Former Drug Czar Speaks Out on Personal Bias and Addiction Policy in the U.S.

Michael Botticelli, former director of the White House Office of National Drug Control Policy (ONDCP)
Michael Botticelli, former director of the White House Office of National Drug Control Policy (ONDCP)

“You can’t incarcerate your way to solving the opioid epidemic,” says Michael Botticelli, former director of the White House Office of National Drug Control Policy (ONDCP), giving the keynote address at the California Society of Addiction Medicine’s (CSAM) annual conference this morning.

He discussed being able to speak freely now that he is no longer a government employee, not having to “worry about what his ‘handlers’ at the Federal Government might think.

“You can’t incarcerate your way to solving the opioid epidemic.” - Michael Botticelli, former director of the White House Office of National Drug Control Policy (ONDCP).

The thrust of his speech described how a “Personal experience can often shape [a person’s] view of addiction in a negative way.” He gives an example: “[Someone might say] I know someone who had a bad experience with methadone, and therefore methadone doesn’t work.”

He even mentioned, “Sometimes the data conflict with my own personal story.” Botticelli was the first director of the ONDCP to come from a public health background and to have a personal history of addiction and recovery. He recalls the difficulty in explaining this past history during his background check as Drug Czar. Even with over 20 years of recovery, past sins caused some people to look askance.

When the ONDCP was formed in 1988, it set up by officials with military and law enforcement backgrounds. Over time, he explained that priorities and funding shifted toward treatment, which was producing better outcomes. This sits in contrast to the priorities laid out by President Donald Trump, whose budget seeks to decrease funding for treatment and research. “Unfortunately, the President’s budget is focused on supply reduction, rather than treatment,” Botticelli says. He further emphasized, “We need an overall return to science in the Federal Government.”

“It doesn’t make sense to call [the opioid crisis] a National Emergency and then dismantle the structures that provide treatment,” Botticelli says in response to President Trump’s proposed budget.

However, he astutely noted, “Emotion changes peoples’ minds more than science or data.” He also noted the demographic impact of the opioid epidemic, stating it has garnered more attention because it has impacted “White Americans, rather than just people of color,” saying, “This changed public opinion.”

During the Obama administration, both liberals and conservatives were aligned in the focus on treatment for substance use disorders. “For years and years, we have known this is a disease and we know there is effective treatment,” Botticelli illustrates, “What was very helpful was that conservative congressional leadership was very supportive of the policies we were working on.” He told the story of working together as an “openly gay man in recovery, travelling with Mitch McConnell around Kentucky, the reddest of red states,” stating, “It was very surreal.”

In looking at public attitudes around addiction, Botticelli quoted Barry et al. (Psychiatric Services, October 2014) with the following findings:

  • 43% oppose giving health benefits to people with a drug addiction vs. 21% for mental illness
  • 64% said employers should deny employment for people with drug addiction vs. 25% for mental illness
  • 54% said landlords should deny housing to those with drug addiction vs. 15% for mental illness

“These attitudes get embedded in our policies,” he asserts. He discussed how the language we use affects our attitudes, even among professionals who tend to be more punitive when patients were are called “Substance Abusers” vs. “”Persons with substance use disorder.”

Botticelli suggests, “We should ban the phrase ‘hitting bottom.’” He compared addiction treatment to that of diabetes, which has a more preventive approach.

On the positive side, he notes, “We have seen dramatic increases in those receiving treatment through the Affordable Care Act, through the Medicaid Expansion.” There have been “dramatic increases in those receiving treatment, because now they have insurance.”

There are many reasons why people don’t seek treatment, among these is stigma. Botticelli opens up, “Initially, I was embarrassed to seek treatment. I was worried I would be considered weak-willed and morally flawed if I admitted I had a problem.”

“We should ban the phrase ‘hitting bottom,’” Botticelli asserts.

He explored the effectiveness of social support systems around recovery. “It’s not about having a job, it’s about whether a person has purpose and meaning in their lives,” Botticelli mentions. This was met by strong applause from the audience. He described, “You can live your entire life now without having a single human interaction. You can order your groceries online. You don’t have to talk to your neighbors.”

Giving a solution, Botticelli maintains, “A fundamental solution to the opioid epidemic is developing community. In a 12-Step program, you become engaged in a community.”

An attendee at the keynote asked, “How do you think the current administration will affect the drug policy over the past 20 years?”

There was a long pause, then laughter from the audience. “One important area is health insurance coverage. We have all seen, as part of the president’s proposed budget, cuts to NIH, SAMHSA, and many other agencies that are critical to treatment and research efforts.”

Botticelli expounded, “President Trump declared the opioid epidemic a National Emergency which is positive in that it calls attention to the problem. However, it doesn’t make sense to call this a National Emergency and then dismantle the structures that provide treatment.”

Michael Botticelli is now the executive director of the Grayken Center for Addiction Medicine at the Boston Medical Center.
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