Rahul Gupta, first physician to serve as drug czar, says stigma among doctors is key culprit in addiction crisis

WASHINGTON — Rahul Gupta is no stranger to the nationwide addiction crisis.

Drug use and overdose defined his tenure as the top health official in West Virginia, arguably the state hardest hit by the epidemic, and before that as the health officer in the state’s largest county.

But even Gupta, now the nation’s top drug policy official, admits that the current U.S. drug crisis is unlike anything he’s ever seen. Over 108,000 Americans are dying of overdose each year. The country’s drug supply is deadlier than ever. And despite the focus on opioids, rates of cocaine and methamphetamine addiction are soaring, too.

Gupta’s selection as director of the White House Office of National Drug Control Policy, however, has ushered in a new era of federal drug policy. As the first doctor to hold the position, he says he will embrace new strategies, including harm reduction tactics, which aim to reduce drug users’ risk of overdose, death, and disease in lieu of a hardline, abstinence-only attitude.

Still, though, addiction treatment is dogged by stigma, underuse of existing medications, and ongoing debate about certain harm-reduction techniques. The debate came to a head last week in California, where Gov. Gavin Newsom vetoed a bill to allow supervised injection sites — essentially clinics where people can use illicit drugs under medical supervision so as to prevent overdose.

Gupta sat down with STAT this week to discuss the ongoing crisis and the Biden administration’s efforts to address it. While circumspect about Newsom’s decision, Gupta did take several positions that are far more aggressive than any of his predecessors: Calling out doctors for their role in poor treatment outcomes; arguing that the addiction medication buprenorphine is widely misunderstood; and advocating for contingency management, a new addiction intervention that offers rewards — often cash — in exchange for cessation of drug use.

The following conversation has been edited for length and clarity.

Which public health crisis do you expect will result in more deaths in the next five to 10 years — Covid-19, or drug addiction and overdose?

We have an American dying [of a drug overdose] every five minutes around the clock, more than 300 a day. Clearly, drug overdoses were here before, and they’ll be here beyond, Covid-19. And the expectation is that they’ll continue to rise unless we implement the president’s strategy.

Given that, why isn’t the public treating a crisis that’s killing 100,000 Americans each year with more urgency?

Well, this has been an urgent priority for the president, to the point that he spoke about it in the State of the Union. He said we’ve got to beat the opioid crisis, and the first two items of his unity agenda were this and the mental health crisis. He sees the link between the two. This administration gets it.

One of the reasons for that apathy is stigma. Right now, we use all kinds of derogatory terms for people. We have, obviously, stigma that prevents so many people from asking for help and others for providing the help. It’s both — in communities, but also in health care. The stigma in my own profession is no less than what we see in communities and individuals.

Methadone, a medication used to treat opioid addiction, is only available through opioid treatment programs, or OTPs, and often requires patients to show up in person each day to receive a single dose. Should it be more broadly accessible?

I’m interested, actually, in standing up an interagency working group on methadone.

Here’s the bottom line: Fewer than 1 in 10 people who need treatment are able to get it, and the president’s strategy asks for universal access to treatment by 2025.

The way we’re going to get there is to reduce stigma, expand access to treatment, and remove barriers that are there now — make sure the regulatory framework matches the need of the hour.

People also express concerns about diversion or abuse of another addiction medication, buprenorphine, even though it’s used to prevent cravings and treat withdrawal symptoms. Do you think there’s a misunderstanding about what using buprenorphine actually means?

So the answer is yes — I’ll give you a straight answer. But let me contextualize it: I’ve actually talked to people who have used buprenorphine that people would say was “diverted.” And they would often tell me they wanted to get treatment. They either are not able to find someone to treat them, or they were in a line where they’d get an appointment 30 days from then, at minimum.

When you’re suffering from addiction and substance use disorder, you do not have 30 days to wait and become abstinent yourself. People seek out treatment and take action by themselves. It’s symbolic of the need to expand access to buprenorphine, and to make sure that more providers are prescribing it; more pharmacies are stocking it; and more manufacturers are making sure that’s happening and the supply chain is continuing; and it’s accessible and affordable.

The federal government has spent many billions of dollars in the past year on Covid-19 vaccines and therapeutics. Why isn’t there a similar nationwide effort to buy naloxone, the drug used to reverse opioid overdoses?

We have 108,000 people dying per year of overdoses, and three-quarters of them are opioids — that means, by definition, those overdoses can be reversed by naloxone. We know that every dollar invested in naloxone has almost a $2,800 return.

We’re doing everything we can from a federal government aspect, and I’ve had great conversations with [health secretary] Xavier Becerra on this. We’re making sure that when states receive SAMHSA funding, they have distribution and acquisition plans for naloxone, including plans for how to distribute to high-risk populations. That includes harm-reduction programs and urgent care clinics.

We’re also looking at an over-the-counter approach, as well.

We’ve talked a lot about how medications used to treat opioid addiction are vastly underutilized. But what does good drug policy look like for substances that don’t have an approved pharmacological treatment, namely methamphetamine?

While we’re working with NIDA to look at pharmaceutical treatments, we recognize that there are many good treatments available for stimulant-based disorders, like contingency management and motivational interviewing.

For example, California just had its 1115 waiver approved that allows $599 per year to be used for contingency management [the practice of offering rewards, including money, in exchange for refraining from drug use]. It is an evidence-based, data-driven, proven treatment for people — in the absence of any other pharmaceutical option. We’re definitely encouraging more states to look at those approaches.

You’ve said many times that this administration is historically open to harm reduction. Were you disappointed that California Gov. Gavin Newsom vetoed legislation that would have allowed a few supervised injection facilities to open there on a trial basis?

First of all, that’s the governor’s prerogative. We have basically said that we’re always looking to understand the clinical effectiveness and research of emerging harm reduction practices. Obviously, having said that, we know there’s the crack house litigation already in court [concerning Safehouse, a proposed supervised injection site in Philadelphia] — so with respect to the court, we try to not make any policy comments yet.

This article was supported by a grant from Bloomberg Philanthropies.