Robert F. Kennedy Jr. and the Treatment of Drug Addiction

If Robert F. Kennedy Jr. is confirmed as the next secretary of the Department of Health and Human Services, and if he carries out even part of his agenda, he will be a consequential -- and controversial -- cabinet secretary. I am concerned about some of his stances, including his record of objecting to vaccines, but in other areas, starting with addiction, his vision and values could transform lives.

As the medical director of a methadone clinic in Washington, D.C., I have a vested interest in Kennedy’s policy suggestions; so does the nominee himself. His own heroin addiction began when he was a teenager, following his father’s assassination, and ended in his arrest at age 29. He was given two years’ probation for felony possession and spent time in rehab. He has regularly attended 12-step meetings since.

Over the course of last year, Kennedy laid out, in speeches, interviews, and a documentary released last June called Recovering America, a heartfelt though incomplete agenda for managing the drug crisis. Here’s my analysis of his plans.

Tough love

At the premiere of Recovering America, Kennedy summarized his approach: “The government has a role in actually pressuring the addict, to say, ‘We’re not going to tolerate you on the street anymore,’ to do tough love… We’re going to clean up your neighborhood… and if we can’t talk you into helping yourself, you are going to prison, you’re going to jail, until you choose some other option.”

Like Kennedy, I favor benign paternalism when addicts are in a dire clinical state or when public order is jeopardized. Addiction and the criminal justice system are closely intertwined -- people seeking and using illegal drugs often commit theft and violate public nuisance laws. These crimes warrant a societal response.

In Recovering America, Kennedy endorses the essential practice of diversion – alternatives to jail that send individuals to drug treatment programs. In the nation’s 4,000 drug courts, a type of diversionary program, judges mandate a form of treatment for a period of one to two years while the addicted offender is closely supervised, including via routine urine testing, and his progress monitored.

If someone in a drug court program violates its rules, swift and decisive, but not severe, penalties are imposed -- such as brief incarceration. Once participants complete their program, their criminal record is expunged -- a major incentive to participate. Studies show that this approach -- call it “tough love” if you like -- reduces substance use and recidivism.

Wellness Farms

The “other option” Kennedy favors consists of rural therapeutic communities, or “wellness farms,” which would be funded by two sources: revenue from work done on these farms, and federal taxes from the legal sale of marijuana “that is designated specifically for drug treatment and rehabilitation.”

In these communal, pastoral settings, recovering addicts live for several years, learn marketable skills, perform vigorous physical work, and participate in a self-sustaining community with its own gardens, livestock, and small businesses. “Ultimately,” Kennedy said, “recovery is through community. It’s the only road to recovery.”

At the Other Side Academy, a wellness farm in Colorado featured in the documentary, 45 percent of its residents are still there after two and a half years, and the re-arrest rate among those with a criminal past is just 14 percent. By graduation, everyone has a job. Four in five who elect to stay a full three years are drug-free, crime-free, and employed six years after graduation.

A review of 23 studies of therapeutic communities found that while participants benefit -- for example, they consume fewer drugs, experience less depression, and are more likely to be employed -- these outcomes are comparable to other, less expensive outpatient approaches.

In my experience, such programs can almost always be strengthened by allowing patients to take medications for addiction, such as methadone or buprenorphine. Many programs do not allow this. Treatment of psychiatric conditions (this often means arranging for a visit with a psychiatrist) while in care and assisting patients to transition directly to housing and support services after graduation would also be important.

Still, I am drawn to the idea of the immersive rehabilitation experience. Some people simply need physical containment in an environment insulated from ambient drugs to help them break the cycle. All the better when places like The Other Side Academy are free to participants and the taxpayers.

A Bad Medicaid Rule

The vast majority of substance abuse treatment, including long-term residential care, is financed by federal, state, and local government. But because of a misguided bureaucratic rule, residential treatment facilities cannot accept Medicaid payments unless they have 16 or fewer beds.

This crippling limitation is called the Institutions for Mental Diseases Exclusion. It was put in place in 1965 as part of the original Medicaid law, which was passed during an era of swift deinstitutionalization. This movement had been accelerated by RFK’s well-meaning uncle President John F. Kennedy to prevent warehousing people with severe mental illness.

In Recovering America, Kennedy mentions lifting the IMD exclusion. Successfully convincing Congress to do so would make him a hero. Advocates and experts have tirelessly lobbied lawmakers to repeal the provision. Repeal would open much-needed treatment beds to people who are severely addicted or have serious mental illnesses that make them dangerous to themselves and others.

FDA-approved Medication

Kennedy has been quiet on methadone, a 60-year-old mainstay medication that reduces overdose death by about half. It is no “cure.” Rather it suppresses opioid withdrawal and reduces craving so that the patient can begin the arduous work of recovery.

Similarly unclear is Kennedy’s attitude toward buprenorphine, usually sold as Suboxone. Drew Pinsky, a physician and addiction specialist with whom Kennedy is close, is a vocal buprenorphine skeptic, citing the difficulty of weaning off of it after months or years. (A legitimate point, but buprenorphine remains valuable to many.)

Attempts to discourage the use of these medications or interfere with their availability would be a disaster. For a sizable percentage of people addicted to opioids, the medication-free model can increase the risk of overdose, possibly even more than receiving no treatment at all.

Conclusion

In Kennedy’s eyes, addiction is a human drama, an attempt to manage existential pain of some kind: “Addicts have a unique opportunity for redemption because they have been to hell,” he said in an interview. I embrace a version of this view. But policymakers should also know that the current gold-standard medications for addiction, as well as psychological interventions, such as cognitive behavioral therapy, can be invaluable.

People who have recovered from addiction often have a fierce commitment to helping fellow addicts. But they can be too attached to the methods by which they themselves achieved sobriety. At a press conference, Kennedy spoke of getting “addicts into all the different forms of treatment that are now available.” I am hopeful, then, that he will use his power to fortify the existing array of clinically proven interventions and support high-quality investigations into new approaches.

Sally Satel is a psychiatrist and senior fellow at the American Enterprise Institute. This is a condensed version of her article in The Free Press that also discussed GLP-1 receptor agonists, cannabis, and psychedelics.