Getting Addiction Treatment Right: Policy & Healthcare
Tom McLellan: I'm Tom McLellan, presently retired but I've been a career researcher in the addiction treatment and policy field for about 40 years. I worked at the University of Pennsylvania. I have my own research institute, Treatment Research Institute, and I'm very pleased to be here because I see this as a place that is the next generation of not just addiction but behavioral health treatment.
Lana Seiler: Thank you, thank you.
Tom McLellan: And it has the advantage of being true.
Lana Seiler: I’m really excited to have you. You and I have already had a discussion earlier today which was really interesting, and I enjoyed it a lot, and I have tons more questions. Let's start from the beginning. What got you started in this work? How did you find your way into this career?
Tom McLellan: Like so many other people who are in the addiction field, I stumbled into it. I am sure, as a literate intelligent person, you must have read my Ph.D. thesis on learning in the cockroach, crayfish, goldfish. It was compulsory reading almost everywhere.
Anyway, armed with that kind of background and having just gotten out of the army, I looked around for something and - surprise, surprise - there was not much interest in hiring somebody who had an interest and a background in animal learning.
So, I drew a circle around the place that I was living and looked for places (and that included insurance sales and everything else), and one of the places was the Coatesville Veterans Administration Medical Center, a mere 20 miles away. So, I went down there and asked for a job, and they said, “Well you know we don't really have any jobs for somebody with your background. Now we do have this thing called a Program Evaluator for a brand-new thing called a Drug Dependence Treatment Program.”
Lana Seiler: Wow.
Tom McLellan: And I said, “Yeah, I could do that,” not knowing anything.
I remember the moment I first walked into the program. There was a whole bunch of guys exactly like me. They were my age, recently out of the military, easy to talk to, with compelling stories. Nobody knew anything, but the person who knew the least was me. It was a real love affair.
I got involved in it with fundamental questions about what do you want treatment to do if it were effective? What would you want it to do? Do you want it to cure cavities or help you never take a drug again for the rest of your life? Or do you just want people to go to work? What do you want? What would be effective?
So, for the next 40 years, I pursued that. I had the very distinct advantage of having been supported by government grants. I did a review, and I've had 125 government grants in my life. That's more than my fair share, and it wasn't all me. It was all my colleagues. Okay, that’s a long answer to a short question.
Lana Seiler: Oh no, it’s perfect. So, I am interested in how your career unfolded. What types of things were questions that arose out of questions? Because I'm sure that's what it looked like to find these answers. You were asking these questions, and tons more questions came up. What was that journey like between then and where we are now on the couch today?
Tom McLellan: Well, it was the mid-1970’s, and at the time, drug addiction was very poorly understood. There were only a handful of treatment programs around. Something important politically happened. The Vietnam era veterans were coming back with opioid problems, and college kids were having drug problems. It was impossible even for a drug warrior like Richard Nixon to say, “Let's lock up those people.” You can't lock up veterans, so they had to do something.
Frankly, nobody knew what to do. So they created the National Institute on Alcoholism and Alcohol Abuse created the National Institute on Drug Abuse and with it, a research portfolio. We had the tremendous liberty to begin to ask questions about what you should do, what would be effective, how you would move the needle, how many programs you would need, fundamental things.
So I was frankly right in the middle of it and working for the Veterans Administration initially. The Veterans Administration was a league leader. That was their guise. And we drew from the meager literature that was available, but most people made it up. And that made a job for me to be the guy to evaluate the latest, greatest, shiniest thing that came by. Therapeutic communities, family therapy, psychotherapy, and supportive-expressive psychotherapy for addiction - who would have thought? Well, if the federal government is going to give you money to ask the question, let's do it!
We looked at the emergence of medications like methadone which was vilified from the very outset as just awful. Yet the research kept showing people properly medicated and maintained did reduce their symptoms, did improve their health, did stop crime and improve social welfare. And so that's how it went, and I had a terrific career with a whole bunch of really smart people and then (sorry) everything changed.
At this point, I was an expert. At this point I had probably written 150 publications, I was being cited, I was going up the academic rungs, and I was an expert in the addiction field. And then my son became addicted. Sorry, I didn't expect this.
I emphasize that I was an expert, and I was surrounded by experts. I emphasize this because it was terrifying for me, I did not know what I wanted to do. Simple question: Where do you send your kid for treatment? What do you want them to get? I didn't know the answer and (maybe I mentioned), I was an expert. So how’s a bus driver, how’s a school teacher, how’s a congressman supposed to answer the same question? And why was that answer so hard to get?
If you would’ve asked me where to go to college, I would have had an informed opinion or how to buy a lawnmower, I would have had an informed opinion but it was a critical one. It was at that moment when I realized a lot of the research that I've been doing - although useful, valuable, certainly made me living - wasn't going anywhere. It wasn’t informing policy and it wasn't (even more importantly) informing fundamental decisions people had to make. So with that and with $12,000 that I borrowed, I started a little institute called the Treatment Research Institute.
We went for 25 years, and we tried to answer these kinds of questions. Basically we thought of ourselves not so much as researchers but as research translators. We tried to translate findings into practical treatments that could be applied in a reasonable budget, that could be replicated, that had robust results that gave a demanding public what they needed and gave policymakers what they needed. So that went along, and then when my eldest son was in treatment for addiction and doing very well, my youngest son died of an overdose.
And once again, it gives you not only the personal tragedy that many people have had. It makes you ask a really fundamental question, “What the hell are you doing?” Months later, I was asked to join the Obama Administration. I was originally asked to be the Drug Czar, and I said I can't do that. I don't know anything about interdiction and you know policing Caribbean waters for marijuana smuggling. I didn't know any of that. So they came back and said, “Well, how about if we get somebody who does know about all that? You be the deputy, and you two will be co-equal.” I said, “Yeah I’ll do that.” I thought it was a sign from God. And that was another interesting chapter.
I get questions all the time from people who want to go into policy positions. I think you said today, “I want to get into policy.” Well, it's important that when I was a part of the cabinet, there was nobody (certainly not me) who had ever had any courses or anything in policy. What brings you to Washington in policy is expertise in an area that the country needs. So I say that as something of hope.
If you do well in agriculture or defense or health, you are the kind of person that's important in policy. There are people who know the mechanism of government, but they don't know what provides value. So I think I was very honored to serve at that time with that president and that cabinet, at a time when healthcare reform was happening. That's another sort of an interesting thing, but I guess I'm going on too long here.
Lana Seiler: No, I mean I have another question, but keep going on.
Tom McLellan: So, it was an interesting time. Healthcare reform was supposed to not reduce health care costs, of course (that's impossible at a time when the country was aging and all that), but it was supposed to reduce the rate at which healthcare costs were going up - called bending the curve. So everybody was digging around trying to find money, etc.
I was brand new. I was a real fish out of water. So here I am at a desk in the White House, and nobody was talking about addiction at all. So I said, “You know, I think there ought to be a part for addiction in this.” And so I did what a researcher does.
You go to a library to dig out a couple of sets of facts, and I looked at the costs of addressing addiction properly and I made a graph of it. And I looked at the conservative estimates of the savings that could be achieved if addiction were properly recognized, treated, etc. I made up two graphs, put it on a piece of paper, and because I was in the White House, I sent it to everybody in the White House.
If you don't know the White House, it's not just three guys or anything, it's 380 people - office managing, budget, everything - and it went to everybody. At this point, I wasn't even Senate-confirmed, so you just don't do that.
Hours later, a director of office management budget said, “Who are you and would you come over here?” because I had said the proper treatment of addiction could save 300 billion dollars in healthcare costs.
The actual figure from the research that I had shown was like 350 billion, but I was afraid of the figure, so I rounded down to be conservative. So, I go into this guy's office and everybody's there, and he said, “You know, everybody walks into this office and says, ‘If you give me a dollar, I’ll save you like five dollars.’ They're always wrong. You actually got it wrong. You could actually save even more than your estimate. Why, when we looked at it, it was over 350 billion.”
So I, of course, immediately went into a pitch that this is why I have to include this in healthcare reform and parity and all that. “Let's get some support this.” They said, “You're in, you’re in. We were looking for 50 million dollars in savings, and you're going to offer 200-300 billion. You're in.”
That was like one of the signal moments that you get in your career - right place, right time, very unplanned. But then I said, you know, this is not the kind of life I want to live. It was a privilege to serve, but I don't have the temperament for government. So I got out, and that’s the end of my story. If that’s too long of a story, I’m sorry.
Lana Seiler: No, it’s not too long of a story. So, we've been working at this as a treatment community for a long time, as you have talked about. I mean I've been in the field only for a little while, and I haven't seen too many places getting it right. We've been trying. What do we do? I know this is probably going to launch into another long conversation, but what do you think we do?
Tom McLellan: Well to be completely presumptuous, I think there are a lot of good answers. First of all, the reason you're getting it wrong is because of the way addiction has been thought about and the way addiction treatment has been structured and financed in this country.
Until very recently, addiction was a sin. It was a sign of bad protoplasm, poor parenting, just low character, moral decay. These are not my made-up words, these are in all kinds of regulations.
As a sin and character disorder, it fell into the control of the criminal justice system: keep drugs out of the country, arrest people that do it, arrest your way out of these sins. It's not crazy. And oh, by the way, we all know addicted people commit all manner of sins, and so it wasn't a crazy idea, and it wasn't any science.
So they set up 15,000 addiction treatment programs in just the early ’70s. Jerome Jaffe was appointed by Richard Nixon as a special Drug Czar. And because healthcare wanted nothing to do with addiction, and doctors weren't being trained and were getting it wrong left and right, and were prescribing substances were actually addicting people (I’m talking in the ‘70s, not recently), they decided we'll make addiction organizationally and financially separate. We’ll set up places, and they'll do their thing. We’ll political box checked, and everybody will be happy.
Well, they got it wrong. They were well-intended, I can understand the whole thing, but they got it wrong. It was a fixed amount of treatment to come in and correct a fundamental character disorder because that's the way it was considered.
Alright, fast forward to decades later, and you now know something about genes, you know something about brain imaging, you know something about neurochemistry. And I'll be damned, it turns out addiction is a chronic illness. That’s not my opinion, it’s a fact. It's a chronic illness.
And so here we are now realizing that it’s like diabetes, hypertension, asthma, chronic pain, and all kinds of other things that are properly learned about in medical, nursing, and social work school that are properly reimbursed and treated in continuous care with monitoring, management, and individualized treatment plans - that's how you treat a chronic illness.
And here we have this system that has nothing to do with the healthcare system. It doesn't share information, it doesn't share budget, it doesn't share personnel (mostly), it’s geographically usually segregated. And they're still doing things. Even the people who now realize it, they’re still handicapped by the old financing and the old acute care model of treatment. It simply cannot work. It never could. It's a miracle (and a miracle that is mostly attributable to continuing care in the form of AA and NA) that anybody ever does get better.
So I'm quite hopeful that the lessons that we've learned from the treatment of chronic illness - monitoring, management, team treatment, proactive care, equipping of a patient and family to self-manage their illness (because you can't cure them, can't cure diabetes or hypertension but you can manage them), those lessons are going to translate into addiction.
And it turns out that we've got a lot to teach chronic illness because it turns out that people with the same illness getting together to change their environments and support each other and train families can really manage a chronic illness very well, given the right opportunities. So, I think it's an exciting time ahead, and I think it's an exciting opportunity for APN.
Lana Seiler: Well, thank you so much. Hopefully, we will have many more conversations like this one. We're going to have to wrap up.
Tom McLellan: Shorter ones though.
Lana Seiler: Longer. We’re on a time crunch here, but we don't have to be forever. I really appreciate it. Thank you this is wonderful, thank you so much.