Howard Dean and the Politics of Recovery
What would it look like if American public policy was aimed at dramatically reducing substance abuse and revolutionizing treatment? An innovative former presidential candidate tells The Fix how the new game would be played.
In 2004, Howard Dean, a medical doctor and former Governor of Vermont, gave Secretary of State John Kerry a run for his money in the race for the Democratic Presidential nomination against then President George Bush. Where Kerry was staid and mincing, Dean galvanized large crowds with his forthrightness, creative approaches and smarts – and his opposition to the Iraq war. Dean, the non-Establishment candidate, lost but took all he learned and innovated about campaigns into his later role as chairman of the Democratic National Committee from 2005 to 2009. His 50-state strategy contributed significantly to Democratic victories in the 2006 congressional elections and the 2008 presidential election.
In 2004, Dean founded Democracy for America (DFA) to house the large, Internet-based organization he created for his presidential campaign. The group focuses on recruiting, financing and campaign training only progressive (vs. corporate or conservative) Democratic candidates, primarily in local and state elections. Dean’s brother has run it since 2005 while Dean remains active as a speaker and board member. These days, Dean gets most of his public exposure as a commentator on CNBC and MSNBC and is fairly often asked by other progressives if he will enter the Democratic primaries for 2014 if Hillary Clinton decides not to run. He tends to brush aside the question.
Given his medical degree and leadership via DFA and other forums of progressive public policies in many areas, The Fix asked Dean to define what he sees as a sane set of public policies addressing substance abuse that might actually improve America’s recovery from its own addictions.
What do you and DFA consider to be progressive positions on drug policy?
It's a multi-factor problem, and you hardly even know where to start. I think the most reasonable place to start is the criminal justice system. We have an enormous incarceration rate in this country. The commonalities are that most people in prison usually have a drug and alcohol problem and they usually don't have a high school education. And the first thing is to focus on the drug and alcohol problem, not necessarily on the criminal problem.
Without dealing with that, the likelihood of correcting the criminal problem is much, much higher. So, I think smart people around the country, including a few people in political office, are now understanding that the first step is not necessarily jail. The first step is rehab. There are beginning to be drug courts, there are beginning to be changes in sentencing, and this is all very important but it doesn't work without rehab. Because this is a long-term, lifetime recurring illness and if you don't see it as such, then there's gonna be a recurrence.
The average heroin addict or alcoholic goes through rehab I think seven times before they have a long period of sobriety – on average. Some do great the first time and a lot don't ever do great. So the first phase is diverting people from the criminal justice system into rehab.
I was brought up as a physician to think that you couldn't send people to rehab unless they wanted to get better. Well, it turns out that's probably not true - that if people have a choice between rehab and jail and they take rehab, they're still better off whether they have the "will to get better" or not in rehab. So, that's number one.
Number two is education, and there are two problems with this. One is the long-debated problem with the education system in this country, which is still not well adjusted to the different needs of people, particularly of members of not just minority groups but mostly poor people. The other is the problem that we do a terrible job educating people about drugs because we still have a reluctance to discuss it. Then, some of the approaches that scare the hell out people never work - and are documented not to work.
You really have to have a matter-of-fact approach to what the use of alcohol and drugs is all about and where it could lead you. One of the problems is the confidentiality problem. I mean knowing that there's a drug or alcohol problem in your family is something that each individual has to know because it is a big determinant about what susceptibility you may have.
Knowing the potency of different drugs and which ones may be life threatening is also something that's really important. We don't do any of that education. We wait till it's too late and we've got to do a better job with that. The right wing will say, "Oh, that's the parents' job." Well, that's just fine and good but if the parents don't do it, then you get left with a gazillion dollar social problem on your lap and there are millions of people. So, I do think the schools have a responsibility, society has a responsibility.
If you were to lay out a dream drug platform for the Democratic Party, what would it be?
It would be education from the age of five up about drugs and what their mechanisms and actions are, obviously age appropriate. This is what a parent does [who is addicted] and what to watch out for, and those in dark glasses that hang around the schoolyard. And not just what the dangers are but what the likelihood is of getting sick from using them. It would be realistic. I think actually people will make informed decisions if they know what the choices are.
And I think that changing sentencing so that you have the judicial system focusing on the drug use and the illness, not just the crime. That doesn't mean you can let a violent criminal out on bail just so they can go to rehab. I'm not advocating that. I am advocating that we look at the underlying mechanism for what got them into the position they're in.
Don't you think the overall system is too backwards to deploy the many wonderful programs out there for educating children in emotional management and coping with their inner lives and relationships with others so they don't turn to drugs?
I agree with that. I think that's exactly right and that's part of what I'm talking about by drug education. It has to be real and it has to be sustained. That's why it has to be the responsibility of the schools. And schools will have to make priorities. I wouldn't want to commit heresy but which is more important, drug education or football? Well, they're gonna say football is but you gotta do both.
I also think this experimentation with the legalization of marijuana makes sense. I'm not sure it's the right idea but we've tried everything else so we might as well try that. The reason is that there are a hell of a lot of young people who end up in jail and with no possibility of ever working in the above-ground economy because of a marijuana conviction. That's silly.
I would certainly decriminalize it, because we've got to stop stigmatizing young people, particularly in inner cities, and basically taking them out of the workforce for the rest of their life.
I don't happen to think drugs are a great thing, and I don't drink and I don't use drugs. So, I come from sort of a prohibitionist slant. But prohibition doesn't work and what the President said is true: that marijuana is less dangerous to society than alcohol because people behave a lot more badly and dangerously when they're drunk than they do when they're stoned, in general. So, I think the legalization movement, at least for marijuana, is something that ought to be pursued. Now that it's been done in two states, I'm not in a big rush to see it happen in a lot of states. I want to see what happens in two or three or four years as a result of this. It may be just the right thing and it may not be, we'll see.
And legalization [of hard drugs is not the right thing] by the way. I was living in England in the 1960s when they legalized heroin and gave prescriptions for it. The problem is it expanded heroin addiction greatly because people split their doses after getting out of the chemist, as they call it, at 12:01 to get their daily dose.
And what about general public education on the matter, with government playing a role in that?
You know, most people in this country are not addicted to drugs and people don't think about it very much although it transforms people's lives when they have a family member who's addicted. And then they suddenly get very smart about what to do. There needs to be more publicity about all of this – half of this [that] has gotten better in the last ten years is the support groups. Part of rehabilitation is not just the person who's ill. It's the family. And that needs to be emphasized more. I don't think there should be anybody who goes to Alcoholics Anonymous without their family going to Al-Anon. And the same would, of course, be true in all the other substances that get abused.
Because it's not only a lifetime illness that people need to understand but also that we are conditioned to believe this is a moral failing when it is just simply a very bad illness that resulted from making bad choices - and sometimes it doesn't even result from that. It results from being medically addicted when the doctors are passing around opiates like they were water and don't think about individualized medicine. Some people can handle opiates and it's no big problem. Some people shouldn't be treated with opiates. And if you knew what [their] genetic background was, you'd think twice about it. Oxycontin being one that obviously has had a long tail of destruction behind it.
On the treatment end, what would be the government role you would like to see?
Government clearly has a role but I think it's one of those complicated formulas where the recovering person needs enough skin in the game to take it seriously but not so much that they can't pay. That's where the balance is. So, clearly the [recovering person’s] payment is income related in some way.
And what would be a progressive policy toward the medical profession?
I think the doctors are incredibly under-educated about drug addiction, both in terms of how to treat it and in terms of how not to encourage it. And then there's the incident of crooks, but there are crooks in every profession who make money off selling stuff like that – out of the back door. You don't need special intervention for just the medical profession but what you do have to worry about - and I think the doctors in the medical profession have gotten better about this - is educating those who practice, both nurses and physicians, anyone who has access to narcotics in particular. Also to all the other drugs which have addictive or abusive potential.
The education about addiction and the likelihood of addiction [is important] because of the profession. I mean, there is no question that doctors and nurses who have a significant problem with drug addiction on a percentage basis [have it] because of the access.
But the main thing is to get this away from a moral failing model which was what we had to do with alcohol and focus on it as an illness. And that starts at the people who are mostly responsible for treating illness, which are health professionals.
That would suggest some requirement that medical schools really dive in?
Absolutely. And it's not just requirements about the standard drug education. It's also about personalized medicine, which is now becoming more accessible because of our ability to look at DNA - this is part of a profile. There are some people who have trouble metabolizing opiates or have what the layperson would call an addictive personality, but that's often biologically based. We can know that - and it needs to be part of a sensible medical history.
Would you step up any or change any of the kinds of regulations around Big Pharma?
Yes. I think Oxycontin was one that got away from the FDA. I actually banned Oxycontin from the pharmacies in Vermont 15 years ago when I was governor because it was so destructive. But the company didn't get the reformulation done [Oxcontin was reformulated to make it harder for addicts to abuse] until a couple of years ago. Now we're trying to organize an effort so the Canadians will adopt the American formula which you can't grind up and you can't snort it and inject it and all that stuff. We've got to be much more careful about that because the addiction potential of a drug like Oxycontin was recognized many years before anything was done about it and it probably should have been taken off the market.
The Fix has been looking into a number of alternative addiction treatment modes outside the norm that have little to no research funding but based on reports from patients, appear to be highly effective. What kind of government policies would you support toward opening the coffers up for research on treatments that are more experimental.
Well, the problem with that is there's a lot of that kind of stuff in all kinds of not-so-well-understood fields. What we really ought to do is pay for double-blind studies to find out what works and what doesn't. [With every treatment] there are some patients where it'll work and some where it won't – but we're not smart about it. We really need to have very, very large studies across large and diverse groups of patients so we can really make some definitive judgments about this and [if a treatment] is very effective in certain populations, we need to know what those populations are. And that needs to happen soon because if you just go and reimburse it, everybody is gonna end up doing [that treatment] and it's not gonna be what everybody needs.
I gather from this you can see restructuring funding guidelines to open the door to more experimentation.
If you use a rigorous process like you have to go through in Pharma when they put a new drug on the market, you can get some idea of what works and for whom it worked and if it is really what you need. And then government treatment funding will follow. But even with the traditional Big Pharma stuff, there can be mistakes. I've never liked the idea of methadone use and when I was governor, I made the state do buprenorphine clinics, not methadone. Well, it turns out ten years later that bupe has its abuse potentials, too. So we learn that as we go along and there's some argument to say [get it right] before you start.
My point about funding is it tends to go to the familiar sources, the safe places, and funding for alternative non-drug treatments isn’t going to come out of Pharma because the profits are not there as they see it. So unless a government agency really says, "We're going to step up and fund the depth research on this in the double-blind studies,” it’s not going to happen.
I think that's right. That's what we should be doing.
Even with government and the medical profession, the bureaucracies have their own cubbyhole mindset.
I think that's right. There's not enough good research by people who do out of the box thinking. It's almost like the out-of-the-box community doesn't want to do the research or can't afford it. And the in-the-box community doesn't want to think, because they like what they do and they get paid for what they do and they don't get paid for innovation. That's gonna take some money but it's worth doing.
What attitudes toward these issues, what resistance, do you find within your own party?
The resistance I find is mostly ignorance. And it's not high enough up on the list. But I'd argue that this problem is at the crux. There's a hell of a lot of money that we spend unnecessarily while we're ruining people's lives by incarcerating them for things that are essentially a medical condition.
Moving over to the Republicans, let me give you a piece of information and maybe you can validate or discredit this. The Fix is researching changes underway in attitudes towards drugs in the evangelical conservative community that are beginning to show up in changes in some Republican-controlled state legislatures that are moving toward treatment support and away from punishment models. Part of this is for financial reasons, for the cost benefits, and part is a growing awareness that punishment is not Christian for drug possession, where there's no intended harm to another human being.
You know there's an interesting parallel here and I'm delighted to hear this because I think it makes a lot of sense. From a Christian evangelical point of view, a lot of the AA kind of activities are mostly – are often - quasi religious. So, I think it makes an enormous amount of sense for religious groups to be involved in substance abuse treatment. Religious groups are uniquely situated because there are support groups to help with this. I mean a 12-step program is not so different than a religious support system, and I applaud that. I think that's absolutely great.
I do think at some point Democrats and Republicans actually have to work together. Otherwise the country is going to fall apart. I actually think the new generation has very little tolerance for the nonsense that's going on in Washington right now. And I do think that the Democrats and Republicans are going to start to find common ground. Some of the most interesting statistics I saw recently were the average age of the Fox viewer is 68 years old and the average age of an MSNBC viewer is 60. There's no future for this kind of, you know, beat the hell out of each other all the time stuff.
I think the time for common ground with people like evangelicals on stuff that you can agree on is now. I don't know anything about [Christian radio talk host and counselor] Craig Roberts but if there are people like that who can treat addiction using methods that are pretty similar to 12-step programs, I think that's a huge positive.
Where the Republicans have problems is with things like methadone – and methadone has its problems. It's not a panacea either. So there's no one size fits all solution to this and I don't think the good solutions are going to come necessarily only from progressives. I do think that evangelicals and other conservatives have a role in this. But it can't be built around guilt. It can be built around forgiveness, though. A lot of what they teach you in AA is about forgiving yourself and then the one-day-at-a-time [component], which I find to be incredibly impressive and incredibly effective.
I've never been in a 12-step program but I struggle with weight sometimes and I find one day at a time is by far the most effective way of losing weight. Because I have no willpower or resistance to chocolate whatsoever.
One of our better-read stories recently was "I'm a Chocoholic.” Changing the subject, what is your take on free needle programs for heroin addicts to prevent the spread of disease?
I came around on that one. I was against them and then Yale did a big study about 15 years ago, maybe 20 almost, that showed it really clearly reduced the incidence of HIV spread. So that's a no-brainer. Needle exchange programs should be basically accepted public health policy.
Republicans have problems with this because there's a significant number of Republicans who don't believe in science. I've been wrong about things and one of the benefits of having a medical education is when you are wrong, you look at the facts as opposed to throwing out the facts to make sure the ideology stays intact, which is what the right wing does. I actually throw out the ideology and change my mind in the face of evidence. So, the evidence for needle exchange is overwhelming. It does not lead to increased drug use and it does lead to reduced HIV and other infections and therefore significantly reduced medical costs.
Let's talk about DFA for a minute. Apart from progressive drug policies, what has been its issues focus?
Their biggest issue - around which they wrap most other things - this year is income inequality, which certainly is tied into addiction but it's also tied into a lot of other issues. They educate around issues but what they really do is try to get people elected. They only focus on progressives and mostly focus on local races. They do a tremendous amount of [candidate and campaign] training. We do training all over the country, in conservative states as well as liberal states.
We do a lot of local stuff because we know and we believe that as Lao-tzu said, "The longest journey begins with a single step," and if you're not working in places like Virginia and Utah, you're doomed to having right wing theocracies for a long period of time. The Democratic party and the Washington establishment really focus on a two-year election cycle and we think you need to focus on the 20-year cycle. We're not bound by just going to the swing states. We think that's an enormous mistake that the national parties make.
Any electoral ambitions at all, even if just to push ahead progressive policies?
Not right at this moment. But you know, who knows?
Jay Levin is editor-in-chief and publisher of The Fix.