Conversation with Robert L. DuPont
In this occasional series we record the views and personal experience of people who have especially contributed to the evolution of ideas in the Journal's field of interest. Robert DuPont is an American drug expert. He has played a crucial role in developing community-wide and evidence-based responses to drug problems. Throughout a highly productive professional life he has shown an ability to make things happen.
Addiction (A): Let us go back a considerable way. What shaped your decision to choose a career in medicine specializing in psychiatry?
Robert L. DuPont (RLD): When I finished the eighth grade in 1950 my family moved from a farm in Ohio to Denver, Colorado. The first thing I did was ride my bike to the neighborhood public library where, on a shelf right inside the front door, I found 20 tempting books. One was a big black book titled The Human Mind. It was a 1948 third edition of the 1930 best-seller by psychiatrist Karl Menninger . I knew from the first day I opened it that I was going to be a psychiatrist. I could not imagine anything more fascinating than ‘the human mind’. The stories Dr Menninger told of patients with mental illnesses deeply resonated with me. I had found my calling.
A: You stuck with that idea all your life?
RLD: Never wavered and never regretted the decision. It was similar to my decision to marry my wife, Helen. I knew the first time I met her that she was the one. It took me a while to convince her, of course, but I knew immediately. I cannot explain it and I do not recommend this approach to making major decisions. There are few other examples of such stability in my life, but those two decisions were instantaneous.
A: How did you think of a career in psychiatry in those days?
RLD: Although I had never met a doctor in my life before I went to college, other than my own pediatricians, even then I thought about medicine as a good way to help people. I was fascinated by people's stories. I was interested in literature for the same reason. That is how I thought about psychiatry then and it is how I think about psychiatry now. Every single patient is unique and wonderful. Unlike reading a novel, however, as a psychiatrist I can hope to be helpful, not to everybody I work with professionally, but at least to some of the people with whom I have professional contact. For that opportunity I am deeply grateful.
A: Your family of origin?
RLD: My father was a salesman, always looking for the product that would sell itself. Early in his adult life he sold tobacco. Later he sold beer. My mother was a social worker who became a 7th grade math teacher. My parents left no doubt that having a profession improved your odds of being able to buy a house, send your kids to college and pay your bills. Because our family did not have much money the financial security of a profession was almost as attractive as the opportunity it gave for public service.
A: You took time off in medical school.
RLD: After graduating from Emory in Atlanta I went to medical school at Harvard. I had worked hard to be on the path to become a doctor, but once I was on it I was claustrophobic, thinking that this tightly circumscribed path would be too constraining for me. I went to the Dean of Students saying, ‘I have to take a year off to see the world.’ The way things were at that time the Dean would say ‘yes’ to just about any harebrained idea that any student had. It was not that I was a particularly wonderful student or that he had great confidence in my vision. He let me know that I could come back to Harvard Medical School whenever I was ready. I put together the adventure of a life-time. I bought a Land Rover in Coventry, England and headed south overland for a year in Africa. I was imprisoned, and nearly executed, as a CIA spy in Guinea. When Patrice Lumumba was killed, I was almost murdered by a mob in Nigeria where I went to a rally of Africans who had congregated to protest his death. The trip was not at all scary. Mostly it was a happy adventure of exploration of that fabulous continent and the wonderful people who live there. That trip left me with a life-long passionate interest in Africa and Africans.
‘The trip was not at all scary. Mostly it was a happy adventure of exploration of that fabulous continent and the wonderful people who live there.’
A: The field was lucky to have you get back to the States in one piece. I know that you later did some work with Martin Luther King Jr. What was that all about?
RLD: My wife, Helen, and I worked very briefly with Martin Luther King Jr after I came back from Africa. Over the Christmas break from medical school in 1962 I got to know him, his father, his family and his church. My Atlanta family came with Helen and me to the Ebenezer Baptist Church for the last Sunday service of the year. I was involved with his organization, the Southern Christian Leadership Council, SCLC, in a strike at the Atlanta Scripto pencil plant. I was one of the speakers addressing the striking laborers on behalf of Martin Luther King Jr that day. At that same time I met Julian Bond, Stokeley Carmichael and Andy Young. I had tremendous respect for Dr King. When he was murdered I felt that a part of me died.
‘I had tremendous respect for Dr King. When he was murdered I felt that a part of me died.’
A: Much of what was going on in your life sounds like you were tending towards a career in the public service from the start. When did you make that commitment?
RLD: After I graduated from the Harvard Medical School I did a medical internship at the Cleveland Metropolitan General Hospital. Then I went back to Harvard to begin a psychiatric residency. I came to NIH to finish that residency. I came to Washington because of the Vietnam War. I would have stayed at Harvard for the rest of my career—which I concluded in later years would have been a bad decision. I came to Washington in 1966, thinking that I would be here for just 2 years before returning to Harvard. People laugh about my decision now, but when I was in college I thought that only dummies went to business school. Smart people went to work for the government. When I finished at NIH, at age 32, it was time for me to get my first full-time job outside of my medical training. That job put me on a life-long career path. I know this sounds crazy or arrogant or both, but I wanted my career to make a difference.
‘I know this sounds crazy or arrogant or both, but I wanted my career to make a difference.’
MOVING INTO THE CORRECTIONS FIELD
A: And that choice was . . . ?
RLD: I chose corrections. I was confident that in corrections I could make a difference in the prisoners’ lives. Here you had a Harvard-trained NIH veteran who wanted to dedicate himself to corrections. That was unusual because corrections was the lowest of the low in the status pecking order then, as it is now. I stayed in Washington. The decision was simple. First, my growing little family was here. The biggest factor influencing my decision, however, was that crime had become a major political issue in Washington. I had been in my new job for 2 months when Ken Hardy, the head of corrections, called me into his office to say that he had a problem: ‘I have to have a deputy who can move this department to the forefront of corrections nationally’. I helped recruit Bob Montilla from the California corrections system. Then there was the 1968 presidential election. Richard Nixon won. Montilla said to me on the telephone from California: ‘I’m not going to work for that SOB’. Suddenly nothing was going to work because of that election. I was a Democrat. Everyone I knew in corrections and mental health was a Democrat. The election of Nixon that November was like death. Everything I wanted was over, or so I thought.
A: How did you find a way through?
RLD: On 20 January 1969, a bunch of new Republicans that I had never heard of came to town to take over. Edward Bennett Williams, the top lawyer in Washington, and Katherine Graham, publisher of the Washington Post, went to Richard Nixon with some of their impressive friends during his first month in office saying, in effect: ‘You campaigned on this city being the “crime capitol of the nation”. Now that it is your city you better do something to fix it.’ Williams told me later that he told the President: ‘We are going to hold a press conference in DC every month to put your feet to the fire if you don’t do something about crime in Washington.’ Nixon and his staff had to come up with good new ideas fast. One of the places they looked was corrections. That was my cue. I said, ‘Do I have an idea for you! Let's create a task force to come up with new ideas in corrections, the best new ideas in the country. I have the man you need to become the chairman of the task force. His name is Robert Montilla. He's in California.’ Nixon was a Californian; he liked that fact about Bob. When I got a green light on this proposal I called Bob Montilla to tell him that we had a new and far better deal than we had dared to dream of in the fall. I explained that everything he and I wanted to do to improve corrections in the nation's capital we could do now. Nixon and his crew were far less interested in the politics of the people involved (including me) than they were in finding ideas and people who could begin to solve the big problem that they had won with the election, serious crime in the capital.
A: I want to lead you back to one aspect of that extraordinary story. I know that as a part of the initiative that you got off the ground there was this huge effort in community corrections and that was a landmark activity.
RLD: Virtually all our new initiatives were in community corrections. Ken Hardy made me the head of community corrections for the city meaning that within less than one year of my joining the department I was head of all of the city's parole and correctional halfway house services. When I joined the District of Columbia Department of Corrections (DCDC) there were no corrections halfway houses. We put in place 10 halfway houses within a year. We had the Youth Crime Control Project, which was an alternative to incarceration for major felons between the ages of 18 and 25. Instead of going to prison these young men went to a model community corrections facility on a random assignment basis. This was the biggest and most innovative project anyone could do in corrections at that time.
A: This really was an early effort in the name of diversion.
CRIME AND THE INTERSECTION WITH HEROIN
A: Then there was the heroin use crisis that was identified in Washington thanks to your study.
RLD: The overriding question in corrections in the District of Columbia in 1969 was, ‘Why is there a crime wave?’ When you looked at the city's crime rate over time it had been relatively stable until the mid-1960s. Then it took off like a rocket going into space. Why was that? The simple way people thought about crime was that it had to do with poverty. There was a problem with that explanation. Over those years that crime shot up the city had seen a rapid increase in employment, including black employment; along with phenomenal increases in the education level in the black community. In the late 1960s the city had big reductions in racial segregation. The national and the local economies were booming. Every social indicator that could reduce crime was in place in the District of Columbia during the final years of the 1960s. Despite these favorable social developments the city had a raging crime rate. The view that poverty was the root cause of crime looked ridiculous in explaining this change. There had to be another hypothesis. That was the context of my work in the summer of 1969. I put together a group of college students to take urine samples from everybody coming into the DC jail for August of 1969. It was an unusual group of research scientists: half a dozen motivated, but unemployed, college students.
A: So why had crime so greatly escalated?
RLD: Our study showed that 44% of the men coming into the jail tested positive for heroin. Even more importantly, a one-page questionnaire that the new jail inmates filled out asked them, ‘What year did you first use heroin?’ We could literally correlate the rising rates of the initiation of heroin use to the rising rate of crime. Heroin use started up in the late 1960s. It gathered strength over time, so that each year it was greater and greater through 1969. Looking at that graph, anyone could see the engine driving the rising crime rate. That study, published in the New England Journal of Medicine, defined the modern heroin epidemic and its relationship to crime. The study was not sophisticated but it was on target. That took us to the next big question, ‘What should we do about the city's heroin problem?’ At that point my interest in corrections led me to drugs. The two people I identified as the best in the country were Jerry Jaffe in Chicago and Vincent Dole in New York City. These two men were the geniuses of that era, the great teachers of all the rest of the people who stepped forward to lead in the development of what was becoming the then new field of drug abuse treatment.
DEVELOPING A COMMUNITY-WIDE RESPONSE TO WASHINGTON's HEROIN PROBLEM
A: What model of response did you develop?
RLD: My signature identity in this public health adventure was to be concerned about the heroin problem on a community-wide scale. Everybody else was interested in a few patients or small drug treatment program. I was interested in the health of the nation's capitol and in the end, in the health of the whole nation. For me the relevant question was not how best to get one person well, it was: ‘What can the government do in a short period of time that is going to reduce heroin addiction in the whole community?’ Only answers that were on a scale that could meet that challenge were useful. Once that filter was applied to the search for the next right thing to do, there was only one answer: methadone. There was a large and growing body of evidence about the value of methadone that was put together by Francis Gearing in an independent study of Vincent Dole's initial methadone treatment program at Beth Israel Hospital in New York City [3,4]. Vincent Dole, a physician who had been a brilliant metabolic researcher, was one of the greatest people I have ever met. He, and his equally brilliant psychiatrist wife Marie Nyswander, were visionaries.
A: How did you start off?
RLD: When we started our methadone treatment program in the Department of Corrections with offenders released to the community I looked around for a doctor to lead our efforts. The only operating methadone program near Washington was the Man Alive program in Baltimore. I hired their talented young doctor, Richard Katon, as our Medical Director. We started 1 September 1969. Think about this timeline: we conducted the jail drug testing research in August. By 1 September we had started our methadone treatment program. That program was the model for the Narcotics Treatment Administration (NTA), which started February 18, 1970, not in the department of corrections, but in the new Human Resources Department alongside the city's public health and welfare departments. By July, 1970 we had 2200 DC heroin addicts in treatment, most of whom were taking methadone as out-patients.
‘By 1 September we had started our methadone treatment program . . . By July, 1970 we had 2200 DC heroin addicts in treatment, most of whom were taking methadone as out-patients.’
A: If I am correct, the program actually went from 20 clients prior to there being an NTA to the 2000 figure in less than 6 months.
RLD: That is right. Twenty was the number of patients who started in the pilot methadone program. NTA had what we called a ‘reportable patient’. At NTA a patient had to be seen at least twice a week for at least 2 weeks before we took credit for having treated that patient. There was another city-wide drug abuse treatment program in Washington that was in the health department. The Senate District of Columbia Committee held hearings on our department of corrections drug abuse treatment program (NTA) and on the programs then run by the city's health department. Subsequently, the Senate District of Columbia Committee sent investigators to look at the health department's drug abuse treatment records. What they found, and what was duly reported publicly, was that the health department drug abuse treatment program had 300 empty file folders. That hearing ended the health department's role in drug treatment in the District of Columbia.
A: What I find extraordinary is the extent to which the NTA, in spite of being essentially a local program, was a concern of both the Congress and the Administration by virtue of its being in Washington and dealing with a politically very hot topic. It sounds as if the treatment program was of interest to a number of prominent political figures.
RLD: Everything we did at NTA, from day 1, was big news. The most impressive visitor NTA had was Jimmy Carter. NTA also was intensely supported by the two newspapers in the city at that time, the Evening Star and the Washington Post.
A: You developed a public health model in which you were literally trying to serve every addict in the community, a goal you came astoundingly close to achieving in just 3 years.
RLD: We treated 15 000 heroin addicts in our first 3 years. There were probably another 4000 or 5000 heroin addicts beyond that who were not treated by NTA then. To give you an idea of the impact of the heroin epidemic, 20% of all of the males born in the District of Columbia in 1952 were treated by NTA for heroin addiction in that period of time. That birth cohort was the peak of the epidemic. NTA changed the dynamics of heroin use in the city. The monthly crime rate in the District of Columbia was cut in half in that 3-year period.
A: In that regard, you also developed a very important relationship with the DC police.
RLD: Exactly. And not just with the police. We had close relationships with the Chief Judge of the, then, new Superior Court, Harold Green, the US Attorney, and the people heading the US Justice Department, John Mitchell, the Attorney General and especially Donald Santarelli, the head of the Law Enforcement Assistance Administration (LEAA). Jerry Wilson was DC's Chief of Police. He made a brilliant contribution in introducing what we now call community policing to the District. On 1 April 1970 Harold Green, along with NTA, started the pre-trial drug-testing program at the DC Superior Court that has continued since that time. It is the premier criminal justice system (CJS) drug testing program in the country. All the crime prevention steps in law enforcement, plus the NTA treatment, worked together to bring down the crime rate, and the rate of heroin use in the city. When we started NTA, growing as it did out of the pilot program in the DC Department of Corrections, about one-third of our patients were referred from the criminal justice system. After 3 years it was two-thirds.
A: How quickly could you take an addict into treatment?
RLD: One of the policies we set then, with some awareness of the problems it created, was accepting everyone who sought treatment each day whether we had room for them or not. At that time NTA would rather treat two people half as well than one person the best way possible. We did not want to leave anybody on a waiting list. We did not want to leave anybody out there using heroin that was ready to come into treatment. If that meant that we had to dilute the treatment program, if that meant we would have to put people in slots that did not exist, if that meant we had to keep the NTA staff working overtime, that was okay. At NTA we had one overriding public health mission—to end the city's heroin addiction epidemic. Today, drug abuse treatment programs say, ‘Well, sorry we’re full’. At NTA we were never ‘full’. We always had room for another heroin addict to come in off the street.
A: How did you secure backing for the NTA methadone programme?
RLD: The first thing I did when we started administering methadone at NTA was to go to the scientific establishment for its blessing. At NTA we were trying to establish the legitimacy of using methadone for the treatment of heroin addiction. I felt that if the National Academy of Sciences and the Institute of Medicine would officially say that this was a good treatment for heroin addiction—not the treatment, just a good treatment for heroin addiction—that would be very helpful. In 1970 the established powers in science and medicine had no interest in endorsing methadone. I find it ironic that today methadone is regarded as the preferred treatment for heroin addiction. In that initial encounter with the scientific establishment, I learned a lesson about the ability of scientists to lead in complex and controversial areas. At that time I found this experience to be profoundly disillusioning.
A: My recollection of these events is that you may well have organized the first program involving diversion from the criminal justice system, which was, in many respects, a forerunner of TASC, then called Treatment Alternatives to Street Crime.
RLD: Jerry Jaffe, the first White House Drug Czar, created TASC based, in part, on what we were doing in Washington. I was never comfortable with the image that TASC had for a time as a way of keeping addicted people out of prison. I do not like that aspect of ‘diversion’. If somebody has committed a crime—including selling drugs—they need to experience the appropriate consequences for that crime. Many people who are interested in ‘diversion’ make the assumption that the prison sentence is itself the enemy. I never felt that the prison sentence was the enemy of the addicted person. I wanted to use the leverage of that prison sentence for pro-social purposes. Everybody wins when ‘diversion’ is approached that way.
I am impressed by drug courts because they take the leverage of the prison sentence seriously. If you do not make it in the drug court you go to prison. Taking prison sentences seriously is important for drug users if they are to get well. It is in the community's interest, in the addict's interest, and in the addicts’ families’ interests to do that. ‘Diversion’ makes sense when it is diversion from drug abuse, not when it is diversion from serving time for crimes committed including drug-related crimes.
A: Thinking back again to the NTA experience, what were the problems involved with acquiring the large number of treatment staff needed to mount the operation in a very short period of time.
RLD: We grew to 20 treatment centers with a staff of 500 within 6 months of starting. Our prominence was a negative factor in terms of the way the rest of city bureaucracy treated NTA. At NTA we did not stay in line and wait our turn. Everyone down the line in the city government was determined to make us pay for that. The amazing thing to me is how we did as well as we did with these difficult support systems.
Drug treatment in DC was big news then. DC drug treatment has been almost no news ever since locally, let alone nationally. From 1971 to 1973 NTA had a staff member, Jim Fair, whose only job—every work-day—was to take around visitors—20, 50 visitors a day. Jim was himself an ex-addict. He took busloads of officials from cities all over the country, and hundreds from overseas, congressmen and newspaper reporters, to visit NTA centers and to talk with our patients. NTA was in the newspapers, on the radio and on TV all the time. Once drug treatment in DC lost its visibility at the end of 1973 there were no more complaints about methadone. The methadone controversy melted away with the publicity about the NTA program.
In 1973 I thought that once I was gone from NTA the city would do away with methadone. I am happy to say that nothing could be further from the truth. Methadone is still a major part of drug treatment in DC but methadone, like all other aspects of drug treatment in the city, has gone under the media radar.
A: NTA not only was significant to the field of drug abuse treatment, but it appears to have provided enormous personal satisfaction for you as well.
RLD: If I had my work life to live over again, and if could do anything I wanted, I would have stayed with NTA. Our group could have done more for the country as well as for the city. We could have worked on the drug problems so much better with the city as our laboratory. We could have figured out so much more about the dynamics of addiction in the modern world. We could have kept our epidemiological work going for decades of productive study. We had a great natural laboratory to deal with all of the city's drug problems. Regrettably, that is an idle fantasy. NTA was unsustainable for two reasons. First, the racial politics of that time made it unsustainable.
Even more, however, NTA was unsustainable for personal reasons. I could not get along with some of the leaders of the government agencies that we needed to rely on. The only way I could understand it was the jealousy of other bureaucrats responding to the prominence of NTA.
LEAVING NTA AND THE MOVE TO THE WHITE HOUSE
A: How long did you stay at NTA?
RLD: I lasted 5 years at the top in the DC government. That is about as long as any highly visible senior bureaucrat makes it in those shark-infested waters. That is not only true for DC government. The same is true in the Federal government. I went to work in the White House after leaving NTA. I learned that the average tenure of Presidential appointees (of whom there are about 300) is 14 months! Humility helps in these publicly visible jobs. If you do not have humility when you start your high-level job you are sure to have it when you leave. Almost everyone leaves these jobs with their heads on platters.
‘I lasted 5 years at the top in the DC government. That is about as long as any highly visible senior bureaucrat makes it in those shark-infested waters.’
A: Speaking of the White House, in those early days you were the face of drug abuse treatment to the White House.
RLD: When President Nixon's top assistant on drug policy, Egil ‘Bud’ Krogh, asked me for suggestions for the first White House Drug Czar in the early months of 1971 I took his representative, Jeff Donfeld, to see my two top mentors, Jerry Jaffe and Vincent Dole. Donfeld saw a distinguished White House future for Jerry Jaffe when he met him in Chicago. Jerry was named White House chief on 17 June 1971. He was the right choice for the country. If I had been made the Drug Czar then (and no one gave me any indication that that was an option) it would have been bad for me and for NTA. I needed those next 2 years at NTA. Jerry was the man for that White House job at that time. I am grateful to Jerry for taking the job. I am deeply respectful of the outstanding job he did as the world's first Drug Czar. At the time the White House drug office was called the Special Action Office for Drug Abuse Prevention (SAODAP).
A: You did go from NTA to become the second Director of SAODAP in 1973. What was that like?
RLD: I was in for a variety of rude awakenings. Within a week of my arrival I had my first congressional hearing representing the federal government. I had more than 50 Congressional hearings under my belt in the previous 3 years. Now I was to represent the whole country, not just Washington DC. Because of my past experience on Capitol Hill I was familiar with Congressional testimony. I not only did not have fear of the process, I thought about hearings as positive experiences.
A: What kind of national database on addiction treatment was at that time available?
RLD: This time I had to present the first findings of a national survey of the nation's drug abuse treatment programs. The highly paid, high status SAODAP staff brought me a mountain of computer printouts. I looked at them carefully. Because I had spent a great deal of time with treatment programs all over the country I had some knowledge of what was out there. Within less than an hour of looking over those data I saw that these papers bore no relationship to reality. For example, the population of addicts reported to be in methadone treatment was not even close to what I knew the facts to be. I thought, ‘I have to appear at this hearing in two days. I have to say something. I cannot report what is on this paper since it is wrong.’ What was I going to do? I could not ask the people on my SAODAP staff to fix these numbers because those people had no connection to clinical reality. I started calling around the country to the people I knew, asking them for their estimates for various categories of treatment.
A: And you used those numbers in your testimony?
RLD: My staff at SAODAP was amazed. I was disillusioned about the data available to me in my new job. This proved to be an enduring problem. SAODAP was not like NTA. I had some people, such as Nick Kozel, Lee Dogoloff and Mark Greene who came with me from NTA to help out, but not enough. One of my new colleagues at SAODAP, Dick Bucher, later came with me to NIDA and eventually to Bensinger, DuPont and Associates. Dick has been one of my closest and longest-lasting colleagues and a great friend.
A: SAODAP had at that time only a short-term fixture.
RLD: My principal job, as the Director of SAODAP, was to take the staff from 174 to 0 in 2 years. That was not the best job in government. The SAODAP law contained a ‘sunset’ provision. SAODAP had been set up as a 4-year office. By 1974 everybody understood that Congress and the Administration were not going to renew it. There was no political backing to carry the office on any further, once the President had decided it was going to go out of business.
TAKING ON THE NIDA DIRECTORSHIP
As SAODAP dwindled the excitement shifted to the National Institute on Drug Abuse (NIDA). I became NIDA's first Director. For a time, I held both Directorships and simultaneously was the acting Administrator of the Alcohol, Mental Health and Substance Abuse Administration (ADAMHA) as well. That was quite a time—I had three large staffs and three big government offices at the same time. Talk about ‘conflicts of interest’, here I was the White House drug chief, the head of NIDA and the boss of not only NIDA but also the National Institute of Mental Health (NIMH) and the National Institute for Alcoholism and Alcohol Abuse (NIAAA). Following the formal closing of SAODAP 30 June 1975, a drug policy presence remained in the White House, with me in charge, under the aegis of the Cabinet Committee on Drug Abuse Prevention, Treatment, and Rehabilitation. From 17 June 1971 when SAODAP was founded until today there has been a continuous presence in the White House of a drug chief. Drug abuse is the only issue in the history of the country that has had a White House office devoted to it over a long period of time.
A: When did NIDA start?
RLD: Some people think that NIDA started in 1974. In 2004 there was a celebration of the 30-year anniversary of its founding. NIDA actually began in September 1973. I have letters from the official historian of Department of Health and Human Services (HHS) and newspaper clippings to prove it. Nothing happened to create NIDA in 1974. There was no event in 1974 that anyone could mistake for an opening. There is apparently an attorney at NIDA who points out that the law, 92–255, that established both SAODAP and NIDA said that NIDA had to be created before 1 December 1974. It was created before that date. NIDA was created in September 1973.
A: Have NIDA's responsibilities changed over the years?
RLD: The NIDA of today is quite different from the NIDA of 1973, For its first decade and a half NIDA had not only research but it was the federal government's principal organization funding both treatment and prevention, functions now handled by the Center for Substance Abuse Treatment (CSAT) and the Center for Substance Abuse Prevention (CSAP), but in the Substance Abuse and Mental Health Services Administration (SAMHSA). NIDA in those years had a much higher media profile than the NIDA of today.
A: In the course of your time with SAODAP and NIDA, you have worked through several different Administrations.
RLD: Three Presidents. Nixon, Ford and Carter.
A: It was, however, Carter's Secretary of Health, Education and Welfare (HEW), Joe Califano, who got you to leave NIDA.
RLD: Running a big government agency is like having a short-term lease on a classy property. You rent it for a while, it feels like your home, but before long you are out on your ear. I had been through that painful, and in some ways humiliating, process at NTA. I went through it a second time at NIDA. I do not want to become personal with any of this, because in the end it never was personal. I have no animosity toward any of these people. I was happy during the 12-plus years I spent in the government, first at NIH in Bethesda, then with the DC Government and finally in the federal government at SAODAP, ADAMHA and NIDA. Those were good years for me. I have also enjoyed every one of my years outside the government since leaving NIDA. In 1966 I came to Washington for what I expected to be a 2-year stay. In the 42 years since I graduated from medical school I worked for the government just 12. They were all wonderful years.
‘Running a big government agency is like having a short-term lease on a classy property. You rent it for a while, it feels like your home, but before long you are out on your ear.’
A FUNDAMENTAL COMMITMENT TO THE PUBLIC HEALTH APPROACH
A: How, if at all, has your thinking about drug abuse changed over the years?
RLD: Ever since I entered the field I have been committed to a public health approach to drug abuse prevention. My frame of reference goes beyond a local program or even a local community to the whole nation, in fact to the whole world. Today's drug abuse problem is an epidemic that started in the mid-1960s. It is not like anything that ever happened before. This is the first time in world history that large segments of the world's population are using many different drugs by potent routes of administration. The modern drug abuse epidemic is as new as the computer. Today people all over the world are dealing with the epidemic of illegal drug use in the context of increasing individual freedom and individual choices, and decreasing traditional controls—legal, moral, religious—over those choices. That political evolution exposes vastly increased numbers of people to the hazards of drugs. In the United States, and around the world, we are looking for the best path to reduce the problems of drug abuse. It is not a simple problem. The solutions are not simple either.
A: Do you think there is sufficient awareness of the inherent dangerousness of drugs?
RLD: Most people today do not understand that, because of the unique biology of drugs, there is a disastrous downside to exposing large segments of the population to drugs used outside of medical treatment. Brain biology is at the root of the drug problem. Drugs produce feelings that drug users like. After using drugs for a while they come to like these feelings very much, commonly putting drug use ahead of jobs, family and friends. There are differences of opinion about how to respond to the facts of this inescapable biology in the context of the values of our time. I have concluded that the best way to deal with it is to restrict the access to the drugs and to reduce the social tolerance for the non-medical use of drugs. ‘Harm reduction’ is a misguided public policy because it starts by accepting illegal drug use and then seeks to normalize that drug use. That will result, down that road, in more suffering and more harm for more people. No policy will end non-medical drug use but various policies will either encourage or discourage drug use. Policies that reduce illegal drug use are the best public health policies. I have explored these issues in a number of publications and on the website of the non-profit organization, the Institute for Behavior and Health, Inc. (see http://www.ibhinc.org). These issues are front-and-center in my drug book, The Selfish Brain—Learning From Addiction, now available in a paperback edition from Hazelden .
A: Over the years have you changed your perspective on methadone?
RLD: When I entered the drug field I was enthusiastic about methadone. I am much less so today. To take casual drug use more seriously rather than less seriously has been one of the big changes in my thinking about drug policy. The biggest change in my thinking over 35 years in this field has been my growing recognition that the 12-Step programs are a modern miracle, the secret weapon in the war against drug abuse.
That brings me back to Vincent Dole, who started methadone treatment, and Chuck Dederich, who started Synanon, the original therapeutic community. They both said that recovery was for life. Staying well was not a short episode in an addict's life. What happened to NTAs ex-addicts showed me that getting well from addiction is a serious, difficult, life-long process. Although those men were all heroin addicts their drug problems were not limited to heroin. One of our most valued colleagues from NTA, an ex-heroin addict, died a horrible death from liver failure as a result of his alcohol drinking. There is just one program of recovery that is for life. One program that is compatible with addicted people surviving long-term. One program that is deeply spiritual. One program that deals successfully with the character defects at the heart of addiction. That is the program of Alcoholics Anonymous (AA), Narcotics Anonymous (NA) and Al Anon.
RECOVERY AS A LIFE-LONG PROCESS
A: The drug use client should be seen as being in a state of recovery for an extended period—if not forever—with treatment simply an early episode in that process.
RLD: Exactly. The big historical event in drug abuse treatment then happening was completely lost on me in the 1960s and 1970s. It was happening at Hazelden, in Center City Minnesota, where they married professional services with 12-Step programs in highly personalized treatment plans that extended throughout the patients’ lives. These new drug abuse treatment programs, sometimes called the Minnesota Model, were more or less limited initially to 28-day residential treatment. Today they include out-patient treatment and even long-term residential treatment. In these programs a portion of the treatment staff is in recovery—including many of the doctors who work in these programs. That fact has a profound effect on the culture of those programs. In good drug abuse treatment programs they validate the 12-Step ‘disease concept’ of addiction. They indoctrinate the patients, their families, everybody with whom the patient comes into contact, with the fact that recovery is a life-long process—and that the patient not only has a responsibility to do something about this disease but that the patient has the means to do something about it, by going to meetings and working the 12-Step program. Some day I hope more people will recognize that this should be the standard of care for all addicts.
A: How have the issues that are being addressed in the field of drug abuse changed over the course of the past 4 decades?
RLD: Underlying the problems with heroin and cocaine is the endlessly fascinating issue of marijuana. The Washingtonian magazine recently featured an article documenting the casual way Montgomery County teenagers smoke pot . Today's marijuana is far more potent than it was 30 years ago. One of the sad consequences of marijuana use is the loss of bright futures for those who play and lose the game of Russian roulette with this drug. The abuse of prescription drugs is becoming an enormous problem, especially the abuse of opiates such as OxyContin. Today pain doctors are convinced that there is a large number of people who are untreated, or who are being seriously under-treated, for pain. They believe that what these pain patients need are more opiates, in huge doses. Many of these pain specialists appear to be oblivious to the social consequences of their prescribing. What do these experts think is going to happen? A single day's dose is worth more than $100 on the street. That same dose is lethal to a non-patient.
A DIVERSE AND CONTINUING SENSE OF PERSONAL REWARD
A: Looking back, what do you see as the significant achievements, the achievements you are proudest of in your own career?
RLD: First, I do not take my own career too seriously. In everything I have done I was one of many. I am proud to have contributed, and to continue to contribute, to a small but important part of the history of my time.
‘I do not take my own career too seriously. In everything I have done I was one of many. I am proud to have contributed, and to continue to contribute, to a small but important part of the history of my time.’
In 1978, when I left the government, I founded the Institute for Behavior and Health, Inc. (IBH), a national non-profit organization. IBH has done good work in the dug abuse field over many years. My wife, Helen, has worked with me in this organization for decades. In 1982, Peter Bensinger and I founded Bensinger, DuPont and Associates (BDA). Peter served as the DEA Administrator at the time I headed NIDA. This organization has made contributions especially in work-places, and more recently in prescription drug abuse prevention. Peter has been a wonderful friend, a great leader in our field and a brilliant businessman. I treasure our relationship and our work together.
A: You have also been interested in anxiety disorders?
RLD: I am proud that when Joe Califano tossed me out of NIDA my insecurity led me to diversify into an entirely new field, the anxiety disorders. In 1980 I was the first President of the Anxiety Disorders Association of America (ADAA), the leading advocacy group for the anxiety disorders in the world. I founded ADAA with Jerilyn Ross who is one of the nation's premier mental health advocates and a truly magnificent friend. With my two daughters, Elizabeth DuPont Spencer MSW and Caroline DuPont MD, I have written two recent books on the anxiety disorders, The Anxiety Cure—an 8-Step Program for Getting Well and The Anxiety Cure for Kids—A Guide for Parents. My two daughters share my passion for the anxiety disorders.
A: And you continue in clinical practice?
RLD: I have had my own practice of psychiatry since 1969. Seeing my own patients over long periods of time is central to my professional identity.
From day 1 I have loved the drug issue, finding it to be deeply interesting and profoundly rewarding. The ever-changing field involves economics, politics, history, biology and even religion. Whatever you are interested in, drug abuse has it. Sooner or later most people working in this field leave it behind. I have stuck with it. For me that stability has been gratifying. The best part has been the people, not just experts, of course, but everyone involved, including addicted people and their families, the real ‘experts’ in our field.
A: Any regrets?
RLD: If I regret something after all this time, it is that I did not spend more time with the colleagues with whom I was fortunate enough to associate. I have cared deeply about the people I have known. I am respectful of politicians, a group that has been denigrated by many. Not only have I liked the politicians I have worked with, but also I have felt that they have been devoted to doing the right thing. I do not know how they do all that they do. There are thousands of issues that clamor for their attention and thousands of people who are trying to get them to pay attention to particular issues. It is hard for politicians, even at the local level, to spend 5 minutes with anyone on any specific issue because they have so many different problems to deal with.
A: Can you characterize for us the very core of your contribution to the drug field?
RLD: With respect to my own contributions, one contribution I made was in the area of drug abuse treatment. Good drug abuse treatment can make a difference not just for an individual, but for a whole community. I helped to establish the scientific base for modern drug abuse policy, including helping to establish the National Institute on Drug Abuse as the nation's premier drug abuse research resource and the systems that monitor drug abuse epidemiology, including the national surveys that help us assess the nature, extent and consequences of drug use in America.
A: Other contributions?
RLD: I played a role in the Parents’ Movement of the 1980s. This small group of dedicated people, mostly mothers, showed just how much a few people working hard in the public interest can accomplish. In addition I helped to bring drug testing into the work-place in the 1980s. That development has had a significant effect on our country as the slogan ‘drugs don’t work here’ has had practical meaning.
A: You see random drug testing as valuable?
RLD: Random student drug testing (RSDT) is the single best new idea to reduce the initiation of illegal drug use, the incidence of drug use. This idea, which I have promoted for two decades, is now spreading throughout the country thanks to two favorable US Supreme Court rulings. I was the expert witness in the first case, the 1995 Vernonia decision. The most recent Supreme Court decision on random student drug testing triggered President Bush's historic support for RSDT in his 2004 State of the Union address.
A: You are keen also on developing responses to drugged driving?
RLD: Few people in America know that illegal drug use has an impact on the highway that is on the scale of drunk driving. The reason they do not know that is because the police rarely test for drugs. IBH supports a drug testing strategy that encourages the police to use on-site testing of urine and oral fluids for drugs of abuse as they now conduct breath testing for alcohol. My current passion is to get those two ideas more widely adopted. Long ago I learned that it takes decades make changes in public policy. Thousands of people have to join together to make change happen. Good ideas are not only cheap, but by themselves they are worthless. The relevant question is: can you make something happen? You never can do that alone. The only way anyone can make an idea happen is by getting a lot of other people to take it on as their idea and to become excited about that idea.
‘Good ideas are not only cheap, but by themselves they are worthless. The relevant question is: can you make something happen?’