Addiction, Drugs, and Morality

Addiction on 2 Fronts: Work and Home


By SARAH KERSHAW
Published: December 7, 2009
WASHINGTON — His son had been dead from an overdose only three months when A. Thomas McLellan, among the nation’s leading researchers on addiction, got a call from the office of Vice President Joseph R. Biden Jr. Would he accept the nomination to be the government’s No. 2 drug-control official? e

Brendan Smialowski for The New York Times
A PERSONAL MATTER A. Thomas McLellan says he is working against not just drug abuse, but also the belief by many that it is a moral, not medical, issue.

Dr. McLellan, 61, makes no secret of his cynicism about government — “I hate Washington,” as he put it in an interview — and he had no intention of leaving his job as a professor of psychology at the University of Pennsylvania School of Medicine and scientific director of the Treatment Research Institute in Philadelphia.
But the loss of his younger son, who overdosed on anti-anxiety medication and Scotch last year at age 30 while his older son was in residential treatment for alcoholism and cocaine addiction, changed his perspective.
“That’s why I took this job,” said Dr. McLellan, who was sworn in as the deputy director of the Office of National Drug Control Policy in August. “I thought it was some kind of sign, you know. I would never have done it. I loved all the people I’ve worked with, I loved my life. But I thought maybe there’s a way where what I know plus what I feel could make a difference.”
Married to a recovering cocaine addict, Dr. McLellan has been engulfed by addiction in life and work. His own family has been a personal battleground for one of the country’s most complex and entrenched problems, while as an expert he has been a leading voice for the idea that addiction is a chronic illness and not a moral issue.
This view squares with that of his boss, R. Gil Kerlikowske, a former Seattle police chief who declared on taking office as drug czar in May that President Obama’s administration would no longer use the term “war on drugs” — and that the term implied the government was waging a battle against its citizens.
Instead, the two men say the government needs to change its drug-control strategy, redirecting some of the resources into prevention and treatment and away from law enforcement and antitrafficking efforts, which consumed 75 percent to 90 percent of the budget during the Bush administration.
Dr. McLellan said that of the 25 million substance abusers he estimated were in this country, only about 2 million were receiving treatment. He and Mr. Kerlikowske want to triple that number, partly by spending more money and partly through other tactics, like integrating addiction treatment into the primary health care system.
Many veterans of the long and frustrating fight against addiction say it is about time. “This is an extraordinary moment of opportunity,” said Dr. Nora D. Volkow, director of the National Institute on Drug Abuse and one of the colleagues and friends who helped persuade Dr. McLellan to take the job.
Still, even Dr. McLellan’s most ardent supporters say the challenges are formidable. The federal drug-control office can do only so much, and the Obama administration decided the drug czar would no longer be a cabinet-level position. State and local governments, law enforcement agencies, the health care system and schools are all big players. And taxpayers tend to have little sympathy for addicts or for treatment programs with track records that are mixed at best.
“I can tell a state legislator that if you would only provide treatment for these guys, we’d have the greatest reduction in crime,” said Joseph A. Califano Jr., chairman of the National Center on Addiction and Substance Abuse at Columbia University. “But those constituents want computers in the schools, better roads, better sewage systems.”
Mr. Califano, who was been involved with government efforts to combat the drug problem since the days of President Lyndon B. Johnson, said that he had great admiration for the new leaders of the drug-control office but that “you need a presidential commitment here.”
“I think if Obama gave these two guys the spark, they would know how to turn into a fire,” he said.
The office is preparing its drug policy strategy, to be released in February along with Mr. Obama’s budget. “We are going to get the money to do this,” Dr. McLellan insisted. “I can’t tell you the amount or where it’s coming from, but we’re going to get it.”
The drug czar himself, who has made passing reference to his adult stepson’s struggles with drugs but does not discuss it openly, was more cautious, as he tends to be.
“I think for some folks, radical change will be their only measure of success,” Mr. Kerlikowske said in an interview. “I don’t think we’ll see that. I think we’ll make a lot of progress, we’ll slow the freighter down and start turning it in the direction of the more balanced view.”
The two make an interesting pair — the former police chief who has plenty of experience parsing words with reporters, and the plainspoken, quirky and mustachioed psychologist who says “ain’t” and “yeah,” and whose candor can make Washington insiders nervous.
Dr. McLellan, who has written or collaborated on more than 400 papers on addiction, is well known among his colleagues and friends for both his passion for the subject and his bluntness.
In a recent interview in his office here — still sparsely decorated except for a photocopied picture of his family, including his surviving son and two young grandsons (or “grand felons,” as he called them) — Dr. McLellan put his feet up on the coffee table and declared, “I hate this job.”

“This is a job that needs scientific background,” he went on. “But if you come to it with the kind of desires to turn everything into a scientific experiment, you will have your poor little heart broken.”
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Despite Mr. Kerlikowske’s insistence that putting more resources into prevention and treatment does not mean the government is going soft on crime, such policies are bound to be controversial. Conservatives point out, for example, that drug treatment and detoxification programs have relapse and dropout rates as high as 80 percent or 90 percent.
“I’m not sure the federal government has an obligation to try to rehabilitate addicts,” said Heather Mac Donald, a senior fellow at the Manhattan Institute, a conservative policy research group. “Government has an obligation to provide safe streets to people, and policing has an extremely effective track record in places in like New York City and Los Angeles.”
Dr. McLellan grew up in Mechanicsburg, Pa., and while his family was “riddled” with addiction, he says he wound up in the field almost by accident. He said that while he drank, he was “constitutionally unfit to be an alcoholic,” and therefore did not have what he and many others consider to be a genetic disease.
He earned his doctorate in experimental psychology, with a focus on animal learning, from the Bryn Mawr in 1976.
“You’ve undoubtedly — I think almost every American has read my Ph.D. thesis by now,” he said. “ ‘Negative Autoshaping in the Rat, Cockroach, Pigeon and Crayfish.’ And armed with this kind of knowledge and obvious preparation for the business world, I was shocked to find that there weren’t many jobs available.”
So he went to the veterans’ hospital in Coatesville, Pa., to see what was available. He was offered a job as a technician to evaluate the effectiveness of one of the nation’s first drug and alcohol rehabilitation programs, and that led him and a team of researchers to develop the Addiction Severity Index, now established as a standard assessment tool for drug and alcohol abuse.
In recent years, Dr. McLellan has focused on the lack of addiction screening in primary health care settings like doctors’ offices and emergency rooms. For example, he said, just as with hypertension or diabetes, there is a concrete way to measure whether someone has an alcohol problem.
The measuring stick is known as “3-14” — so if someone is having 3 or more drinks a day, or 14 per week, that should raise a red flag, and physicians should be much better equipped to intervene and offer treatment options if there is a problem. Ideally, Dr. McLellan said, that treatment would be available in the medical system itself, not segregated in rehabilitation and detox programs, with their high failure rates.
He said another goal was to get a better handle on measuring the use of drugs and alcohol by those under 21, the time of highest risk for the onset of addiction. His younger son was in eighth grade when he began to struggle with addiction, and by then Dr. McLellan was a prominent researcher in the field.
“If it has to happen, better it happens to me, I’m an expert, right?” Dr. McLellan said. “I didn’t know what to do and none of my buddies knew what to do, and let me tell you they were experts. So I said, ‘What the hell are we doing?’ ”
That prompted him to start the Treatment Research Institute to evaluate addiction treatment. But both of his sons continued to struggle with addiction.
Dr. Volkow, of the national drug-abuse institute, said the death of the younger son “epitomized how unprotected people who are addicted to drugs are, even with that father.” Of Dr. McLellan, she added, “He’s an absolute true warrior in the best sense of the word.”
The older son is doing well now, and the two enjoy working together to restore houses and sell them. “Maybe when I get out of here, I’ll do more of that,” Dr. McLellan said.
Then he quickly added, “There’s a lot of need for drug-free housing.”