A Veteran Addiction Researcher Tells All
Whats going on in Iraq and Vietnam with drug addiction? What's up with Obamacare? With research and unlicensed addiction counselors? The word from Dr. Richard Rawson.
Dr. Richard Rawson PhD has been on the front line of addiction research and treatment development for 40 years. A member of the UCLA Department of Psychiatry for over 20 years and the Co-Director of the UCLA Integrated Substance Abuse Programs at the Jane & Terry Semel Institute for Neuroscience & Human Behavior, Dr. Rawson oversees an impressive portfolio of addiction research. A major focus of his work is the study of how treatment strategies are applied in a wide range of institutions and societies.
During the past decade, Dr. Rawson has worked with the U.S. State Department on large substance abuse projects, exporting technology and addiction science to the Middle East and Southeast Asia. Currently the principal investigator of the Pacific Southwest Addiction Technology Transfer Center and the NIDA Methamphetamine Clinical Trials Group, Dr. Rawson focuses on improving the educational standards for addiction treatment professionals.
In his interview with The Fix, Dr. Rawson provides an insightful historical perspective on the evolution of addiction treatment and research. With a body of unique experiences and work, Dr. Rawson elucidates the present state of addiction treatment and research in light of the Affordable Care Act while providing a rare illumination of what is to come.
You recently completed the Iraq Drug Demand Reduction Initiative. You were given a State Department contract to conduct a national household survey of drug use in Iraq. What did you learn from that survey and how is that knowledge being used?
Our work actually predates the survey. From 2011 to 2013, we had a previous State Department contract in collaboration with SAMHSA (the Substance Abuse and Mental Health Services Administration, a federal agency) where we worked with a team from Baghdad Medical University in Iraq. The focus of the work was training them in basic information about addiction and treatment strategies, helping them to develop treatment services in Baghdad. We wanted to understand what were the drug problems in Iraq and where was the treatment needed.
It’s going to be a fascinating next ten years of figuring out how to move substance use services into mainstream healthcare, how to educate and serve mainstream healthcare.
To give a little background, during the time of Saddam Hussein from 1980 to 2003, there really were no drug problems in Iraq. From everything I can find and from all the past data that still exists, limited as it is, because of his dictatorship and very tight control of the borders and capital punishment for any drug-related offenses, the availability and use of drugs in Iraq was extremely limited. Some of the first studies done after the Americans went into Iraq suggested the major drug problems were psychiatric medications like anti-psychotics. They were drugs that here in America nobody would ever abuse because they are not particularly enjoyable, but that’s literally all that was available.
Once the U.S. invaded and once we took down Saddam’s government and the borders opened up, drugs have been coming into the country in large amounts. Next door in Iran they have arguably what could be the world’s worst addiction problems with heroin and methamphetamine. Drugs started coming into Iraq across that very long and porous border.
In 2011, we went in and started working with the folks in Baghdad. We took them to Cairo where we had connections at Cairo University, then we took them to Beirut to show them Suboxone treatment in practice. As a result, there are about 15-20 Iraqi doctors, nurses, psychologists and pharmacists who now have a basic background in addiction treatment. They have a treatment unit in Iraq that was one of the first treatment options in Iraq and several satellites have branched off from that unit. The United Nations is now providing them with ongoing support to extend the training and expand the treatment options.
The other piece that we did in that first contract was to chair a meeting called the Community Epidemiology Workgroup in Baghdad that included law enforcement, education, health, security people and army officers to talk about the nature of the drug problem in Iraq. We published a paper about the findings from that report a couple of months ago. One of the major findings from the report and the resulting recommendation was that they needed to do a survey in Iraq, a household survey to get a better handle on the drug problem. That survey is in the field right now.
We have now done interviews with 2,000 individuals and the goal is 3,600. The teams are out surveying as we speak in Iraq. It will be the first national survey of drug use ever done in Iraq and hopefully we’ll have the data sometime this fall. We are both doing interviews and taking saliva samples because it is not clear how forthright the people are willing to be in Iraqi society about their use of drugs and alcohol. Under Saddam which was only ten years ago, if they were using drugs and alcohol, they would be shot. It wasn’t something you were likely to talk about so the accuracy of the survey in the context of Iraq’s history is challenging. That’s why we are also taking saliva drug samples to inform the self-report or confirm the self-report.
You received both your undergraduate degree in 1970 and your PhD in 1974 in Experimental Psychology from the University of Vermont. What then motivated you to enter the field of addiction treatment? Is there a personal reason why you made this choice?
I wish I had a better answer to that question. It was 1974 when I finished my PhD, it was during the Vietnam war; a time when many of us were looking for positions in academia. I was expecting to get a position as an assistant professor in a nice college and teach undergraduates and do a little research, but those were not the options available to me.
One of the options that I found most intriguing was a position at UCLA where they had one of the first grants issued by the National Institute on Drug Abuse. This particular grant was studying the medication naltrexone and a set of behavior therapies for the treatment of heroin addiction. Since that seemed like a very new area and an area where there wasn’t a lot of knowledge, I thought it was a good opportunity. At that point, I must admit I had no particular interest in addiction research or treatment per se.
In 1980, you worked for a nonprofit agency, setting up methadone clinics across California. Do you think methadone treatment for opioid addictions has proven effective? Should methadone clinics continue to operate given the recent advances with opioid antagonists like naltrexone and Suboxone?
After my first five years doing addiction work with patients using naltrexone and behavior therapy, I spent one year in New York City where I got to see the use of naltrexone and those other treatments in action. But I also got to see the use of methadone and the use of LAAM. LAAM was another medicine that was being developed in conjunction with methadone, but it had a longer lasting effect. (Editor’s Note – Like methadone, LAAM or levomethadyl is an opioid analgesic that is not used for relief of pain but was used in the past as a narcotic abuse therapy adjunct in the United States.) I became intrigued by the tremendous benefits that patients seemed to derive from these medications.
I came back to California and was given the opportunity to work on setting up what was essentially a service delivery system that focused on methadone. While we established those clinics, however, we continued to use naltrexone and LAAM and behavioral strategies for the patients as well. Although labeled as methadone clinics, it wasn’t simply methadone, but a variety of treatments.
In answer to your question about methadone and its future in relation to the other available medicines, I don’t think we’ve ever heard anyone say, “Well, gee whiz, we have a new antibiotic so maybe we shouldn’t use penicillin anymore.” There’s always going to be a need for methadone. Methadone is a tremendously effective treatment. It has the benefits of being relatively inexpensive as a medication. Around the world where we are seeing big problems with injection drug use and HIV, there’s nothing even close to methadone for its efficacy, effectiveness and efficiency.
And it will always play a role in the United States as well. There are some patients who need methadone because the other medications are not as effective with them. We are always going to need multiple medications. It’s not that a new one comes along and we drop the old ones. We are going to need all of them.
In 1984, you started the Matrix Institute in Beverly Hills during the peak of the cocaine epidemic and worked there until the end of 1995. Can you describe the goal of the Matrix Institute, its methodologies in terms of an intensive outpatient treatment program and whether you consider it to be a success?
With a number of partners in 1984, we opened the doors of the Matrix Institute. This was during the Reagan years, and our approach to the drug problem was to ‘Just Say No’ so there really was very little in the way of federal funding for research or the development of new knowledge. I was interested in looking at what kinds of treatments could be developed that would assist this newly emerging group of people who were using and abusing cocaine. The knowledge in the early 80s, at least the purported knowledge, was that cocaine wasn’t addicting, that cocaine was a drug that people took too much of occasionally, but they didn’t really get addicted to it. Well, 30 years later, we’ve recognized that’s certainly not the case.
Matrix was set up with the expressed intention of collecting information on stimulant dependence and using that information to develop strategies based on evidence that were effective treatments. It was our intention to look at the data we collected and to develop treatments that had evidence to support their use.
For the first five years or so when patients would come into Matrix and they would pay for the treatment themselves, they would also have to sign a consent form that basically said we don’t really know how to treat cocaine dependence. In fact, by coming into treatment at Matrix, you essentially were entering an experiment where we were trying to learn about cocaine dependence and trying to develop treatment strategies.
From 1995 to 2002, you focused your work on what would become a national plague – methamphetamine abuse and crystal meth addiction. From 1996 to1999, you were a member of the Federal Methamphetamine Advisory Group for the White House Office of Drug Control Policy and Attorney General Janet Reno. How damaging are methamphetamines and is the battle against them being lost?
While I was still at Matrix in the late 80s, the Department of Public Health in San Bernardino County asked us to open an office out there. While we were seeing hundreds and eventually thousands of cocaine users in Beverly Hills, in San Bernardino they were seeing the same great demand for treatment but for methamphetamine dependence. We opened an office in 1987 and we started seeing hundreds of methamphetamine users. With the same empirical approach we were developing in Beverly Hills, we started to collect data on methamphetamine use – what it did, who it affected, how methamphetamine addictions affected the person, what kind of effects did it have on their body and their brain.
In 1996, General Barry McCaffrey called a meeting to address the problem of methamphetamines. McCaffrey was Drug Czar under President Bill Clinton. He had been alerted by the Federal Attorney in San Diego who said that methamphetamine abuse was a huge problem on the West Coast and no one was addressing it. McCaffrey calls this meeting, and it turns out that we were the only ones who had any data. The data that we presented helped the government begin to address the methamphetamine problem in a larger way.
Over the next decade, there was a tremendous effort by the National Institute on Drug Abuse to develop medications and behavioral treatments for methamphetamine dependence. There were many other efforts on the law enforcement side to reduce the availability of precursor chemicals to stop the rampant Mom and Pop production of methamphetamine.
As we sit here now in 2014, methamphetamine is still most definitely a substantial public health problem across much of the country. We have not made significant progress in the area of medication development. The precursor controls of reducing the availability of drugs like ephedrine have reduced the production of methamphetamine in the United States.
The Mom and Pop labs or, as we used to refer to them, the Beavis and Butthead labs that dominated methamphetamine production in this country in the late 1990s and early 2000s were not able to continue to operate without access to the precursor chemicals. Most of the middle-sized labs in people’s garages and in Breaking Bad-like campers have mostly gone away. Now we have these portable laboratories of small-time users that are found in backpacks and on kitchen counters. Beyond these tiny individual user laboratories, the Mexican drug cartels stepped in and took over both the production and distribution of methamphetamine through giant-sized industrial labs. As fast as we develop laws to restrict the precursor chemicals or we restrict the other ways to get the drugs, the drug traffickers seem to find a way around them.
Today, the methamphetamine problem is still severe in many parts of the United States. We still need a lot more knowledge and information. The good news is that the precursor controls have reduced the spread of methamphetamine from the West Coast to the East Coast by stopping the homemade labs that were springing up when ephedrine was readily available. We actually don’t see very much methamphetamine use on the East Coast or the Northeast because it basically never got there. But it remains a problem in the West, the Southwest and in the Midwest. Many of the people now entering the criminal justice system in those parts of the country are affected by methamphetamines. We have a long ways to go.
You have worked for both LA County and the State of California to upgrade the public addiction system. Can you tell us what you were able to accomplish and what proved challenging?
The work in California with the county and the state was focused on two different areas. One area or theme was trying to promote the use of data to guide policy. We were trying to work with counties and the state to look at the data that they collected on who their patients are, what their patients need, which treatments work and for whom. Based on that information, we wanted them to ask the question of how we should expand treatment.
The second theme was how to build a substance abuse treatment workforce and how to build an awareness of substance abuse disorders into the educational system, thus making a better trained and better educated workforce to provide treatment. I think we made progress in terms of the use of data and will continue to expand with the new Affordable Care Act. I believe the data we collected will be used more effectively and become more valuable in the coming years.
Around the treatment workforce issue, I feel less successful. We have not gotten the workforce to the point where the training and the minimal standards for professionals in the addiction workforce are comparable to any other area of healthcare. We still have in California no license for counselors working in substance abuse care. There is still a whole variety of certification bodies that have all kinds of different standards; some of which are so minimal as to be almost laughable. It makes no sense that people with virtually no professional training are providing treatment to people with a life-threatening disorder like addiction. I feel like we haven’t done a good job there and I hope there will be some pressure to upgrade that process in the state of California. At the present time, California is one of only two states in the entire country without a license for people who provide substance abuse counseling, and I think that really is a mistake.
I think this licensing situation contributed greatly to the recent problem we had with the Drug Medi-Cal fraud. I think when you have people working in treatment centers who have no training in ethics and no training in professional standards of behavior, you are much more likely to have fraud and all kind of shenanigans going on that you wouldn’t have if you had a licensed workforce.
As the Co-Director of UCLA Integrated Substance Abuse Programs and Professor-in-Residence at the UCLA Department of Psychiatry, you have experienced the academic difficulties of conducting substance abuse research first-hand. UCLA in particular seems to have been broken down into several fiefdoms of addiction study, rather than one integrated program. Why is this and what can be done to change the system?
UCLA has a long and storied history in addiction research going back to the 1960s when Sidney Cohen was one of the original directors of the National Institute of Mental Health and was one of the people who helped shape the development of the National Institute on Drug Abuse and the National Institute on Alcoholism and Alcohol Abuse. Tom Ungerleider at UCLA did some of the first research on marijuana. Jolly West, the Chair of Psychiatry at UCLA, notoriously did research on LSD that purportedly resulted in the death of an elephant in Oklahoma. He was quite an interesting man.
UCLA is a huge place, and it’s one of the largest public universities in the United States. It has close to fifty thousand students and there is limited campus space. Many of us are scattered around off-campus, and we have offices separated by crowded city miles that make daily integration of our work with each other somewhat challenging. As you start to develop bodies of work, you become specialized and particularly focused on the topic areas that you currently are working on. Your neighbor a mile away may be working on a variation of that work, but he has a whole different angle on it and different kinds of funding.
In the last several years, I think UCLA has tried to pull these different pieces of research closer together. For example, we work with Dr. Edith London, a brain imager at UCLA, and we’ve worked with her for well over a decade. We work with Steve Shoptaw in the Department of Family Medicine and Laura Ray in the Department of Psychology, however, at the end of the day, I work in my offices in Santa Monica and they are doing their work on campus in Westwood. There is a geographical issue that is characteristic of Los Angeles.
We are so spread out that we tend to develop our own little mini-silos of work. There are efforts to promote integration, but it certainly has a ways to go before it will be successful. There is a huge challenge to integrate our substance abuse disorder research with the medical research and the psychiatry research that is going on at the same university. It is a big challenge because the funding streams for research tend to foster the siloing because you tend to stay focused on a specialized area of research where you have access to funding. There is a lot of pressure to stay focused on your area in order to continue to be at the forefront of your field so it often makes lateral work with other groups somewhat challenging.
At this point in your career, about 50% of your time is spent out of the country. You have led addiction research and training projects for the United Nations, the World Health Organization, and the Drosos Foundation, exporting science-based knowledge to many parts of the world. Can you describe the motivation behind this international work?
The primary motivation was curiosity. I came out of school during the Vietnam war, an era when we were doing lots of protesting for peace. I was of a generation that really felt that we could do a better job with the image of America in the world. We wanted to do things that were more positive than invade countries. We didn’t want America to be solely identified by our weapons and uniforms.
One of the things that drew me to doing international work was the idea that if you could contribute useful information in different parts of the world as an American and providing it as a participant along with the local professionals, it may actually help to change the world’s perception of our country. When I first got invited to go to Israel and Palestine, it was right after the Oslo Accords and a lot of it was about building cooperation. The issue that we were talking about with the Israelis and Palestinians was addiction, but really the overarching goal was cooperation. Both the Israelis and the Palestinians had problems with drugs and alcohol that were damaging their respective societies. Since their societies are so intertwined, the question was how could they work together to address these problems. At the end of the day, both the Jews in Israel and the Muslims in Palestine don’t want their children to grow up with addiction problems.
Almost all of the work I have done internationally has been about addiction, but it also has been about building cooperation and fostering a positive image of the United States in relation to this goal in parts of the world where the reputation of our country has not been as popular as it could be.
You were the Principal Investigator of the SAMHSA contract to establish the Vietnam HIV-Addiction Technology Transfer Center. Can you describe this project and illuminate the connection between Vietnam and HIV?
What the United States has done in the last decade in Vietnam has really been something that we can be proud of when compared to what happened in the past which was such a different story. In the last decade, the PEFAR Program or the President’s Emergency Plan For Aids Reduction has been in Vietnam providing technical assistance to the Vietnamese government along with the World Health Organization and Global Fund to help the government and the people address the problem of HIV and injection drug use. Earlier studies done by WHO indicated that in certain pockets of Vietnam like Ho Chi Minh City, Hanoi, Haiphong and a number of other places, among injection drug users, the HIV rates were extremely high – 60 to 70% in some places. They had limited treatment for HIV and no treatment at all for injection drug use.
Beginning in 2008, a pilot project with methadone treatment began in Haiphong and soon after Hanoi. Since methadone treatment has been introduced, the data has been extremely promising on the ability of methadone to reduce not only heroin use, but injection use and transfer of HIV in Vietnam. It’s been a really remarkably successful example of how the proper treatment can not only reduce the damage from addiction, but the damage from infectious diseases as well. Vietnam has been a real shining light in this area, and they’ve done a tremendous job. They now have in the neighborhood of 40 to 50 clinics in the country, and they’re treating somewhere in the neighborhood of 20 to 25,000 people with methadone. They are well on their way to reaching the goal of treating 80,000 people by 2016.
One of the biggest challenges is finding the workforce to deliver the treatment. All of these clinics require doctors, nurses, counselors, pharmacists to run them. None of these people were available in 2008. The VH-ATTC (Vietnam HIV-Addiction Technology Transfer Center) that we’ve helped to develop in conjunction with PEFAR and SAMHSA is all about creating the workforce to handle the treatment needs. It’s a huge undertaking and we could not have done it without the folks at Hanoi Medical University. They have been remarkable in terms of their ability to gear up and develop training and become very active across the country. Their expertise is just superb and it’s such that they could now do trainings in the United States.
Even though technical assistance from American professionals is still being provided around injection drug use and HIV, the big demand now is around amphetamines. Just as we start to make inroads in terms of opiate dependence, they start to have problems with amphetamine abuse in Vietnam. As a result, we are starting to help them develop the behavioral treatments that we have been using in the United States. That’s an even bigger job because training doctors and nurses to provide methadone with some counseling is very different from training them to treat amphetamine dependence. Since it is a behavioral treatment, it is much more training intensive. Being successful with such training is the next issue on the horizon and hopefully it will be continued with a subsequent contract.
You have said the Affordable Care Act is one of the most significant transition points in how addiction will be treated. Can you tell us why?
In my almost 40 years in my work in addiction – it will be 40 years in September – I have worked pretty much exclusively in the silo of addiction treatment. I’ve set up methadone clinics, outpatient clinics, helped people set up residential care and looked up the data from all of them and done training for all of them. One of the intentions of the Affordable Care Act is to help better integrate treatment services into the broader world of healthcare. The ACA provides the opportunity for people like me and the future generations working in addiction to see how we can better integrate our services into mainstream healthcare.
The goal is to get out of our silos and to expand outwards into a much broader set of services beyond the 2 million people we treat every year in all of our specialty clinics and silos of addiction care. We want to provide services for the other 20 million Americans with substance use problems who don’t go into specialty care. They might see doctors, nurses and psychologists in broader healthcare settings, but their substance use problems are not addressed because historically addiction is not a concern of primary care. Unfortunately, this separation of the silo of addiction care from the rest of healthcare has really restricted our impact and our ability to see the impact of how our substance use knowledge and treatment services would benefit the larger health system.
It’s going to be a fascinating next ten years of figuring out how to move substance use services into mainstream healthcare, how to educate and serve mainstream healthcare. If substance abuse service providers want to integrate into the bigger healthcare system, they have to understand their role in that system. It’s not like everyone is going to drop everything else they are doing and say, “Okay, addiction folks, you’re right and we’re going to focus all of our efforts on addiction because it’s really important.”
The people in the bigger healthcare system actually have lots of other really important stuff that they need to pay attention to so we have to learn how to helpful to them. We have to make our services of value to them and not the other way around. We have to show them that if you treat alcohol and substance abuse issues, you will see broader benefits to patients' lives and to their overall health issues.
It’s going to take a good deal of time, some very creative models, a lot of persistence and working on the funding mechanisms to make sure all the pieces can fit together.
Where do you think the most notable progress has been made in addressing substance use disorder problems?
The benchmark that changed things in how people viewed addiction in the United States was in the late 1990s when Alan Leshner, the then Director of the National Institute on Drug Abuse together with Barry McCaffrey, then the Drug Czar, took on a campaign to reeducate the public about addiction as a brain disease. Up until that point, we would talk about substance use, about alcoholism and drug addiction "as if" it were a disease.
There was always the “as if” because it was like a disease and it was "a disease of the spirit" or "a disease of attitude" or some kind of "allergy" to alcohol. There were all kind of metaphors of how addiction was a disease, but nobody really understood it as a disease.
I didn’t understand it as a disease. But when I first started seeing the pictures of how addiction changed the brain and how the brain recovers or doesn’t recover depending on the study and the type of drug, a switch flipped. It was like, okay, now I get it. You start using drugs and alcohol for a whole variety of reasons; because you’re curious, because your friends do it, because it’s cool, but after you use them for a while, your brain changes. Then the process of your decision-making and your continuing use of drugs is based on a whole different set of brain circuitry. Not only did that help me understand addiction, it also helped me to communicate with other people about addiction.
As I’ve gone around the world, it’s been the one message that seems to resonate with all audiences whether you’re talking to judges or to people in rural Egypt or to people in Vietnam in the mountains. If you can make it clear and express it in a way that they can understand it given their educational level, if you can communicate the fact that drugs and alcohol change your brain and that changes how you make decisions by affecting your impulse control, it really makes a difference in people viewing addiction as a health problem as opposed to misbehavior or criminal behavior. That’s been the single biggest point that I’ve seen; the recognition, acknowledgement and acceptance of addiction as a brain disease.
What do you hope to accomplish in the future?
As a result of these efforts that we’ve been doing around the world, UCLA and these colleagues of mine have gotten a reputation for conducting training of young professionals. I’m hoping that we’ll have more of an opportunity over the next decade to help train the first generation of addiction clinicians and addiction researchers in many parts of the world. In the Middle East and Southeast Asia, there was no history of doctors going into addiction, psychiatrists specializing in addiction, nurses and psychologists developing careers in addiction. We seem to have the opportunity now to be able to really increase the knowledge and work with different universities to develop addiction programs.
I really hope to be able to continue spreading the information and not just the information, but spreading the relationship between U.S. professionals and professionals in other parts of the world in a mutually collaborative way. Those relationships have been some of the most rewarding parts of my life; the people I’ve met in Egypt and the United Arab Emirates and Beirut and Iraq and Iran and Vietnam. Those relationships have become extremely valuable to me, and I think if we can do more of that kind of work and have a bigger impact on the training of new professionals in those parts of the world, it’ll have both a good impact on the image of the U.S. in those parts of the world as well as helping people develop high quality and effective treatments for people with substance use problems in their societies.