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Interview with A. Thomas McLellan

The following is the edited transcript of an interview by Bill Moyers with A. Thomas McLellan, Ph.D., on addiction and recovery. McLellan is a professor at the Center for Studies of Addiction at the University of Pennsylvania School of Medicine in Philadelphia. Portions of this interview appear in the CLOSE TO HOME television series.

Moyers: What is research telling us about how people recover? How they do unlearn harmful behaviors or severe addictions?

McLellan: I'd like to tell you that we have found definitive answers. We're only just beginning to understand it. But among the things we've learned is that for addicted people, alcoholism and drug dependence are often the least serious of their problems. So, while it's the case that as a treatment provider, you're focused on changing their alcohol and drug use, you may have to help them make other changes at the same time, or even before you can begin to deal with the addiction. Chronic pain and psychiatric illness are two prominent problems which addicts frequently present.

Moyers: You mean the main problem is not the addiction?

McLellan: I wouldn't say that. As a matter of fact, there've been a lot of mistakes made that way. There's a whole history of trying to treat alcohol and drug addiction as the results of an underlying cause. But there've been other mistakes made by saying that alcohol and drug use is responsible for all the other problems that are typically seen. The best evidence we have at this point is that the way to help change people and sustain that change -- which is the real important part here -- is to concurrently treat the problems that are presented, much as you would if there were any other medical disorders. If someone has both hypertension and diabetes, you don't say, "Well, we have to get one of these under control before we do anything about the other." You treat both simultaneously.

Moyers: So, I come to you with an addiction, let's say I'm an alcoholic, what do you look for?

McLellan:  The very first thing we would tell you, by the way, is, "Atta boy! Way to go! I'm glad you came. You did the right thing." That's a very important part of this. For years it had been this moralistic approach, almost scolding people when they came in the door. What they really need is encouragement. They also really need a thorough assessment. Show me an alcohol- or drug- dependent individual and I'll show you other problems. Not always the same ones. But, typically, a gamut of employment and medical and family and legal and psychiatric problems. And, just asking which problems are most pressing to the patient -- that alone is a good way to start a therapeutic relationship and something which has often been ignored by treatment providers in the past.

Moyers: So you want to know if I've lost my job, if I've had a series of jobs, or if I had depression, or if I've had some kind of chronic pain.

McLellan: Yes. That's exactly right.

Moyers: Other things than just simply the symptoms of my addiction?

McLellan: Yes. And you might ask, "Is that well beyond the scope of addiction treatment? Aren't we just there to get them to stop drinking?" In fact, that's a reasonable perspective. But think about it. If you focus only on someone's alcohol and drug use, you can force or temporarily cajole them into reducing that. But if they are unemployed, if they have serious psychiatric problems, if they have chronic pain, just to mention the most common ones, the effectiveness of your alcohol and drug reduction efforts can really be measured in hours. On the other hand, if you reduce that alcohol and drug use -- I'm not minimizing that, it's extremely important -- and concurrently deal with these other things, which are themselves likely to produce relapse, you can sustain change and get what society really wants out of alcohol and drug abuse treatment. Meaningful change in many dimensions.

Moyers: Less harmful behavior and less cost? 

McLellan: Yes.

Moyers: Given that, what are the ingredients of change?

McLellan: Here are a few. First, counseling. And, I say that based on research findings. We've done lots of research with different kinds of counseling, group and individual; different types of counselors, different kinds of backgrounds and so on. Not all counselors are effective. Not all baseball players hit like Rod Carew. But those who are effective are extremely effective in both the patient's eyes and in the data. What quality is most important in a counselor? The research finds that it's empathy -- counselors who are tough or confrontational lead more patients to drop out. Experimental studies will also tell you that without counseling, other ingredients don't work very well.

Moyers: What does counseling do?

McLellan: First, it structures the approach to change. A good counselor can evaluate all your problems and then lay out a program by which you can reasonably attain your goals. And that gives you optimism. If you can meet some of these early goals and see that the counselor can help you, that reinforces the relationship, gives you hope and makes it possible for you to aim for other longer-term goals. Also, a good counselor can give you early warning signs about problems which are likely to prevent you from reaching your long term goals. They can get you services, hook you into fellowship meetings, AA, NA, CA meetings, things like that.

Moyers: So counseling is the first ingredient. What about others?

McLellan: Another ingredient in successful treatment can be medications. And, this, amazingly, has been controversial in the past. It has been thought that you do not treat a drug problem with a drug. Well, I think that's nonsense, and experimental evidence is showing that it's nonsense.

Moyers: There's research behind this?

McLellan: Oh yes. Among the most effective medications to treat any addictive disorder is methadone for the treatment of opiate dependence. It is extremely inexpensive and produces substantial reductions in drug use and crime and long-term benefits to patients. It truly saves lives for opiate-dependent individuals. But very controversial: most people don't want their relatives on a maintenance medication. Most Americans don't want to take any medication, let alone an opiate. And, it's not for everyone. But for IV drug users injecting opiates and at significant risk of AIDS, significant risk of harming themselves and others out there, who can't or won't give up that opiate effect, it is a tremendous public health benefit. But, it's not the only one. Now, naltrexone is an opiate antagonist -- it works right on the same receptor as the opiates, but in the opposite way. It blocks the opiate receptor without producing an opiate effect and so it prevents heroin, methadone and other opiates from working. In a sense, it's an insurance policy. You take this narcotic antagonist, you can't feel any opiate.

Moyers: So, it does me no good then to take heroin? 

McLellan: Exactly. And, very interestingly, naltrexone has been shown to be effective recently in the treatment of alcohol dependence. It's not so popular with opiate addicts, perhaps because their opiate systems have become so attuned to opiate effects -- it seems to cause some dysphoria. But not commonly in alcoholics -- for them, it reduces craving and seems to prevent minor slips from becoming full-blown binges. And that's interesting because it works on the opiate system, which traditionally hadn't been thought of as a major site of alcohol's action. It's showing us a lot about the commonalities between addictions. Most importantly, it provides at least thirty percent more benefit in the treatment of alcohol dependence than treatments without it.

Moyers: So, you're saying that just as people with depression take Prozac, there could be some medications that help people who are addicted?

McLellan: Exactly. And, you know what? You probably shouldn't take Prozac without talking to a psychiatrist and getting some counseling and making some life changes. Similarly, I am not saying that you take methadone or you take naltrexone or you take acamprosate, another new medication for alcoholism, and don't make any life changes. No. You've got to do these things concurrently.

Moyers: Life changes are what you're really after in the treatment of addiction, are you not?

McLellan: Yes. In fact, I think that's the thing that's been missed in addiction treatment. Addiction treatment has a very bad name in the public eye. It is widely perceived to be ineffective. And, I think the reason it's perceived to be ineffective is the standards by which people evaluate it. I think the treatment community has been part of that. The treatment community has been saying a successful patient is one who never uses alcohol or drugs again for the rest of their lives. A cure. Well, the fact is we don't have a cure for opiate dependence, alcoholism, cocaine addiction. We don't. We don't have a cure for hypertension, diabetes, asthma, either. But, you don't hear the world talking about how ineffective those treatments are. If you look at relapse rates in those, which I always call "real" medical disorders, asthma, hypertension, diabetes, you're going to see the same rates of relapse as you see in alcohol, cocaine, and opiate addiction.

Moyers: You mean, some diabetics don't take their insulin or do their diets properly?

McLellan: That's right. Even though the consequences are extreme. The major cause of blindness and amputations is unmanaged diabetes. But the fact is the precipitants of relapse in diabetes, hypertension, asthma, and lots of other chronic medical disorders are low socioeconomic status, lack of social supports for behavioral change, non-compliance with treatment,  and psychiatric co-morbidity. Exactly the same things which are predictive of relapse in substance abuse.

Moyers: I'm not sure I understand this.

McLellan: If you're poor, you're less likely to do well with any chronic illness. If you are depressed, you are not only more likely to relapse with addiction, but less likely to take your asthma medication. And if you have no social support, don't have a supportive family and friends to help you change your behavior, not only are you more likely to go back to drinking, but you are more likely to be unable to sustain the proper diet and medication regime for hypertension.

Moyers: Diabetes, hypertension, depression? Just as likely to do poorly on those as you are with recovering from addiction?

McLellan: Exactly. Now, there are things that treatments for those other medical disorders do that treatment for substance abuse doesn't do. Those who treat chronic illnesses have a much more realistic view of their goals. Nobody's trying to instantly cure anyone, no one's expecting that there won't be crises. And in the interim, they're trying to maximize people's function, minimize their suffering, minimize the impact that they have on public health problems. And, when people with chronic illnesses fail, they're not castigated. They're not looked at with scorn. They're urged to stay in treatment, and to try new things. Substance abuse treatment frankly, hasn't done that. They have castigated people who have relapsed and people who have relapsed have felt terrible -- so terrible that they didn't think they should get back into treatment. Bad mistake.

Moyers: Why is this? Is it because of the stigma that still attaches to the addict in our society?

McLellan: Right.

Moyers: If somebody relapses with addiction, it's a moral failure. If somebody relapses with diabetes or a heart condition, it's an explainable misjudgment?

McLellan: Yeah. I'll tell you, a real sad note was a study done out on the West Coast by Connie Weisner and her group. They looked at how people see addiction, reasons people believe addiction occurs. You talk to cops. You talk to social workers. You talk to judges. Would you believe they're more likely to think of addiction as a medical disorder than most treatment providers?  Even the people who provide substance abuse treatment, who often give lip service to the disease notion, are not convinced that it is a medical problem. They see it as a crime or moral issue. And I think that's been an impediment to treatment success.

Moyers: Are you convinced it's a medical problem?

McLellan: Yes, I am. I'm absolutely convinced. And, I wasn't. I really thought that a medical problem is a real disorder, one where you could trace the etiology quite clearly to a little bug or something. That said, even if that's not true, there's another whole way to think about it. Suppose that I don't know whether something is a medical problem or a social problem or a criminal problem, I just want to do whatever will reduce it the most. And, of all the things that I've seen with addiction, criminal justice, purely social means of addressing it like cutting poverty, they just don't work well. By far, the health-related approach has the biggest benefits. It has benefits to the patient directly in terms of improved life quality and certainly benefits to the family. But, the big payoff is to society. The reduction in public health problems, reductions in social problems like crime and reduced productivity, which are directly related to addiction.

Moyers: What turned you around? You said you were skeptical in the beginning that it is a disease, but now you're not.

McLellan: What turned me around was a review which was suggested to me by a person working with us, Debron Gubare. She was quite interested in the perception of addiction treatment compared with other kinds of disorders. So, with her, we went through the published literature on relapse rates. And, in turn, the course of illness and the treatment strategies, and the non-compliance with treatment rates for these other kinds of chronic disorders. And it is really striking to me how similar the course of addiction and addiction treatment is compared with some of these others.

Moyers: Isn't there a difference here, as Steve Hyman and others have told me, because alcohol and drugs change the brain and they affect the rational faculty of the person who is addicted, whereas if I'm recovering from a heart surgery or a diabetic, my brain hasn't been changed by that disease?

McLellan: That's an interesting observation and I'm sure there's some truth to it. Our own work has shown brain changes as a result of chronic amphetamine administration. But while having diabetes may not change the brain, the habit of eating poorly, just like the habit of taking drugs, may be deeply ingrained. Non-compliance and difficulty changing are present whenever people need to get into a different routine or change their lifestyles, addiction or not.

Moyers: But treatment can work on that?

McLellan: It's like Mark Twain said when asked if he believed in Baptism. He said, "I believe in it. I've seen it done." Well, I've seen it done. We have lots and lots of anecdotal and large-scale population evidence and randomized clinical trial data showing pervasive and prolonged effects of substance abuse treatment.

Moyers: You've seen people change?

McLellan: Oh, yes. But it's just interesting to me that it is simply not believed, and I think it's not believed because the standard is, "Where's the cure?"

Moyers: Well, let me read you a paragraph from a very prominent columnist in the Washington Post. "For many, treatment is a revolving door. A 24-year follow-up study of heroin addicts found that 85% had participated in treatment programs and, of these, the median number of times enrolled in treatment was five. Imagine a study that found that sufferers of appendicitis, on average, had five previous surgeries for their condition. The abdominal surgery industry would be shut down tomorrow." And, he calls it the "drug treatment hustle."

McLellan: Right. Let's just take his analogy. The guy at least is in the right ballpark. I think it's a legitimate argument to compare it to other forms of medical illness. But I certainly don't think it's legitimate to think of this as some kind of infectious disease or surgically correctable problem. I mean, it isn't. You might've thought it was, the way treatment used to be. And, as a matter of fact, if you were a Martian and you landed here in the 1980s and you saw all these inpatient 28-day programs,  you would think, "Oh, I get it. This addiction stuff must be some kind of bug or something, because they put them in these places and they get the bug out of them, and then, I guess, they're cured."

Moyers: And, then they let them go?

McLellan: Right. And you know what? They went right back to drugs. Absolutely right. There was an extremely high relapse rate. But that doesn't throw out the possibility that this is a medical disorder. It just narrows the type of medical disorder that it could be. A chronic, not acute condition.

Moyers: Meaning?

McLellan: Meaning, let's apply the same standard to addiction treatment that we use for other chronic illnesses. Suppose I said to you something really shocking that diabetics or asthmatics or hypertensives had been in treatment five times in their lives. Let's say he's forty years old and he'd been in five times in his life. The first thing a responsible physician would say is, "What do you mean, 'been in treatment'? Why was he ever out of treatment? He should've been continually in treatment. He should've been continually monitored. We would've expected some ebbs and flows here and we should've adjusted accordingly." It would be malpractice to try to take a diabetic and say, "Well, we're going to try to get you off your insulin and then you'll be cured." It's just not done. In fact, if you had to take your pick between all the chronic disorders to get, which should you pick? I'd pick cocaine addiction because that one, at least, you'll find with sustained treatment and involvement, you will have very little impediment for the rest of your life, and that's not the case with these other disorders.

Moyers: What about this Federal study of 1993, which showed that for every 10 cocaine addicts admitted to treatment, 8 relapsed into heavy use within 3-5 years after their rehab. What about that?

McLellan: To tell you the truth, I don't think that's correct. I think it's probably closer to 8 out of 10 relapse within 1 year, as a matter of fact.

Moyers: Oh.

McLellan: Let's not hide from the facts. What happens in substance abuse treatment is rapid, very predictable, very positive, behavioral, symptomatic improvement. And, it is sustained, typically, for six months following cessation of treatment. And I don't just mean abstinence. I mean better employment status, reduction of crime, reduction of unnecessary medical expenses, things like that. These are sustained for at least six months and, often, eight to twelve months following cessation of substance abuse treatment, even if there's a relapse. And, I return to my point: Why was treatment stopped? If this is truly a chronic, relapsing condition, what in the world are we trying to stop treatment for? Why don't we try to treat substance-dependent individuals the way we would treat other chronically impaired people? Why not -- and I don't mean inpatient treatment for the rest of their lives -- but I mean, keep them in the loop. Make treatment easy. Make access available. Take the stigma away so that when someone begins to relapse, starts to drink again, before they get to the point where they're drinking and driving, losing their job, ruining their family, get them back into outpatient treatment or some kind of care. Which is, of course, what AA has always said -- you don't quit AA, because you have alcoholism for the rest of your life.

Moyers: Are there studies which show that treatment is cost-effective?

McLellan: Yes. In fact, there are studies by the RAND group and the recent CAL-DATA study out in California by Dean Gerstein and Rick Harwood and several other large studies. The typical finding is that for every dollar spent on substance abuse treatment, you'd have to spend seven dollars on enhanced law enforcement to get a similar return in terms of reduced crime. Every dollar spent on treatment produces at least seven, if not more, dollars' worth of savings in terms of healthcare costs, increased productivity and reductions in accidents, things like that. It's a very robust and pervasive finding.

Moyers: So why do the politicians persist in believing that treatment doesn't work?

McLellan: You'd have to ask them that. Because what people really want out of treatment is not just reduced alcohol and drug use, they want improved social function. They want an end to the crime that's associated with alcohol and drugs. They want an end to the family disruption and the embarrassment and violence associated with it. They want an end to the high insurance costs caused by excess utilization. All of those things. Now, is substance abuse treatment able to deliver on that? The answer is, yes. And, again, I'm not giving you my opinion. I'm giving you the results of years of work. When you evaluate substance abuse treatment on its ability, not to eliminate but to reduce crime, to improve social function, to reduce healthcare costs, substance abuse, time and time again, we see it can be very effective in all those ways. But you know what? That's still an obfuscation, really. 'Cause, you know, even if I told you or convinced you substance abuse treatment did that, it still doesn't mean that it's the best thing to do. Right? Maybe the best thing to do is put them in a labor camp. Put them in jail. Lock 'em up. Maybe that would be even more effective. Well, there's lots and lots of studies of just that issue. Substance abuse treatment vs incarceration. Substance abuse treatment in addition to incarceration. And time and time again, you find that incarceration does only one thing: postpones return to substance abuse and in some cases actually increases crime. And while that's going on, you're spending thirty to forty thousand dollars a year. We had a study with Dave Metzgreen, Jim Cornish, at our shop where we looked at naltrexone, this opiate antagonist I was telling you about, in Federal probationers who were there for opiate-related crimes. One group got standard probation. Another group got twice the amount of probation, double the probation. And, the third group got naltrexone plus standard probation. We had a ton of outcome measures. But here's the one that really stuck out. Sixty percent of those who had double the usual probation were re-arrested and reincarcerated within a year after probation. But just twenty-three percent of the people on naltrexone were re-arrested and reincarcerated within the following year for any crimes. So, twice the criminal justice effort was not as effective as simply adding substance abuse treatment to standard probation.

Moyers: And are people who get treatment in prison less likely, once they get out, to commit the same kind of crimes which got them there in the first place?

McLellan: Yup. Just as simple as that. Lots of data on that.

Moyers: How should a family cope when one of its members needs treatment? I mean, with all that I know, when someone close to me needed help, I didn't know where to turn.

McLellan: Yes. That's a very bad part of this disorder. We all have experiences with family members who are affected. And when it hit close to home for me, I didn't know where to send my affected loved one either. My very expert, esteemed colleagues were just as clueless. To me, it is like the funeral industry. You've got a very emotionally charged time. Lots of really wild promises about fantastic fixes and tremendous variability in the kinds of things that are suggested. Everything from acupuncture to psychotherapy to medication, and you just don't know where to turn. Most of the treatment that's out there hasn't been evaluated in comparison to other types, so while we know that treatment works, we really don't know which type works best for whom. Thankfully, it is changing. One of the good things about the reorganization of health care which the whole country is facing is that there's been a press for more evaluation. And my research group is personally involved now in eight states around the country doing statewide outcome evaluations in response to just these kind of concerns at the legislative level. So, I think that in the very near future, we will know at the programmatic level, whether Program A is good and how good, and is it good for young cocaine-addicted males or is just good for alcohol-addicted women? That kind of comparative sort of consumer's report data is really at hand.

Moyers: So, what does your research tell you is a good measure of success? How should the public think of treatment as successful?

McLellan: I think the public's standards are really quite correct. If I took a public health perspective on substance abuse and I took a count of the kinds of social and financial and health-related problems associated with addiction, I'd want to reduce them. And, being of Scottish descent and very thrifty, I would want to do so at a very reasonable price and I would like the results to be sustained. With those considerations in mind, if I have somebody who's got a substance abuse problem, I'd want them in treatment. Not because I'm a do-gooder. Not because I want to make 'em happy. Because I want to minimize the impact of substance abuse on society, on the families of those people and on themselves. With all that said, I don't want to give the impression that all substance abuse treatment is good and it's a magic bullet. The fact is, and we've done lots and lots of studies, we've evaluated well over one hundred treatment programs so far, and there's a good twenty percent which actually make people worse. They take patients, and they harm them.

Moyers: But that makes it very hard for the family.

McLellan: That's right. Right now, there is no consumer's report on substance abuse treatment, although there are ways to determine, at least, if a treatment center is likely to be doing a good job.

Moyers: Is it true that the longer you're in treatment, the greater of a chance of success?

McLellan: Yes, you could almost say it was a law, rather than simply a fact. People who stay in treatment longer, do better. And, I don't care what modality it's in, whether it's inpatient or outpatient or methadone maintenance or a patch for nicotine or nicotine gum, whatever. People who stay in this longer, do better. That would not be at all surprising if, again, we were talking about hypertension, asthma, diabetes, tooth decay. There it would not. But somehow, it's different for addiction.

Moyers: Why do you think it is? Is it because of the moral stigma? So many people think, well, the addict is a moral failure of absence of character, loss of willpower. You choose to use and that's moral choice.

McLellan: Relapse is only evidence of failure for people who believe that the addict is a person of weak will. They have no reason to use now, right -- they stopped already? The fact is that that's why they call it addiction. Dependence lasts well after the physical tolerance is cured, really. That's the easiest part of addiction. If we were to measure our success by the proportion of people who start a detoxification, finish it, and have no symptoms at the end, my God, we'd be one of the most effective treatments around. That's not the game. The game is to keep somebody off. That's when real pressure starts. You have external pressures like, let's talk about cigarettes. Do you think those high prices that the cigarette prices companies pay for advertising, do they pay them just to sustain the economy, to employ otherwise useless ad people? No, these are very powerful cues that are designed to stimulate a craving for their product. Similarly, alcohol and cocaine and heroin have their own cues which stimulate recall. A heroin addict can't walk past the neighborhood where he used to cop without feeling that craving. That's one kind of cue. But even more important, often, are internal cues. Depression. Anxiety. Anger. All of these. AA gets it right. They say, "Avoid people, places, and things," and they also say, "Don't get too hungry, angry, lonely or tired (HALT!) -- seek help." There may never be an end to your response to cues. But you learn, through practice to handle them. And, it gets easier over time, the more you practice.

Moyers: Wait a minute, now, you say you learn through practice.

McLellan: That's right. That's why I've been emphasizing the fact that addiction is a chronic disorder. You show me a chronic medical disorder, any one, and I'll show you the need for behavioral change if the treatment is to work. If people don't change their behavior in addition to taking their insulin, they don't change their behavior in addition to taking their hypertensive medication, if they don't in addition to taking methadone or Antabuse, or naltrexone, you will see relapse. So behavioral change is necessary. And, behavioral change needs to be practiced and needs to be supported. That's amongst the many wonderful contributions of AA, NA, CA and other support groups, families, Al-Anon. All these things help a person who wants to change his behavior, change.

Moyers: You have found that those do encourage change?

McLellan: Absolutely.

Moyers: The whole group just talking about it?

McLellan: Over and over and over. Every study that looks at this finds that participation in the self-help groups is quite consistent with maintained change. But, I want to say that that's the latter stage of treatment for most people. For most people, there needs to be some period where things have gotten out of control. They have psychiatric or emotional or financial problems and some period of stabilization is required. But that ain't enough. I don't care if you stay in an inpatient treatment for a day or a year, it won't be enough. It's not like learning a lesson. You must practice the behavioral changes that you learn in an inpatient program and keep them up, sustain them after you leave. If you are never exposed to cues, to stress, to challenges, you cannot possibly have a lasting recovery. That's why they talk about the difference between "talkin' the talk and walkin' the walk."

Moyers: When I listen to you, McLellan, you make me feel hopeful about this. You know, I know from personal experience it is difficult. When the person I love and care about came out of twenty-eight day treatment, I was scared. I wanted him to stay there because he was safe while he was there.

McLellan: Right.

Moyers: And, sure enough, over the next few years, he relapsed twice.

McLellan: It's very hard. And I think that one thing which is different with addiction than with other chronic diseases is the kind of devastation that alcohol and drug abuse has on the families. It is dreadful to watch a loved one go through these dark, emotional, moral changes that can occur when they're deeply embedded in addiction. That's the part that's really scary. The recovery shares many of the same principles as other forms of recovery. But you can't take away that kind of gnawing doubt, that gnawing worry, that terror really that the bad old days are coming back, nor the stigma associated with a disease which people view as a moral failing.

Moyers: If you're in recovery from diabetes, you probably didn't steal to get your insulin or commit crimes or hurt your loved ones the way you can with addiction. I mean, I've seen wonderfully moral people act immorally under the influence of the addiction.

McLellan: Absolutely right. It's true.

Moyers: And, it devastates families. Does your research show that it's important for families to participate in recovery and in treatment?

McLellan: Yes. And it don't take no rocket scientist to figure out why that is. A person who has become committed to change and who's gone through some period of initial stabilization, detoxification, even some extended rehabilitation, they come out of treatment and they are truly changed. They are physiologically different people. They've learned lessons. They've established relationships. They've learned some things about themselves. They feel optimistic. But, at the same time, they feel scared, too. They leave that warm relationship and now, they're back out into the same stressors, the same cues, the same environment and the same emotional problems that lead to the addiction in the first place. That's when they need a family. That's when they need continuing support from the recovering community. That's when they need institutions, families, and friends that will support them in that continuing effort in the behavioral change. It's the toughest part of the treatment. And it's the least supported.

Moyers: How do you mean?

McLellan: Well, once someone has gone to a treatment center, there's lots of people in society, employers, for example, who say, "Okay, look, Moyers, I sent you out to that treatment. I spent a lot of money and I sent you to that treatment program and, okay, Moyers, there's none more of this foolishness now. You're cured now." Wrong. You are now at the point where you can start the kinds of behaviors that will sustain you in a different kind of life. You need a lot of support for that. And unfortunately, this is a time when, even families that have been supportive through most of the early parts of treatment now begin to become suspicious. They were happy to support the early efforts to try to keep the patient person safe and all that. But now they recall the awful things that were done and it all comes back. It is a time when more, not less, support is needed.

Moyers: And family members themselves have to go through a recovery, irrespective of the addict? So often, I've seen the family so devastated, the spouse or the brother or the sister, that they need help, too, don't they?

McLellan: Oh, my, yes. Well, that's why there are support groups for the families. Certainly Al-Anon and other groups like that, family therapy, all of those things. We treat a lot of physicians and they have some of the best prognoses because they have a job they value and want to keep, but even physicians, with all they've got going for them, they often need couples therapy or family therapy after the initial stabilization to readjust, to find a new way of living, to support new behaviors, new habits that will sustain a productive recovering life.

Moyers: What effect is managed care having on treatment?

McLellan: I will say at the outset that managed care was needed in substance abuse treatment. It was needed because there have been excesses in the past. Excesses that were born, I think, of an incomplete understanding of what addiction was. The need for protracted periods of inpatient care followed by no outpatient continuation is simply not consistent with good practice. And that was widely done. There are lots of treatments out there done by well-meaning people who really have no idea what they're doing -- they based what they did only on their own experience of recovery and it wasn't generalizable, but they blamed the patients for failing rather than changing their approach. Managed care reduced some of that. But that's about the best I can say about it. I've summoned everything in me just to say that. And we have completed studies in Philadelphia where we've looked at substance abuse treatment under fee-for-service compared to managed care conditions. The practices of managed care have done the following and it's quite prevalent around the country. We've talked about it already. People who stay in treatment longer, do better. People who receive a broader array of services to deal, not just with their alcohol and drug use, but the concomitant problems that they face which are materially related to their relapse potential. The people who get more services for those things do better. And people who get more professional services do better, okay? Well, managed care has quite systematically eroded the duration of care. What used to be twenty-eight days inpatient is now, like, fourteen days with numerous impediments to even getting that. Second, they've eliminated a great deal of the range of services which are available. Psychological services. Social work -- the so-called wrap-around services have really been cut sharply in managed care practices. Also, the professionalism has been reduced. There just aren't enough dollars now to involve the doctors and the trained people. You might say, "Well, wait a minute. Sounds like, to me, those were all sort of unnecessary services. What these people really need is somebody to tell them not to drink. Not to use drugs." Well, that's what substance abuse treatment is becoming in this country. It's becoming a series of group meetings with concerned and capable counselors doing alcohol- and drug-focused care with no other services. And -- for very brief periods of time. We saw that in Philadelphia, and not surprisingly, we saw a concomitant reduction in the outcomes. Particularly, the outcomes that society is most interested in.

Moyers: You saw fewer people get better?

McLellan: Yes, we saw fewer people get better and the people who got better didn't get as better as they had done under traditional insurance. And I'm talking about Medicaid-supported treatment here -- not some fancy private care for affluent people. We saw significant changes in employment, family function, psychiatric status, and they were quite related to the provision of services for those problems. When those services were cut and alcohol and drug abuse treatment became alcohol- and drug-focused groups, you saw reductions in alcohol and drug use. Surprise, surprise. But nothing else. And, because you saw nothing else, you saw more rapid relapses. We're getting ready to publish that, as a matter of fact.

And I don't want to talk for all managed care. But let's just speak hypothetically. Just imagine, for a moment, you were running a business where first, you got the money for the services that you were going to provide. Then, you got to choose who it was that you would allow to receive those services. Next, you got to choose how much and what kind of services you would provide, okay? Now, suppose, again, hypothetically, that you found, in the group of people that you were chartered to serve, a group who had a history of using as many as ten times the amount of services as the others. Would that be an attractive group for you to retain in your little business?

Moyers: Not for the next quarter. [Laughter.]

McLellan: And that's it. And that's it. If health insurance ever gets to the point where it's contracted for five- or ten-year periods and HMOs have charters with their patient populations which mandate that they will keep them for that period of time, I think you'll see a big change in the way care is practiced. Not just substance abuse, but for all chronic diseases. You would then see much more attention to long-term benefits. On the other hand, if you can drop your managed care company at any time and they can drop you and they know that you're not likely to be there, these are not the circumstances that are conducive to long-term planning for chronic diseases.

Moyers: So managed care companies really don't want addicts to enroll in them?

McLellan: I certainly don't want to speak for all managed care companies. I don't have experience with all managed care companies, but we have quite a bit of experience, unfortunately, with some, and because we do outcome evaluations, my answer to you is, I don't think so. And I have a poignant little anecdote to illustrate that. We did an evaluation of several treatment programs sponsored by a managed care company. I don't want to identify it, but one of the treatment programs had a very good evaluation indeed, really showed very excellent evidence of treatment effectiveness measured in hard ways in terms of improved social performance, reduced substance use and everything. The rest really were quite bad and they were quite bad because they had very few services for very short periods of time. So the day came when they were all to receive this evaluation, and the individual who was running the program where they had done a particularly stellar job was just virtually beaming with pride. So was he praised by the HMO? Just the opposite -- the director absolutely refused to even listen to any of the ways that this individual had achieved the successes that he had. He forbade him from advertising. And then the conversation turned to the procedures that the other groups had used which had been associated with eliminating these people from treatment and reducing them from the rolls.

Moyers: So the director didn't want people to know that they had good treatment, he didn't want to attract addicts?

McLellan: Yes. This is what is called in the trade "adverse selection." God forbid that you would advertise something that would bring people in who were likely to use ten times the services that everyone else does. Remember, first you get the money, then the only thing you have to do is prevent services from being delivered to have a handsome profit. It's the only industry I know of like this. So God forbid you would get somebody in there who's likely to have legitimate need for costly services.

Moyers: Well, this brings up another problem. Because lots of addicts don't really want treatment, and if the HMO makes it hard to get, how will that motivate them?

McLellan: Well, here's an area where, frankly, I would take a business approach, as a treatment provider, not an HMO manager. To say regarding addicts, "There's something the matter with those people. They don't realize how bad they are and we have to smack them in the behind to get any kind of results." That's one reasonable perspective, and there's been lots and lots of efforts put towards coercing people into treatment. And with some success, as a matter of fact. But, if you're running a business, if you were selling sneakers, you wouldn't say, "Look at those stupid people walking past my store. They are in denial about how wonderful my sneakers are." Instead, you would go out and find sneakers that public really wanted, and you would find a way to make them even more attractive to them. And, I think more of that needs to be done with drug treatment. It needs to be user-friendly. We need treatments that can be delivered in a context where it's not stigmatizing to walk in the door, where addicts don't need to fear being shamed and humiliated. We need better medications. We need more services and we need them in surroundings that are better. Imagine, McLellan develops an opiate problem and wants to get help for it. I have to go to one of these little ghetto boxes called methadone maintenance programs. It's dingy, it's in a bad neighborhood, I have to pee in front of someone once a week, and my counselor at best has a high school education. But that's the only place I can get methadone. And, I'd have to go there, at least at first, every day.

Moyers: They make it an ordeal.

McLellan: Exactly. Very basically, you have to crawl through barbed wire to get this kind of treatment. And then the patients are castigated because they don't want it. Would you want it?

Moyers: But how, from the managed care perspective, could you make a good business out of it and still get people the services they need?

McLellan: To be fair to the managed care companies here, their loyalties are to their stockholders and they have to return a profit and they have to return a profit this quarter. I can't be a hypocrite; I invest in companies, and I'm looking for returns in a quarter, okay? So how can you be fair to the consumer and how can you be fair to the business at the same time? I think one of the ways is contracts, longer-term contracts such that when you sign up with a managed care company, you should not be able to drop them except for some just cause and they shouldn't be able to drop you -- for some significant period of time. I think that would foster the kind of planning and treatment strategies that would be designed to prevent recurrence of disorders, and it would lead to the kind of preventative planning that's really needed for most, not just addictions, but other chronic care conditions.

Moyers: In 25 years of looking at this, are you more or less hopeful than you were a quarter-century ago about our ability to confront addiction and to change people?

McLellan: Oh my God, this is the best of times. This is not the best and the worst; this is the best of times. Tremendous strides have been made at every level: understanding the genetics of these disorders, which will lead to treatment options; understanding the brain chemistry which is going to lead to new treatment options. Understanding behavioral change, learning, conditioning, social supports for change, we know more than we ever knew. We know more about the epidemiology of these substances. We know about the risk factors now. We know prevention strategies that we didn't begin to know 25 years ago, and, very importantly, we've begun to move from a cottage industry which rested on folklore about treatment to research-based treatments, which should give tremendous hope to people who have these disorders, and their families.

Moyers: What about studies that find that many people get better without any treatment? I have had a number of people tell me that they went cold turkey, never went to a treatment center. I'm OK. What about people who don't get treatments?

McLellan: Oh, that's a fact, and the best example of that is cigarettes. Most of the people that stop cigarettes don't get treatment for it. Partly because until recently there haven't been really good, available, cheap treatments for it. But I wish I had a nickel for every person who got better because he met a good woman, or a good job, or found religion. These are things which have quite regularly been associated with improvements. My reading of that, by the way, is that what's occurred is the opportunity for sustained behavioral change. In all of those situations if you can get yourself to a place which supports behavior that is inconsistent with drug use --  your good woman will throw you out of the house if you come home drunk. Your good job will disappear if you don't report to work. You can't sing in the choir if you're drunk -- those kinds of things. They do some of the same things treatment does, it's just not as systematic.

Moyers: So you run the risk of losing something that means more to you than the drug or alcohol?

McLellan: Yes. That's the negative, and the positive is that you get pleasure and warmth and support and satisfaction from the companionship of religion, or love, or the job. Those are exactly the kinds of ingredients you want to sustain behavioral change, and I would never say that you should have treatment instead of any of those. I think you should have treatment as an additional option to those.

Moyers: But does that mean we really don't need to provide treatment? Can't we just send them to church?

McLellan: Just because some people remain physically fit without gyms, doesn't mean you shouldn't have gyms available for those who get fit that way. Options are very important, because addicts don't recover just one way. Different treatments work best for different people. And treatment makes it systematic -- you don't learn relapse prevention when you fall in love. Also, treatment is only going to get better, because we are improving every single area, and that's really not hyperbole. The kind of research funding that's been available over these last couple of decades has led to real substantial hard results, and they are going to translate directly into better treatments.

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