Q+A with Michael Botticelli on the Future of Treating Substance Abuse Disorders.
For Michael Botticelli, one of the toughest tasks he faces as the new director of the Office of National Drug Control Policy is fighting the lingering perception that he’s the tip of the spear leading the charge in the so-called “war on drugs.”
Botticelli is the featured speaker at the April 8 Public Health Forum, where he will present “The Future of Treating Substance Use Disorders: What Is the Role for Health Care Professionals?”
Language is freighted with power, and Botticelli is all too aware that shedding decades of militaristic, get-tough rhetoric about drug addiction is difficult. But harder still is spreading the message that substance abuse is a pervasive public health issue that deserves to be addressed as such at the highest levels.
“I’m a public health guy,” Botticelli has emphasized in multiple speeches, interviews, and Congressional hearings prior to being sworn in as director on February 11, 2015. If he’s fighting for anything, Botticelli is battling to change how drug addiction is still perceived as a moral issue laden with societal, religious, and criminal baggage.
Before he joined the ONDCP in 2012 as deputy director, Botticelli served as director of the Bureau of Substance Abuse Services at the Massachusetts Department of Public Health. There, he saw that to be effective, he would need to be less of a drug czar than a CEO, able to build partnerships with local, state, and federal law enforcement agencies; coordinate resources of state and local health and human service agencies; and encourage agencies to develop and implement evidence-based programs.
He advocated for a mosaic of components: treatment systems for adolescents, early intervention and treatment programs in primary care settings, jail diversion programs, re-entry services for those leaving state and county correctional facilities, and overdose prevention programs.
And along the way, he rarely fails to remind people that he’s one of those people given a second chance, having faced his own spiral into substance abuse and involvement with the criminal justice system. He also reminds people just as strongly that he is in long-term recovery from that substance use disorder, and has recently celebrated more than 25 years of sobriety.
Q: Since starting at the ONDCP, you’ve emphasized in multiple interviews that you’re a “public health guy” and that perhaps it’s time for a change of thinking of how drug abuse is treated, on various levels. Can you elaborate a bit on the shift that the office has helped bring about?
A: For a very long time, our practice as it related to people with substance abuse issues was based on our understanding of—or really our misunderstanding—about drug abuse. For a long, long time we saw this as kind of a moral failure, that this was about bad people doing bad things. Policy and practice reflected that. We thought if we arrested and incarcerated our way out that would be the solution to our problems. Thank God that we now have a lot of scientific evidence and data to show that addiction is a disease. It has all the classic components of many other chronic diseases like diabetes or hypertension. We need to come at this from a classic public health standpoint.
So we need good data and surveillance — we need to understand the prevalence and who’s affected, so we can use screening and early identification, good treatment, and good after-care and support – just like we do with other chronic diseases. We know we have to refocus our policy and our practice to deal with this with a classic public health framework.
Q: Until fairly recently it seemed as if the conversation was more about approaching the drug problem from a law-enforcement standpoint than through the healthcare system. To that end, do you think that the way that we have treated our fight against substance abuse—calling it a “war on drugs” and things of that nature—do you think that has been counterproductive?
A: Dramatically counterproductive. I think the former director of ONDCP, even though he was a former law enforcement guy, really kind of began to change policy and practice. Even he, as a former chief of police, said that we couldn’t arrest our way out of the problem and that a war on drugs was fundamentally a war on people. I remember being in Massachusetts at the time and hearing that from the Office of National Drug Control Policy was a clear indication to me that there was a dramatic shift in kind of our country’s drug policy.
Just as a side note, I hate being referred to as the “drug czar.” While it is shorthand for the position as people know it, I think it still denotes kind of a law enforcement-centric approach to dealing with people with substance abuse disorders.
Q: Here at SPH, Dr. Richard Saitz has been a vocal advocate of reframing drug abuse or drug addiction as substance abuse disorder, to both reduce stigma and to re-focus the attention on addiction as a health issue. You’ve incorporated that language for several years, and in multiple presentations. Has the shift gained traction?
A: I think it’s beginning to happen, but I think we still have a long way to go. Let me give you some examples of that. A poll by the Pew Charitable Trust showed that the majority of Americans favor treatment over arrest and incarceration. I think we’re beginning to change public perception in terms of how we approach those issues. But, I think that we still have a long way to go, particularly in making issues around substance abuse being seen as mainstream medical care.
We still see the most significant referral source of people into treatment is the criminal justice system. One of the smallest percentages is coming from health care providers. I think that there are some historic reasons for that.
One is that a lot of treatment and recovery efforts for substance abuse disorders didn’t come from the medical profession. It was a 12-step community-based model for a long time, before we really had a corresponding set of good treatment programs. We had separate care and delivery systems. So, even now, people with substance abuse disorders often go to specialty treatment and are not getting their treatment or even early identification in primary care settings. We often have not done a good job in doing kind of early identification through primary care settings.
Q: Only about 11 percent of the 23 million Americans with a substance abuse disorder are actively seeking treatment or are currently in treatment. Would more referrals via medical settings as opposed to law enforcement referrals be one way of possibly boosting that number? Are there any other ways that the ONDCP might help with this?
A: We know insurance or lack of insurance plays a big role in not getting care. So, under the Affordable Care Act, mental health and substance abuse disorder benefits are one of the 10 essential health benefits that have to be offered. It can really play a huge role in increasing access to care for people who have insurance.
The second piece that the Affordable Care Act does is it makes sure that those benefits are given on par with other medical surgical benefits. If you look at some of the reasons why of the people don’t get care even if they have insurance it’s because their insurance either doesn’t have a benefit or doesn’t have a benefit for treatment that’s on par with other medical surgical benefits. So, that’s one piece.
Another piece that I often talk about is we haven’t done a particularly good job of identifying people who are often coming into contact with the primary medical care system. We need to do a better job of early detection and screening so that people don’t progress to an acute phase, or refer people while they’re still in contact with the medical care system for treatment in a specialty program.”
Q: Deaths from heroin overdoses have spiked in Massachusetts and throughout New England over the past 18 months, continuing a disturbing upward trend. What factors might be involved, and have these been mirrored nationwide?
A: One of the drivers around the increase in heroin use has been the dramatic increase in prescription drugs misuse. You can trace that to the vast over-prescribing of prescription pain medication that we have here. Clearly we want a balanced approach to making sure that people with pain are getting adequate treatment, but if you look at where some of this started, when you look at new users of heroin, about four-fifths of them actually started on prescription pain medication. New England was a little different because they always had higher levels of heroin use than the rest of the country.
And, we know that people’s perception of risk of taking prescribed medications is lower than other illicit substances. So, because they’re prescribed by a physician, people see the meds as less risky. We know that they can really start people on this path to opiate misuse.
Certainly the widespread availability of very cheap, very pure heroin has escalated the heroin use issues. This is happening nationwide—it’s not just restricted to New England anymore—where you see very pure, very cheap heroin, very available heroin in many parts of the country that historically hadn’t seen much.
Q: In light of those factors, and considering that that Governor Baker recently declared those overdose deaths a public health emergency, is there any sort of guidance or resources that the ODCP can offer regional officials here?
A: In 2011, our office actually put out a plan to reduce prescription drug use issues. If you look at the main pillar of that plan, many states are following that as a template as they’re doing their work. There’s an emerging consensus to focus on some key areas—one is educating prescribers. If you track back to the fact that a major driver of opiate misuse is prescription pain medication, we want to make sure that prescribers have some good education around how to prescribe these.
Physicians and other health care providers generally get very, very little training around substance abuse disorder issues. I think that part of the reason why we have this over-prescribing issue is that prescribers don’t do a very good job at identifying who might be at risk—particularly people with histories of substance abuse disorders themselves or their families, and monitoring people as they’re taking these medications. These drugs were pretty aggressively marketed as safe, effective, and non-addictive when we clearly know now we have some major problems with them.
We know that when people start misusing pain medications they are often getting them free from friends and family. So, we talk about the epidemic of the medicine cabinet. We’ve really been focusing on disposal and drug give back programs to make sure that people are emptying their medicine cabinets of these medications so that they’re not getting diverted and misused.
We know people need access to care and treatment. That’s been a particular important area of focus for us. Clearly, the Affordable Care Act plays a role, but also states play a key role here in terms of making sure they have good benefit packages under Medicaid, and that private insurance is upholding their obligation to provide good coverage.
And then, the last piece is looking at a host of overdose prevention strategies, including distribution of naloxone to people who are likely to witness an overdose. We now have over 25 states that have passed some level of overdose prevention. Many of them allow for a wide variety of first responders to carry and administer naloxone.
Public Health Forum: “The Future of Treating Substance Use Disorders: What Is the Role for Health Care Professionals?”
April 8, 2015
8:45–10 a.m.
Michael Botticelli, Director of the Office of National Drug Control Policy
Hosted by the Department 0f Health Policy & Management
Hiebert Lounge