Why Obama's Deputy Drug Czar Ditched DC
Noted addiction pioneer Dr. Thomas McLellan recently fled D.C. after just a year as Obama's Deputy Drug Czar. In a candid interview, the cranky academic—who lost a son to an overdose— explains why he left, what he accomplished, and why he thinks health reform may be the best weapon against addiction.
Candid and cantankerous, Dr. Thomas McLellan has never been one to sit still at meetings or tailor his rebellious opinions about addiction to please his audience. A Washington insider he ain’t, and damn proud of it, as he might say of himself. So McLellan was wary about heeding Vice President Joseph Biden’s personal call in 2009 to join the Obama administration as deputy drug czar. If one of his own sons hadn’t died of an intentional overdose of anti-anxiety meds and alcohol three months earlier even as another son was in residential treatment for alcoholism and cocaine addiction, he may have refused.
But facing the failure of the nation’s war on drugs in his very own home inspired McLellan to take a break from his job as professor of psychiatry at the University of Pennsylvania School of Medicine and scientific director of the Treatment Research Institute in Philadelphia. Equally persuasive was the fact that his boss, Drug Czar Gil Kerlikowske, the former Seattle police chief, had already announced that he was retiring the phrase “war on drugs” after 30 years because it implied that the government was doing battle against addicts themselves rather than the disease of addiction. It just so happens that McLellan has devoted his academic career to pioneering the disease model, doing as much as any other single individual to replace moralism with science in society’s view of alcoholism and drug addiction.
In the end, his stint as Washington insider was perhaps shorter than even he might have predicted. McLellan lasted only a year plus change—but it was a key year, with health-care reform (the Patient Protection and Affordable Care Act) on the move and the Mental Health Parity and Addiction Equity Act enacted in 2010.
Now back at Penn directing the new Penn Center for Substance Abuse Solutions, the folksy, moustachioed 62-year-old professor-activist is trying to get the private sector behind his campaign to treat substance abuse as a chronic illness. McLellan compares America’s too-little, too-late approach to the treatment of addiction—the “hitting bottom” scenario—to allowing a diabetic to lose a foot before addressing their diet.
He also argues that segregating substance abuse treatment from the rest of health care has scared away patients—not to mention funding for research to find solutions. But despite his cynicism about government, McLellan is remarkably hopeful that this entire failed system will begin to turn around now that health care reform and the Parity Act are law. Together, the two reforms are set to not only vastly increase medical coverage of mental health and substance abuse treatment but tie compensation of doctors and clinics to health outcomes rather than number of patients or services. More money, plus a new incentive for interventions that work, may set in motion far-reaching transformations.
I talked to McLellan over the phone while he wandered the streets of Honolulu between sessions at the annual American Psychiatric Association conference in May.
What do you mean when you say that addiction has been “segregated” from the rest of health care—and what exactly is the way out of that problem?
I don’t think segregation is unique to the addiction field. Other illnesses have moved from the periphery of mainstream health care into the middle—polio, TB, a lot of cancer, AIDS, depression, and now substance abuse. But when they’ve been segregated, a couple of things have happened: First, they’ve not gotten respect from the rest of health care, and, in turn, the patients who have gotten treatment have typically been the most complicated to treat—the sickest, those who really had no other choice.
Typically, a segregated illness moves into the mainstream only when there’s been political pressure or scientific discovery. New funding usually follows, and then a lot more people get treatment and they are a lot different from the people who have characterized the illness to that point. They’re much more likely to be earlier in the course of their illness, they have a far better prognosis—and that creates hope. As more people self-identify earlier, market forces and primary care take up the diseases and finally pharmaceutical firms say, “Oh, so it’s not just a couple thousand doctors who are going to prescribe our drug. It’s going to be 500,000 docs—good, that’s a market." More drugs means more options, and so on.
McLellan compares America’s too-little, too-late approach to the treatment of addiction—the “hitting bottom” scenario—to allowing a diabetic to lose a foot before addressing their diet.
How far along is the treatment of addiction in the movement from segregation to mainstream?
We’re moving from an “addiction treatment” system to a “substance-use disorders intervention” system. And I think the reasons are political pressure—read the Mental Health and Addiction Parity Act—and also a lot of science. New medication, advances in neurology, all the interesting work in prevention have changed the atmosphere, and that creates opportunities to move into the center. And that’s what I think the Affordable Care Act—health care reform—will do.
In America, if you want to see real policy change, somebody’s gotta make a buck. There has to be something in it for somebody financially and it has to be sustained. One of the problems with the segregation of the substance abuse field is that we’ve carved out a very big market: There are 60 million people who drink or use substances in a harmful manner. Yet we’ve chosen instead to focus on the 2.5 million who are at the extreme end of the spectrum. I want to show businesses and local governments that they can actually save money by addressing all 60 million people through prevention and early intervention. If we can do that successfully, the forces of the marketplace will take over. All we lack is good ideas and preliminary data to show that it works.
Did you know that you needed a tablet computer a year or two ago? You did not. You never even imagined it. But in the first year they sold…what? 18 million iPads? Look out, marketplace.