prohibition sort of explicitly in the US about physicians treating addiction with medications and that goes back to the early 1900s and flowing from that there's just been sort of an established separation between treating addiction and medicine. And so at this point, it sort of became not part of medical practice. It's not an expected part of medical practice and we're seeing that change now and actually change quite a bit. 

But I think it's true for many aspects of behavioral health. There is this sort of separation between physical medicine, behavioral medicine and I think with addictions, even kind of an additional overlay of that doctors were told explicitly that they should not treat addiction back in those early years, and then it carried down. 

DR. THEA GALLAGHER: Because of the fact that it was prohibition, kind of like don't ask, don't tell almost, like don't acknowledge it? 

DR. JENNIFER MCNEELY: Yeah. I mean, it's interesting. So this was back in sort of coming out of Victorian times and there were very few medications to treat anything and one of the medications that was widely used was opioids—morphine, tinctures—and a lot of people were using them and actually becoming dependent or addicted to them. And doctors were using the medication to stabilize people or to wean them off. You know different from how we use it now, but with some similarities.

So doctors were involved in working with people who were using drugs. They had become actually medically addicted, most of them. With making drug use illegal, then there was sort of a sharp separation that was drawn and doctors were told that they couldn't be involved and you could even lose your license to the extent that licensing was the same back then for being involved in treating addiction.

And we see it play out today. There's a lot of regulations around methadone treatment, which is one of the best evidence-based treatments for opioid use disorder that we have as a medication and it is the most regulated medication in the US because it's used to treat addiction, sort of the longest-standing medication to treat addiction. There are tons of federal in addition to local regulations on who can prescribe it and how it can be provided that really does stem from this early 1900s act that said that doctors can't prescribe medications to treat addiction. 

So it's changed a lot now and in fact we use a lot of medications very effectively to treat addiction as medical providers. But there's not a robust tradition of doing that. 

DR. THEA GALLAGHER: So now are primary care physicians able to prescribe methadone? Is that kind of something that has changed? 

DR. JENNIFER MCNEELY: Methadone? No. Other medications, yes. So methadone still remains…can only be provided in regulated opioid treatment programs that exist in our special regulations federally and state. But there are medications, in particular, buprenorphine and the other medication that we're able to use is naltrexone for treatment of opioid use disorder. And buprenorphine is highly effective, not more effective than methadone, but probably equally effective. There are some things that make it better for some people and methadone better for other people. But it's this interesting thing. It's a slightly different medication. But because of the way that it was regulated from the beginning of it being used for addiction treatment, we're able to prescribe that without special licensing or programs. 

It was when it was first approved, there was an X waiver. So you had to do additional training, apply for a different DEA number, a special DEA number to be able to prescribe that medication for addiction treatment. You could prescribe it for pain, and we can prescribe methadone for pain and OxyContin and many other opioids. But for the treatment of substance use disorder, you had to have a special DEA number to do it. But that actually got lifted a couple of years ago. And so now any medical provider with a DEA license is able to prescribe, though all DEA license providers have to do some amount of training on opioid. 

DR. THEA GALLAGHER: And in your work, have you found that there is any resistance or hesitation from primary care physicians with even wanting to do it? I mean, maybe they want to theoretically, but then are maybe nervous about doing it.

DR. JENNIFER MCNEELY: Yeah, I think a lot of people were very hopeful when that X waiver got lifted that…it was definitely a barrier to prescribing and to treating opioid use disorder. But there was a lot of hope that if you just lift that barrier, then the floodgates will open and people will start to integrate this just naturally into their practice. But that's not what happened and I think those of us who kind of do this work, that wasn't our expectation. It's an important barrier to remove, but there's more to it.

And I think the more to it is to help people get familiar and comfortable and primary care needs more resources to be able to actually support the providers in doing this well. 

DR. THEA GALLAGHER: Yeah. It sounds like if there's not a lot of education and training, that's naturally going to likely make someone more apprehensive about doing something if they don't feel comfortable, competent, and it's interesting, even in my psychological training, it seems like it's so siloed. You know substance use, alcohol use disorder, and yet it's something that's so integrated with so many other conditions, comorbid with so many other conditions. When you think about it, it's almost strange that that of all things has kind of been separated and it sounds like what you're trying to do is bring it back to kind of be more integrated. 

DR. JENNIFER MCNEELY: Yeah, exactly. And it's absolutely true. It's an incredibly common condition. So there's more people with substance use disorder than diabetes in the US. Probably just about 50 million people with substance use disorder. But in primary care, we learn tons about diabetes, early detection, prevention, management at every level, but we don't have anything like that, anything near that education on substance use disorder or it’s just not integrated into practice.

But at the same time, all of the things like diabetes and hypertension and depression and all of these things, when there's substance use happening, unhealthy use, substance use disorder, it complicates and has a lot to do with the management of all those conditions. And so leaving it out of the medical visit really leaves a big gap in being able to effectively treat anything.

DR. THEA GALLAGHER: It sounds like a lot of your work is really focused on detection, assessment. Can you talk a little bit about what that looks like? 

DR. JENNIFER MCNEELY: Sure. That was kind of my first line of research into this. I really started my work with this belief that this should be more integrated into medical care and when you start to ask that question of like, why isn't it? Or where do we start? Particularly with drug use, there's not information about it in medical records or in the visit. Back then, there was some good work happening, starting to happen with alcohol screening and essentially no regular screening for unhealthy drug use. So I started looking at how do we just identify this and identify unhealthy use before it's gotten to the level that it's so severe, where we could actually do more at the earlier stages to intervene and to help our patients.

So I began my work on screening and then developing screening tools that would be clinically useful and be feasible to integrate into medical care. I did a lot of work on that and we actually have some good tools now developed by me and others. And then my work sort of progressed into implementation of screening. How do you actually get this into the regular medical visit?

And now I'm working more on so what do you do next when you do uncover substance use disorder or unhealthy use? But I think screening is a necessary starting point to even know what's your population, where are the needs, and to begin to think about how to design services. 

DR. THEA GALLAGHER: Are most of your clinical tools clinician administered or are they self-report measures? How do they work? 

DR. JENNIFER MCNEELY: I'm a big proponent of patient self-administered screening. Initially, I was thinking of it as a workflow issue. So if your physician has 10 minutes to spend with you, you don't want them to spend two minutes of that asking you sort of a structured questionnaire. But then as I did more work on it, I found that just the quality of screening is much better if you allow people to fill out the form essentially themselves.

As humans we are uncomfortable and reluctant to report things that are stigmatized or that we have an internal fear of being judged about. And that's true in survey research. It's a well-known fact. And so for substance use screening as well, people are able to report more accurately what their behavior actually is when it's self-administered. And you get out of the problems that come up. 

If you were asked to deliver…there's validated screening language which is very important for the accuracy of screening. But if you as a human person are asked to ask the exact same question with the exact same words 50 times a day, every day, it's hard to do that well. And so the quality of screening, the accuracy of screening, as well as the workflow issues, make me a big proponent of self-administered. 

DR. THEA GALLAGHER: That makes so much sense, kind of even like an initial step in breaking that stigma. And then where do you go from there? Because I imagine even primary care physicians might not have any clinical psychological training or motivational interviewing training. What do they do once they have this information in a way gather more information or help the patient without making them feel judged or stigmatized? 

DR. JENNIFER MCNEELY: Yeah. I mean, I think that's the big question and the important one. I think that even before going there, the information itself does have value for informing your management of other conditions. So I think even to make an accurate diagnosis of anything, just knowing the information is valuable. But I, like you, want to do something with that information to actually help the patient. So there are a number of things, but it's an area where we need better evidence of models that make this both feasible to do as part of care and that we know are effective.

So we have some good starts on that, but there's more work to be done. That's where a lot of my research is focused now. But I think to back up, primary care physicians in particular, we do learn motivational interviewing. We do patient-centered care. We talk about incremental change with lots of conditions, weight loss, medication adherence, many, many things. So it's not totally foreign to primary care, but making that connection to substance use is something that people have similar ways of changing is the challenge. 

So there are brief interventions that are very brief and structured and feasible to do in primary care. There's strong evidence for those being effective at helping people reduce their drinking when they have unhealthy alcohol use. For drug use, which is a much sort of more varied category of substance use, there's mixed evidence, but it seems like it takes more than just a very simple brief intervention to be effective in helping people to change their use. But there are other things that we can do in primary care. 

DR. THEA GALLAGHER: It sounds like what you're not doing is, though, getting this information and immediately referring out. You're using it as part of the clinical picture. And it sounds like you said that this is almost new just to have a measure to assess this in a primary care center. So in and of itself, it's already data that you said can inform the clinical picture. Has that been helpful for physicians? Have you found that it's helpful for them in understanding a broader picture with their patients?

DR. JENNIFER MCNEELY: Yeah. I mean, I'm not going to say like across the board, everyone is asking…you know the first thing they look for is the substance use screening information. But in work that I've done where we have implemented this into primary care, oftentimes you hear these stories about patients, I've been taking care of this patient for 10 years and we could never really get a handle on their blood pressure and then the screener told me that they drink heavily. They're highly functioning. They don't even have an alcohol use disorder, but they're drinking a lot more than I would have guessed. And heavy alcohol use will drive hypertension. And so it's like this missing piece for years in taking care of a patient who was actually very willing to provide the information, but no one had asked.

And so I've heard versions of that story many, many times, even for people who were, just don't tell me to do one more thing, which I also understand and am sympathetic too. But there is clinical value to the information if you can collect it efficiently and deliver it in a way that's understandable.

DR. THEA GALLAGHER: It sounds like you've talked about the barriers of time and maybe even feeling overwhelmed by the nature of substance use disorders, or you know I'm out of my depth here. Any other barriers that you think kind of make it difficult in the implementation of this tool in primary care settings?

DR. JENNIFER MCNEELY: The culture of we don't do that here is probably the most meaningful barrier and the hardest one to break down. And I think that that one starts to break down with more comfort, more identification of these are our patients and many of our patients have substance use disorders or unhealthy use and they're not bad people and we take care of them. But because that information has been so hidden, it kind of perpetuates this idea that they're out there and we're doing what we do and we don't do that.

So I think that is…identification, all of these things kind of need to go together to address this complicated barrier of time and overburden and lack of knowledge, but then ultimately stigma. But you know I think that our care suffers if we don't take that on. It’s like I said, if there's more substance use disorder out there than diabetes, we can't just say we don't do that as part of our care. 

DR. THEA GALLAGHER: And with this idea of kind of a measure being like one more thing, or then I have to talk about it and maybe adding on to one more thing. I can totally understand for so many people working with people, one more thing can feel overwhelming. And yet if you use a measure and then you find that it does ultimately save you time or help your treatment plan or really help you to help the patient, it can almost be self-reinforcing. Is that what you're finding maybe with physicians who have utilized this, that yes, it's annoying. Change is hard. Adding another thing is hard. But if it ultimately saves me time and helps someone more effectively, then I can kind of see the benefit myself over time?

DR. JENNIFER MCNEELY: Yeah. I mean, I think that there's certainly people like me, as a primary care trained, you know medicine trained first, once you start to use especially these very effective medications for opioid use disorder, it's amazing. It's very easy to see the immediate value of that and that becomes very self-reinforcing. 

I think that anything, though, that takes time is hard and sometimes good care takes time. And that's a fundamental problem in primary care, is that time is insufficiently valued. I think there's potential to reprioritize some care and substance use care should really kind of rise to the top of that priority list when it's identified. And I think maybe other things that are of lower immediate value could be deprioritized and that there's some role for decision support or to help people use their time well. But it will add time. But it will make the overall management better. So ultimately you're saving, but maybe that day when you're running five patients behind, it's not a winning argument.

But I think also that we can't just pile it all on the individual primary care provider. We need more team-based care for this and for other conditions too, probably. But especially here, I think there's value there. 

DR. THEA GALLAGHER: Yeah, that's kind of the bigger issue of physician burnout and making sure there's resources, which leads me to wonder, you know AI can mean so many things. But even like a self-report measure in and of itself, it's like kind of digitally administered. And then you said there are even some resources that can be digitally pushed out for patients. Is there any hope that there could be an alleviating of the burden on the physician with more AI connection to resources or education or information? 

DR. JENNIFER MCNEELY: Yeah, I think so. I think the potential is there. It's all in how it gets implemented, probably. But I think particularly with the screeners that are frankly best done by patients on their own, but to have some interface to make it easier for them to do it, less technical, and to be able to provide them directly with some information is valuable. There have been models that tried to take the physician out of that picture and just give resources or make referrals and it doesn't work for a lot of people, but it's a start. 

I think the other way that technology could be really useful is in this point-of-care prioritizing decision support that's very sophisticated, that tells me, today you should address your patient's stimulant use and don't worry so much about their colonoscopy today. And where I have that and it's well-informed enough and I have enough trust in it that I can follow that guidance, know that I'll get to the stuff that I need to get to that's highest value, but acknowledges that I can't do everything every day.

DR. THEA GALLAGHER: Almost like a decision tree, but you said that there's algorithms that have been kind of created to say like, hey, this is the highest priority?

DR. JENNIFER MCNEELY: The information is out there and people are working on it. I don't know that anyone has cracked the code because it's really complicated. But there's certainly known value-based care, particularly for prevention, that can help to guide the providers to really what's the most important. But it's hard and it's complex. But I think that that is a place that technology probably has a useful role to play in primary care. 

DR. THEA GALLAGHER: Is your hope that these screeners are used kind of in all primary care settings and EHRs? 

DR. JENNIFER MCNEELY: Yeah. It's guideline recommended care from the US Preventive Services Task Force that for adults there should be screening for alcohol and for drug use in primary care. So that means universal screening at some frequency for adult patients just as part of routine care. And the evidence is very strong for alcohol, and the evidence is mixed but strong enough for drugs that that recommendation is there.

DR. THEA GALLAGHER: In another one of our episodes we were talking about even screeners in schools, colleges. Are there any other places that you hope to see these kind of screeners? I know employment might be a strange place to have it, but I don't know, it sounds like some people might not even be going to their primary care doctor at all. Is there a hope that kind of from a population health perspective that this is something that maybe is a screener in other places? 

DR. JENNIFER MCNEELY: Yeah. I mean, I think you know my focus is more on the medical setting. I think there's lots of folks who work more on broadening out more in the community. There's really strong reasoning to say, particularly for younger people who don't have a lot of interaction with medical care, that you need to look for other places to do screening. The question is, then what? 

So if there is some unhealthy use identified, you need to have an answer to that. I did some work early on in dental care, so that's a great spot. It's a medical setting with a very different kind of medical setting. Pretty easy to integrate screening in there, but then harder to make the connection to intervention or treatment. 

DR. THEA GALLAGHER: There is some debate in the field, right, about whether primary care should be the place. It sounds like you feel passionate about this. Can you just kind of tell us your reasons? 

DR. JENNIFER MCNEELY: Like I said before, I think it's part of the medical picture. It needs to be part of the medical visit. And if what we care about is improving the health of our patients, which I think is what we all care about, then this has to be part of it. I think there's a lot of controversy when you get to the, "What are we supposed to do and what works and what's feasible?" And frankly, there's been some research, but not nearly enough, to be able to say, absolutely, this is what works. This is what doesn't work in terms of intervention for substance use disorders or unhealthy use when it comes to drug use. For alcohol use, it's clear and the evidence base is robust.

So I think philosophically and also the data, the evidence is behind me, and saying that substance use is an important component of health and mental health. So there I feel very strongly. But then the controversy about how much evidence do we have now to know what to do versus what evidence do we still need is kind of where my work sits at. 

DR. THEA GALLAGHER: And it sounds like as far as risk, you know substance use detection and alcohol use detection, is so important and in some ways likely should be at the top of the chain of this kind of collaborative care model. And then it can, again, hopefully save lives in the long run. 

DR. JENNIFER MCNEELY: That's the idea. 

DR. THEA GALLAGHER: Well, thank you so much for this conversation. It was really helpful. 

DR. JENNIFER MCNEELY: Thank you. It was fun. 

DR. THEA GALLAGHER: All right. And thank you to everybody who is watching or listening to this podcast. If you enjoyed this podcast, make sure to rate and subscribe wherever you watch or listen to your podcasts. I'm Dr. Thea Gallagher, and from all of us here at NYU Langone Health, thank you so much for tuning in.