There are very strong moral forces, and this is a very puritanical country still. So this idea of coming down hard on drug users or drug dealers, execute them, as the president said in some talk not too long ago.
There's also a touch of racism about this, because when you look at the demographics of people in prisons in the United States – we have the highest rate of imprisonment in the world by far – they're people of color and poor people, and a good portion of them are there for nonviolent crimes. People don't realize that the hammer will start to fall on Ohio, and Pennsylvania, and New Hampshire, and Vermont, and southern Massachusetts – epicenters of the opioid epidemic – which are white and middle America.
Many readers may be surprised at your description of why people begin using drugs: "People use drugs for a purpose. They work." Do you believe the way we as a society views drugs is fundamentally mistaken?
I think that the two principal strategies, control and consequences, that have been used in this country for well over 100 years are indeed mistaken because they're ineffective, and they're very costly in terms of human lives and money. So until we move to solutions that are built on understanding the complex relationship between a person and a drug – that person's biology, that person's psychology, that person's social setting and the drug – we'll be trapped in the ineffective solutions that have gone on a very long time, and there are effective solutions.
What are the treatments that do work to reduce and treat addiction?
One of my activities, successful over the years, has been introducing depression measurement and intervention in primary care settings, an instrument that the patient fills out that quantifies your depression state, and if you have a number that's in a moderate or very severe range, that goes into the medical record. What we need now is an analog to that for drinking and drug use.
Comprehensive treatment sounds like a slogan, but if you understand the brain
in a simple way, there's a circle in the brain that's triggered by opioids, by tobacco, by having a baby or being a new mom or new dad, or seeing a rainbow. There's a reward center in our brain, and that's like the accelerator pedal for getting the brain going about something that feels good, that's the pleasure center, and there's a dopamine spike, and that leads to a cascade of other sections in the brain that are related to motivation, which is about wanting to get more about what made you feel good. And then there are areas of the brain that register memory by cues, smells, taste or vision. Each of those represents a touchstone for intervention. If you just focus on one area, just give people medication, or just give people psychotherapy, or help them with relapse prevention, each one of them helps, but each one of these interventions is additive to the other.
What sorts of broader policy recommendations would you suggest local and federal officials adopt?
When you think about public health – how we've made dramatic reductions in infectious diseases in the world, principally through vaccination and sanitation – the same principles of prevention, screening or early detection, early intervention, treatment and certain research apply.
It took a while for [Albert] Sabin to find the polio vaccine. It took a while to figure out how to keep people alive with HIV/AIDS. Good money went into that, and it paid off.
The prevention programs, aimed at elementary school kids, aimed at middle school kids, and their parents have been studied and they're effective, but we don't use them. And they're not actually high cost programs, but they cost. And school budgets more or less can't afford them, they have no money, they can't buy supplies for their kids. So there has to be state and federal money to do that, not from bake sales.
This is a complex condition, and there are solutions, but you have to advocate for them. And that advocacy not only for your loved ones but who you vote for, because governments, elected officials, hew to what the voters demand. And that's what voters have to start demanding, which is not lock them up, but prevent, screen, treat, and then put more money into research.