Questionnaire

Want to fix the illegal drug problem in the United States? It'll take a combination of evidence-based clinical interventions and long-term monitoring, says psychologist A. Thomas McLellan, PhD, the newly appointed deputy director for the White House Office of National Drug Control Policy. By emphasizing prevention and helping addicted people recover, rather than tossing them in jail for mandatory sentences, McLellan hopes to bring the war on drugs to a peaceful conclusion.

His previous experience has prepared him well. In 1992, McLellan co-founded the Treatment Research Institute, a non-profit organization that uses science to transform the fields of addiction and substance abuse, where he worked as a director until his Senate confirmation in August. McLellan spoke to the Monitor about how he plans to bring his 35 years of experience as a treatment specialist to a new administration with a fresh perspective on combating drug abuse in the United States.

How will your office's drug policies differ from the past administration's?

One of the first things our director did was announce an end to the war on drugs. We'd rather harness our attention on treatment and recovery alongside supply reduction to reduce the problems that drugs have caused. Our administration also celebrates and wants to invest in those who have overcome their addictions—the people in recovery.

How has your research prepared you for this new job?

I have spent 35 years looking at various ways of measuring, developing, designing and testing interventions to reduce drug problems among those who have them. It came to the point where I found that a lot of the important, useful evidence-based treatments available simply could not be implemented in contemporary addiction treatment systems. I came to this administration because I think we can change that.

Our director is a guy with a terrific law enforcement background, and who is very committed to improving prevention, treatment and recovery systems. I thought, "I could partner with this guy. Here's a cop who likes treatment."

By the way, another point about this new administration: I don't like Washington, D.C., and I don't like politics, but I'm relieved that not once so far has the administration tried to change any kind of policy where we showed scientific evidence.

What trends in drug abuse most concern you?

It's hard not to worry about prescription drug abuse, especially among adolescents. Opiate overdoses in particular are now the second highest cause of death among young people, right after traffic accidents. As kids develop prescription opiate addictions, they often move on to street opiates, and this is a problem we need to address soon.

In the 35 years I've studied addiction and treatment, I've seen a drug-of-the-year trend, from heroin and LSD in the '70s to cocaine and crack cocaine in the '80s and recently to methamphetamine. Now opiates are gaining in popularity again. Throughout this cycle of fad drugs, tobacco and alcohol, the legal drugs, also continue producing the greatest number of problems. So, we think a general strategy to reduce the overall problems produced by all drug abuse provides a better solution than a bunch of drug-specific strategies.

How does the government encourage better prevention?

This administration is going to focus at the community level for prevention, intervention, treatment and recovery efforts. With regard to prevention, many have felt schools should handle prevention efforts—like there ought to be an eighth-grade course to teach kids that drugs are bad. The thought is that once the kids get through that course, then they'll know never to abuse drugs. Well, that clearly has not worked.

Data show that substance abuse begins in your early teens and sometimes before. But the risks go down substantially after you turn 21. So kids are at high risk for drug abuse—including alcohol and tobacco—for around 10 to 12 years. If youth face continuous risk during this time, we need a continuous education plan that involves all the segments of the community throughout the period of time when kids are at risk.

So we envision a two-part strategy. The first part emphasizes full community involvement: Parents, police, education, health care and political leadership are all responsible, but they're not responsible by themselves. Everyone must work together, because they all have influence on developing kids throughout the at-risk years.

The second step harnesses and unifies the numerous government programs in a way that allows communities to best help themselves. Right now we're working with 35 federal agencies to utilize funding and purchasing power in a coordinated way so we can bring effective prevention services to the community to cover the kids throughout their at-risk years and through several spheres of influence.

Does a treatment approach work better than a punitive approach?

It's a false dichotomy. In fact, one of the hallmarks of this administration will be effective coordination and service exchange between the criminal justice system and the treatment community.

The best way to address drug-related offenders in the community is through swift and certain, but graduated, penalties for failing to abide by the conditions of probation or parole—especially failing to attend treatment. This type of monitoring can be combined with evidence-based, individually tailored treatment options. Another important part of the equation is shared, contemporary information between the two systems. This is simply a function of putting evidence-based treatments, drug courts and recovery systems together. We have great optimism that this kind of approach will work.

What are some promising new approaches in the treatment of drug abuse?

The drug courts I mentioned before are one example. They combine the best of a public safety monitoring and sanctioning with carefully structured treatment. Medications can also reduce relapse rates while promoting recovery. Right now, four medications for opiate and alcohol dependencies help addicts through recovery (methadone, buprenorphine, naltrexone and accamprosate). Promising medications for marijuana and cocaine abuse may further help with treatment in the future.

However, we need more implementation and comparative research in real-world settings to see what kind of strategies, policies, interventions and practices are practical, economical and effective.

Is it fair to say the "war on drugs" has been a failure?

I think the idea of blaming other countries for this country's drug problem is pretty much like blaming fast food companies for this country's obesity problem. I think what we really need are sensible drug supply reduction efforts combined with equally potent community-level efforts on reducing demand because less demand means fewer drugs will find their way across our borders.