Obama's Odd Drug Control Plan: Appoint Qualified People

20.03.2009
The New Republic
Harold Pollack

Harold Pollack is a public health policy researcher at the University of Chicago's School of Social Service Administration, where he is faculty chair of the Center for Health Administration Studies. He is a regular contributor to The Treatment.

I'm not a fan of the Office of National Drug Control Policy (ONDCP), the "Drug Czar's" office. I wish the office would moderate its near-exclusive focus on illicit drugs to pay greater attention to alcohol, tobacco, and prescription drugs. Of course ONDCP should place greater emphasis on treatment, harm reduction interventions for street users, and measures to reduce the large-scale incarceration of so many drug users and drug sellers.

Ironically, these ideological matters mask a larger problem: ONDCP has done a bad job at what it is trying to do. The office's self-marginalization under Bush-43's John Walters exemplified the dysfunction, but the problem is deeper than any one person or administration.

Some excellent people have worked at ONDCP and have done some good. (I will do them the courtesy of not naming them, given the broadside I am now delivering.) By and large, however, ONDCP has been an obvious hindrance in efforts to form and communicate effective policies, even in areas that fit the office's narrow policy agenda.

If a congressional aide or a reporter needed a sensible take on (say) the effectiveness of Mexican drug interdiction or the operational challenges of retaining street drug users in treatment, ONDCP would not make the first round of calls--unless, that is, one were seeking the predictable red meat from an extreme use-reduction perspective. It is almost impossible to imagine an academic making that call.

There is something fundamentally amiss here. This is not (wholly) a question of partisan politics, though the capture of ONDCP by cultural conservatives is an aggravating factor. Maybe things would have turned out differently had William Bennett enjoyed less success in making needle exchange and other matters a profitable front in the culture wars. We'll never know. Somehow, drug policy brings out the worst in American politics.

I may be sensitive because I spend much of my day researching health policy. However much I disagree with conservatives such as Gail Wilensky and Douglas Holz-Eakin, I cannot doubt their expertise and their good faith. Yeah, there are plenty of health policy hacks out there, but the serious players on all sides are generally expected to be conversant with a large and growing body of evidence and to make some minimum of sense.

For years, Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases, has been America's de facto AIDS Czar. Last year, he spent a day on our university campus fielding questions from students and faculty about AIDS research and care. He spoke with evident mastery about virtually every major challenge ranging from the molecular biology of proposed vaccines to the prevention challenges of "treatment complacency" to the politics of needle exchange and Ryan White CARE Act funding, to the cultural, political, and implementation challenges facing PEPFAR in different countries. The contrast over time in expertise, sustained commitment, high-level access, and sheer civility between him and his ONDCP counterparts is damning.

Things are looking up, though. The new Drug Czar, Gil Kerlikowski combines the credibility of a big-city police chief with a solid reputation for pragmatic and decent law enforcement practices. More important are those being brought in to back him up, particularly on clinical and scientific matters beyond the Chief's personal experience.

Sources report that Tom McClellan will be Kerlikowski's deputy director, and second-in-command. McLellan's appointment is part of a weird pattern of hires made by the Obama administration: Appoint people who actually know what they are talking about rather than ideologues or the President's smiling and funny roommate from boarding school.

Moreover, Kerlikowski and his superiors might actually listen to him. McClellan isn't the first drug policy expert to hold that post. William Bennett had at-hand an authentic treatment authority, Columbia's Herb Kleber. As Mark Kleiman tartly notes, Bennett was content to trade on Kleber's reputation without allowing Kleber's expertise to interfere with his culture-warring.
You probably have never heard of McLellan. He doesn't blog or banter on the Daily Show. He is a household name within the worlds of substance abuse treatment and drug policy. He's spent the last few decades tending the vineyard of evidence-based treatment practices. A prolific researcher, he edits the flagship Journal of Substance Abuse Treatment. He directs the University of Pennsylvania's Treatment Research Institute. He was a major development of the Addiction Severity Index, the standard assessment tool for entering treatment clients. He worked with Vietnam veterans returning home facing complex challenges alongside their substance use. Sadly, this work is especially timely.

He was also lead author of one of the most widely-cited articles ever published on substance abuse, which argued that drug dependence is a chronic medical disorder which should be insured, treated, and evaluated in similar fashion to asthma, type-2 diabetes, and hypertension. In its understated way, this remains an important, humane, and pragmatic statement of the challenges facing clinical practice and public policy in this difficult area.

Kerlikowski and McLellan have their work cut out for them. They will operate in a DC environment that breeds bad drug policies and that fails to provide needed resources for programs of proven value. The recent stimulus debate was sadly typical: Substance abuse treatment received kind words in the final legislation. Yet these services received almost no money to offset cutbacks imposed by state governments.

As the presumed point-man on matters of demand reduction, Dr. McLellan faces a particularly daunting challenge. He must challenge politicians to provide greater treatment resources. He must challenge the treatment community itself to provide better, more-accessible, more effective and evidence-based services. So often, treatment falls far short of what we can do. Most Americans with drug or alcohol disorders will never access formal treatment. We need to find better ways to serve them in other ways. Prevention programs raise similarly serious concerns.

Perhaps most important, McLellan and his boss must nurture ONDCP as a serious and capable organization, creating an environment in which good people not only visit, but stay to do good work. A depressing number of Drug Czars and staff quickly move on to greener pastures.
These are hard problems, and one shouldn't expect too much. At least the President has assigned good people to the task.

--Harold Pollack

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