THE TREATMENT NOVEMBER 15, 2009
Harold Pollack is a professor at the University of Chicago School of Social Service Administration and Special Correspondent for The Treatment.
American drug policy has gone badly for many years. More than 150,000 injection drug users have died of AIDS. We have endured the crack epidemic and recent dislocation from with methamphetamine use. Opiate overdose deaths have tripled in the past decade, and now outnumber gun homicides in the U.S. At great economic and human cost, we incarcerate a half-million drug offenders, more than Western Europe locks up for all types of crime. Despite such policies and supply-side interdiction efforts, the street price of many illicit drugs has declined since the Reagan years. Meanwhile, alcohol, tobacco, and prescription drugs (and yes, marijuana, too) pose major public health challenges. Drug markets provide the impetus for violence in Mexico and elsewhere around the world.
Perhaps for these very reasons, this may be a propitious time to change American drug policy. Republicans and Democrats have expressed concern about federal sentencing disparities between powder and crack cocaine. Measures such as California’s Proposition 36 and New York’s revision of Rockefeller-era drug laws reflect bipartisan desire for less punitive approaches. Medical marijuana ballot initiatives enjoy political success.
The White House Office of National Drug Policy--better known as the drug czar’s office--has been at the center of drug policy for two decades. For most of this period, ONDCP has operated as a bully pulpit for conservative culture-war politics on marijuana, needle exchange, and other matters. Drug czars William Bennett, Barry McCaffrey, and John Walters frequently tangled with the medical and public health communities.
The Obama administration has struck a different pose with its selection of progressive Seattle police chief Gil Kerlikowske to direct ONDCP. One of his most noticed moves was to appoint Tom McLellan as his Deputy Director and right-hand man. McLellan has been a prominent and blunt drug treatment researcher for many years.
McLellan and I held a blunt, wide-ranging Curbside Consult at his Washington office regarding needle exchange,medical marijuana, global supply-side enforcement, prescription drug abuse, overdose prevention, and why so few people with substance abuse problems are in treatment programs. (Believe it or not) the interview has been edited for space, and also to mark the transition between written speech.
Pollack: You cut your teeth with a generation of Vietnam-era vets and servicemen. Now we’ve got people coming back from Iraq or Afghanistan who are having some problems of their own.
McLellan: I was not sent to Vietnam, but I was a Vietnam era veteran. At the end of 1974 when I got out of the Army and graduate school, there were no jobs. So, I said alright if I can't get a job doing animal learning psychology, I'll at least go live where I want to live. I bought a small farm in Central Pennsylvania. I went to the Coatesville Veterans Administration medical center and asked: Do you have anything?
They said: Yes, we have a job as a research technician in a brand new thing called a drug addiction treatment program: $14,178 as a technical assistant. I said: “I am your man.” So I can remember getting off the elevator at the Drug Dependence Treatment Center, and there was a whole group of guys dressed exactly like me. They had part of their fatigues on. They had their army boots on. They were ragtag. They were exactly my age. It was fascinating from, quite literally, the moment I got off the elevator… I didn't know anything about [drug treatment]. Nothing in my career had prepared me for this.
I was supposed to evaluate various things that they were trying out. I had the advantage of not knowing a God damn thing. I asked a lot of questions…. Then it went on from there.
Then, 27 years later, I walked out precipitously. I was truly fed up. I was fed up with the Veterans Administration. They had, as far as I'm concerned, lost their soul. It was the era of managed care, and the VA was doing, frankly, unethical things. They wanted me to go to a shopping center and give free blood pressure tests to veterans that were at the shopping center. If I did this, I was to get their Social Security number. This counted as a visit and a new “social.” I found it unethical. I left.
Now, it’s 2007… I went to the New York VA, and I swear to God I thought it was back in 1975. There were younger patients, a whole bunch of young physicians, a palpably different atmosphere: “Let's try something. Let's solve something. We can do stuff,” all of this kind of stuff. I think it's really quite a turnaround for the old VA.
Challenges in substance abuse treatment
Pollack: You've suggested that maybe 10% of people with drug disorders are in the treatment system. How do we change the way we think about drug policy if we say most of the people with drug problems are never going to be in treatment, and are certainly not in treatment now?
McLellan: It's a great question, and I've got a couple of answers to it. The first is a clinical answer. You ask most of the clinicians in this field, and they are not surprised at this. Indeed, that's what they expect. They say, “After all, addiction is a disease of denial. Patients with these symptoms don't realize that…la la la.” That's why we need to force more people into treatment. Part of the treatment process is breaking through this denial…
You probably know about all of these confrontational methods. They even have a TV series about these interventions. Perhaps you can tell from the tone of my voice, I about half believe that. It's not that I haven't seen it. It absolutely is true that people are in denial, but it's such a facile argument: “It's not our problem. It's their problem.”
I’ve worked with people at the Wharton's school since about 2002. They have such a different perspective on exactly the same data. A guy named John Kimberly, a professor at Wharton, looked at [the low rate of people in treatment] and said, “Wow, what a business opportunity you have. Look at all of these untreated people. It's a shame you don't have any interventions that your customers want.”
We've also got to intervene earlier in ways that aren't quite as threatening, that enable people to take control of an issue that they may not be able to understand is hurting their quality of life. I'm very interested in, and this office is very interested in, screening and brief interventions.
Hypertension is a silent killer. People don't know they have it, it doesn't have any symptoms. When you take the medications, you don't know that anything went away. So people drop out of that all the time. Indeed, that's one of the efforts in hypertension is to try to intervene in ways that will get people to take notice of, and control symptoms, while they can.
The other thing, without question is, we've got to develop much more attractive, engaging, enduring treatments. If this is largely, at least today, about lifestyle management, that's what treatment really is. There are stages of it. There's an acute phase where you have to arrest the emergency symptoms. But after that, it's realization of the problem and lifestyle management. Just like any other business, we've got to come up with an engaging way of selling a new and healthier lifestyle. Because it's hurting us financially, it's hurting our kids and our lives.
Pollack: If you look at the National Institute on Drug Abuse’s Principles of Drug Treatment, it highlights the fact that outcomes look as good among people who are coerced into treatment as people who enter without explicit legal pressure.
McLellan: That's a fact. There are a lot of people who just go kicking and screaming, biting and scratching. And they end up saying thank you so much. Gil Kerlikowske experiences this all the time. He gets thanked by people he's arrested, because he's forcibly stopped them from being out of control.
But it's also so facile. It's such an attractive thing to say: "I k
now best for you. You're an out of control drug addict or alcoholic; do what I say, I don't have to listen to you.” So, that's such a seductive kind of approach. And I don't think it's fully justified…
Pollack: It also seems as though we have to have more interventions for people who are just not going to be in formal treatment…
McLellan: Yeah. I think that's right…. That's a harm reduction approach as a matter of fact.
Harm reduction and syringe exchange
Pollack: Let the record reflect that someone in the Office of National Drug Control Policy has used the words “harm‑reduction.”
McLellan: For the record, we have a very simple way of describing this. We support all harm reduction efforts that also reduce drug use. Why do I say it that way? Because we believe drug use, itself, is harmful. Notice that I didn't say “eliminate.” I said “reduce.”
Pollack: Of course the follow-up question has to have the words “syringe exchange…”….
McLellan: We do not think it's reasonable to sustain the federal ban on funding for needle exchange, period. That is the guts of our view, even though there will be nuances to the ultimate Obama administration policy guidance that have yet to be worked out. We've talked a lot with the AIDS people. ONDCP never used to collaborate with the AIDS office, but we actively sought out and have a great collaboration with Global AIDS Ambassador Eric Goosby, Jeff Crowley at the White House AIDS Office.
Based on the review of the research literature, we see no basis for forbidding the use of federal funds for needle exchange. Why? Because the dire predictions simply haven't come true. Wherever we look we don't see increases in drug use, increases in HIV, needles littering playgrounds, all that kind of crap.
… I wasn't an expert on needle exchange. I knew about it, but I wasn't an expert. So I did the research, and then I talked to Eric Goosby. I talked to Jeff Crowley. They were really shocked when they walked into this office and sat where you're sitting. They expected a fight. They expected I was going to say, “Now let's see what we can do to eradicate any needle exchange.” The research simply doesn't support that. So they were already there. They are experts in needle exchange. They had already gotten there, and so it did not take us much time at all to come to a sensible consensus.
But, we also don't see massive reductions--from needle exchange by itself--in HIV and any of the other diseases--nor should we, by the way. I think that's too much to ask, actually. Especially at the point during most infectious cycles when needle exchange is instituted. When it's early in the game you have a shot of preventing new infections.
Our policy may in some ways be better called advice, because no matter what happens with federal funding the big decisions about needle exchange will be made mainly at the city and county level--health departments, mayor’s offices, places like that. And our advice is that we think needle exchange has its best results when it is part of a broader public health strategy for people with substance abuse problems: one that engages patients, brings them in, treats their other conditions to include their substance use.
Narcan distribution is very similar in principle to the position we have with the needle exchange. Narcan distribution is not dangerous, per se. [Well] there is one danger, and that is that so many of these long acting opiates out there like Oxycontin, for example. You could overdose, and you could self inject or your buddy could inject you with Narcan IM intramuscularly. And no danger, and all that. You will come out, which is a great thing, but you may imagine, “OK, saved. I'm OK now.” And that Narcan will wear off in 20 minutes, basically. And you could go back into overdose.
So we don't think the best way is to have just any old buddy do it. Instead, we're suggesting real, significant increases in availability and training for anybody in a public service position, to include cops, ambulance workers, all the ERs, school nurses, homeless shelter staff, everybody. Those people have some kind of public health service responsibility. And we think part of that would be to ensure that people who OD get additional care. Like they may have fallen down and had a concussion as part of their being in the OD. They may have infectious wounds. They may have HIV. They may have drug dependence. They may have a lot of things that can be treated.
So we suggest--and this is advice--that Narcan be distributed through an expanded array of public health service venues. And that it is best considered as part of a broader public health program. Make services available. And you know? I think I'm right about that, because imagine somebody says, “All right. Yeah. Let's make that Narcan available, but I don't want to spend any real resources on drug users. So let's just give it to them, you know? Make it available under that bridge on I-95, along with those syringes. But that's it. No more healthcare than that. Screw them. I don't care about those guys.” That would be wholly unacceptable. That would be unacceptable to me, and I would hope that it would unacceptable to most people.
So there will be people who say, “Eh, you're still trying to restrict availability.” I don't want to seem that way. I don't see it as restricting. I see it as trying to provide sensible, reasonably comprehensive care to people who desperately need it. People will disagree. But anyway, I think you can tell, our policy stance is very different from, “Thou shall never have syringes. Thou shall never have Narcan under our watch.” We don't feel that way. We don't think the evidence supports it; whether I feel that way or not is irrelevant.
Marijuana use, medical and otherwise
Pollack: …. California does a medical marijuana ballot initiative, to take a random example. States do things that are contrary to the general tenure of the policy of this office and maybe to federal policy at large. Attorney General Holder has basically said: “California has made a decision. We've got scarce resources, and we're not going to get in the way of that.”… How do you negotiate that federal/state set of issues?
McLellan: A very tough question. I'm still very new at this. And I don't speak entirely for the office, so I'll give you my personal reactions. In the narrow scope of things, the idea of being judicious about the use of your federal prosecutorial resources is first of all the Attorney General’s call and second of all probably smart. You've got a rapist and a marijuana user. Who are you going to go after? OK.
But, I'm disappointed that it was done with such drama, and that ONDCP and DoJ did not better-coordinate the policy’s release and answer questions about it side by side. For the first 3 or 4 days, the policy was spun in the media as a stalking horse for legalization and political activists claimed it meant all these things that it didn’t. That happened in part because we didn’t have a clear, coordinated message across the government. This administration, certainly including ONDCP and the Department of Justice, opposes marijuana legalization and believes that it's worth it to try to reduce availability of marijuana. Normally we work well together on that and a bunch of other issues. We just didn't work very well together on this one, in my opinion.
The issue of marijuana has been interestingly framed by legalization activists. It's been framed as, “Marijuana's not bad for you. In fact, it's really medically good for certain people.” That was extremely cleverly done, because we could debate that all day long with existing evidence. How bad is marijuana? Is it as bad as alcohol? Does it even have some medical benefits for people that have nausea or glaucoma and all that?
Well, that's not what's at issue. What's at issue is: there are efforts being made to increase the availability, and thus the use, the penetration if you will, of marijuana use. In order to show that availability expansion efforts are sensible and that we should reverse policies and laws and everything else, it seems to me the argument to be proven is, “It's good for you.” That should be the standard, rather than “Marijuana's not that bad.” Name for me another substance that you would say, “It's not that bad, so let's reverse state laws. Let's increase availability to a product that really is targeted to young people.” For that, you should have to prove that it’s genuinely good, not just “not that bad”.
And our position is very simple on this, and I think, frankly, you can't refute it. Marijuana is not good for you. You have to get that one exactly right. I didn't say, “Marijuana's not that bad.“ I said, “Marijuana's not good for you.” And more people using marijuana is not good for society. And I believe these to be facts, by the way….
It is possible to reduce availability, not eliminate, but reduce availability. It's already been done. It is possible to prevent abuse of marijuana, and it's possible treat marijuana and other drug addictions. If you do those things, you have a better socially functioning society.
The other artful thing that's been done by advocates about marijuana is that it has been pitched on one side of the base, “You know, marijuana's not that bad for you. OK? And by the way, the only alternative to legalization is mass incarceration, which is really bad and it's really expensive and all that.”
It's a beautifully crafted, misleading argument. Our argument's entirely different. Nobody wants mass incarceration of marijuana users. Jesus, Mary, and Joseph--what a waste of money that is. But, marijuana's not good for you. So we need policies that keep marijuana illegal, are sensible, and that reduce availability and use of marijuana. And those policies--unlike the current legalize and tax proposals being floated --could generate revenue for the public. A city or state could generate a lot of revenue through fines for marijuana users.
Pollack: In my own public health work, I don't really do that much with marijuana. It’s striking to me that marijuana is such a touchstone of drug policy debate.
McLellan: It's the center of the universe. Yeah (laughs). With all the really serious problems that we've got facing us--prescription drug use probably among the top, and you know, name the other drugs, why we're spending this time on this nonsense about medical marijuana and legalization. It's the damnest thing to me. I can't get over it. It’s almost as though there were a contingent of people out there really eager to keep it at the front of the newspapers. Well, it isn't us. We don't want it there.
Pollack: There's a culture war in which marijuana is one of the key fronts.
McLellan: People make a living debating this on stage. You know? That's hard for me to believe, that there's a living to be made going around debating about marijuana's benefits and why you ought to legalize drugs and crap like that. It's just like a silly discussion to me.
Pollack: Your office has pretty much been anathema within the public health and progressive communities for a long time. How would you describe what you’re now doing?
McLellan: Two words: we are seeking to add value in the world. That requires a couple of things. One, it requires knowing who your customers are. We don't make anything at ONDCP. What we really are is the hub of a trade organization. As such, we have a number of customers, patients, organizations that deliver prevention and treatment services, states, trade organizations, the doctors, the nurses… And another set of customers are agencies within the federal government and indeed entire countries that have drug related problems.
To do business, what we really have to do is to show sensible ways of addressing substance abuse issues will add value to our customer's agenda. In health care, can we add value to primary care? I think we can. We can help them with pain management, things they aren't thinking about with addiction. Science can help them with this. I think we can help business do better with more sensible insurance policies, and employee assistance programs. Schools want to make kids more competitive. They want to reduce drop out, depression, bullying, early teenage pregnancy. Helping them incorporate addiction prevention, substance use prevention, into their repertoires can help them achieve their goals. If we do that kind of stuff, we will not be isolated, and we will be appreciated.
Pollack: You must be getting pushback from some of the traditional constituencies that look to ONDCP for a particular viewpoint...
McLellan: One, from a purely monetary perspective, we're not going to get pushed back because we're not saying “supply reduction, we want your money.” We're specifically saying we think it's time to rebalance, specifically, bring demand reduction funding efforts to become an equal contributing partner with supply reduction.
From quarters that you might imagine to be competitors with us, specifically, the police and the courts, we're getting total cooperation. Indeed, Gil Kerlikowske has had most of the police organizations in the country in our conference room, at one point or another. At one point, near the end of one such thing, I whispered to Gil: “I thought you told me these guys were cops. They're not cops. They're all social workers and treatment guys.” Every single one of them wanted more treatment and more prevention--every single one.
Now the third potential source of pushback is from the traditional demand reduction quarter: traditional prevention and traditional treatment. I think there's going to be some upset there because we're not suggesting let's keep doing things the 'good old fashioned way'. We're asking for rather different ways of approaching the purchase, evaluation, and delivery of prevention and treatment programs.
Evaluating law enforcement measures
Pollack: You talked about striking the right balance…. When you talk about treatment, people say: “Show us the data.” There's a real demand among policymakers: show us that this is effective. Show us that this is cost-effective. Yet when you look at the criminal justice side of the ledger, not only is there no evidence, but there's not even a demand from policymakers that there be such evidence.
McLellan: It's funny that without demand, you don't get any product….
Pollack: In fact the evidence we have, such as declining street drug prices since 1980, is not particularly encouraging. So how do we bring an evidence‑based perspective to thinking about that side of the ledger?
McLellan: I've noted that as well; we all have. Yet let's take a look at contemporary Mexico. I've just been down there. I haven't been to the most severely‑affected places, but I've been to several other places that have been affected… The fabric of society is quite literally coming apart. There's widespread corruption. There's murder; most of the murders are not even reported. The violence is unprecedented and vicious. Now if you were a citizen there, what would you want? I always ask: “Do you want group therapy, or do you want helicopters and flame‑throwers?” “Give me the helicopters and flame‑throwers. I'll do the evaluation later.”
So much of the response to particularly drugs ‑ much less so for alcohol ‑ has been born of emergent problems at the fundamentally social level: lawlessness, school violence, robberies, on and on. So people don't react in planned, contemplative ways ‑ and frankly, I don't blame them. Now when it finally gets down to the point where you say: “Well I guess we've locked Johnny up, but I'm still quite skeptical that this by itself is enough,” you have the luxury of saying: “I wonder if adding some medications or some counseling or some preventive services would be helpful?”
Everything that we do has to be evaluated, but I do take your point too. Even if soldiers and cops and armored personnel carriers are employed, there still needs to be an evaluation, especially at the macro strategic level ‑ and there hasn't been.
Pollack: I do want to get to the prescription drug issue…. That's a different challenge from heroin or cocaine. How do we have to think differently in terms of the public policy in dealing with Ritalin, Oxycontin, and the rest?
McLellan: That produced a major pivot point in my thinking, on a number of fronts. First of all, think about this with regard to the drug legalization issue. People argue for drug legalization saying that we can control legal drugs easily: Kids won’t get them. Adults have the right to use and all that. Well, prescription opiates provide one of your best examples of this model. They're tightly controlled by the FDA and DEA. You can only get them, supposedly, from a doctor's prescription. Doctors are trained to know when to prescribe and not prescribe. Yet, in what should be an ideal circumstance‑-and there's obviously known benefits from prescribed opiates--in 16 states prescription drug overdoses are now higher than car fatalities as a cause of death. It's unbelievable. In my lifetime, I never thought I would see that. So that's the first thing, prescription drug overdose, that's turned my brain around.
I also got to thinking about international supply reduction policies. There's been a very convenient mythology for quite a while: The drug problem is one where rogue third‑world countries produce these poisons, and they ship these poisons mercilessly to our innocents within the country. Therefore, we must make war on these countries and those who would use, and we need aggressive, massive interdiction efforts. And we must force these drug producing countries, drug transiting countries, to stop their nefarious schemes to destroy our life.
Now that is probably a bit overstated but I could argue it's not way off the thinking that's been going on for a very long time--I'm not just talking about the last administration, by the way--a very long time.
Well, the five major drugs that I know of in this country now have one thing in common. And I'm talking about tobacco, alcohol, prescription drugs, most marijuana and most methamphetamine. What do they have in common? Made in the USA. We are a drug producing country now.
But wait, there's more. It turns out that Mexico, Honduras, Colombia, Venezuela, lots of these countries are coming to us now for help with their internal drug demand problems. So what have always been considered drug producing countries, now they are having significant internal addiction problems.
So I've begun to revise the way I think about things, and I've had help in doing that with the latest economic crisis. I think there are a lot of parallels. We got ourselves into this mess and it's terrible. More importantly, even though we're the biggest country and the one responsible, we can't get out of it by ourselves. We have to use all our efforts to assure that these partner countries of ours have themselves got stable economies and stable, sensible trading patterns in order for us to extract ourselves from the economic mess that we're in.
I think exactly the same thing can be said about the drug problem. We produced most of the world’s drug demand. We're the biggest market, we have been. But that's changing, too. Russia, China, other countries certainly per-capita are eclipsing us. Like these drug producing countries, we can't get out of our own drug problem without collaboration and cooperation with other countries. These countries that have been our enemies in the war on drugs have got to become our partners. We've got to help them solve their own internal problems and they have to help us work jointly to reduce drug transit.
Pollack: One of the striking things about American drug policy is the ambivalence that we've had about the sovereignty of other countries….
McLellan: Right. Even when US aid has been provided it has been resented by many within the country.
I will also say something that I wouldn't have said before I came to this office. I don't think it's fair to say that it's all been for naught. Stick with the Colombia example for a moment. I think some of that stuff has helped Colombia. I think that it stabilized the government and enabled them to get back on their feet. But was it worth it in terms of our image around the world? Was it worth it in the benefits to our own internal drug problem? I wonder.
Doing the job in Washington
McLellan: It's a difficult job for me, and I think it would be a very difficult job for any person with a research background, because you simply don't have the time to be contemplative. I run around all day long, stupid most of the day… (laughter)
There just is such an array of issues that come through here where you have less than an hour to make a decision or issue a statement or develop a talking point…. There's not a single scientific paper I ever published that wasn't like the 10th or 20th draft. “Now we need a statement on medical marijuana, and we need it in 20 minutes.” You basically draw on your instincts and your relationships and the principles that you've learned, but you rarely have the opportunity to draw upon the contemplative, methodical research that you'd like to. The pace is just too fast for that.