To much of official Washington, the portrait of substance abuse in the United States is grim:
More than 22 million Americans abuse drugs or alcohol.
Just 10 percent of them get treated - and an alarming number relapse.
At treatment centers designed to help them, half the counselors quit each year. Worse, the newest research-based therapies often do not reach clinics at all.
In the dysfunction, A. Thomas McLellan sees opportunity.
"We've got to put scientific information into policies that make sense and will deliver for Americans," said McLellan, who left Philadelphia six months ago to become the nation's No. 2 drug-policy official.
Science, he says, can make treatment inviting, catch abuse before it turns into addiction, save communities millions of dollars - in short, remake a system that has been shaped by the politics of avoidance. There is even a "science of recovery," and he said he believed that talking about it would help move the national conversation about recovery from one of shame to one of triumph.
Passionate about bringing science to Washington, yes. Enjoying doing it, no.
Seated on a couch in his sparsely furnished office a few blocks from the White House, the lanky and mustachioed psychologist was characteristically blunt.
"I guess I could be called a ready, fire, aim kind of guy," said McLellan, 61. "Government is ready, aim . . . aim . . . aim . . . you get the drift?"
Two years ago, happily rehabbing his boat and content directing a leading research center on Independence Mall, McLellan had no interest in Washington. Then his 30-year-old son died of a combination of antianxiety medication and alcohol poisoning; his older son was in treatment at the Betty Ford Center at the time.
When Joe Biden called and personally asked him to join the new administration, McLellan said, he saw the personal tragedy as "maybe a sign" that he should go where he could have the greatest impact. His job, as deputy director of the White House Office of National Drug Control Policy, is to reduce demand for illegal drugs.
A big test of his influence is due in the coming days, when President Obama releases his National Drug Control Strategy. The document, written by McLellan and his boss, drug czar Gil Kerlikowske, will guide the actions of 11 federal agencies that deal with drugs, from education to homeland security.
The moment is ripe for change. The last two decades have brought effective new therapies and several proven medications; vaccines are on the horizon. In recent years, the medical view of addiction has undergone sweeping changes: Genetics is now known to play a role, and research suggests that brief interventions over the long term can trump intensive hospitalization.
Unlike other scientists in his field, McLellan does not study any one treatment. He compares them all.
"Tom has spent his whole life preparing for this job," said Charles P. O'Brien, a mentor and director of the Center for Studies of Addiction at the University of Pennsylvania School of Medicine.
To hear McLellan tell it, that preparation has been a series of coincidences and lucky breaks.
Raised in Mechanicsburg, Pa., and armed with a Bryn Mawr College doctorate in experimental psychology - his 1976 thesis examined negative conditioning in rats, cockroaches, pigeons, and crayfish - he had to choose between an $8,000 faculty position at Yale and a $14,000 technician's job evaluating substance-abuse treatments at the Coatesville VA hospital.
McLellan "didn't know beans about addiction," but needed the money.
That work led to his Addiction Severity Index, a series of measures - medical status, employment, drug, alcohol, legal, family, and psychiatric - that are now known to be related to treatment outcomes. The ASI is the standard hour-long interview used to plan treatment and judge progress around the world.
He was soon hired by O'Brien, who was building a top treatment center at the Philadelphia VA while heading up addiction research and doing animal studies at Penn.
In 2007, McLellan sat down with Nancy D. Campbell, author of Discovering Addiction: The Science and Politics of Substance Abuse Research, and recounted how his vision evolved for an oral-history project.
Working at the Penn lab for more than a decade was like being "in hog heaven," he told Campbell.
"And then my eldest son gets addicted," he said.
"He was 16, and he was addicted to cocaine, alcohol, marijuana. OK, Mr. Expert, where are you going to treat your own son? What kind of treatment are you going to ask for? Wow, was I punched in the stomach by that," he said.
"Neither me nor any of my very smart, very concerned science buddies knew what to do for my son."
He cofounded the Treatment Research Institute in 1992 with the goal of getting scientific findings from the laboratory out to treatment centers, into policy, and accessible to parents. Meanwhile, his son went through nine months of intensive treatment and six months of follow-up. He got clean, relapsed, got clean again. He was at Betty Ford when his younger brother died and is now doing well.
"I began thinking about how illnesses like diabetes, and hypertension, and asthma were treated," McLellan said. "It turns out that they don't have diabetes programs where you go for 28 days and then stop treatment. I think that would be called malpractice. . . . So those treatments try to retain patients in care, use medications, and education, and family training to reduce symptoms, but also to change behavior to deal with the fact that these illnesses will not be cured - only managed."
McLellan's argument for addiction as a chronic illness, made in a 2000 article in the Journal of the American Medical Association, is increasingly accepted as the mainstream scientific view.
But researchers say it has not resulted in much change at treatment programs nationwide, many of them mom-and-pop operations with few financial incentives to improve.
Delaware is an exception. Like most states, Delaware paid independent centers a flat fee to provide outpatient substance-abuse treatment. Numbers mattered; results did not.
But beginning in 2002, payments have been based entirely on how well the program performs. If patients do not show up for all the therapy sessions, the clinic gets less; if they complete the program, the clinic gets more. New, evidence-based therapies are encouraged but not required. As it turns out, they don't need to be.
"It forced us to look at outside industries for ideas of what would make it work," said Lynn Fahey, executive director of Wilmington-based Brandywine Counseling, who was in charge of a site at the time.
To improve outcomes, they took up evidence-based practices that they previously had ignored. To make the center more inviting, "we got vending machines, and added a phone out in our front lobby that clients could use to call for a ride," Fahey said.
After five years, the number of patients who completed treatment rose from 53 percent to 70 percent statewide. Costs are believed to be unchanged.
When Jack Kemp, who led the pay-for-performance experiment as the state director of substance-abuse services, retired in 2008, McLellan hired him part time to try to get other states to follow Delaware's lead.
The sum of McLellan's worldview - convince the public that substance abuse is a medical issue, not a moral failing; that treatment must be ongoing, not crisis-driven; that the system needs to be restructured to attract customers, not just serve them - is known as a public health perspective.
"If I come up with a better drug to try to treat cocaine, that could be very useful for the individual cocaine addict," explained Herbert Kleber, director of the New York State Psychiatric Institute Division on Substance Abuse.
"But a public health perspective says: Where are these cocaine addicts and how can we get [the treatment to them] when they get right out of prison?" said Kleber, McLellan's predecessor under President George H.W. Bush.
Since his Senate confirmation in August, McLellan has been meeting with dozens of agency heads, professional organizations, and medical groups that traditionally have not seen addiction as their responsibility. Working together, he says, could ultimately save millions of dollars now spent on emergency-room care, building new prisons, and fighting crime.
He is pushing primary-care providers to see substance-abuse screening as part of their role as gateways to the health-care system. When asking patients what medications they are taking, for example, doctors and nurses should include alcohol. Patients who have more than three drinks a day or 14 a week should be counseled to cut back, he said.
McLellan's mainstreaming of the word recovery - not a term typically associated with the drug czar's office - is intended to send a message.
"The public knows that people abusing drugs and alcohol do stupid things. What they don't know is that people in recovery go on to do amazing things," said researcher Deni Carise, a former cocaine addict who says she has been in recovery for 141/2 years.
Carise and McLellan married in 2000 and have a home in the Bella Vista section of Philadelphia. Three months ago, she was named chief clinical officer for Phoenix House's 150 treatment centers around the country.
In McLellan's view, addiction and recovery are two stages of the same lifelong disease. Why focus on the former when you can celebrate the latter?
Contact staff writer Don Sapatkin at 215-854-2617 or firstname.lastname@example.org.