Treating addiction as a chronic illness
Michael Botticelli’s personal experience informs his approach at BMC’s Grayken Center
You’ve shaped drug policy at the Massachusetts Department of Public Health, at the White House, and now as executive director of the Grayken Center at Boston Medical Center. But it seems like the most important item on your resume is the fact that you’re in recovery from substance abuse yourself. That’s not an uncommon trajectory. It’s an acknowledgement that in many respects you’re one of the fortunate few who found their path through recovery. For me, it comes from a deep sense that I have an obligation to give back and to try to recreate what I had for everybody else. I’m doing that in a professional capacity, but there are a lot of people who do this on a day-in-day-out basis—not as part of their job but as part of their sense of obligation.
You dealt with your alcohol problem through a 12-step program, right? With a little court help, yeah. I was arrested for drunk driving after a car accident. I went before a judge who said to get my license back I needed to attend a group counseling program for people who have driven under the influence.
What’s the lesson you’ve taken away from your own personal experience? I am the classic case of things going wrong. I had a family history of addiction and we know genetics has about a 50 percent role in the disease. I started exhibiting symptoms of the disease from a young age. No one ever intervened with me. I don’t remember a pediatrician saying to me, Michael, you have a strong family history of this so it might be a good idea if you don’t drink. It’s often not until people reach their most acute stage that they get treatment.
How many people with substance abuse disorders do get treatment? About 14 percent. The treatment rate for diabetes is 75 percent. Why is that? Well, because we identify people who are at risk and we pay very close attention to them over the course of their life to try to reduce all the costs associated with emergency care. I’m sure you’ve heard the phrase hitting bottom. We don’t need to let people hit bottom before we motivate them to seek care. We don’t let people with hypertension progress to the point where they have cardiac arrest before we do interventions.
How does that sort of attitude impact people with addictions? We know that stigma plays a huge role in people not seeking care. I was really afraid to admit that I had a problem because I was afraid of what people would think. Would they think I was stupid or weak-willed?
What’s the attitude in government? Historically, we’ve spent much more on supply reduction and law enforcement strategies and spent comparatively little on health approaches. It wasn’t until the end of the Obama administration when federal spending for health approaches equaled supply reduction strategies. We hoped this trajectory was going to continue, but it appears like it’s not.
What’s the best treatment? For people with opiate use disorder, the evidence is crystal clear that treating addictions with a medication is far better than treatment without medications.
How long should treatment last? It’s a chronic illness. Length and time of treatment are significant predictors of long-term outcomes. Historically, people received very short-term treatment. They’d say I’m going to detox for 30 days. But the relapse rates are pretty staggering with that. If you can get people to one year [on treatment], the relapse rate significantly drops off. And it’s not because detox is ineffective. It’s because people aren’t getting the full continuum of services that they need and often aren’t put on medications that we know to be highly effective in treating an opioid disorder.
How do most people enter treatment? The biggest percentage comes from the criminal justice system—36 percent. Only 8 percent are coming from our health care system. People with substance abuse disorders intersect with the health care system all the time. Given those percentages, we clearly need to do a better job of diagnosing.Aside from family history, is there anything else to look out for? One of the most significant predictors about whether or not people will become addicted is under-age use. The unholy trinity is alcohol, tobacco, and marijuana. If you start using [any of these] at a young age, it sets a trajectory for you to develop a significant addiction later in life. It also basically predicts that you will move to other substances beyond alcohol, tobacco, and marijuana, and usually within three years. Does that mean every person who smokes marijuana goes on to develop an addiction? No, but early use is a significant predictor.
Are we sending the wrong message to young people by legalizing recreational marijuana? One of the things that national surveys track around drug use is the perception of risk that people have as it relates to individual substances. The survey results look like a DNA strand. Perception of risk of marijuana use goes up, use goes down. Perception of risk goes down, use goes up. What we’re seeing now is a bit of an anomaly. Perception of risk of marijuana use among youth is at its all-time lowest level, but we have not seen an uptick in use. We don’t really know why. I can’t prove this, but I think it’s because the volume of discussion around legalization has prompted parents to have conversations with their kids about the dangers.