University Times

Shortly after taking the helm of the Office of National Drug Control Policy in May 2009, drug czar Gil Kerlikowske made headlines by advocating an end to the “war on drugs” analogy.

The office’s deputy director, A. Thomas McLellan, came to campus to discuss the shift in national drug policy strategy and offer examples of successful approaches to regional drug problems in a May 14 lecture, “The Drug War Is Over — Now What? Translating Science into Drug Control Policy in 2010.”

Eliminating drug use isn’t a realistic goal, “But drug problems can be controlled if use can be prevented, abuse can be detected and early intervention measures utilized, and addiction can be treated in new and better ways,” McLellan said, offering examples drawn from scientific research that inform new federal drug policy.

The Obama administration’s drug policy, released May 11, is available online at whitehousedrugpolicy.gov.

Among the policy’s priorities are prevention, early intervention, engagement of primary care providers, better integration of substance use treatment into health care and breaking the cycle of incarceration for drug offenders.

“I want to talk about not just what our strategy is, but what’s behind it and give examples of the kind of things we think are possible in translating science,” McLellan said. “That is the foundation of the drug control policy. It’s not ideology.”

The federal government’s longtime anti-drug policy focused on foreign producers: “If they could just stop, if we could just invade them, bomb them, do whatever it takes to stop them, then we wouldn’t have a drug problem,” McLellan said was the old attitude.

The new policy balances external factors such as reducing drug importation with a sober look inward.

“The truth is the U.S. has an insatiable demand for drugs,” he said.

“Further, we may talk about the drug-producing countries, but five of the biggest drug problems in the country are made in the U.S.A.,” he said. “Alcohol, cigarettes, much of the marijuana, much of the methamphetamine, prescription drugs. … These are our problems.” The problem isn’t solely one for the federal government, he said.

The new federal policy aims at families and communities, McLellan said, “In part because the drug problems themselves are regional; but more importantly that’s where we think we’re going to have most impact.

“Our policies are now trying to distinguish, based on what science tells us, between simple drug use, drug abuse and addiction. We see drug abuse as being identifiable and preventable, we see addiction as being treatable now better than ever before, and the thing that is most important is we see realistic evidence-based practical interventions that are available to families and communities that should show results where people live, where they raise their kids. And we’re hoping that will give the country the kind of results they are hoping for: reduction in drug use, but as importantly reduction in the expensive and quality-of-life consequences associated with drug use.”

Understanding the difference between drug use, drug abuse and addiction is important, he said, noting that many people — including federal lawmakers — don’t realize that drug use is preventable and that there are effective treatments for substance abuse and addiction.

Simply legalizing drug use is a bad idea, McLellan said.

“Use is largely a function of access and availability just like any other commodity: If you have candy bars and you have more of them and you put them in more places, more people buy them,” he said.

“Once that occurs, then there are side effects associated with any product. If it’s candy bars, diabetes — not everybody that tries a new candy bar is going to end up with diabetes, certainly, but some proportion will.” While all the elements that lead to addiction aren’t known, “we do know that quite reliably that roughly 10 percent of new users will ultimately develop an addiction. Along the way there will be other side effects.”

To those who say that everyone’s using anyway, McLellan says: “No, they’re not. In places where drugs are more available, more people use.”

Using the image of a pyramid to represent the spectrum of drug use, most people fall at the broad base — either not using drugs at all, or using only modestly. “The policy implication: Let’s keep it that way,” he said, adding that sound science-based prevention strategies exist.

Further up the pyramid is a non-distinct threshold at which the frequency and intensity of use have reached harmful levels.

“These are the guys who drink two six packs of beer … and get in a car and drive. These are the guys that are smoking dope and then come into work and not do a very good job. These are the guys that are dating your sister,” he quipped. Some 68 million people fall into this category.

Topping the pyramid are an estimated 23 million-25 million people who reach a diagnostic threshold for substance abuse and dependence — a number roughly equivalent to the number of Americans with diabetes.

McLellan said only one in 10 of those who meet diagnostic criteria for substance abuse or dependence get any kind of treatment, adding that there is no illness in which the proportion of affected people who receive treatment care is smaller.

“We want to reach those people who have the most serious problems,” but policies for people who fall elsewhere on the substance use pyramid also are needed, he said.

Prevention

“The best way to deal with addiction is not to get it in the first place,” McLellan said, adding that research has shown there is an at-risk period for developing addiction.

The starting point is open to debate, with some arguing that it begins at birth. But there is agreement that the end point is at the end of adolescence. “Kids who don’t acquire a cigarette or marijuana or alcohol or cocaine dependence by the time they’re around 21 are very unlikely to ever get one,” he said, arguing for policies and interventions that span that entire at-risk period, rather than just at intermittent points throughout adolescence.

Risks such as early teenage pregnancy, dropping out of school, delinquency, depression and substance use have common predictors, he said. “And interventions that are effective at reducing the risks for any one of those things — pregnancy, dropouts, whatever — seem to have generic effects.

“If you want to create a prevention system, you want to make it generic. You don’t need a bunch of very specific pregnancy prevention, school dropout prevention, cocaine prevention programs,” McLellan said.

Plus, research has found that adding prevention interventions from one sector of influence, such as parents, to another, such as school, yields a “1 plus 1 equals 3 or even 4,” result, he said. “It’s just smart to combine things.”

Rather than offering kids the “drugs are bad” lecture in 8th grade health class and some input from law enforcement at some other point, a more effective prevention approach would include age-appropriate interventions throughout adolescence in which parents were taught proper monitoring and learned how to communicate with one another, law enforcement was contributing by educating families about new drugs and areas of concern, and environmental policies  (such as keg registration, server training, curfews and elimination of cigarette vending machines ) worked together.

“What we call that is a prevention-prepared community,” he said. “What we also call it is a damn good business investment.”

Currently, nine federal agencies offer a total of 164 different drug abuse prevention grants, he said. “Instead, suppose we created places — and made it competitive — where communities, if they got these sectors of society together and agreed to work together, if they did a proper structured analysis of what the threats to their community really were, if they became smart shoppers for evidence-based interventions, then government could work together. No single agency has enough money to provide all that but together they would.”

McLellan cited the Seattle-based study of 4,400 students in grades 5-8 in 24 towns across seven states. The students were measured for substance abuse and delinquent behaviors. After four years, students in active intervention communities were found to be 49 percent less likely to become tobacco users; had 37 percent less binge drinking and exhibited 31 percent fewer delinquent behaviors than students in communities without the integrated interventions.

Intervention

Another area in which research has shown promise is screening and brief early interventions as a way to impact drug use.

“In the work we’ve asked the president to support, we’re asking for more money and less paperwork and better training to get physicians’ offices — physicians themselves or the nurses or any of the allied health professions — to do screening, and do brief interventions with patients,” McLellan said.

People who fall into the harmful use category often can be found in physicians’ offices, he said. “There’s no health care environment where there isn’t at least 20 percent prevalence, and in emergency rooms and trauma centers 50-70 percent prevalence,” McLellan said. “It’s like fishing in a stocked pond.”

Brief interventions can be effective, he said. It also is wise for doctors to inquire about patients’ drug use because alcohol, illicit drugs or misuse of other prescription drugs could interact with something they prescribed. In addition, even low-level substance use is a factor in low adherence rates for prescribed treatments for virtually any illness, he said.

A study of more than 1,500 people to measure health care utilization, substance use and cost for one year following emergency room visits found that talking for five or 10 minutes about reducing substance use yielded a $4,000 per patient savings in medical costs compared with patients who had not received the intervention.

A study of Medicaid patients in Washington state showed similar results. “They saved $8 million a year just doing it in three emergency rooms,” McLellan said.

Treatment

A variety of counseling therapies and medications already are available; nicotine and cocaine treatment vaccines are likely to be available in the next three-five years, McLellan said.

However, an outdated treatment system in which substance abuse care is segregated from  treatment  for  other conditions stands in the way of making the full range of treatment available to people who need it, he said.

Another barrier is high turnover among drug counselors due to low pay and little chance for advancement. “If you want a continuing care strategy to address the chronic problem of substance abuse, you need a workforce that is going to be there,” McLellan argued. In addition, turnover discourages employers from training their staff in new therapies.

Obama’s 2011 budget calls for $30 million to begin integrating substance abuse treatment into Health Resources and Services Administration qualified health centers (which provide care to the uninsured) and Indian Health Service centers, which treat a combined 27 million patients a year, he said. An estimated 50-70 percent of the people already getting care meet diagnostic criteria for substance abuse disorder but are not getting treatment, he noted.

McLellan said the government pays for about 80 percent of all courses of drug treatment, but the quality of those services needs to improve, he said.

Delaware got good results by “buying” them. The state offered treatment providers a chance to get 106 percent of the money they received in the previous year by meeting utilization and participation targets. Otherwise they would receive only 90 percent of their payment.

The incentive worked. He said they cleaned up their facilities. They paid more money for those counselors who were better able to attract and treat patients. They added services that they hadn’t previously offered. They increased the hours of operation, they increased the number of clinics that were close to public transit — all the things a business would do. “The reason they could do it was they could [take a] risk for new dollars — there was something in it for them financially.”

Recovery

McLellan estimated that of the approximately 5 million people under community supervision in the nation today, about half are drug-related offenders. Of 700,000 people leaving jails every year, “about 350,000 going back into society are drug-related offenders and they’re going to your communities.”

Simple management practices that include certain, swift but modest sanctions (rather than lengthy  jail sentences) coupled with services are meeting with success. “This has kept the community safe, which is the first order of business, and also reduced the cost and increased the likelihood of positive rehabilitation,” McLellan said.

Implementation of a drug court that combined services and sanctions in San Diego reduced recidivism to 14 percent, where in the prior year some 70 percent of released drug-related offenders were readdicted, reoffending and reincarcerated within a year.

One program in Hawaii requires mandatory regular drug testing for drug-related offenders who are being supervised in the community. If the test is positive, offenders immediately are arrested and jailed for one or two nights.

“In very short order there was an 80 percent reduction in positive urine tests and a 93 percent decrease in missed probation appointments, and a corresponding dramatic reduction in incarceration rates,” McLellan said.

—Kimberly K. Barlow