After decades of the war on drugs and little success to show for it, the federal government is looking to change its approach. The idea, as outlined in the new plan released by the White House's Office of National Drug Control Policy (ONDCP), is to shift from a focus on law enforcement to more rehabilitation and addiction treatment programs.
"The main distinction with this plan is the general acknowledgment that substance use is a public health issue," said Michael Botticelli, acting director of ONDCP and the Obama administration's nominee to permanently head the office. "We can't arrest our way out of the problem, and we really need to focus our attention on proven public health strategies to make a significant difference as it relates to drug use and consequences to that in the United States."
In the plan, however, most of ONDCP's funding still goes toward law enforcement efforts. But even though it's not everything reformers — particularly opponents of criminalization — would like, the transition shows the federal government is perhaps beginning to move away from the tough-on-crime approach that dominated American drug policy for the past few decades.
The Obama administration has been tweaking the war on drugs for years
Even before ONDCP's new plan, mental health and drug addiction programs got dramatic funding and regulatory boosts under the George W. Bush and Obama administrations.
Various new policies over the past few years — the Mental Health Parity and Addiction Equity Act, the 2008 Medicare Improvement for Patient and Providers Act, and Obamacare — imposed new rules on health insurers that require them to cover drug and alcohol addiction as an essential health benefit. That means public and private plans, like Medicaid or employer-provided insurance, need to insure a higher standard of addiction services, just like they fully include heart disease or diabetes treatments in their coverage.
Keith Humphreys, a psychiatry and behavioral sciences professor at Stanford University who previously served as senior policy adviser at ONDCP, said the actions of both the Bush and Obama administrations will have a huge effect on US drug policy.
"Access to and funding for addiction treatment is better now than it has been at any time in the United States," Humphreys said. "Most people in this country have better coverage than they did five years ago — either because they had no insurance and now they do, or they had insurance but it had a crappy addiction treatment benefit."
Botticelli said this treatment gap has always been a big issue in US drug policy because of its implications for both public health and public safety. "If you look at data, only about one in nine people who have a diagnosis with a substance use disorder can get treatment for that disorder," he says. "That's really abysmal. Not getting access to adequate treatment leads to all sorts of not only health consequences, but involvement with the criminal justice system."
ONDCP's new plan attempts to build on the gains of previous policies. From 2014 to 2015, ONDCP's budget increases the share of funding going to treatment and prevention programs from 40.1 percent to 43.1 percent.
Botticelli characterizes the plan as a "sea-change" within ONDCP. "What the plan acknowledges is that yes, historically, a lot of the efforts have focused on the supply side," he said, "and we haven't paid enough time and attention to the public health issues."
ONDCP plans to put this extra funding in new evidence-based programs that can treat drug addiction and prevent its worst consequences, with a particular emphasis on the country's increasing use and abuse of prescription painkillers. Among ONDCP's proposals: more support for drugs that help reverse opioid overdoses, Drug-Free Communities Program grants that finance education and prevention campaigns, and funding for programs that train medical personnel to better detect and prevent drug addiction.
These changes on the public health side, Botticelli points out, also coincide with the Obama administration's criminal justice reforms. In 2010, President Barack Obama signed the Fair Sentencing Act, which loosened mandatory minimum sentences for crack cocaine possession. In April, the Department of Justice announced a new initiative that will allow hundreds, maybe thousands, of prisoners to get their sentences reduced. The idea, the Obama administration argues, is to move away from decades of mass incarceration, particularly when it involves low-level, nonviolent drug offenders.
A lot of money will still go to law enforcement efforts
Even with the changes, drug policy reformers point out that a lot of federal spending will continue going to the law enforcement end of the war on drugs. About 57 percent of ONDCP's budget will still go to domestic law enforcement, interdiction, and international anti-drug efforts in 2015. By some estimates, the war on drugs costs the US nearly $100 billion each year in spending and lost potential tax revenue.
"ONDCP has been putting greater rhetorical emphasis on treatment over 'drug war' since day one of this administration. Emphasis on rhetorical," Tom Angell, founder of the pro-legalization Marijuana Majority, wrote in an email. "The drug control budgets continue to strongly emphasize funding for failed strategies like arrests, incarceration, and interdiction over effective approaches like treatment and prevention — popular rhetoric about 'ending the drug war' to the contrary."
Over the past few decades, increases in drug enforcement have shown little correlation with illicit drug use in the US. The Nixon administration effectively launched the war on drugs in the early 1970s, but drug use continued to climb among high school seniors, a key demographic for detecting early drug abuse, into the later part of the decade. After the Reagan and George H.W. Bush administrations increased funding for anti-drug enforcement in the 1980s and early 1990s, drug use started to climb again. Throughout the 2000s, the Bush administration increased law enforcement funding and funneled aid to Colombia to help fight drug cartels in the region, yet drug use continued to trend up throughout the decade.
When asked, Botticelli didn't acknowledge the failures of the war on drugs in the past few decades. But he emphasized that the law enforcement and public health policies could go hand-in-hand to reduce drug abuse.
"We have an epidemic of prescription drug abuse and misuse in the United States, largely driven by the supply and over-supply of prescription drug medication. We are seeing spikes in heroin use, and that's being driven by the readily available, cheap, very pure heroin we have in the United States," Botticelli argued. "If you think what our public health strategies have been, I reduce it to getting that stuff out of the community, and getting good stuff in."
Humphreys, the drug policy expert from Stanford University, would like to see significant reforms on the criminal justice side of the war on drugs, but he argues that both sides of anti-drug policy — law enforcement and addiction treatment — don't necessarily have to be in conflict.
"It's not treatment versus enforcement," Humphreys said. "Our health-care system is as big — literally — as the entire economy of France. The money was there [for addiction treatment]; we chose not to fund it because of stigma, lack of knowledge, and lack of understanding."
From Humphreys' perspective, funding for addiction treatment should increase regardless of what happens with the law enforcement side. Whether the federal government and general public embrace drug decriminalization, legalization, or more criminalization, drug policy experts like Humphreys argue education, prevention, and treatment programs should always get a lot of support.
Unlike the law enforcement side of the war on drugs, such programs actually have some evidence of success. Previous studies found education campaigns like Be Under Your Own Influence and ONDCP's Above the Influence led to a dip in alcohol, tobacco, and marijuana use among teens. And places that obtained Drug-Free Communities Program grants also reported a decrease in some drug use, particularly alcohol and tobacco.
Given those successes, ONDCP's plan — and the other policy changes that preceded it — are welcome news for some drug policy reformers. It might not be everything they hoped for, but it's a start.
The feds are looking to reform the war on drugs, and Michael Botticelli, acting director of the White House's Office of National Drug Control Policy and the Obama administration's nominee to permanently head the office, is at the center of the efforts. Instead of focusing so much on drug abuse as a criminal justice issue, Botticelli, a recovering alcoholic himself, says he and his office want to treat drug addiction as a public health issue. To understand how and why, I spoke with Botticelli by phone on September 8 about the plan and the messaging surrounding the Obama administration's new strategy to combat illicit drugs.
German Lopez: How do you envision ONDCP's new anti-drug plan?
Michael Botticelli: The main distinction with this plan is the general acknowledgment that substance use is a public health issue. We can't arrest our way out of the problem, and we really need to focus our attention on proven public health strategies to make a significant difference as it relates to drug use and consequences to that in the United States.
The second thing, which I think is a sea-change as it relates to this policy, is that this is done in partnership with significant criminal justice reform. We know arrest and incarceration are not only ineffective, but they're also expensive. I think the track record of this administration has shown that really, unlike any other administration in the past, a significant amount of modifications to our criminal justice system are meant to deal with drug use and its consequences in a much more compassionate and humane way.
German Lopez: What kind of treatment programs are getting more support?
Michael Botticelli: One of the exciting things about working in this field for the past 20 years has been the dramatic increase in what we know to be effective treatment in the United States. Through a lot of the work that's sponsored through the National Institute of Drug Abuse and others, we have a compendium of evidence-based treatment programs that could grow.
One of the most promising areas that we've seen, particularly in light of the opioid epidemic, has been the dramatic increase in FDA-approved medications to treat opioid addiction. We now have an ever-increasing arsenal of therapies and treatments that we know to be effective. That's one of the exciting things about doing this work.
German Lopez: One overlooked aspect of the Affordable Care Act is it greatly boosts coverage requirements for mental health issues, including addiction. How do you see this in light of your office's plan?
Michael Botticelli: One of the areas that has been a significant concern has been what we call the treatment gap. If you look at data, only about one in nine people who have a diagnosis with a substance use disorder can get treatment for that disorder. That's really abysmal. Not getting access to adequate treatment leads to all sorts of not only health consequences, but involvement with the criminal justice system. For many, many years, unfortunately our criminal justice system was our de facto treatment system, because people didn't have access to good, evidence-based treatment.
When you look at the reasons for why that treatment gap exists, some of the main reasons include not having insurance or having insurance that didn't have an adequate substance abuse benefit. This is where the Affordable Care Act really dramatically changes the landscape.
One, it obviously extends coverage to a vast number of people either through the Medicaid expansion or through the exchanges. If you look at federal spending, largely as a result of that treatment expansion, we're spending more on prevention and treatment and recovery support services than we have in the past 12 years.
Two, the Affordable Care Act says to private care providers that they can no longer institute discriminatory practices as it relates to providing a substance abuse benefit. Historically, insurance companies had different copays, deductibles, lifetime limits, and authorization protocols for accessing substance abuse treatment than they did for other health benefits. The Affordable Care Act says they can't do that anymore. If insurance companies are providing a substance abuse benefit, they have to provide that benefit on par with other surgical, medical benefits.
I cannot tell you how many parents I've talked to who have mortgaged their house and gone through second mortgages on their house because they had coverage, but the coverage wasn't adequate to support treatment for their loved one. So it really has the opportunity to revolutionize our approach to the treatment gap. It's often that untreated addiction that has resulted in people ending up in our criminal justice system in the first place.
German Lopez:Looking at some of the numbers for ONDCP's budget, it shows that, while treatment programs are getting more funding particularly in the next few years, the law enforcement and supply side are still getting a lot of money. Do you feel that the treatment side, even with this increase, will be getting enough funding from the federal government, or do you think the government will have to do more in the coming years?
Michael Botticelli: I have a public health perspective. I come from 20-plus years of a public health approach to this issue.
But here's how I conceptualize it: People often put this divide between supply reduction efforts and demand reduction efforts, and there is clearly an intersection between the two.
Let me give you some telling examples. We have an epidemic of prescription drug abuse and misuse in the United States, largely driven by the supply and over-supply of prescription drug medication. We are seeing spikes in heroin use, and that's being driven by the readily available, cheap, very pure heroin we have in the United States. If you think what our public health strategies have been, I reduce it to getting that stuff out of the community, and getting good stuff in.
If you think of our public health strategy as it relates to food policy, we'll often talk in terms of looking at diminishing the number of bad fast food outlets in particularly poor communities and communities of color and ramping up their access to good and healthy foods.
I think there is an under-appreciation, quite honestly, for looking at how diminishing this supply of drugs in the community through law enforcement implicates demand reduction. We know that when people choose to use a substance, availability is one of the risk factors.
So these aren't necessarily separate strategies. They really reinforce one another.
I think what our new strategy does, however, is say that we haven't paid ample attention to our demand reduction strategies, particularly when you look at this treatment gap. So continuing to ensure that we have resources on the demand reduction side is going to be an area of growth for our national drug control budget.
German Lopez: Some of the drug policy experts I've talked to point out that the supply side and law enforcement approach hasn't, by a lot of measures, worked in the past few decades. So why not just focus on reducing demand through treatment programs?
Michael Botticelli: Well, continuing to have a more robust public health response is something that we're clearly more invested in. Again, if you look at the budget, that's where those resources are continuing to grow.
I think we have had some success in terms of supply. I don't think that we can minimize what the availability of both illicit and licit substances has in our communities.
Let me give you another example: One of the issues we used to spend a lot of time on in Massachusetts was reducing underage drinking. If you look at not just Massachusetts but across the country, you see significantly more alcohol outlets in poor communities and communities of color. So part of this is reducing the number of alcohol outlets.
Or with tobacco policy as well, reducing the availability of tobacco obviously has a key role to play. CVS has stopped selling tobacco products, and that's been part of a public health strategy to reduce the magnitude of tobacco use.
Again, I think we need to continue to focus on the public health aspect and make sure we have a significantly robust public health response to this. But I don't think we can abandon the role that bad substances in the community play in terms of increasing the probability that people are going to make bad choices just because of their availability.
German Lopez: I think almost everyone would acknowledge that, in a perfect world, these harmful drugs should be removed from communities. But we've seen over the decades that the demand strategies haven't really worked: illicit drug prices have dropped, and drug use has fluctuated with little correlation to the supply-reduction policies. So why continue this approach at all?
Michael Botticelli: Well, this has been the sea-change in this office. What the plan acknowledges is that yes, historically, a lot of the efforts have focused on the supply-side, and we haven't paid enough time and attention to the public health issues.
We have a treatment gap in the United States that we have for no other health issue. The rate of substance abuse disorders is comparable to diabetes rates. But the treatment rate for diabetes is upward of 85 percent, yet we have a 10 percent treatment rate for addiction. That has significantly increased demand for these drugs.
As someone who has been doing this for a long time, and someone with my own history, I know addiction is probably the last disorder for which we wait until people reach their most acute phase before we have a treatment system to respond to them. I'm sure you've heard the expression of hitting bottom — that people have to hit bottom before they're ready for help.
From a policy perspective and from a humane perspective, that's crazy. We don't say to someone who has a heart disorder, "We're going to wait until you have a heart attack before we respond to you." Part of our response to all of this is ensuring we have good, early intervention services, and we're identifying people early in their disease progression before it reaches the acute stage.
German Lopez: Some of the most abused drugs in history and some of the deadliest have been legal substances, particularly alcohol and tobacco. Is there anything your office is doing about those legal drugs?
Michael Botticelli: In terms of statutory mandate, we only deal with alcohol use as it relates to underage drinking. This is where, if you look at data over the past few years, we actually have made significant progress in reducing underage drinking. I think it's because we've increased our capacity to understand good prevention messaging.
Some of the programs that our office supports are Drug-Free Communities Program grants. They put our resources at the local level to really change the environment, to not make it so underage drinking is a rite of passage. That really changes those communities' norms. They work on things like alcohol outlet density issues and good social host liability laws. Communities that have had drug-free community grants, they've seen a reduction in both underage drinking and substance use in those communities.
One of the things we know from a public health perspective is that if you look at particularly kids who start using at a young age, they're the ones who are at most significant risk to really developing lifelong problems. Those usually focus on alcohol, tobacco, and marijuana. There's pretty clear evidence that if kids start using those substances, often they use them in combination. And if they use them at a young age, there's a significant increase in likelihood that they're going to develop a more significant problem later in life.
So the focus with kids is getting them not just to reduce bad choices, but really focusing on using positive youth development skills to make sure they're making good choices in their lives and realizing that alcohol, tobacco, and marijuana don't support those healthy life choices.
German Lopez: Since you mentioned those strategies for legal substances, states like Colorado and Washington are now legalizing marijuana — and removing the law enforcement approach that goes with criminalization — and focusing on education and treatment programs. What do you make of this approach — of legalization and moving prevention efforts almost entirely to the demand side?
Michael Botticelli: I think those states, particularly those that have legalized marijuana, are obviously doing the right thing in really focusing time, energy, and attention in amping up their prevention messaging as it relates to underage substance use.
Part of the challenge becomes that, looking at the alcohol industry or tobacco industry, these companies often target youth and rely on very heavy users to make their industries profitable. So while we support these states' overall prevention messaging, I think it's going to be really challenging to prevent significant increases in underage marijuana use.
This interview has been edited for length and clarity.