America’s Addiction Crisis: Treatment Research Institute Founder Dr. Tom McLellan on Science-Based Approach to Drug Treatment and Policy

Dr. Tom McLellan

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Female Speaker : Welcome to Conversations on Health Care with Mark Masselli and
Margaret Flinter , a show where we speak to the top thought leaders
in health innovation, health policy, care delivery and the great minds
who are shaping the health care of the future. This week Mark and
Margaret speak with Tom McLellan founder of the Treatment
Research Institute, it’s a no n - profit organization dedicated to science
driven reform of treatment and policy in substance use disorders.

Lori Robertson also chec ks in the Managing Editor of FactCheck.org
looks at misstatements spoken about health policy in the public
domain separating the fake from the facts . And we end with a bright
idea that’s improving health and well - being in everyday lives.

If you have commen ts , please e - mail us at [email protected] or find
us on Facebook or Twitter , iTunes or wherever you listen to Podcasts
and you can also hear us by asking Alexa to play the program
Conversations on Health Care . Now s tay tuned for our interview with
Tom McLellan on Conversations on Health Care .

Mark Masselli : We're speaking today with Thomas McLellan PhD founder of the
Treatment Research Institute an independent non - profit organization
dedicated to science driven refo rm of treatment and policy in
substance abuse. Recently a retired professor of psychiatry at the
University of Pennsylvania , Dr. McLellan served as senior editor for
the U.S. Surgeon General ’s 2016 report Facing Addiction . He
previously served as senior sc ientist and deputy director of the White
House Office of National Drug Control Policy. Dr. McLellan holds his
PhD from Bryn Mawr College and did his post graduate training in
psychology at Oxford University in England. Tom, welcome to
Conversations on Heal th Care.

Tom McLellan : Well thank you for having me.

Mark Masselli : You know it ’ s been 25 years since you founded the Treatment
Research Institute and since then we’ve seen just this devastating
impact of the growing epidemic of opioids in the United State s. And
still it seems we lack this consensus on both treatment of substance
use disorder and the best policies to address the public health crisis . I
wonder if you could share with our listeners some insight into why
this is still so difficult to do.

Tom McLellan : Yeah . I think the way most of the world has understood addiction for
centuries as weak character, poor upbringing, things like that . And
now here's a fact , a ddiction is a chronic illness that affects the brain ,
specifically the motivation, inhibi tion, reward and stress circuitry and
the brain . And what has happened is we have institutionalized
prevention , treatment , all kinds of other policies based on this

Dr. Tom McLellan

understanding that addiction is something that bad boys do and
should be punished for . We ’v e flat ly got it wrong , and w e're just
making that transition now, the science is finally leading the way . But
it's going to be tough the institute, the proper policies and the most
effective and efficient forms of prevention and treatment , but it's
going t o be made even more difficult because we have to displace
centuries of thinking and institutions that are based on antiquated
models.

Margaret Flinter: Well Tom, you've written so extensively on this topic of addiction and
evidence based treatment , and I think that one of the most seminal
documents you played a role in producing was US Surgeon General
Vivek Murthy’s very powerful call to action Facing Addiction . Can you
share with our listeners what you and the Surgeon General saw to set
in motion?

Tom Mc Lellan : I think two things have to be communicated and these are fact s
backed by the 30 years of research ; t he first is , addiction is not an
intractable social problem that we simply have to live with. This is a
medical condition and we can prevent most ca ses , when we can't
prevent those cases, we can intervene effectively and arrest th e
devastating effects. It is possible to treat even very serious cases of
addiction and with full recovery now being an expectable outcome of
the right kind of care , so t his is a solvable problem. We know an awful
lot about what to do and that is both the promise and the pity of this ;
t he pity is it's just simply not been implemented . There's a second
point that it is in the interests of mainstream medicine to finally
embrace the study , management , understanding of substance use
disorders. Not only because these are treatable medical conditions in
their own right, but even more important in the context of the rest of
medicine where the re are desperate efforts going on to contai n costs
and improve quality . Undiagnosed , unmanaged substance use
disorders are costing main stream health care over a $ 1 20 billion a
year , and that's from misdiagnoses , w ay too frequent, unnecessary
emergency room and other high cost procedures. Medicine h as been
a reluctant participant in this , and it is time , and it is in the direct self -
interests of every physician, but particularly primary care to learn how
to recognize it and manage it because they can and because it will not
be possible to deliver hig h quality mainstream health care for most
other illnesses unless they do.

Mark Masselli : Speaking of that, you've been an advocate of something that we've
practice d at our health facility , Medication Assisted Treatment or
MAT which uses a drug regimen to help manage addiction in the
ambulatory care setting . Your research has yielded powerful evidence
of the effectiveness of this approach, especially in reducing incidents
of relapse. There's a lack of uptake by primary care providers on
medication assisted treatment , s o tell us more about the research on

Dr. Tom McLellan

it, but also why you see reluctance to start to providing this very
needed service.

Tom McLellan : Yeah. This is where politics, ideology and science , all meet. If I said
Type 2 Diabetes is a chronic medical illness and it is a good idea to
have FDA approved medications in addition to changing your lifestyle ,
t hat would cause exactly no st i r at all . And the reason is diabetes has
been accepted as a real medical condition , p hysicians are trained to
diagnose i t, to understand it, to manage it. Three , as a chronic illness ,
we know that it's basically not possible to cure it, but it can be
managed . Finally , every insurer and every payer for health care
understands all that and w ill reimburse treatment teams to do it.
When I say the same thing s about opioid and alcohol dependence, we
still as a country haven't fully accepted that this is a medical
condition , p hysicians haven't fully accepted this , but these are
medical facts.

So Medication Assisted Treatment has b een a big philosophical point
because for decades it was thought that drugs are drugs and a person
who is drug dependent, they should be abstinent of all drugs. It's been
the prevailing and often very effective way to treat lots of patients ,
but the opioid addiction, that kind of view has to be reconsidered.
Now overdose deaths are the largest cause of death in people under
50, so let's just accept that the addiction is a chronic illness. Okay ,
w ell, what would you want from an effective treatment? One, you
want to reduce the cardinal symptom of the problem. Again, if it's
diabetes, you want to reduce hemoglobin A1C. If it's hypertension,
you want to reduce blood pressure. First and foremost, thing you
want any treatment to do is to protect the patient and r educe the
cardinal presenting symptom of the illness, in this case drug use.
That's not enough, you also want generally improved health and
function . And finally , because it's a chronic illness, you're going to
have to convert the patient and their family to be actively monitoring
and managing their own disease, and that's effective care for any
chronic illness. In the addiction field, if you put those three things
together, that is called recovery , s o in my mind we want Medication
Assisted Recovery because that's what patients’ want, that's what
payers want and it is entirely possible.

Now, especially for opioids, especially for alcohol, where there's a risk
of overdose and a risk for relapse, it is a fact that medications are the
safest way and the most r eliable way to protect the patient and
reduce the presenting symptom , the substance use. Even when
medications are necessary, usually they are not adequate in and of
themselves. Just in the case of diabetes, nobody would advocate
driving up , getting insuli n, driving off as a treatment for diabetes. You
need to change your lifestyle, you need to change your diet, you need
to change your exercise and you need to self - monitor and get the help

Dr. Tom McLellan

of your family. That's what good addiction treatment does too , i t
he lps you change your lifestyle, recognize triggers for relapse and be
protected with the medication while you're doing that.

Margaret Flinter: Tom, I want to just focus for a moment on another element of the
important work that you've done on addiction, and that's developing
tools for those clinicians who are engaged in working with patients on
treating addiction. Two of them that come to mind are the Addiction
Severity Index or the ASI and the Treatment Services Review, the TSR,
which I understand are reall y quite widely used now in clinical
settings . So maybe if you could expand upon that a little, is that for in
the substance ab use specialty treatment domain ? And if it is, what
would you recommend in the primary care domain?

Dr. McLellan: So these instrume nts have a purpose, they are not to screen to see if
there's presumptive evidence of a problem. In fact, it's now clear that
you can get a presumptive idea of whether an individual , adolescent
or an adult may have a substance use problem with a few [inaudi ble
00:11:47] questions and it's still not widely enough used. The next
thing you want to do is diagnose it whether there is loss of control
over their substance use that can be done with a diagnostic interview.

Okay, now you've got a diagnosis. Next ques tion is, what are we going
to do to treat that patient and how you are going to prepare yourself
as a clinician and how you're going to prepare the patient to
understand the problem? That's where the ASI was designed. We
[Inaudible 00:12:18 ] the premise th at addiction is best understood in
the context of the problems that may have preceded, may have
resulted from the substance use, typical life scenarios, medical
conditions, employment, legal, family and psychiatric problems.

At the end of the 40 - minute int erview, a clinician and the patient
ought to better understand how they got into this substance use
problem and what other problems have to be addressed. I foolishly
thought that the person with the worst substance use problem would
also have the worst fin ancial, the worst legal as well , and the first sort
of surprising finding is that that isn't true at all. Think about it , y ou
know celebrities who have no problem with their employment and
they've got an enormous substance use problem because of ready
avai labilities , where another group addicted physicians who have
often very serious rates of substance ab use, but no other problems.
Meanwhile, you can have an unemployed, pregnant teenage girl who
has a rather modest cocaine problem, but is going to be an awf ul lot
more difficult to treat than a ver y seriously addicted physician. The
Addiction Severity Index was designed to prepare treatment providers
to address the often complex in terrelated problems that occur.

The second thing that’s design ed to do was to e stablish a baseline to

Dr. Tom McLellan

what do these patients look like when they walk through the door to
your treatment facility? How bad are things recently in the last month
so that later you could reassess the patient and you could compare to
see whether there's been improvement ? Most patients enter
substance abuse treatment have many problems, so you're not just
dealing with drug use, you're dealing with a combination. Good news
is patients who undergo treatment do better , t hey improve relative to
where they were whe n they come in the door , p atients who get
tailored treatments do better . And again, these are things that have
been found with the research, so it is guided the thinking I suppose to
take it off simply focusing on substance use and begin to think about
the whole package . And it has led away from programmatic care to
more individualized , tailored , personalized treatments as are now
typic al for other chronic illnesses.

Mark Masselli: We are speaking today with Thomas McL ellan , Founder of the
Treatment Researc h Institute , dedicated to science driven reform of
treatment and policy and substance abuse. Tom, I was listening to you
sort of walkthrough those numbers about the size of the opioid crisis
in America . We always keep our eye on what's happening in
Washing ton in terms of how they're allocating money for this and also
the policies that they're implementing. President Obama and his
former drugs are adopted a pretty aggressive approach , it seems since
2017 things have slowed down. Tell us what's happening in t here and
your prescription for wh at policy should be implemented.

Dr. McLellan: I ’m dismayed by federal policy towards addiction and in fairness, I
don't think the Obama Administration guide right either. I think we
moved further towards a view that addict ion is a public health
problem that is best addressed with prevention, early intervention
and treatment , and moved away from addiction is a criminal p roblem
and needs to be punished , a nd now I see it going the other way. I'm
trying to take a cold - blooded w hat's going to work approach , and the
truth is that top national policies that punish but offer no treatment
or national policies that simply say everybody needs treatment and
there's no punishment and no sanctions for use a re wrongheaded .
The best policie s that I know of are those that combine them , and it's
an artificial separation between police and treatment professionals.
You can't treat any addiction when there’s ready availability of the
substance in the street, it ’s just not , i t's like treating diph theria with a
place where there's polluted water. Further, you can punish an
addicted person all you want but i f they don't get the right kind of
monitoring and supervision, they're simply going to go back to it.

So I favor policies that reduce the availab ility of substances , I'm not
for legalization of or even medicalization of marijuana just because it
makes the availability increased t he likelihood of more people using
you're going to have more misuse and you're going to have more

Dr. Tom McLellan

addiction. I'm for poli cies that expand incentives for mainstream
health care to embrace substance use disorder , i t's in their interest
for providing high quality general medical care to know something
about addiction . Less than 30% of American medical schools have
even a single course in it , t hat's what science tells us are the best
ways to prevent , intervene early , and treat substance use disorders.

Margaret Flinter: We've been speaking today with Dr. Tom McClellan, founder and CEO
of the Treatment Research Institute. You can l earn more about his
groundbreaking work by going to tr i search.org or follow them on
Facebook @ Treatment Research Institute . Tom, we want to thank you
for your dedication to this incredibly important health issue , for your
body of research and for joining u s today on Conversations on
Healthcare .

Tom McLellan: Well, thank you. It's been a pleasure.

Mark Masselli: At Conversations on Health Care we want our audience to be truly in
the know when it comes to the facts about healthcare reform in
policy. Lori Robe rtson is an award winning journalist and Managing
Editor of Factcheck .org a nonpartisan, nonprofit consumer advocate
for voters that aim to reduce the level of deception in US politics. Lori,
what have you got for us this week ?

Lori Robertson: President Do nald Trump has repeatedly said that Obama Care is dead,
but recently he has been making a misleading boast about low
insurance premium growth for 2019 marketplace plans.

Trump claimed that the “rates are far lower than they would have
been under the previo us administration”. He added “because we're
managing it very, very carefully”. One study disputes that , and experts
say , most administration actions in the past two years have driven
premiums up , t he actions the administration has taken “by and large,
have destabilized the market”, said Cynthia Cox, the Director of the
Program for the Study of Health Reform and Private Insurance at the
Kaiser Family Foundation. Experts also espoused a longer view at the
trajectory of premiums for the individual market. The expected low
average premium change for 2019 plans comes after a double digit
increase last year which was also under the Trump administration and
driven by the administration's elimination of cost sharing subsidies
and uncertainty over the ACA’s future.

K elly T u r e k, the Executive Director of Employer and Commercial Policy
at America's Health Insurance Plans told us that insurers are also
getting a better sense of the market. For plan year 2015 , premiums
for the second lowest cost Silver plan went up 3% on average for 27
year old according to the Department of Health and Human Services.
Premiums went up 8% for 2016, 24% for 2017 and in the first year
under Trump 2018, they went up 37%. Silver plans in particular were

Dr. Tom McLellan

affected for plan year 2018 by the admini stration ending cost sharing
subsidies paid to insurers to lower the out pocket costs of low income
policy holders. For plan year 2019 HHS sa id, it is projecting a 2%
average decrease for benchmark silver plans in Healthcare .gov state .
An analysis by the A ssociated Press and the consulting firm, Avalere
Health upstate rate filings by insurers found a 2% average increase for
48 states and Washington DC for 2019 overall premium.

Avalere Health Founder Dan Mendelson told us the low growth for
2019 was due to a n absence of political disruption this year and an
expectation of slower growth in medical expenses. Next year the
individual mandate penalty will be eliminated and the Trump
administration has announced new regulations to expand the use of
association and short term health plans. One study from the
Brookings Institution found that the nationwide average premium and
the individual market would decrease by 4.3% if such policies hadn't
been enacted, and that's my Fact Check for this week. I'm Lori
Robertson, Managing Editor of FactCheck.org.

Margaret Flinter: FactCheck.org is committed to factual accuracy from the country’s
major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you
would like checked, e - mail us at www.chcradio.com , we will have
FactCheck.org’s Lori Robertson check it out for you here on
Conversations on Health Care.

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Mark Masselli: Each week Conversations highlights a bright idea about how to make
wellness a part of our communities into everyday lives. Tinnitus is the
vaccine condition that afflicts millions of Americans, a condition for
which there is really no viable treatment to date, but a University of
Michigan researcher may have found a solution. Lead researcher Dr.
Susan Shore says tinnitus marked by a constant ringing in the ears is
really the results of misfiring brain signals. Her team has developed a
device aimed at getting to the root cause of Tinnitus . N eurons in the
region of the brain stem , w hen those cells become hyperactive, they
create a signal that is transmitted to the part of the brain where
hearing perception occurs and the constant ringing can wreak havoc
on sufferers ’ lives.

Dr. Susan Shore : Wh at you're doing is you're tricking the brain into altering its circuitry
to go back to normal.

Mark Masselli: The device is called a targeted bi modal Auditory somatosensory
stimulation and works on two fronts. It uses both weak electrical
impulses target t o the brain region responsible for their problem, and
also sends time sound to interrupt the auditory sensation caused by
the tinnitus.

Dr. Tom McLellan

Dr. Susan Shore : We developed this treatment for a particular class of Tinnitus in which
the person who has the Tinnitus is able to modulate either the pitch
or the loudness of their tinnitus by pushing on their face or pushing
on their forehead or clenching their jaw.

Mark Masselli: The study group has been relatively small so far, just a few dozen
participants, but the re sults have been quite promising. Dr. Shore says
that the severity of the tinnitus was greatly reduced in most of the
participants and some got to the point where they no longer
interfered with their daily lives.

Dr. Susan Shore : We need a good solution for Tinnitus as it's affecting millions of
people.

Mark Masselli: A relatively simple targeted device that could potentially help millions
of tinnitus sufferers from the worst effects of their condition, allowing
them to diminish or even ignore what is often a debilitating condition
for many to live with , n ow that's a bright idea.

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Mark Masselli: You've been listening to Conversations on Health Care. I'm Mark
Masselli.

Margaret Flinter: I’m Margaret Flinter.

Mark Masselli: Peace and Health.

Conversati ons on Health Care is recorded at WESU at Wesleyan
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