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Question and Answer Session
A. Thomas McLellan, White House Office of National Drug Control Policy

This is an edited manuscript, with changes made to clarify, but not alter, the meaning of the exchanges.

Mark Constas: … In an earlier part of your talk you mentioned the problem of comorbidities. I wonder if you could give us an indication around, with the problem of comorbidities, how prevalent it is, and how you’re going to deal with that as you try to move forward with this policy, both to educate the public and to structure the research program that can support interventions.

Tom McLellan: So I’m saying to you that I’ve got a really bad problem, and you’re saying you think you could add comorbidity, then you’ve got a real problem. [laughter] Well, here are the facts about comorbidity. One is you go to Google and you put in dual disorder and you’re going to see hypertension and diabetes, because that is about the most prevalent form of dual disorder. In our field, behavioral health, in round numbers, 40 to 60 percent of people who have a substance abuse diagnosis, also have some additional mental health diagnosis, typically, depression, anxiety, or a phobia. And just flip it. About 40 to 60 percent of people in any mental health clinic have a cocaine, opiate, alcohol or marijuana problem. Cigarette dependence as well. So it is quite prevalent. The reason dual disorder is a problem is less because of the available medications or therapies or personnel that deal with them, it is primarily because of the separate payment structure for mental health and substance abuse. The payment structure seemingly demands segregation, and unfortunately the patients don’t come that way. So notice how I have repeated back in a much more artful way the nature of the problem, but have not given you an answer. I don’t know what we are going to do. But it doesn’t make it easier.

Timothy Curby: Very interesting talk. One thing that comes to mind is that it seems to me that the elephant in the room is that you’re dealing, at least in many instances, with an illegal substance. If we were talking about, to use an extreme example, criminal activity as a chronic illness, would we tolerate, "Oh, I just stole a little bit." even while I was on this? I guess what I am asking, is if you’re talking about cocaine, or something like that, how does this model work for a little bit of use, in a situation where they would still be using an illegal substance?

Tom McLellan: You probably wouldn’t need treatment if you were just using a little bit. But the idea that because the substance that is associated with their medical problem is illegal, they are not entitled to medical care, is not a good idea. If a guy breaks his leg on the way out of a bank that he has just held up, I bet he still gets his leg set. Moreover, since at least 50 percent of all crimes that are committed in this country that wind up in incarceration, are drug related, you’re really crazy to simply lock up people and deny them, and society, the benefits of treatment. Believe me, we have done that. We have tried simply locking people up, and "now that will teach you. Don’t use drugs anymore." No it won’t. It doesn’t teach them. Relapse rates just came back from San Diego. Relapse rates following one year incarceration for drug-related offenders-74 percent.

And the reason that’s very significant is that failure to address the underlying drug use leads almost inevitably to the additional expense and public safety problems of rearrest and reincarceration. What San Diego and so many other places have done - and by the way this is a crime care model - they have mixed treatment with ongoing parole and immediate sanctions. So they are both punishing illegal behavior but simultaneously providing treatment for what many feel is at least one underlying contributor, if not a cause. They saved about $27,000 per client and their reincarceration rate went from 74 percent to 14 percent.

Irene McAfee: Have they thought about changing the previous plan of rehab, where instead of just going into rehab for two months or whatever, you go into rehab over a period of five years and that might be six weeks or two months, but assuming it’s not going to work the first time, second time, third time...

Tom McLellan: Right. Yes, indeed we have. Once again you’ve got financing problems, but I think that your point is still a really important one. And that’s what I’m trying to convey. I am sure I am not the first person to tell you, this is one of the many reasons research findings don’t, bingo, off they go to policy changes. You’ve got an existing infrastructure and an existing public wisdom that says, you put somebody away for treatment, they will learn their lesson, they will learn that drugs are bad, and then they will stop. But it’s wrong. And because people haven’t thought about addiction as a chronic illness, it has stopped them from seeing a different paradigm and a different political structure and a different payment structure, with different incentives and a different way of evaluating the effects. So that’s exactly the situation we’re in now. So directly to your point, one way to go would be to go directly to the existing specialty care system and say, "Hey, why don’t you change?" And we can do that. And that’s why I was talking about the power of the fact that, unlike any other part of the health care system, the government buys such a large proportion of addiction treatment. So we ARE the market. If I say, "I sure wish I could get a blue shirt. All I can get are these stupid striped shirts," if I only buy one shirt, that’s tough. If I am buying 80 percent of all the shirts and I can’t get a blue shirt, shame on me. Order what you want. That’s why we’re trying to promote demonstrations where you begin to purchase, if not long-term out comes, interim outcomes. Like remaining in treatment, actively participating, possibly urine test results, things like that. Not many of these market-driven efforts have been done. And, believe me, there’s a career there for somebody who’s interested in evaluation. Because the model has changed, but the procedures and the evaluation and the financing are catching up.

Ron Ferguson: This is not something you have talked directly about today, but I am curious about your point of view. My impression is that alcoholism, or alcohol use, has become epidemic, or at least chronic, on college campuses. I’m the father of a college senior, who is concerned about this. I am thinking about nationally, in our prevention strategy, for alcoholism and other types of drug use, where does the attention to high school and college use come? I am probably not the only parent in the room that has a college-age student who wonders about this. Any advice you might have for parents in this context, in addition to saying, where in the nation’s strategy this fits, I would be curious to hear.

Tom McLellan: Well, Dad, I’ve got some problems for you. Here they go. I will try to give you facts and periodically I will give you my opinion. Here are the facts. And the facts come from many studies. Most recently, one by Amelia Arria, at the University of Maryland, where she followed kids from high school into a very middle-class state school, the University of Maryland. She followed them every four months throughout the course of their college. During that course, 25 percent met diagnostic criteria for alcohol and/or other substance use disorders. The best predictor of developing was their substance use patterns in high school. So that’s bad news. And please also know that now, in this country, alcohol is still the biggest drug and marijuana is second, but a close third, a very close third, is prescription opiates. In Amelia Arria’s study of college girls, stimulant abuse was prevalent as part of an effort to loose weight and the girls use opiates to party. For college guys, it was stimulants to be able to drink more, and to catch up once they had found out that they had screwed up their studies. Alcohol and other drug use is the major cause of drop-out from college. Alcohol and other drug use is the major the cause of vandalism and expense on college campus. These are fantastic costs. Any business could not put up with it. And yet, two years ago, you probably saw, as I did, a letter in the New York Times by about 100 of the most irresponsible college presidents I can imagine, asking for a lowering of the alcohol drinking age. It was preposterous. It’s a terrible problem.

There’s a very significant difference between drug USE- here I mean alcohol, prescribed drugs and illicit drugs- and drug ADDICTION. Drug addiction is not simply a lot of drug use. There’s a biological change. We don’t understand what it is yet. It’s likely gene expression. It certainly involves brain changes, where you now lose control of your ability to control your intake. So that illness, of alcohol and drug addiction, is an illness of adolescence. That at-risk period is somewhere between 10 and 21. If you haven’t developed the diagnosis for alcohol or any other drug use by that time, by the time you’re 21, you probably will never develop it. We don’t know exactly why that is, but it is likely due to progressive brain development. We know that the brain matures now up to around 21, 24 even. But that is what is now informing our prevention efforts. Those kinds of scientific findings. Think about it terms of another illness. If I said, "Look, we just discovered that there are things you can do with young women, between the ages of 10 and 21, and if you do them well, they won’t get breast cancer." Well this country would pull out all stops to do that, and they should. Well, that basically is the case with the diseases of addiction. Why am I making a distinction between the addiction and just a lot of other drug use? Because even when you’re not addicted, college kids particularly, high school kids also, drink way too much, use way too often. There are far more of them, and they do far more damage, less because of the frequency and intensity of their use, but because of the consequences that occur once they use. In round numbers, there are 25 million people in this country, adults, with an addiction disorder. About the same as the number of people with diabetes. There are about 68 million people, adults, who drink or use to the point where it’s harmful to their relationship, their work, their school, their health. Wait, it is not quite done, because that is not where the bad new stops. Most college campuses are terribly ill-equipped to treat substance use problems. Most do not have the requisite personnel. So I’ve got absolutely no good news for you, Dad, sorry.

Question: The other achievement model that I’m familiar with is a model of online counseling, where there are peer communities. I’m familiar with this from a friend of mine who is involved with this work in Massachusetts, in tobacco addiction. I was wondering what the effect size is, and if there are similar effect sizes in studies like this in other areas.

Tom McLellan: Right. That has been evaluated. It is online counseling, really advice more than counseling because it’s not really a therapeutic relationship. It’s more you enter the problems you’re having. “I smoke every time I get in my car. I really get a lot of cravings every time I get in my car. Give me some advice on what I should do.” It will give you handy tips. If you’re a woman, put your cigarettes in your purse and put your purse in your trunk. Keep the keys. And it works. And that kind of peer to peer, sorry, online advice, is best done with these medications that are also increasingly available, Chantix (Varenicline), and other nicotine replacement kinds of medications, have really made a tremendous dent in this country. Smoking rates are still on the decline, except for college-age women. That’s because of good public policy, a lot of research, aggressive legal action against a known target pharmaceutical, the tobacco industry, and that’s exactly the kind of policy that we’re hoping to pursue.

Question: Is there a similar program for other addictions?

Tom McLellan: Yes. One of the things that is true about any addiction…for a long time people thought, well once the drugs are out of your system, now you’re back to normal, right? No, you’re not. We know that your brain changes. It may never go back to the way it was-but even if it does, it can take a very long time, at least a year. And the importance of that is that stimuli that have been associated with your use of tobacco or alcohol or other drugs -it might be a song, it might be a friend, it might be a $20 bill, it could be anything- will for very long periods of time, just like Pavlov’s dog, basically cue strong cravings and physiological withdrawal. “No, it’s not my imagination.” Lots of good research has been done on this and those cues are difficult to manage. They may be managed in part with some medications, but also by preparing for them with the kinds of advice that you’re talking about. And it will work for any kind of drug.

Chris Rhoads: In the context of your earlier answer, you made an analogy with breast cancer. If there are things that you could do between the ages of 10 and 21 for breast cancer, we would all want to do those. Could you tell me, what are the things that one would do between the ages of 10 and 21 to prevent addiction?

Tom McLellan: I’ll tell you what the science has shown about prevention. I’m going to try to differentiate between addiction and substance abuse problems, but the things that are most predictive of substance abuse are also predictive of other very serious problems that confront our young: school drop-out, early pregnancy, bullying, depression, all those problems. There are two classes. Personal problems: hyper-aggressiveness, hyper-shyness, learning disabilities, and there are others. I’m sorry, I’m not getting them all. The other class is environmental: lax supervision, no clear guidelines, easy access, all that. So, point one: the predictors are generic. Good news. Interventions that are effective in reducing any one of those threats or any one of those problems show a lot of generality as well, so you get a lot of bang for your buck.

If you institute a depression prevention program, you also reduce substance use, you reduce bullying, you reduce drop-out. Point three: it turns out that interventions, prevention efforts, are much better when you get interventions mixed across different sectors. Sectors are areas that affect the behavior of youth, so parents, the mall, the school, the police, the health care system, their peers. So let’s go through this. The predictors are generic. The interventions are generic. And you get more of a bang for your buck if you combine effective interventions from multiple sectors. And since there is an at-risk period, basically 10 to 21, people will argue, that but it’s certainly within that range, think about how you would build a prevention system. That really is our job, to try and translate that science into something that we can quite literally purchase. We want to purchase generic prevention programs, and we want to come from many sectors that influence a kid, and we want them to occur continuously. We don’t want any little program that in the eighth grade says drugs are bad. Box checked. Goodbye. Well where would you buy such a thing? We think the place to buy it is from the community. All those sectors are present. But not just any community. You’ve got to learn to assess the threats to the kids within your community. You’ve got to learn what the effective interventions are. You’ve got to organize so that you can effectively provide those prevention interventions throughout the course. You’ve got to measure the effects, and then you’ve got to do it all over again because there’s going to be a new threat. So we’re calling for prevention-prepared communities. We would like to construct those, and this is another thing we need big evaluation help on. We are going to be having no less than 30, hopefully 50, prevention-prepared communities that will be organized and developed and be competitive and they’ll learn how to prepare to deliver evidence-based practices for prevention. But remember the other thing I told you. We are the market. We, being in this case, the federal government. There are nine separate federal agencies offering prevention grants for substance abuse. They’re not taking advantage of the marketplace. We want to consolidate them. We think of these prevention-prepared communities as a damn good business investment. Now you’ve got places that know how to spend your prevention dollars wisely, and if you could put the Department of Justice with the Department of Education and the Department of HHS together to purchase this, why a dollar from HHS is now going to be linked nicely. You’re going to get leverage. That’s exactly what we’re doing, and that’s going to be part of our prevention strategy. It’s easy to say, “we’re going to prepare this community.” It’s easy to say, “they’re going to do evidence-based practice.” Easy to say, “they’re going to be able to be self-sustained.” We need evaluation help, we need the right kind of measures, we need to know how to do it. There’s another career there for some of you guys.

J Lawrence Aber: This is a follow-up to exactly that question. You are at a society for research on effective education. I’m wondering whether the White House Office might focus on the education sector as well as the health sector. I agree with you that communities are the right level, but for kids from 10 to 21, they’re in education settings more than they are in health settings, and it would require some change in focus on what are legitimate outcomes for education. So I’m all in favor of cognitive development in school achievement, but it’s irrefutable that schools have effects on behavioral health and you thought the comorbidity problem was a big problem. Any thoughts about the effect on the education sector?

Tom McLellan: Actually I want to tell you something amidst all this gloom and doom. I want to give you a little bright spot. If you’re like me, regardless of what party you’re in, you’re probably fed up with Congress, and their inability and unwillingness to do anything in concert. Well I assure you, and it was a surprise, but a very happy one, that is not the case at the agency level. We are enjoying really excellent collaboration, real roll-up-your-sleeves, let’s get down to work, let’s forget about the budgets, let’s work together stuff from Education, Justice, HHS in particular, but others as well. On the issue of education, we went to Mr. Duncan and made him a pitch about this prevention idea. He said, “No. Get out of here. We don’t want anything to do with it,” and here’s why: because for decades our agency had simply said, “We want you do student drug testing. That’s it. You’re responsible for keeping kids off of drugs.” And I think frankly, correctly Education said, “The hell I am. I’ve only got so many hours in the day. I’m supposed to make kids more competitive in a competitive world. I’m supposed to stop drop-out factories. I’m supposed to get my curriculum through. I can’t take responsibility for preventing drug abuse.” So we said, “You know what? You’re right. Let’s not make Education fully responsible. In fact, let’s return to this community. If Education will play a part of the role, not only is that manageable, but Mr. Duncan, we think you’re going to be far more likely to achieve the goals that we want you to achieve. A much more competitive student body, with less dropout, less teenage pregnancy, the whole thing. We think we can help you.” It’s a business deal. We’ve got Mr. Duncan. He was an enthusiastic supporter, and Kevin Jennings from Education has been a regular in our work. We made the same kind of deal with Justice and we made the same kind of deal with HHS. That’s about as close as I can get.

Judy Gueron: I’m surprised that you talked about the importance of thinking of this as chronic, rather than short-term, treatment. You go in the washing machine and you’re done. And there is one group out there, it’s not exactly prevention, but it does explicitly view it as chronic and that’s AA, in 12-step programs. They don’t view that it’s a washing machine. They view the exact opposite. So what do think about that?

Tom McLellan: Absolutely. You have a really great question. I’ll see if I can redo it. Basically she says, “Look, you... unfairly characterized the whole field as acute care, short-term kinds of things. What about AA? What about other 12-step kinds of programs?” I’ll actually add another-methadone maintenance. Do you know what? They have excellent outcomes and they have enduring outcomes. No secret, my wife and my son are both in AA. They will never tell you that they’re recovered, cured. They are recovering. It is an active process. They have to keep their life changed. So you’re completely right. That is a model. And there are another couple good things about that. There are about 20 million people who label themselves as being in active recovery. Meaning they are not using, they are in good health, they are working, the kind of people you would like for a neighbor. It’s free and it’s everywhere and it’s all the time. Right now, right here in Washington, there’s got to be at least 30 AA meetings going now. And actually I’m remiss. That’s the kind of a politician I am. I’m supposed to tell you that our office, for the first time, is starting an Office of Recovery. This is the kind of thing that gives people hope. People don’t believe that you can overcome an addiction. Well you can. Lots of people do. You can’t get cured from it, at least not yet, but you can manage it, just as you can manage diabetes, hypertension or anything else Here’s the problem. In its wisdom, Congress has set up lots of laws designed in what they thought were going to be preventive efforts.

So they said, “If you get an addiction problem and we catch you, you’re never going to get a pilot’s license, you’ll never get federal housing and you won’t get any federal student loans.” By the way, quite literally, you can rape, you can murder, you can pillage, and get convicted for it, but those things aren't true. So addiction, it’s the gift that keeps on giving. It’s hard to imagine that those laws are preventing anybody from becoming addicted, but they sure as hell make it tough for somebody who has gone through treatment, to now resume normal life. So we’re going to try to work on that.

Rob Greenwald: We heard today from two different people who advise an individual who has said he would rather be a great one-term president than a poor, two-term president. I think in a k-12, one-generation of kids, frame. Can you give us some insight, from where you are sitting, on the timeline of these things? What are the prospects?

Tom McLellan: I’m not really happy with the tone of the presentation I gave, because I thought you guys were going to load me up with all kinds of brilliant evaluation ideas and all that. So I was pitching it more that way. But I actually will take this opportunity to say that I think if you gotta be addicted, boy this is the right time. You’re going to see more and better care, more and better prevention, more and better understanding at the parental level. That’s an important part that I also forgot to tell you about. There are evidence-based parental interventions that are really quite effective, but parents don’t know about them. They haven’t been translated into things that they can do. The United States has done about 85 to 90 percent of all the addiction science that there is. We’ve got medications that work. We’ve got interventions that work. We’ve got, I think, a better conceptual model. And we have, and this is not me doing rah-rah political stuff, we’ve got an administration that understands, and is committed to trying to do something. So really, a very committed administration, and as I said, we’re working very closely with HHS and Justice and Education, hopefully Labor as well. So I don’t think tomorrow morning we’re going to have this thing licked but I think the corner has been turned. The corner has been turned because of the science. The corner has been turned because the public is simply fed up with the failed systems of the past. And no, I’m not taking a shot at the last administration. The last 30 years, we’ve tried the same old things, and it hasn’t worked. Finally, I think the way to really sell this, and we’ve been doing it over and over, we’re not asking Medicine, Education, Justice, the American public, to do addiction a favor and sort of let us in. That’s really wrong. It’s time for addiction to do the American public and Health and Justice and Education a favor by bringing some of these evidence-based practices to bear. I really believe this will markedly improve commerce, safety, health, all the things that we’re looking for. All in, all done? We’re going to go have, crab cakes, right? So I’m sorry for the rambling talk, but I do appreciate the time to talk with you and thank you very much.

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