Remarks by Director Michael Botticelli at Emory University, Rollins School of Public Health

Remarks by ONDCP Director Michael Botticelli
“Mental Health Lecture Series”
Emory University, Rollins School of Public Health
 Atlanta, GA

April 1, 2015

“A 21^st Century Approach to Drug Policy and Public Health”
< 60 minutes >

Thank you, Dr. Druss, for that kind introduction and for inviting me here today.  I am especially pleased to be at the Rollins School of Public Health.

I look forward to talking about our 21^st century approach to drug policy, as well as the important role the public health profession can play in drug policy issues.

Let me start by telling you a bit about the Office of National Drug Control Policy. 

The Office of National Drug Control Policy was established by Congress in 1988.  Our office is in the Executive Office of the President. 

ONDCP oversees the drug control budget for Federal agencies, including drug budgets within the Departments of Health and Human Services, Justice, Homeland Security and Defense.

These drug budgets reflect the priorities as established in the Administration’s National Drug Control Strategy.  The Strategy is the blueprint for the Administration’s approach to drug policy and is issued annually.

Strategy Overview

The Strategy is based on science and evidence.  It begins with recognizing that addiction is a brain disease that can be prevented, treated, and from which one can recover.

It recognizes there are effective interventions to prevent substance use. 

I was confirmed by the US Senate earlier this year and am the first person to hold this position – previously referred to as the “drug czar” – who is in recovery. 

I say this to you because I believe it is important for those of us in recovery from substance use disorders to speak up, to defy the stereotypes and strike down the stigma too often associated with people in recovery. 

The words we use to describe those of us with substance use disorders help to reinforce these stereotypes and feed this stigma.  Words such as “addict” or “junkie” are far too common in our society. 

Pick up any newspaper or watch any TV news program and I’m sure you’ll hear and see those words used to describe people with the disease of addiction.

I recently came across an article[1] that illustrates public attitudes toward people with substance use disorders. 

Researchers at Johns Hopkins University conducted a web-based public opinion study to compare public attitudes toward people with a substance use problem and mental illness.[2]

Questions in the study included the following:

“Would you be willing to have a person with a drug addiction marry into your family?” and

“Would you be willing to have a person with a drug addiction start working closely with you on the job?”

Results showed that Americans hold significantly more negative attitudes toward persons with substance use disorders than toward those with mental illness.  The study also showed a high desire not to associate with individuals with these conditions.

For example:

• 90 percent of respondents indicated they were unwilling to have someone with a substance use disorder marry into their family;
• 78 percent were unwilling to work closely on the job with someone with a substance use disorder;
• 63 percent of respondents believed discriminatory practices against someone with a substance use disorder was not a serious problem;
• 64 percent of respondents agreed it was okay for someone with a substance use disorder to be denied employment, and 54 percent felt it was acceptable to deny them housing;

Respondents also generally did not feel that treatment for drug addictions work --- 59% felt treatment was not effective.

The bottom line – respondents were more likely to oppose public policies aimed at helping people with substance use disorders, compared to those with mental illnesses.

And our public policies – and societal norms - reflect this stigma. 

I – along with millions of others who are in recovery – are living proof that substance use disorders are diseases, treatment can work, and recovery is possible.

I would like to now turn to the issue of drug use and its consequences in the US and how the Administration’s Strategy seeks to address this issue.

Prevention

The National Drug Control Strategy is based on science and evidence.  It recognizes there are science based interventions that can prevent substance use.

And we believe in using science based efforts to prevent substance use because the age of first use predicts future dependency.   

Evidence based prevention is not a slogan.

Evidence based prevention is not going into a school and scaring young people. 

Evidence based prevention includes focusing on an individual, as well as the community. 

Community based prevention includes public messaging and strategies such as liquor density restrictions, and enforcement of existing laws. 

One example of an evidence based and community rooted prevention strategy is the Drug Free Communities program.

ONDCP funds the Drug Free Communities program in over 600 communities nationwide.  These evidence based programs work to prevent youth substance use by combining individual efforts such as teaching life and social skills with other community based efforts.  

We have come a long way from the early days of drug policy when scare tactics were the norm.  We know what works – and what doesn’t – and we are putting scarce prevention dollars behind what works.

And we understand how important intervening at an early stage of use is -- 

Opioid Abuse and Overdose Deaths

In addition to reducing stigma and promoting prevention, we at ONDCP are also focused on reducing prescription drug abuse, heroin use and overdoses in this country.

In 2013, there was one drug overdose death every 12 minutes.

We are indebted to researchers at the Centers for Disease Control and Prevention (CDC) who brought the prescription drug overdose epidemic to national awareness, characterizing it as an injury prevention opportunity, and further placing drug control squarely in the public health domain.

In 2010, drug poisoning deaths surpassed the historically most lethal cause of preventable injury – traffic crashes – and rates continue to escalate.

While we are seeing some signs that prescription drug overdose deaths are declining, heroin overdose deaths are increasing.

The injury prevention community has made enormous headway in reducing harms associated with automobile crashes, leveraging high-impact policy and environmental interventions like seatbelts and airbags.

The 2013 drug overdose mortality data from the CDC show a 6 percent increase in all drug poisoning deaths from 2012 and a 1 percent increase in deaths involving opioid medicines.[3] An additional reason for concern is that deaths involving heroin had the largest upsurge overall, with a 39 percent increase from 2012.[4]

RX plan Progress to date

To address this issue, the Administration released a Prescription Drug Abuse Prevention Plan in 2011. Since then, we have made substantial progress towards accomplishing many of the goals established under each of the Plan’s four pillars – education, monitoring, drug disposal, and enforcement.

Education.

The majority of prescribers do not receive any training in medical school on identification or treatment of substance use disorders.  We have therefore developed continuing education training programs that teach prescribers skills such as how to start a conversation with patients about substance use; managing pain appropriately; and treating patients using opioids more safely. 

Monitoring.

Prescription drug monitoring programs are another part of our plan to address prescription drug overdose deaths.  All but one state – the state of Missouri – have a database that allows prescribers to check on drug-drug interactions as well as to alert them to early signs of dependence on opioids.

Disposal.

The third element of our plan is disposal.  Since the majority of individuals who begin misusing prescription drugs get them from family and friends, we must make it easy to dispose of the drugs.

The Drug Enforcement Administration (DEA) published the final regulations on controlled substance disposal in September 2014. Now ONDCP and our Federal partners and stakeholders are beginning to inform the public about the regulations and looking at ways to stimulate local disposal programs in partnership with pharmacies and law enforcement.

Enforcement.

Finally, work on enforcement and strengthening existing laws is ongoing at the Federal, state, and local levels.  Those engaged in fraud across the drug-control supply chain are being investigated and prosecuted.

As gratifying as this progress has been, overdose rates are still too high. And there are too many people with opioid use disorders who cannot access treatment.

Treatment:

Based on the most recent National Survey on Drug Use and Health, far too few people who need substance use disorder treatment at a specialty facility actually receive it.[5]

And the increase in deaths involving opioids, including prescription pain medications and heroin, has created a need to dramatically redouble our efforts. Heroin is striking a younger and more rural and suburban population, overwhelming already strained criminal justice and treatment systems.

Federal Efforts to Increase MAT

Today, a number of FDA-approved medications are available to care for people with opioid use disorders. These treatments include methadone, a long-acting injectable form of naltrexone), and several medications containing buprenorphine.

This type of treatment involves using medicines along with a full array of counseling, adherence, diversion-prevention efforts, and recovery-support services, sometimes for years, so patients learn the skills they need to function in recovery and avoid relapse.

Studies have shown that treatment plus medication can help save lives by preventing overdose deaths.[6] Medication-assisted treatment is the recognized standard of care for opioid use disorders. 

Unfortunately, for too many people, it is out of reach.

For instance, in 2012, only a small percentage of treatment facilities provided treatment with methadone and/or buprenorphine,[7] and the data show that criminal justice too frequently is the source of treatment referral indicating that the medical community has in some ways failed these patients.

If we wait for people to rise to the attention of law enforcement, their substance use disorder is likely to be chronic.  We will have waited years for them to enter treatment. The health profession must do a better job identifying individuals earlier, screening them, and referring them to the help they need.

Buprenorphine is a Schedule III controlled substance and is used in the treatment of opioid use disorders.

Medicines with buprenorphine can be given in a doctor’s office once the doctor has received an eight-hour training. More widespread use of this drug has the potential to improve integration of substance use disorder treatment with regular medical care.  

Of the more than 1.1 million physicians who can write controlled substance prescriptions, only about 25,000 have received a waiver to prescribe office-based buprenorphine.[8] And while there are many narcotic treatment programs in the country, not enough physicians elect to use medication-assisted treatment for their patients.

To expand the use of medication-assisted treatment, ONDCP has convened a group of Federal agency representatives to review government programs, policies, and administrative authorities. The Treatment Coordination Group is identifying barriers to medication-assisted treatment and exploring ways to increase use of medication for opioid use disorders.

In addition, the President’s FY 2016 Budget instructs SAMHSA to provide $10 million in new funding for medication assisted treatment to communities hardest hit by the opioid problem.

Federal Efforts On Overdose Education and Naloxone

More access to treatment is needed.  But we also must do something immediately to address the number of overdose deaths in our country.  Fortunately, we have a medication that can help reverse overdoses – naloxone.

This product is fairly easy to use and is becoming more available nationwide.  Our goal is to get this overdose reversal drug in every community where overdose deaths are prevalent. 

Naloxone is being made available through law enforcement agencies, community groups, pharmacies, and can be co-prescribed by physicians.

The President’s FY 2016 Budget, released in February, directs SAMHSA to permit the use of block grant funds for naloxone purchase. It also provides funding specifically for law enforcement to purchase naloxone.

In addition, the Department of Defense now has its law enforcement carry naloxone.

Making naloxone more available is part of our public health approach to drug policy.  And by engaging with law enforcement in naloxone administration, we are truly pursuing a 21^st century approach to drug policy, one that combines public health with public safety.

As staggering as these numbers are, they do not fully describe the breadth of destructive public health and safety implications of drug use and substance use disorders, such as family disintegration, loss of employment, failure in school, and domestic violence.

To effectively reduce the harmful consequences of substance use in this country, we must recognize its relation to substance use disorders in the same way dietary habits contribute to other chronic diseases like diabetes or heart disease.

However, societal attitudes and beliefs, as illustrated by the study I mentioned earlier, as well as policy and legal responses make substance use one of our most complex public health challenges.

Just as we must recognize that there are multiple drivers of the problem, we must recognize that an effective response requires a comprehensive 21^st century approach.  One that can be achieved through a coordinated effort among public health, clinical medicine, and public safety.

As the Hopkins study suggests, we must confront the stigma associated with substance use disorders which so often impedes users from seeking and receiving the quality care they so desperately need. Science demonstrates that substance use disorder is a chronic disease of the brain. For too long, having a substance use disorder has been seen as a moral failure – a matter of weakness – rather than recognized as the disease that it is.

If there is a takeaway message here for this audience, it is understanding that you, the public health community, can play a critical role in the national response to this crisis.

Just as the public health community has led efforts in tobacco control through evidence-based policies and interventions that have significantly reduced tobacco use, public health has a responsibility to inform, alert, and educate the public about the dangers of non-medical use of prescription drugs. 

Through public health efforts such as newborn screening and lifesaving intervention and treatment, we’ve seen significant reductions in infant mortality. Neonatal Abstinence Syndrome (NAS) is another maternal and child health challenge that is on the rise. From 2000 to 2009, we saw a 3-fold increase in the number of babies experiencing withdrawal symptoms after birth as a result of maternal drug use during pregnancy.[9]

People in public health understand how effective evidence-based, public health approaches can be to halt the spread of infectious disease. With the resurgence of heroin use, we must leverage the tremendous power of public health approaches to reduce opioid misuse before we see a reemergence of HIV and HCV cases.

Just last week, the Indiana governor declared the HIV outbreak in southeastern Indiana a public health emergency. Many of these infected individuals began by injecting prescription drugs. This illustrates the strong link between substance use and infectious disease.

Our Strategy acknowledges that while there may not be a cure for substance use disorders, with the right care, people can and do recover.  Seeing people in recovery doing well and leading by example is one of the best ways to show that a public health approach to drug use works.

In closing, I want to take a minute to reiterate that for many years, drug use has been addressed as a public safety issue rather than a public health problem.

The staff and leadership at ONDCP rely on epidemiologists, scientists, and data experts. Federal policymakers have moved the focus of U.S. drug control policy toward a more balanced approach. We now have an approach that addresses not just public safety but also public health. It shines a bright light on the need for health system changes, like getting more doctors qualified to deliver office-based medication treatment and willing to co-prescribe naloxone to patients on powerful pain medications.  

It is my understanding that, unfortunately, few schools of public health have specific training on substance use disorders – apart from perhaps tobacco and underage drinking.

In short, America must bring the power of public health to bear to accelerate the progress of reform. This is necessary to:

• prevent costly downstream consequences;
• reduce the number of people engaged in prescription drug misuse who are vulnerable to starting heroin;
• prevent the need for costly spending on arrests and incarceration to address fraud and illegal drug markets; and
• most importantly, help save lives and give individuals, families, and communities a chance to recover.  

You are the next generation of researchers, health educators, epidemiologists, communication specialists, and health care administrators, and we need your help. You all play critically important roles in finding solutions to our Nation’s drug problem.

Let’s tackle these issues together so we can help all Americans live safer and healthier lives.

Thank you for your time today. I look forward to your questions.

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Notes