Curbside Consult: Who's Winning the War on Drugs?

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.”