“We’ve got a mismatch between treatment that is short, and the disease that is long. … Addiction is one of the most serious, most prevalent, often fatal diseases, and it needs to be managed for a lifetime, like diabetes is managed for a lifetime, like asthma is managed for a lifetime.”
Dr. Robert DuPont, former director of the National Institute on Drug Abuse (NIDA) and the second White House drug chief, spoke with KET about the opioid epidemic as part of an upcoming one-hour documentary on the crisis in Kentucky and possible solutions.
Dr. DuPont served as the first director of NIDA from 1973-78 and as the nation’s drug czar from 1973-77. [under presidents Nixon and Ford] He earned his M.D. from Harvard Medical School and completed his psychiatric training at Harvard and at the National Institutes of Health. He became the founding president of the Institute for Behavior and Health, a nonprofit devoted to curbing drug abuse in 1978. Since 1980, he has served as a professor of clinical psychiatry at Georgetown University, and also maintains a private practice focusing on addiction and anxiety disorders.
Parts of this interview will be featured in the documentary directed by Justin Allen, which is scheduled to air in early 2017.
If we’re framing addiction as a disease, how does that change our approach to treatment?
The current narrative is that somehow, just in the last few years, we’ve changed our thinking about addiction and see it as [a disease that needs] treatment, and before that we were just doing law enforcement. That’s not really even close to what has happened. In 1971, President Richard Nixon balanced a law enforcement approach with a treatment approach, and there was a massive investment in treatment from the federal government that has been there ever since.
I think the narrative has changed to some extent, but the narrative has changed in one way that I don’t support, and that is to dismiss the importance of law enforcement. While it’s often said we can’t incarcerate our way out of addiction, we also can’t treat our way out of addiction. We really need law enforcement to work with treatment programs to do things that neither can do alone, and that includes reducing the supply of the drugs, and it also means getting people who are users into treatment, with the force of law to get them into treatment: 40 percent of people in treatment in this country are there because of law enforcement.
You’ve been a champion of drug courts. Some people see drug courts as forcing them into a specific treatment program, and that a judge is deciding what that treatment is instead of a doctor.
Well, I think in the last 20 or 30 years, the best new idea to come along is the drug court movement because, as you say, it brings together law enforcement and treatment. It’s called therapeutic jurisprudence – it’s using the law to promote health. So, the drug courts basically function to keep people out of prison and in treatment. That’s the basic idea. Now, what treatment do they go to? That is a question. And I think the question is about particularly the use of medication-assisted treatments, buprenorphine and methadone. But that’s something to be worked on, and worked out over time. I can tell you that the programs that work with the criminal justice system, by and large, do not just require one particular kind of treatment.
Our current White House drug czar, who is really a hero for me, Michael Botticelli, got into recovery because he was arrested for a DUI and was forced to go into treatment and go to 12-step meetings by a judge, and that created the guy we know now. So, his story is a wonderful example of just how powerful the criminal justice system can be.
What about Kentucky’s history?
Kentucky has been at the center of drug policy for a long time. In the first American heroin epidemic at the end of the 19th century and the beginning of the 20th century, heroin was sold initially over the counter. It was a regular pharmaceutical product, and it was particularly used for pain and other kinds of problems, and the typical heroin patient was a middle-aged woman, particularly rural in that time. Kentucky was the absolute center of that issue.
When the Harrison Narcotics Act [of 1914] came in and closed down the medical access, there was an interest in saying well, we use these drugs in medicine and they’re very good, but what we need is a pain medicine that is not addictive. That was the goal. And you know it’s pretty interesting; in 2016 that’s still the same goal.
Anyway, because of that interest, the Narcotic Farm was set up in Lexington, Ky. which was the center of research from the 1930s all the way through the 1970s and 1980s. [The research facility was established as part of a U.S. Public Health Service (USPHS) hospital. It became the Addiction Research Center in 1948. –National Institutes of Health website www.nih.gov]
And the University of Kentucky was ground zero for knowledge about addiction, for all over the world and not just in the United States. And of course it’s so interesting that again, related to the prescription drug epidemic, Kentucky is the center of activity, and now there’s a new aspect of Kentucky’s leadership. That is Rep. Hal Rogers and Operation Unite and the Rx Drug Abuse and Heroin Summit. Kentucky is leading the country in terms of drug policy today as it has in the past.
“I think medication-assisted treatment is not just here to stay, I think it’s a blessing, I think it’s a good thing. But I would like to have more thinking about the long-term aspects of what is happening to those patients.”
Let’s talk about medication-assisted treatment in general. What is that and what are the expectations of that?
The great development in medication-assisted treatment was methadone. You can say hey, you’re just substituting one drug for another, methadone for heroin – but it’s not that simple. It’s much more positive than that. Methadone is orally used, not injected. Heroin is injected. Methadone is long-acting, heroin is short-acting. So what that means is, when a person takes one dose a day of methadone, he has the methadone in his receptors all through the day. Heroin doesn’t do that, it’s up and down all the time, which is how heroin addiction goes.
Now, added to methadone are two other related drugs, the first being buprenorphine, which is a partial-agonist, it’s partly an agonist for the opiates [activating any receptors in the brain that opioids activate] and partly an antagonist. So it doesn’t have the overdose potential, and it can be used by individual doctors with special training, and that’s been a gift too. And then the third one is naltrexone, or Vivitrol, which is a drug that blocks all effects from happening; it is injected and lasts for a month. These three drugs have changed the treatment of opiate and heroin addiction in a positive way.
The problems with medication-assisted treatment are number one, continued drug use by patients, including opiates but also lots of other things such as alcohol while they’re in treatment. That’s a problem. And the second problem is that the treatment program is short-term but the problem is life- long, and that limits medication-assisted treatment.
I think medication-assisted treatment is not just here to stay, I think it’s a blessing, I think it’s a good thing. But I would like to have more thinking about the long-term aspects of what is happening to those patients – the ones who drop out, not just the ones who stay in. What happens to those people? Because right now what happens is, they just go back to opiates, they just go back to heroin. That’s not a good solution to the problem.
“For me the great miracle in this country is the 12-step programs, it’s Alcoholics Anonymous and Narcotics Anonymous, which is how most of the people who are in recovery got into recovery. Treatment is expensive, you’ve got government and insurance and all these things, but recovery is free.”
What are the downsides to each of the treatment options?
There a sense among some people that medication-assisted treatment is the silver bullet – it isn’t. It’s not even close. It helps, but it has very big limitations. Let’s start with the most obvious one: the treatment drugs have a street value, they’re diverted, and going into the illegal drug market. That’s a problem, particularly with methadone for overdose deaths. But buprenorphine is used to promote and extend continued opiate use. People will treat their withdrawal symptoms with buprenorphine, between periods of using heroin. They’re not getting off with buprenorphine; they’re just using it to manage the withdrawal symptoms that they have with their active heroin addiction problem. So there is a diversion problem that is very significant.
But I think the biggest problem is the vision that goes with a medication-assisted treatment, and whether that vision includes sobriety and really addresses alcohol. I started a big methadone program in Washington D.C., and I had a group of ex-addicts that I really cared about, and many years afterwards, one of them had a retirement party from a job he had, and I went and talked to him. I had a great time reminiscing, and I asked about the other guys in the group, and he said they were all dead; they were all heroin addicts. They were all dead, and what happened to them all? They all died of alcoholism – yes, they stopped their heroin use, but they died of alcoholism.
I’m a big supporter of the concept of recovery, long-term recovery. So, I have proposed a standard way of assessing treatment for five years of recovery: meaning no use of alcohol, no use of marijuana, no use of heroin, no use of other drugs such as methamphetamine. Sobriety is the term in recovery, and that is really, really important.
And for me the great miracle in this country is the 12-step programs, it’s Alcoholics Anonymous and Narcotics Anonymous, which is how most of the people who are in recovery got into recovery. Treatment is expensive, you’ve got government and insurance and all these things, but recovery is free. You go to the meetings, and you work the program, and it makes a tremendous difference.
Are there certain candidates that are more suited for certain types of medication?
The naltrexone or Vivitrol issue is that the drug is not an agonist, meaning it does not activate any receptors in the brain that opioids activate, which methadone does and buprenorphine partially does. So, the addicts don’t like it. It’s very hard to get anybody to take it other than involuntarily, through the criminal justice system. So you’ve got half a million people or more using methadone, a million people using buprenorphine in the country, and Vivitrol is maybe 30,000. I mean it’s tiny in relationship to the others for that reason. I think it’s very useful, but again, the typical person taking Vivitrol is going to do it for a few months.
Addiction is a lifetime problem. We’ve got a mismatch between treatment that is short, and the disease that is long. The real future of this is to get the health care system to recognize that they know they want to identify, treat, and manage chronic, serious diseases. … But they haven’t yet figured out that addiction is one of the most serious, most prevalent, often fatal diseases, and it needs to be managed for a lifetime, like diabetes is managed for a lifetime, like asthma is managed for a lifetime. And when that happens, that would mean that every doctor would have a patient, and would manage and know that this is a patient who has a history of heroin addiction, let’s say. You could manage that patient all through the patient’s life.
There’s a stigma about medication-assisted treatment. A lot of people are saying that if you’re on methadone, you’re not sober.
I have a very simple way to think about this, and that is that if you’re taking naltrexone, buprenorphine or methadone as it is prescribed, and if you’re not using alcohol and other drugs, you are in recovery. Now, the problem is that a lot of those people that are taking buprenorphine and methadone and naltrexone are using other drugs at the same time.
I had a situation involving a halfway house program called the Oxford House, which is a wonderful national system of halfway houses. They have had a problem having people come in who are on medication-assisted treatment. I helped them create some halfway houses that would take methadone patients. … And one of the first things that happened, a patient came in and started selling his methadone, and they threw him out. So, just because a person is taking methadone or buprenorphine doesn’t mean that they’re clean. You’ve got to make another step to figure out who that person is.
“Relapse is the expected outcome of treatment. Everybody knows that’s the predominant outcome. People go back to their drugs when they leave treatment. And I thought, well, what could be done?”
Can you talk more about your five-year standard and what that means, and how the long-term nature of addiction conflicts with the short-term nature of treatment? What is treatment vs. recovery?
I have been in this field of treating and studying heroin addiction in particular, but drug abuse in general, now for 48 years. And I’ve seen that relapse is the expected outcome of treatment. Everybody knows that’s the predominant outcome. People go back to their drugs when they leave treatment. And I thought, well, what could be done? What kind of standard could possibly be achieved? And what I found was, in my practice I had doctors who were in recovery through the physicians’ health programs. So, I did the first national study of the state physicians’ health programs all over the country. And what we found was that these physicians’ health programs are phenomenal at making recovery the outcome of treatment.
Well, how do they do this? They don’t use medication-assisted treatment, which is interesting, even though a third of the doctors are opiate-dependent. What they do is put the doctors into, particularly, residential treatment, or sometimes outpatient treatment, for up to six months. That’s the treatment, but they manage them for five years. So the treatment is at the front end, for relatively short periods of time, but then they’re managed with random testing for alcohol and drugs for five years. Even one positive test is a violation that will get them out of their practice and put their licenses at risk, so a single positive test is very, very serious. Missing a test is also a violation. The other thing they do is they get everybody involved in AA. They immerse the people in the 12-step systems.
Go forward for five years. A very high percentage of those in the physicians’ health programs – 80 to 90 percent – successfully complete a single contract. And some of them who fail come back a second time, but most of them make it through, a very large majority. And we just did a new study that was really exciting, which looks five additional years past the mandatory five-year monitoring that went on – 96 percent of them were in recovery. That’s long-term recovery. That’s what we want to do.
The reason I’m committed to the five-year recovery standard is because once we have that as the standard, everybody can compare medication-assisted treatment to drug-free treatment. The same standard is applied to everybody. Let’s find out which program produces recovery most reliably, and let’s have the people who are paying, the insurers, know who it is. Let’s have the families know who it is. And each program would then compete to try to get to that standard because the results would show that they were the best.
“One of the great things about recovery is that it doesn’t just bring you back to the point when you started using and get you on track. You’re a better person for having confronted addiction. And that’s something that really is important – turning a terrible, life-threatening disease into an opportunity for growth of character in a remarkable way.”
What are some avenues you see for dealing with the problem of heroin addiction long term?
The long-term key to dealing with the problem of heroin addiction, and drug abuse more generally, is the family. That’s the key to prevention, and that’s the key to treatment. Families need to be empowered and supported in promoting long-term recovery for addicted family members, whether children or adults. That’s very important. And right now what we’ve learned from the physicians’ health programs is that monitoring is very important, and that includes testing for drugs and alcohol on a consistent basis. Family members can do that themselves. They can administer commercially available drug tests. A better way would be for the family to work with a treatment program or a doctor to set up a monitoring system that has random testing. So, the person could be tested over a long period of time and when a positive test occurs, there’s an intervention to get the drug and/or alcohol use to stop. There aren’t a lot of examples that I can give you of where that’s being done now.
The other thing is, families have to become aware of the fact that going to AA and NA meetings is really an important part of long-term recovery. Everybody in those programs has a sobriety date, which is the last time they used alcohol or other drugs. And that sobriety date is a matter of pride.
One of the great things about recovery is that it doesn’t just bring you back to the point when you started using and get you on track. You’re a better person for having confronted addiction. And that’s something that really is important – turning a terrible, life-threatening disease into an opportunity for growth of character in a remarkable way. So those are the things I’m thinking about.
Are there non-opioid alternatives for people with chronic pain? We’ve heard about things like the medical marijuana movement.
Well I find it just bizarre, thinking about smoking medicine. I find it bizarre to think about medicine that has 420 separate chemicals in it. I find it bizarre that you’d have a medicine that doesn’t have a dose. This idea that you go to the doctor and the doctor says, ‘Yes, you need medical marijuana – how much do you need? Here’s as much as you’d like, for the next year. And then come back in a year, and for $200 I’ll give you another certificate for medical marijuana.’ Is that medicine? I don’t recognize that. I’m a doctor, I don’t understand that.
What you do with medicine is, you have a particular chemical, you have a dose, you have an indication, and you go through a pharmacy. So I’m not sympathetic to the medical marijuana argument. You know, THC, the main active ingredient in marijuana, has been approved for any doctor to prescribe orally in this country since 1986. It’s not hard to get that as medicine, but people don’t want that. They want to smoke dope or nothing else. It’s very interesting.