Drug Czar: Treating Substance Abuse as a Crime is “Inhumane”

February 23, 2016
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In 1988, Michael Botticelli woke up handcuffed to a hospital bed, injured, and under arrest for causing an accident while driving drunk on the Massachusetts Turnpike. A judge gave him two options: Seek care for his drinking problem, or go to jail.

Today, 28 years later, Botticelli is not only sober, but helping to shape a dramatic new approach to how the United States confronts drug and alcohol abuse. As the first former addict to run the White House Office of National Drug Control Policy, he has a different perspective from any of his six predecessors.

For nearly three decades, the war on drugs meant that low-level, nonviolent drug offenders would receive stiff mandatory minimum sentences. While that drove the prison population to record levels, critics say it did little to solve the problem of addiction.

“We’ve come to understand that our largely punitive responses to people with substance abuse disorders is ineffective,” says Botticelli. “It’s inhumane. And it’s costly.”

As the nation’s drug czar, Botticelli says substance abuse needs to be treated as a public health issue. “Law enforcement has a role to play,” he says, “but our efforts need to be focused on increasing prevention, treatment, supporting people in recovery.”

In the below interview with FRONTLINE’s Martin Smith, Botticelli talks about his own struggles with addiction, the nation’s heroin and opioid epidemic, and why he says “we can’t arrest our way out of our problem.”

This is an edited transcript of an interview conducted on Sept. 16, 2015.

Let’s talk about the moment we’re in here. You are a public health professional. You’ve come into this job after a long line of generals and police chiefs, and here we are in a moment in which we’re rethinking how it is that we’re going to think about drug abuse, drug addiction, all of these things. Why now?

I think my nomination and my confirmation and my background and personal history around these issues are really emblematic of a growing consensus of where we are in drug policy, not just in the United States but around the world. …

I think the basis for that is really rooted in a number of different things. One, our scientific understanding of addiction has just grown tremendously. … We know that this is a disease like any other chronic disease, that it has genetic components to it and environmental factors to it.

I think also we’ve come to really understand that our largely punitive responses to people with substance use disorders is ineffective. It’s inhumane, and it’s costly. And what I think is really important to note is that this consensus is without a political battlefield, right? We see people from the far left and the far right coming to agreement that we can’t continue to sustain our historic approach as to how we’ve dealt with addiction and substance use.

There are racial questions in this, that we applied this sort of an incarceration model when the majority of drug users were black or brown. Once white people started doing these drugs, we started to talk about other models. Is that unfair?

I think there was a growing consensus, particularly with this administration, that we needed to really deal with the historic racial and ethnic inequities in our prison system, and that’s been largely focused on people of color who have been incarcerated, many of whom are there as low-level nonviolent offenders around drug-use issues. But I do think that there is a building conversation and recognition not just as it relates to people of color, but as it relates to people with substance use disorders in general that this has been an ineffective approach to what we’re doing.

You were watching this from Boston, where you were working in public health and drug policy. But you were starting to see these shifts going on in Washington. Did you ever think you would be here?

I didn’t. Particularly as someone with a history of addiction, I didn’t ever think that I would end up being the White House director of National Drug Control Policy. It was very startling to see the shift under President Obama and then-Director [Gil] Kerlikowske.

I recall being on a telephone call when the administration released its 2010 inaugural strategy, and I heard things that I’d never heard from federal drug policy, things like: we can’t arrest our way out of our problem; that we have to deal with this as a public health-related issue; that law enforcement has a role to play but our efforts need to be focused on increasing prevention, treatment, supporting people in recovery. It was really startling for me to hear that kind of change coming from this office. I think the history of this office, while it’s been evolving, was largely focused on law enforcement-centric approaches to dealing with the problem of substance use in the United States.

“We’ve come to really understand that our largely punitive responses to people with substance use disorders is ineffective. It’s inhumane, and it’s costly.”

Still the balance of your budget, not by a wide margin, but still most of the money is for interdiction and law enforcement.

If you look at our drug control budget writ large, you’ll see that the biggest increases that our budget has taken have been on prevention, treatment and recovery support services. Spending on those public health approaches is now at its highest level that it has been within the administration.

But it’s still less than interdiction and enforcement.

Well, I’ll say this: that when you look at supply reduction efforts, some of those areas are not just typically law enforcement approaches. They’re about institution building with other countries. But I will also say, too, that I have seen a remarkable change, particularly with domestic law enforcement and their approach to how they’re dealing at a community level with people with addictive disorders. So law enforcement, I think, understands that we need to have good prevention and treatment services.

I’ve seen law enforcement across this country understanding that we can’t arrest our way out of the problem. When I hear that echoed back to me by local police chiefs and law enforcement folks, I know that we’re continuing to make progress on understanding at a community level that arrest and incarceration are not appropriate for the vast majority of people who have substance use disorders.

So while we do still spend dollars on domestic law enforcement, I think it’s important for our communities to not be riddled with substances in their communities. That’s really important. But what I also see is tremendous partnerships happening between public health and public safety advocates really calling for a balanced, holistic solution to this problem.

[Editor’s Note: On Feb. 9, 2016, the White House announced that under the administration’s 2017 budget, federal efforts to reduce the demand for drugs would for the first time be funded at similar levels as efforts to reduce the supply.]

You talked about getting on the phone and listening in on a call and hearing things that you were really floored that you were hearing. It was Kerlikowske who said, “We’re no longer going to call this a war on drugs.” What do you remember when you heard that?

If I remember him correctly, he said, “A war on drugs is fundamentally a war on people.” Framing it that way I think for me was a real eye-opening experience around how we’re dealing with people.

It also promoted things like reversing overdoses by police and supporting things like syringe-access programs. … It really was for me a very, very clear signal from the Office of National Drug Control Policy that they were clearly pivoting away from a war-on-drugs approach to really how we think of a much more compassionate and humane response of dealing with drug use and its consequences.

You’ve talked about your own personal history. Though you weren’t primarily abusing an illegal drug — you were abusing alcohol — I’m interested in how you reacted to, you know, “Let’s treat these people not as criminals; let’s treat these people as people with problems.” You must have related to that.

My personal experience significantly guides my work here, and clearly, I can look back on my own experience that, as a result of a drunk-driving accident, I was offered a choice by a judge who said, “Get care and treatment, or we can continue to pursue prosecution as it relates to your drunk driving.” So I had the opportunity at that point to get care and treatment, and was diverted away from the criminal justice system. That’s what I want to see for everybody. …

I’ll also say that my own trajectory really indicates how we need to regard this as a chronic disorder. I, like many people, started drinking from a very young age. I had a history of addiction in my family. Unfortunately, my drinking and my addiction was undiagnosed, unchecked by anyone within the medical system.

We know that we don’t have to wait for people to progress to their most acute disorder or, unfortunately, wait until an intersection with the criminal justice system identifies people with a substance use disorder. Part of what we’ve really been trying to do is reframe addiction as a chronic disorder that has components of early onset, so focusing on prevention, doing a better job at identifying people earlier in their disease progression, and getting people care and treatment before it develops into this acute disorder. I often say — and you’ve often heard the expression that people have to hit bottom before we get care. That is ridiculous.

We don’t say with any other disease, “We’re going to wait till you reach your most acute stage before we decide to intervene.” So if our understanding of addiction has changed, that it is a chronic disorder, we need to mirror other disorders in terms of their care, intervention and treatment.

Is there any difference between the abuse of alcohol and any other drug? Does the analogy carry over, I mean, that they’re all chronic diseases?

They’re all chronic diseases, and there are very similar biologic and development components to addiction. So whether it’s alcohol, marijuana or other drugs, there are similar issues and properties that all substances share as it relates to addiction.

Somebody’s going to be listening to you and they’re going to say: “Well, he was using alcohol. That’s not what we’re talking about here. We’re talking about illegal drugs.” So they don’t necessarily immediately make the connection between you as an alcoholic and a drug addict using heroin, meth or crack cocaine.

Well, you know, I think you had talked to Dr. Nora Volkow, who’s the director of the National Institute on Drug Abuse, and she’ll tell you addiction is addiction is addiction. Just because my substance of choice happened to be alcohol, that doesn’t mean that I can pick up or use another substance safely. …

“You’ve often heard the expression that people have to hit bottom before we get care. That is ridiculous. We don’t say with any other disease, ‘We’re going to wait till you reach your most acute stage before we decide to intervene.'”

The Affordable Care Act is signed in March of 2010. You said it was one of the most important things that we’ve seen.

Yeah. Significant drug policy change in a generation.

And tell me why.

We know that unfortunately only about 11 percent of people who have a diagnosable substance use disorder get care and treatment. When you look at the reasons why people don’t get care and treatment, one of the biggest reasons is not having insurance coverage, or not having insurance coverage that appropriately treats addiction.

The Affordable Care Act does two remarkable things. One, it says that substance use disorder benefits are part of an essential benefit package under the Affordable Care Act. The second thing that it does, it says for insurers who offer coverage, they have to offer that coverage just the same that they would any other medical surgical condition. That is huge in the sense that if we know that insurance coverage is a significant obstacle for people seeking care, that the Affordable Care Act dramatically changes people’s ability to access care and treatment.

Somebody’s going to say, “Well, can we really afford that?” And they’re going to say: “These people have made a choice. This is not something that we should be rushing in to and providing them a health care benefit.”

We actually can’t afford not to do it. That untreated addiction has such an economic toll on our medical system, certainly on our criminal justice system – there have been numerous studies to show the economic return on investment by offering people care and treatment for their disorder.

And I quite honestly think that that’s one of the reasons why we are seeing broad-based support for not only care and treatment, but criminal justice reform. It costs us tens upon tens of thousands of dollars to incarcerate someone. We know that it’s much more economical to give them care and treatment than it is to incarcerate them.

Can you put any numbers to that?

Most of the studies that I have seen have shown for every dollar that you invest in treatment, you save about $7. Those benefits usually are in medical expenses and criminal justice expenses. …

Do we have enough treatment spots to provide everybody that has an addiction problem with adequate treatment?

As I’ve traveled the country, and I think particularly now in the midst of this opiate epidemic, we know that we need to do a better job of expanding treatment access. That’s why this administration continues to fund treatment services and resources for state and local treatment programs.

[Health and Human Services] Secretary [Sylvia Mathews] Burwell just announced $100 million in new funding going to community health centers, which are often a place where newly insured people get care and coverage. So we continue to support treatment and treatment access, and will continue to support increased resources to ensure that people have adequate access to care and treatment.

We want to get to a point where we have treatment on demand, just like we do with other conditions, that when people are identified or when people step forward to need care, that we have a place for them in a good, high-quality treatment program.

That includes medically assisted treatment.

That includes medically assisted treatment.

Like methadone.

Like methadone, like buprenorphine, like Vivitrol. Like any good evidence-based program.

People don’t want those kinds of clinics in their neighborhoods.

It’s really unfortunate that many communities, despite the fact that they often have, and are quite honestly subjected to the consequence of untreated addiction in their community through violence and crime, often don’t want those kinds of treatment programs in their communities.

I think it’s really based on a misperception that this is someone else’s problem, this is not a problem in my family or my community, and that it’s going to be a magnet for crime and for addiction when all of the evidence points to the exact opposite.

… The epidemic of prescription drug use in the United States and the increased heroin use in many parts of the country is really changing that conversation, and communities are coming to understand that they do need good community-based treatment programs and that they know that it’s having an effect on their communities.

I want to talk about this problem of prescription drug use leading to heroin. How did we get to the mess we’re in?

Having spent a lot of time in this work, the prescription drug epidemic really came from a different set of circumstances, right, so not a cartel coming into our town selling prescription medications. … It was about, I think, a gross misunderstanding in the medical community, often driven by the pharmaceutical industry, on underestimating the addiction properties of these drugs.

These were legally prescribed substances, right? So we know that people think when you’re getting these prescriptions that they’re safe, that they’re beneficial. We know in this country that we had a significant problem in terms of undertreatment of pain, but we also had a significant misunderstanding about the addiction potential for these drugs, that we gave them in such vast quantities that it generated a significant amount of addiction.

So here’s a bottle.

Here’s a bottle.

Take four of these a day for a week.

And I would even say beyond week — sometimes for months, sometimes for years. And [we] really did not adequately understand the addiction potential of these drugs. So this came at us in a different way. It was an epidemic that was driven by the vast overprescribing of prescription pain medication in the United States.

Isn’t there a profit motive here? How is it that a company could push these drugs as aggressively as they did? And how is it that the doctors didn’t know the addictive properties?

If you look back at the history, the basis for the marketing of these substances and the scientific understanding was based, quite honestly, not on very good research that showed the addiction potential for these medications.

… No one’s arguing that we don’t need to adequately treat pain in the United States, but our understanding and monitoring of people who are on these medications, who went on to develop significant prescription drug disorders, has been startling and shocking.

So when you look back at the genesis and the development of prescription drug misuses in the United States, you can track that. It correlates identically to the amount of overprescribing that’s been happening here in the United States. A recent survey by the Centers for Disease Control shows that in 2012, we were prescribing enough pain medication to give every adult American 75 pain pills.  Again, we want to make sure that pain is adequately treated, but we just don’t have that much pain in the United States.

You know, I have my own personal story, as many people do, around being prescribed these medications when a medical practitioner knew I had a history of substance use disorders. … We know that medical practitioners get very little training in their residency programs and beyond around addiction in general and in particular around safe and effective opioid prescribing.

Talk about how we got from overprescription of pain relievers to a heroin epidemic.

Sure. So prescription drugs and heroin are very similar in many components in terms of they are both opioids, and they act in very similar ways in the brain. What we’ve seen is that about 5 percent, so not the vast majority but about 5 percent of people who misuse prescription pain medication begin using heroin.

But if you look at newer users to heroin, four-fifths of them, about 80 percent, started using opioids by misusing prescription pain medication. We’re really trying to unravel the exact circumstances of why people transition. One we know is an economic standpoint, that as people progress in their misuse of pain medication, buying those medications on the street is often much more expensive than heroin is.

We know that heroin supply and purity really has led to that transition from prescription drug to heroin, and we know that addiction in general is a progressive disorder and that people often progress to much more impactful substances just as a function of their addiction.

So I think it’s really important for us to think about how do we intervene for people who have a prescription drug use issue so that we are preventing them from transitioning to heroin use. But we know that the current increase in heroin use in the United States has been driven by prescription drug misuse.

So why aren’t doctors being trained effectively to recognize the problem?

Many states have already passed state legislation to require some minimal level of continuing medical education. Part of our strategy is continuing to push for federal legislation. …

What’s the resistance?

… We’ve seen significant pushback from the medical community in terms of what they see as another government mandate. My position, however, is we’re in the middle of an epidemic, and requiring a physician to have some level of minimal medical education on safe and opioid prescribing is not an undue burden when we have 120 people dying every single day of a drug-related overdose — and many of those are on prescription pain medication.

What position have the pharmaceutical companies taken?

I think the pharmaceutical companies have been helpful in terms of understanding our need for enhanced medical education. Actually, many pharmaceutical companies are now required by the FDA to provide what’s called risk-mitigation strategies and training for prescribers whose pharmaceuticals are being used particularly for chronic long-term therapy.

“No one’s arguing that we don’t need to adequately treat pain in the United States, but our understanding and monitoring of people who are on these medications, who went on to develop significant prescription drug disorders, has been startling and shocking.”

We’ve been looking at various drug treatment programs out there, and there’s some interesting experimentation going on. Talk a little bit about what you think is working and where we’re going, especially when it gets to programs like the Law Enforcement Assisted Diversion. We’re looking at some heroin addicts and their involvement with LEAD.

… For many, many years we’ve seen the explosion of drug courts in the United States, which I think are a really good model. But I think what we’re interested in is this continued evolution, quite honestly, of street-based diversion opportunities that we see.

I think LEAD seems to be a promising program. We’re continu[ing] to look at the evaluation of LEAD program to make sure that we have the best scientific understanding of the efficacy of that program.

The other piece that I think is really remarkable is, as I’ve talked to law enforcement folks across the country, that they are taking it upon themselves to establish relationships with treatment programs and moving people toward care and treatment.

I’ve talked to the police chief in Gloucester, Mass., who really did a remarkable thing when he said that anybody in Gloucester, Mass., who needed care and treatment could walk into the police station, and the police would find a treatment program for them and would actually help support them through the duration of their early recovery program. I’m tremendously heartened by the broad-scale understanding that police can play a huge role in terms of street-level diversion tactics. So our office is continually interested in effective and evaluated programs that can demonstrate diversion opportunities and set people on a path to recovery.

The critics would say that we’re taking the stick away from the police, we’re taking the stick away from society, and we’re enabling people to go into treatment programs without any real disincentive to stop using.

We’ve tried that approach. We’ve tried the punitive approaches before, and we’ve seen that that hasn’t been successful. What we have seen as successful are opportunities to divert people to care and treatment.

If you have some level of accountability, whether it’s to a police officer or to a court, we know that that can be a powerful motivator in not only getting people into care, but keeping them in care.

Recently in the Boston Globe, two former drug czars called for the return of the war on drugs. Your reaction?

I was actually quite shocked to see that. Again, I think there is a growing understanding within our administration and within the broader world that we’ve been down that path before.

Apparently they didn’t get the message.

Well, at least I have the message. We have the message that we’ve been down that road before and that it doesn’t work. …

So how do you see the role of your office going forward?

We’re going to continue to pursue an agenda that supports prevention, treatment, recovery, support; continue to look at reforming our criminal justice system. Diverting people away from the criminal justice system and making sure that people have good care and treatment is one of the singularly [most] important things that we have to do.

Clearly, our work focusing on the opioid epidemic has focused our time and energy, so we will continue to pursue a reform agenda that supports greater therapeutic responses to substance use and its consequences rather than punitive response.

Should we expect then, in the future, that you will spend less money on interdiction and law enforcement than you’re spending on treatment? I mean, right now you’re still spending more money on the old drug-war tactics.

I think you’ll continue to see and as proposed in the president’s FY16 budget a continued emphasis to increase spending on prevention, treatment and recovery.  Again, our spending on those areas are at its historical levels. …

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