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Dr. Robert Dupont

 

Can you tell us how you got into this specialty?

Dr. Robert DuPont: I got into addiction through an interest in crime.  I went to work in the Department of Corrections, and was very interested in finding ways to help people in prisons because I actually liked the people who were in prisons and wanted to help them, and found that the way to do that best was to deal with addiction, which was a major cause for people going to prison.  From that, I’ve had a career of 45 years in addiction treatment.

You have been a Drug Czar, for which Presidents?

Dr. Robert DuPont: I’m the only person who’s been a Drug Czar for two Presidents, Richard Nixon and Gerald Ford.

What were the issues you focused on?

Dr. Robert DuPont: Those were the days when treatment was just new in the country.  President Richard Nixon established a federal commitment to treatment, and prevention, and research for the first time in 1971.  In 1973 we established the National Institute on Drug Abuse, NIDA, and rolled out a national treatment system for the first time in the country’s history.  So this was done through working with the states in partnership, with federal grants to fund treatment.  Most of the treatment in this country, particularly government treatment, was from that era.  It was the time in the country when the biggest percentage of federal money was spent on treatment of any time since then. Our priority was to make treatment available to more people.  In those days, the major problem was heroin.  So we were mostly talking about heroin addiction treatment, and methadone was a big part of what we did.

How did NIDA get formed?

Dr. Robert DuPont: The first act was 92255, was the public law passed in 1972, established the National Institute on Drug Abuse as a center for research, and also in those days to treatment and prevention as well.  It was authorized in 1972 but began in September of 1973, and it was part of what was then Health, Education, And Welfare, and now the Department of Health and Welfare.  It’s a very important part of our government.  It’s evolved over the years to focus just on research.  So the current NIDA is just a research organization, and the treatment and the prevention has gone to another agency called SAMHSA, the Substance Abuse and Mental Health Administration.

What were your hopes for NIDA?

Dr. Robert DuPont: Things were so new then.  It was interesting, most of the leaders was very young, as I was at that time, and it was a very exciting time and a lot of very innovative people were in the drug field.  It was exciting, the future seemed fairly limitless to me.  I now look back on it, it all seems kind of primitive and there were a lot of things that we could have done better, but there was a sense of real excitement and enthusiasm.  We were interested in building a knowledge base.  For the whole world, NIDA has been the center of research for more than 40 years.  It’s kind of exciting to think about the brain research that came as a result of that, and understanding what the nature of the drug problem was.  Before that time, people thought that what made a drug addict was withdrawal, that the problem was that when a person stopped they would be sick and so they couldn’t stop.  If you think that’s the problem with addiction, then you do detox and you get them off and then they’re free.  But in a hundred years of doing that, nobody noticed that as soon as you stopped and turned the person out into the community they went right back to the drugs.  So we learned from NIDA’s research that it isn’t withdrawal that makes an addict, it’s relapse that makes an addict.  So the goal of treatment is not to get them off the drugs, it’s to help them stay off the drugs.  That all has to do with understanding how the brain mechanism works, or what is the biology of addiction.

How do you know that treatment for addiction works?

Dr. Robert DuPont: I don’t think treatment works as well as it could.  I think we’ve got a long way to go in this.  The current way people think about evidence of treatment working is that people who are in the treatment use less drugs than people who are out of treatment.  That’s, to me, a horrifying way to define the goal.  Clearly the goal should be no use at all.  But then you get a question that if a person is a heroin addict, is treatment defined that they stop using heroin?  What about their use of other drugs, including other opiates, or cocaine, or marijuana, or alcohol for that matter, or cigarettes?  Are those all one problem, or are they all different problems?

The way I think about it is that the drugs that impairing, like marijuana, or cocaine, or heroin, or alcohol, are one.  I think about them as one.  Whereas tobacco, cigarettes is really different.  It’s more like food in the way that it doesn’t intoxicate, you don’t have an accident, you don’t stop your work, you just get sick and die from smoking.  But it’s not the same as the drugs which are disruptive of behavior as well as health.  So I take those drugs together, and to me they’re all one problem.  So to get well from a heroin problem or a cocaine problem, you have to stop using all the drugs and alcohol.  That’s what I think about as recovery.  That’s a debatable point within the field, and there’s a lot of discussion about that.

I am very clear though, that getting well and a question about what is evidence, is evidence has to do with no use of any of those drugs, alcohol, marijuana, cocaine, methamphetamine, heroin, and prescription drugs of abuse as well.  No use of any of those for long periods of time, really for a lifetime, that’s what recovery is about.  Mostly that means going through the 12-step programs of AA and NA to sustain that.  To me that’s the goal, and we ought to assess treatment on the basis of the extent to which that’s the outcome.  We’re not there now.  Right now it’s a much more fuzzy, and I think, really an unsatisfactory definition which has to do with reducing the drug use compared to what they were doing before their treatment.

Let me make a statement of my own, well why not?  I think that the question is, how good could treatment be?  What is the benchmark, what is the goal, the standard that we’re trying to reach?  To me, that’s lifetime recovery.  That means no use of drugs including alcohol and other drugs, and that means changing one’s lifestyle.  The key problem of addiction is, first of all, continued use despite problems and relapse of use when you stop, that’s one, and the other is dishonesty.  You can’t be an honest addict, you have to be a liar to be an addict.  Well, why do you have to be a liar?  That’s not the chemistry.  It’s because people around the addict want the person to stop.  The family wants them to stop, the employer wants them to stop, the judge wants them to stop, the doctor wants them to stop, but the person doesn’t want to.  The only way they can keep going with the drugs is to lie to those people, and that’s why you get that.  In recovery, the most striking this is the person is not using and they become honest.  It’s a very interesting thing to talk to somebody who’s in recovery about their drug use, because it’s such a different story than they had about it when they were using, when they were rationalizing.  To me the recovery is the answer, and the model for that is programs that have been built for doctors, physicians, for airline pilots, commercial pilots, and attorneys.  All of those programs include active monitoring with drug testing for long periods of time.  They all have no tolerance for any drug or alcohol use during that period of time, they put that person’s ability to fly an airplane, be a doctor, be a lawyer on the line for continued use.  So there’s severe consequences for any use, and those programs set the standard for recovery.

What I say about treatment, is treatment is part of this process.  But the really exciting future is the managing the environment over many years in which the decision is made to use or not to use.  That’s what I call the new paradigm, and that works very well in the criminal justice system, that works well in all kinds of situations.  The goal in the future, my goal is to get insurers, to get families, to get employers, to get the criminal justice system to understand that the future of recovery is in managing the environment in which the person makes the decision to use or not to use.  That has to be done in a way that says, “No use at all is acceptable.”  Its intolerant of continued use, with immediate, serious consequences for any use, and for 95% or more it means going to meetings of AA and NA for many years or even a lifetime.  That’s the package that makes a difference, that’s what changes people’s lives, that’s what gives them stability, that’s what builds a character that is anti-addiction and really a miracle to observe.  That’s to what I have dedicated my career, is the achievement of that goal.