Will My Insurance Pay for Rehab?
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Interview with Michael Botticelli, Obama's "Recovery Czar"
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Michael Botticelli was sworn in as Director of the Office of National Drug Control Policy (ONDCP) at the White House on February 11, 2015. As Director of the ONDCP, Mr. Botticelli leads the Obama Administration’s drug policy efforts to balance the health needs of the American people with a public safety approach. Since being confirmed, Michael Botticelli has helped advance and transform the drug policies of the nation in light of healthcare reform and a new emphasis on evidence-based treatment options. He has been an active proponent of innovations in prevention, criminal justice, treatment, and recovery.
Although his position is widely known as the Drug Czar, he prefers being called the Recovery Czar, particularly in light of his own experience in long-term recovery. Mr. Botticelli is the first person in recovery from a substance abuse disorder to hold the position. Instead of limiting him, as it might have done in the past, his personal experience in recovery is seen as proof of the government’s shift away from the War on Drugs and towards a zeitgeist of treatment and healing. The Fix is honored to have the opportunity to interview him.
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At the recent White House Symposium on Addiction Medicine, you stated in your opening remarks, “America must bring the power of medicine and public health to bear to reduce substance use and its consequences. Today’s symposium can help ensure that the next generation of physicians is well-equipped to bring an effective public health response to substance use disorders.”
Can you describe how the surge in the role of addiction medicine is related to healthcare reform and the Affordable Care Act?
Sure. Just to kind of step back for a minute, John, I think that we’ve known for a long time that we’ve treated diseases of the brain differently than we’ve treated diseases of the body. We’ve looked at diseases of the brain as being entirely separate issues. We’ve had specialty treatment programs for a long time, but we still haven’t seen the integration of issues around addiction as part of mainstream medicine, and that gets reflected in the minimal amount of education that physicians and other healthcare providers get around addiction. We still see very few referrals to treatment coming from the medical community.
The Affordable Care Act has done a number of different things to face a number of different challenges. In light of what has happened in the past, it is really unbelievable and impressive that the Affordable Care Act sees substance use disorder as one of the 10 essential health benefits. ACA looks at integration issues about addiction in primary medical care through a number of really innovative programs. What we also want, however, is as we see increased demand, we have to increase the number of providers who are able to treat addiction within a primary care setting. We know we need to do a better job integrating substance use issues as part of broad medical education.
As a result, this forum was really historic in that it brought together ONDCP and other federal agencies as well as a whole host of people in the medical community. Not only the American Board of Addiction Medicine, but the American Society of Addiction Medicine as well as many specialty societies that are providing primary care came together with the goals of walking away with specific pledges and actions to do a better job at integrating substance use disorder education into medical education. For example, looking at things like screening and brief intervention within primary care settings.
The Affordable Care Act really provides an opportunity not only for increased coverage, but better integration between mental health and behavioral health services.
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How have evidence-based treatment options become more important in the national discussion about the treatment industry? Is the treatment industry going to have to change its methodologies of treating addicts and alcoholics whether it wants to or not?
One of the bright spots, John, that I think is really helpful in working in this field is that our evidence based on what is considered effective treatment has grown enormously over the past 20 years. Our goal at the federal level is to ensure that treatment programs, particularly federally funded treatment programs, are implementing evidence-based treatment as part of their curriculum.
With your background, you know that in response to the opioid epidemic we have been significantly pushing treatment providers, but also the criminal justice entities to make sure that people with opioid use disorders are getting access to medication-assisted treatment. The evidence has been clear for a long time that people with opioid use disorders that get medications combined with other behavioral and recovery support services do far better than people who don’t get those medications. It’s become very clear that we want to make sure that every treatment program offers, either in the program itself or by association with other providers, medication-assisted treatment.
I think it’s really, really important, and I hear this time and time again from parents who identify that they have a son or daughter or a loved one that has an addiction that they often feel confused. They are unsure how to pick a treatment program, and these people are making probably the most important decision of their lives as it relates to the care of a loved one. We want to make sure that treatment programs continue to implement effective and evidence-based treatment options for their patients.
Without question, Medication-Assisted Treatment (MAT) is at the forefront of the latest options being championed for addiction treatment. Despite the proven effectiveness of such options, like Suboxone for the treatment of opioid dependence and abuse, there has been a wave of resistance in the 12-step community. Like myself, you are a member of a 12-step program in long-term recovery. What would you say to 12-step members that are resistant to MAT, claiming that such patients are not really sober?
As a member of a 12-step program, I would say that such a reaction actually goes against what 12-step programs actually talk about when it relates to medications. I am sure you are probably familiar with a widely-used pamphlet that basically says if people need medication, then they need medication. We need to continue to foster that information.
I do think, John, such perspectives are dramatically changing in 12-step programs. I have visited many community recovery organizations that don’t see this division between people who are in recovery on medications versus those who are not. I think that we’ve come a long way as a recovery community, knowing that there are multiple paths to recovery and that medications for many people are an important part of their path.
We are really seeing a diminution of this arbitrary line between people who are in recovery who are on medication and those who are not. As a 12-step community, as a recovery community, we understand that there is no one right path and that each person has their right to their own individual path to recovery. I feel optimistic that these kinds of dividing lines are falling away, and the opioid epidemic is really accelerating that change in beliefs for many people.
Given your past tenure as director of the Bureau of Substance Abuse Services at the Massachusetts Department of Public Health, what do you think of the Angel Program in Gloucester that has been initiated by Gloucester police chief Leonard Campanello to help addicts access treatment and the path of sustainable recovery as opposed to being arrested and punished for their disease?
One of the experiences, John, which has just been extraordinary for me is that as I travel the country and I talk to local law enforcement, there is a huge and growing consensus about the fact that we can’t arrest our way out of the problem. I hear that echoed back to me by law enforcement officers all across the country. You know that we’ve seen dramatic increases in law enforcement personnel who are administering naloxone as part of their day-to-day operations.
I look at the program in Gloucester as another example of how police are coming together with the treatment community with the understanding that they play a pivotal role, not just by arresting people, but by how they can help get people to treatment. It’s really amazing to me when I look at programs in Gloucester and other communities.
I actually just met a police chief in Dayton, Ohio, who’s creating what he calls "Conversations For Change" where they identify people who have experience with overdoses, and they invite them and their loved ones to come to a community session. Law enforcement is not involved in it. They do motivational interviewing with peers and treatment programs to try to get people care. We are seeing this huge expansion of public safety working together with treatment programs to try to facilitate people’s access to care. I see it as this huge bright spot in this otherwise very devastating opioid epidemic that we have law enforcement that are willing to be innovative and partner with treatment programs. Rather than arrest people, they are trying to get them into care and treatment. It’s really been remarkable to see law enforcement step to the table in very dramatic and innovative ways to try to look at how we get people into care and treatment.
With John Rosenthal, Chief Campanello has taken the Angel Program a step further by founding PAARI (the Police Assisted Addiction Recovery Initiative). PAARI is designed to help spread the ideas of the Angel Program nationally. Do you think this is a good idea? Will it work, and could the Office of National Drug Control Policy help in making it happen?
Part of what our national drug control policy really talks about is how we use a broad array of tools to divert people away from arrest and incarceration and toward treatment. We’re particularly interested not just in this model, but in other models that really help divert people away from arrest and incarceration and get them into treatment. Our office does play kind of a key role in evaluating these models, in looking at the success and examining the evidence behind the success, then really trumpeting what we see as effective programs as it relates to moving forward and getting people into treatment.
We also look at the particular role that law enforcement plays. It’s going to continue to be a growing area, not just for ONDCP, but also for law enforcement communities to look at these kinds of models. They should study them, evaluate them, and look at the opportunities that we have. It’s really been encouraging to see this grassroots movement of law enforcement folks who are interested in being part of the solution to the problem.
On October 9, you tweeted, “Faith communities played an important role in my recovery, and can help millions more get care.” Can you illuminate for us how faith communities played an important role for you? Although faith communities can help people in the grip of addiction and recovery get care, what are your thoughts about the communities administering that care as well? Beyond faith-based support, isn’t a medical role in treatment a necessity?
Let me talk a little bit about my own personal experience, John, then I’ll answer the second part of your question. When I look back at my early recovery, I joined a faith community. It was really because a lot of my friends in early recovery were going to that congregation. And for very good reasons; this was both a pastor and a community that understood issues around addiction, understood the role that spiritual healing plays in addiction recovery. I recall sermons by the pastor that often incorporated passages from 12-step meetings as part of the spiritual component of the Church. For me, it really played an instrumental role in providing a place of healing and support.
John, you’re a fellow traveller on this path, and you know how important it is to establish a community of support, whether it’s in faith-based group or a recovery organization or a 12-step program. I know that having such a community played an instrumental role for me. Not just because I found a place for spiritual healing, but also because I finally found a place where I belonged. Although I can only speak from my own experience, I know it helped a lot of my friends as well. The experience of seeing it help others is a powerful one.
We know that faith communities play that role for many, many people and can be a place where they can safely diminish the shame and stigma by talking about it openly and honestly. A faith community offers healing and compassion, not just for people recovering from addiction, but also for their family members as well. It is often said that there are multiple paths to recovery. While there are people who need specific medical treatment, we also know that faith communities can play a huge role in helping people get help, treatment and recovery support. This clearly is not an "either/or" proposition. It is an "and" where faith communities can play, have played and will continue to play a huge role in this work.
I actually was in California a few weeks ago at the Saddleback Church. It’s this huge, mega-church. They did an entire session with their congregants about the role of faith communities in raising awareness around mental health and substance use addiction issues. They talked about the healing role of the Church, and how they can play a larger role in helping people in the congregation. It was really gratifying to see an example of one of these faith communities that has long been part of this work being so supportive of addiction recovery.
I do want to add that one of the last pieces that you are talking about, John, that I think is really important and that you were getting at in your question is that for people who are in treatment programs, participation in faith activities, at least as it relates to federal funding, needs to be separated. We shouldn’t be predicating that people have to participate in faith activities as a condition of their enrollment and participation in federally funded treatment programs. This needs to remain a clear priority. While faith communities play a huge role, while spiritual healing plays a huge role, we can’t predicate people’s participation in federally funded treatment programs on the fact that they need to be involved in specific faith activities.
I completely agree, yet I also know how important a faith community was for me in my early recovery. I actually got sober at Beit T’Shuvah (Hebrew for The House of Return), the Jewish rehab in Los Angeles.
I have heard good things about their program for a long time, but I haven’t had the opportunity yet to visit them.
Even though I am not Jewish in terms of my spirituality, being a Jew is an important part of my cultural heritage and tradition. While in the program, I embraced the faith activities, including Torah Study every morning where lessons from the Five Books of Moses were compared to the lessons learned in the 12 steps. It played a remarkable role in my early recovery and really helped me find my footing on the path of a sustainable sobriety.
As they say in the 12-step rooms, it’s only the first step that talks about alcohol or drugs. The rest of the steps are really about a way of life, which I think many faith-based groups and religious organizations support by their teachings. In very similar ways, John, I just found great comfort and great healing in a faith community.
Barbara Theodosiou founded The Addict’s Mom eight years ago as a Facebook Group. Today, it has over 70,000 members. A major goal of The Addict’s Mom was creating a safe place to “Share Without Shame” where the mothers of addicts could share their challenges. Do you see a connection between the ideal of “Sharing Without Shame” and your earlier work in the LGBT community, helping to raise awareness and allow members of that community to express themselves and overcome the stigma of prejudice, particularly during the early days of the AIDS epidemic?
I have talked about this quite a bit, John, both from my own experience as a gay man and from my experience working in the health department around HIV services. There are many, many parallels and lessons to be learned around this. It brings me back to the early days of the AIDS epidemic when HIV was primarily affecting gay men. People really did not care because it was affecting somebody else, and they didn’t necessarily see the devastation that it was causing.
Back at that time, I volunteered for The Names Project that put together the first memorial AIDS quilt. Started by Cleve Jones in San Francisco, it created quilts in honor of the people who had died as a way to remember them. I remember being part of a contingency that unveiled that quilt at the National Mall. I see a lot of parallels between that and the current opioid epidemic, particularly the overdoses. I talk to parents who are riddled with shame and guilt, and it often prevents them from talking about this openly and from seeking care.
I believe that parent groups around the country like The Addict’s Mom are addressing this problem, and these groups clearly want to help those in the midst of this opioid epidemic by removing the stigma and the shame. This is what our office wants to do as well. We are in contact with parents’ groups that are providing support and offering help. We are seeing many of these parents’ groups developing memorials in order to show to their communities that this life mattered. They are doing their part to diminish the shame and stigma. This is such an important step in the right direction.
We have seen, John, as I’m sure that you have as well, many reports of parents expressing in the obituaries of their kids that they are not going to be filled with shame. They are willing to say in the obituary of their children that their children died of an overdose. I remember back during the AIDS epidemic when people would not put in the obituaries that people died of AIDS, and there were lots of codes that people had for that.
Indeed, there are a lot of parallels between the two epidemics, but, on the positive side, one of the things that really changed with the AIDS movement and the LGBT rights movement, was people who were willing to come out and be visible about who they were. It was too easy to hate people if you didn’t know them. It was that kind of invisibility that really diminished public policy. Again, on the positive side, we see both parents and people in recovery who understand that to really help shape public policy, to diminish the shame, we need to be open about who we are. If we are going to remove the shame and stigma, one of the key strategies is people’s willingness to say, “This is not someone else’s kid. This is not someone else’s family. This is not someone else’s community. It touches all of us.”
While we have seen a movement in this direction building for a while, the opioid abuse and overdose epidemic has accelerated this process. For example, last month at the National Mall, there were 40,000 people present, including myself, who wanted to show that there are millions of people in recovery. There are lots of parallels and lessons to be learned from the LGBT movement, from the AIDS movement, and the Recovery movement as well.
According to Infectious Disease News, “Methamphetamine use is 10% to 20% higher among MSM (men who have sex with men) than in the general population, and 20% to 25% use the drug at least weekly.” In addition, according to the CDC, “A growing body of research supports the relationship between methamphetamine use… and an increase in behaviors (sexual and those related to injection drug use) that can put the user at risk for HIV infection.” Do you believe there is a direct connection between crystal meth use in the gay community and increased HIV infection rates? What can be done to lessen such behaviors?
The data had been clear for a while in terms of the connection between meth use in parts of the gay men’s community and increased HIV infection. We’ve seen that for a long time. It says a couple things about what we need to do because we’ve seen the dramatic increase in meth use in general. It’s important from a data standpoint that we need to continue to look at and to ask, “Are there specific populations that are disproportionally and dramatically impacted by this drug?”
I have been concerned and done work, not only in my time in Massachusetts, but my time at the ONDCP as well, about how do we change community norms around substance use issues in general. Even though we don’t have the best data, there are a number of studies that show that alcohol and drug use are elevated within the LGBT communities. There are many, many reasons why. Histories of oppression experienced throughout individual lives is a big one. The history that continues to this day of the bars as one of the central places of activity for LGBT folks plays a role.
In order to counter these trends, I think we have to continue to focus on the key issues like how do we continue to raise awareness about the intersection between crystal meth use and HIV infection rates. There is a lot of work happening, both at the state and the local level, to develop specific outreach campaigns focusing on this connection. We need to make sure, for instance, that our LGBT-serving health organizations are doing screenings and brief interventions for people who are coming into their facilities. This is a really important strategy in helping to identify those issues. We need to make sure that we have good support groups for gay men that address these issues and help to raise awareness. When you provide some level of support and help for gay men that are struggling with crystal meth use, a lot of these issues come out and the problems become uncovered. By reaching out, you open the door and gain access to this information. This is why we need good care and treatment, good outreach services, and we need to continue to have good data to really understand the effect that crystal meth has had, particularly in some parts of the gay community.
Before becoming ONDCP Director, you were an active member of the National Action Alliance for Suicide Prevention. A popular saying in 12-step groups is, “Alcohol and drugs were not my problem. They were my solution. They just stopped working.” Suicidal ideation, suicide attempts and suicide are common for people in early recovery. Do you think suicide prevention should be a part of any treatment program and emphasized by the treatment industry to avoid such tragic outcomes?
I think you really articulated well, John, a problem that we face not just in early recovery, but also in substance use disorders as a whole. We know that there’s a strong nexus and interrelationship between substance use and suicide, suicidal ideation and suicide attempts. It’s really important to recognize this connection not just for the substance use disorder treatment community, but for the suicide prevention community as well.
I was pleased and honored to be part of the National Action Alliance for Suicide Prevention group. We helped include in the national strategy a recognition of the interplay between substance use, mental health, and suicide issues. If you look at the action items for each, they really parallel and support each other. A major action item is better access to treatment for mental health and substance use disorders. All three call for diminishing the stigma associated with suicide, mental health, and substance use disorders.
We need to ensure that we are doing good treatment and assessment, both in treatment programs as well as within suicide prevention programs, to identify and diminish the negative interplay between these issues. For instance, treatment programs should be doing suicide assessment as part of the intake process and treatment plan. Suicide prevention and intervention folks should make sure they are doing screening for substance use issues. If substance use is an issue for a person at risk in such programs, then they need to be able to get good care and treatment. It works both ways in ensuring that there is good screening and assessment for both substance use and suicide issues for both treatment programs and suicide prevention professionals.
In an interview with National Public Radio about the legalization of marijuana in Colorado and Washington, you said, “We see escalating use. We know that marijuana is addictive. About 1 in 9 people who use marijuana regularly become addicted.” In response to the national push towards marijuana legalization, is the ONDCP in a holding pattern? Given the dangers of marijuana abuse, do you feel like you are caught between a rock and a hard place as your efforts at improving public health run counter to this legalization?
Our position has remained steadfast, and it does not come from a political standpoint. It comes from a public health standpoint. We remain opposed to legalization efforts. We believe there is significant harm and consequence to marijuana use, particularly among youth in this country. The data is clear in regards to the dangers of youth use. We have seen data that show that the perception of the risk of harm from smoking marijuana among youth in this country is at its all-time lowest level. I, and many other public health professionals, believe it’s a function as to the messages that youth are getting as it relates to marijuana legalization efforts.
The other concern that we have is the significant increase in the commercialization of marijuana that will use some of the same techniques that tobacco has used to target the most vulnerable people, including youth, in the United States. We continue to monitor the impact of legalization In Washington and Colorado, but our position has remained steadfast that we believe that legalization runs counter to a public health approach for our national drug control strategy.
In the same NPR interview, you go on to say, “I do think that the public, quite honestly, has been getting some erroneous messages from the proponents of legalization.” Is it the responsibility of the ONDCP to correct these messages? Should a national campaign by the federal government raise awareness about both the dangers of short-term and long-term marijuana abuse and dependence as more and more state laws are pushing towards legalization?
It’s certainly a key role for the ONDCP, but also for state and local community partners as well. We have drug-free coalitions in over 700 communities that do an extraordinary job at looking at prevention and education efforts, not just around marijuana, but also around a whole host of substances. It’s important that we, meaning the ONDCP and the local drug coalitions, get really good and accurate information out about the impact of marijuana. When you look at the data, there is significant cause for alarm when youth do not see smoking marijuana as harmful.
The dangers of marijuana goes well beyond anecdotal. When you start looking at the data, particularly the perception of the risk of harm of marijuana use among youth in this country, we all have reason to pause, and we all have a responsibility to get good, accurate, scientifically-based information to youth in particular, but also to the public as a whole as they are making these kind of choices around legalization efforts.
On August 31, you tweeted, “The odds of surviving a drug #overdose depend on how quickly the victim receives treatment.” Do you believe there should be greater access to the opioid antagonist naloxone (also known as Narcan®) that reverses the effects of heroin and prescription painkillers, particularly in cases of acute opioid overdose? The drug also reduces respiratory or mental depression due to opioids. Should people be able to buy this life-saving drug over-the-counter?
Since the beginning of this administration as part of the 2010 National Drug Control Strategy, increasing access to naloxone for people who are in a position to witness an overdose, particularly first responders, has been one of our prime goals. As I mentioned earlier, we have seen police departments all across the country in support of naloxone and naloxone administration. We are tremendously pleased by the number of states that have implemented state-level legislation to expand the availability of naloxone as well as the establishment of 911 Good Samaritan Laws that provide some level of limited immunity for people who are reporting an overdose. We want to make sure that we are doing everything we can to improve the chances for people who are experiencing an overdose to be revived. The ultimate decision about over-the-counter rests with the Food and Drug Administration (FDA), but again we have been looking at and been supportive of many mechanisms to expand naloxone distribution.
We see this expansion as part of a comprehensive strategy. We want people who are in treatment to remain in treatment. Since day one of this administration, the expansion of naloxone and naloxone distribution has been and will continue to remain a priority of our office.