Sunday, June 29, 2014
A Veteran Addiction Researcher Tells All
Whats going on in Iraq and Vietnam with drug addiction? What's up with Obamacare? With research and unlicensed addiction counselors? The word from Dr. Richard Rawson.
By John Lavitt
Dr. Richard Rawson PhD has been on the front line of addiction research and treatment development for 40 years. A member of the UCLA Department of Psychiatry for over 20 years and the Co-Director of the UCLA Integrated Substance Abuse Programs at the Jane & Terry Semel Institute for Neuroscience & Human Behavior, Dr. Rawson oversees an impressive portfolio of addiction research. A major focus of his work is the study of how treatment strategies are applied in a wide range of institutions and societies.
During the past decade, Dr. Rawson has worked with the U.S. State Department on large substance abuse projects, exporting technology and addiction science to the Middle East and Southeast Asia. Currently the principal investigator of the Pacific Southwest Addiction Technology Transfer Center and the NIDA Methamphetamine Clinical Trials Group, Dr. Rawson focuses on improving the educational standards for addiction treatment professionals.
In his interview with The Fix, Dr. Rawson provides an insightful historical perspective on the evolution of addiction treatment and research. With a body of unique experiences and work, Dr. Rawson elucidates the present state of addiction treatment and research in light of the Affordable Care Act while providing a rare illumination of what is to come.
You recently completed the Iraq Drug Demand Reduction Initiative. You were given a State Department contract to conduct a national household survey of drug use in Iraq. What did you learn from that survey and how is that knowledge being used?
Our work actually predates the survey. From 2011 to 2013, we had a previous State Department contract in collaboration with SAMHSA (the Substance Abuse and Mental Health Services Administration, a federal agency) where we worked with a team from Baghdad Medical University in Iraq. The focus of the work was training them in basic information about addiction and treatment strategies, helping them to develop treatment services in Baghdad. We wanted to understand what were the drug problems in Iraq and where was the treatment needed.
It’s going to be a fascinating next ten years of figuring out how to move substance use services into mainstream healthcare, how to educate and serve mainstream healthcare.
To give a little background, during the time of Saddam Hussein from 1980 to 2003, there really were no drug problems in Iraq. From everything I can find and from all the past data that still exists, limited as it is, because of his dictatorship and very tight control of the borders and capital punishment for any drug-related offenses, the availability and use of drugs in Iraq was extremely limited. Some of the first studies done after the Americans went into Iraq suggested the major drug problems were psychiatric medications like anti-psychotics. They were drugs that here in America nobody would ever abuse because they are not particularly enjoyable, but that’s literally all that was available.
Once the U.S. invaded and once we took down Saddam’s government and the borders opened up, drugs have been coming into the country in large amounts. Next door in Iran they have arguably what could be the world’s worst addiction problems with heroin and methamphetamine. Drugs started coming into Iraq across that very long and porous border.
In 2011, we went in and started working with the folks in Baghdad. We took them to Cairo where we had connections at Cairo University, then we took them to Beirut to show them Suboxone treatment in practice. As a result, there are about 15-20 Iraqi doctors, nurses, psychologists and pharmacists who now have a basic background in addiction treatment. They have a treatment unit in Iraq that was one of the first treatment options in Iraq and several satellites have branched off from that unit. The United Nations is now providing them with ongoing support to extend the training and expand the treatment options.
The other piece that we did in that first contract was to chair a meeting called the Community Epidemiology Workgroup in Baghdad that included law enforcement, education, health, security people and army officers to talk about the nature of the drug problem in Iraq. We published a paper about the findings from that report a couple of months ago. One of the major findings from the report and the resulting recommendation was that they needed to do a survey in Iraq, a household survey to get a better handle on the drug problem. That survey is in the field right now.
We have now done interviews with 2,000 individuals and the goal is 3,600. The teams are out surveying as we speak in Iraq. It will be the first national survey of drug use ever done in Iraq and hopefully we’ll have the data sometime this fall. We are both doing interviews and taking saliva samples because it is not clear how forthright the people are willing to be in Iraqi society about their use of drugs and alcohol. Under Saddam which was only ten years ago, if they were using drugs and alcohol, they would be shot. It wasn’t something you were likely to talk about so the accuracy of the survey in the context of Iraq’s history is challenging. That’s why we are also taking saliva drug samples to inform the self-report or confirm the self-report.
You received both your undergraduate degree in 1970 and your PhD in 1974 in Experimental Psychology from the University of Vermont. What then motivated you to enter the field of addiction treatment? Is there a personal reason why you made this choice?
I wish I had a better answer to that question. It was 1974 when I finished my PhD, it was during the Vietnam war; a time when many of us were looking for positions in academia. I was expecting to get a position as an assistant professor in a nice college and teach undergraduates and do a little research, but those were not the options available to me.
One of the options that I found most intriguing was a position at UCLA where they had one of the first grants issued by the National Institute on Drug Abuse. This particular grant was studying the medication naltrexone and a set of behavior therapies for the treatment of heroin addiction. Since that seemed like a very new area and an area where there wasn’t a lot of knowledge, I thought it was a good opportunity. At that point, I must admit I had no particular interest in addiction research or treatment per se.
In 1980, you worked for a nonprofit agency, setting up methadone clinics across California. Do you think methadone treatment for opioid addictions has proven effective? Should methadone clinics continue to operate given the recent advances with opioid antagonists like naltrexone and Suboxone?
After my first five years doing addiction work with patients using naltrexone and behavior therapy, I spent one year in New York City where I got to see the use of naltrexone and those other treatments in action. But I also got to see the use of methadone and the use of LAAM. LAAM was another medicine that was being developed in conjunction with methadone, but it had a longer lasting effect. (Editor’s Note – Like methadone, LAAM or levomethadyl is an opioid analgesic that is not used for relief of pain but was used in the past as a narcotic abuse therapy adjunct in the United States.) I became intrigued by the tremendous benefits that patients seemed to derive from these medications.
I came back to California and was given the opportunity to work on setting up what was essentially a service delivery system that focused on methadone. While we established those clinics, however, we continued to use naltrexone and LAAM and behavioral strategies for the patients as well. Although labeled as methadone clinics, it wasn’t simply methadone, but a variety of treatments.
In answer to your question about methadone and its future in relation to the other available medicines, I don’t think we’ve ever heard anyone say, “Well, gee whiz, we have a new antibiotic so maybe we shouldn’t use penicillin anymore.” There’s always going to be a need for methadone. Methadone is a tremendously effective treatment. It has the benefits of being relatively inexpensive as a medication. Around the world where we are seeing big problems with injection drug use and HIV, there’s nothing even close to methadone for its efficacy, effectiveness and efficiency.
And it will always play a role in the United States as well. There are some patients who need methadone because the other medications are not as effective with them. We are always going to need multiple medications. It’s not that a new one comes along and we drop the old ones. We are going to need all of them.
In 1984, you started the Matrix Institute in Beverly Hills during the peak of the cocaine epidemic and worked there until the end of 1995. Can you describe the goal of the Matrix Institute, its methodologies in terms of an intensive outpatient treatment program and whether you consider it to be a success?
With a number of partners in 1984, we opened the doors of the Matrix Institute. This was during the Reagan years, and our approach to the drug problem was to ‘Just Say No’ so there really was very little in the way of federal funding for research or the development of new knowledge. I was interested in looking at what kinds of treatments could be developed that would assist this newly emerging group of people who were using and abusing cocaine. The knowledge in the early 80s, at least the purported knowledge, was that cocaine wasn’t addicting, that cocaine was a drug that people took too much of occasionally, but they didn’t really get addicted to it. Well, 30 years later, we’ve recognized that’s certainly not the case.
Matrix was set up with the expressed intention of collecting information on stimulant dependence and using that information to develop strategies based on evidence that were effective treatments. It was our intention to look at the data we collected and to develop treatments that had evidence to support their use.
For the first five years or so when patients would come into Matrix and they would pay for the treatment themselves, they would also have to sign a consent form that basically said we don’t really know how to treat cocaine dependence. In fact, by coming into treatment at Matrix, you essentially were entering an experiment where we were trying to learn about cocaine dependence and trying to develop treatment strategies.
From 1995 to 2002, you focused your work on what would become a national plague – methamphetamine abuse and crystal meth addiction. From 1996 to1999, you were a member of the Federal Methamphetamine Advisory Group for the White House Office of Drug Control Policy and Attorney General Janet Reno. How damaging are methamphetamines and is the battle against them being lost?
While I was still at Matrix in the late 80s, the Department of Public Health in San Bernardino County asked us to open an office out there. While we were seeing hundreds and eventually thousands of cocaine users in Beverly Hills, in San Bernardino they were seeing the same great demand for treatment but for methamphetamine dependence. We opened an office in 1987 and we started seeing hundreds of methamphetamine users. With the same empirical approach we were developing in Beverly Hills, we started to collect data on methamphetamine use – what it did, who it affected, how methamphetamine addictions affected the person, what kind of effects did it have on their body and their brain.
In 1996, General Barry McCaffrey called a meeting to address the problem of methamphetamines. McCaffrey was Drug Czar under President Bill Clinton. He had been alerted by the Federal Attorney in San Diego who said that methamphetamine abuse was a huge problem on the West Coast and no one was addressing it. McCaffrey calls this meeting, and it turns out that we were the only ones who had any data. The data that we presented helped the government begin to address the methamphetamine problem in a larger way.
Over the next decade, there was a tremendous effort by the National Institute on Drug Abuse to develop medications and behavioral treatments for methamphetamine dependence. There were many other efforts on the law enforcement side to reduce the availability of precursor chemicals to stop the rampant Mom and Pop production of methamphetamine.
As we sit here now in 2014, methamphetamine is still most definitely a substantial public health problem across much of the country. We have not made significant progress in the area of medication development. The precursor controls of reducing the availability of drugs like ephedrine have reduced the production of methamphetamine in the United States.
The Mom and Pop labs or, as we used to refer to them, the Beavis and Butthead labs that dominated methamphetamine production in this country in the late 1990s and early 2000s were not able to continue to operate without access to the precursor chemicals. Most of the middle-sized labs in people’s garages and in Breaking Bad-like campers have mostly gone away. Now we have these portable laboratories of small-time users that are found in backpacks and on kitchen counters. Beyond these tiny individual user laboratories, the Mexican drug cartels stepped in and took over both the production and distribution of methamphetamine through giant-sized industrial labs. As fast as we develop laws to restrict the precursor chemicals or we restrict the other ways to get the drugs, the drug traffickers seem to find a way around them.
Today, the methamphetamine problem is still severe in many parts of the United States. We still need a lot more knowledge and information. The good news is that the precursor controls have reduced the spread of methamphetamine from the West Coast to the East Coast by stopping the homemade labs that were springing up when ephedrine was readily available. We actually don’t see very much methamphetamine use on the East Coast or the Northeast because it basically never got there. But it remains a problem in the West, the Southwest and in the Midwest. Many of the people now entering the criminal justice system in those parts of the country are affected by methamphetamines. We have a long ways to go.