National drug policy leadership emanating from the White House has a rich history, with this modern history dating from Dr. Jerome Jaffe’s 1971 appointment to head the Special Action Office for Drug Abuse Prevention (SAODAP). Since its creation in 1988, the Office of National Drug Control Policy (ONDCP) has been directed by a series of individuals—William Bennett, Bob Martinez, Lee Brown, Barry McCaffrey, John Walters, Gil Kerlikowske, and Michael Botticelli—who have been known colloquially as the US “Drug Czar.” Under President Obama, national drug control policy has for the first time integrated recovery as an operational concept at a national policy level. This is reflected in an Office of Recovery within the ONDCP, a number of recovery-focused policy initiatives, and the appointment of Michael Botticelli, a person in long-term recovery, as the director of the ONDCP. I recently had the opportunity to interview Director Botticelli about his life, his leadership of the ONDCP, and the state of recovery advocacy and support in America. Please join us in this engaging conversation.
Bill White: Michael, could you share some of your personal and professional background predating your entry into work in the addiction field?
Michael Botticelli: My earliest aspiration was to be a dean of students, and during my early career I served in personnel administration at several colleges and universities around the country. I first worked at Cornell University and later spent six years at Brandeis University where I got into recovery. It is interesting, Bill, to think of the juxtaposition between my job and my recovery. I was the assistant director of resident’s life and spent a lot of time talking about alcohol policy, and we’d actually begun to hire resident assistants in recovery. So, I began my own recovery at the time we were beginning to recognize the value of recovery on the campus, and, like many people in the addiction field, it was my own recovery that led me to pursue a career in this area.
In 1990, my sponsor in a Twelve Step group was working for a private addiction treatment company, and he was being transferred to San Francisco. He asked me if I would be interested in working for this company. They were looking to do more outreach to college communities and wanted to focus on LGBT substance use issues. I decided that I would make this change in career focus by leaving higher education and entering the addiction treatment field at the height of managed care when the private treatment focus was what was euphemistically referred to as “getting heads on beds.” The focus was all about getting people into care and how to get insurance to pay for this care. It was exceedingly difficult because of the growing restrictions managed care was placing on inpatient treatment. And quite honestly, I felt this preoccupation with census counts and payor mix was not fulfilling any sense of public service. I personally disliked the marketing end of the treatment business.
Bill White: How did the opportunity arise to pursue public service within the state of Massachusetts?
Michael Botticelli: Even though I was working for a private company, I served on a task force of the Bureau of Substance Use Services at Department of Public Health, which was then headed by Dennis McCarty. It was through work with the task force that I became enamored with the potential of this kind of public service, particularly helping uninsured, disenfranchised or homeless people get quality addiction treatment. It was not about profit and census; it was really about creating systems of care.
I started my work with the state in the early 1990s thinking that it would be a short-term opportunity. My thought was that I’d work two or three years and then transition to something to make some money. I had to work two jobs, because entry level public health work at that time paid so poorly, but I loved the social values that undergird public health work. It was really about social justice. It was about creating opportunities for disenfranchised populations. It was about changing the circumstances of people’s lives. Being able to do that through substance use services really made me appreciate the people who were working there and those working in HIV/AIDS, maternal and child health, and other allied fields. I quickly developed respect for my colleagues. I got to know a lot of the addiction treatment providers serving the public clients, and I deeply appreciated the work that they were doing with so little financial compensation. Their programs were skating by financially year after year with a tremendous commitment to do public good. I worked for the substance use services division for a couple of years and then had the opportunity to do HIV/AIDS. The latter work was particularly difficult as a gay man in recovery and seeing a lot of my friends who got sick and died, but I drew valuable lessons from that experience that I carry forward to this day.
I worked in the HIV/AIDS division for about seven years, and I loved it. I learned really important principles about consumer participation and consumer involvement at all levels of decision making. I learned about the value of collaborative relationships with providers, about systems development, and about how insurance companies set policy. Then Howard Koh, who was the commissioner of public health, asked me to be his chief of staff, which I was incredibly honored to do. I served in this role for three years and it gave me an incredible overview on the breadth of public health work, but also an opportunity to work with senior leadership in the department on substance use issues, both from policy and programmatic perspectives. This underscored for me the magnitude of untreated substance use disorders (SUDs). Then there was an administration change and I actively sought the role of director of the Bureau of Substance Use Services. I knew from the beginning that this was a perfect fit for my experience and the kind of contributions I wanted to make. I was fortunate to work in a very supportive health department within a pretty supportive administrative structure and a supportive legislature. I ended up staying in that position for nine years, which was quite a long tenure for a state agency director.
I loved it, Bill. I really treasured my time and the team effort involved in working with the advocacy community, the provider community, the legislature, and the administration. We were able to get a lot of good things done. We developed from scratch an adolescent treatment and recovery support system that included three recovery high schools. I think Massachusetts is probably still one of the few states that have state-sponsored recovery high schools. We opened other recovery support programs, including six recovery community centers. We did a lot of work around integrating substance use services in primary care settings by pushing screening, brief intervention, and referral to treatment (SBIRT) programs and further integrating addiction treatment into primary care and the community health center system. I am also particularly proud of the work we did as a team in the area of overdose prevention by implementing naloxone distribution. I think we were the first state to train law enforcement and family members in the use of naloxone. This was all tremendously rewarding work. I will always look back fondly on my time in Massachusetts.
Bill White: With those initiatives as a foundation, how did the opportunity to serve at the ONDCP then arise for you?
Michael Botticelli: When I was in Massachusetts and the Obama Administration inaugural drug control strategy came out, I was struck by the President’s and then-ONDCP-Director Gil Kerlikowske’s calls for a more public health-focused response to the nation’s drug problems. They were saying that we can’t arrest our way out of the problem and they were supporting things like naloxone distribution and expanded access to treatment. I was really taken aback at the significant change in policy at the ONDCP. That’s not to say that people before Gil, like General McCaffrey and others weren’t working on some of these things, but there was clearly a big leap forward in policy and focus. The work we were doing in Massachusetts at the time came to the attention of the ONDCP through multiple visits by Gil and ONDCP Deputy Director Tom McLellan. I’d worked with Tom for many years when he was at the Treatment Research Institute and I was the director in Massachusetts. Tom had provided me with what amounted to executive coaching while offering my state and other states technical assistance on systems development and improving addiction treatment access and quality. When Tom left the ONDCP, I got a call from them saying that Director Kerlikowske would like to talk with me. I met with him in Washington and he asked me if I would be interested in the deputy director position. At that point, I had been the director for nine years. I felt like I had accomplished the things that I wanted to accomplish. I felt both personally and professionally that it was a good time to make a change.
Bill White: You later had the opportunity to seek the position of ONDCP director. What was it like as the first person in recovery to go through confirmation hearings for that position?
Michael Botticelli: Bill, I was really surprised to the extent that it wasn’t an issue.
Bill White: Interesting. That says a lot.
Michael Botticelli: It does say a lot and I think for a couple reasons. One, I had been the deputy for a number of years and obviously had developed some good working relationships with people in Congress. And I think some of my work in Massachusetts in response to the opioid epidemic made my appointment very timely given the growing national concern about the increased prevalence of opioid deaths and opioid dependence. I faced some minor questions along the way about both my criminal background and my financial background, but people understood that in the context of my later recovery. It was understood that many people who are in recovery have criminal histories and that financial difficulties are a common consequence of addiction. I was actually pleasantly surprised by the fact my recovery status helped rather than hindered my nomination.
Bill White: Do you feel like that status also has contributed to the increased recovery orientation within the ONDCP?
Michael Botticelli: Bill, that credit first goes to the work Gil and Tom did in developing the initial Obama drug strategy. It was Gil that established an Office of Recovery here at the ONDCP. I really want to give them a lot of credit both from a policy and a structural perspective. But I think it is significant symbolically in terms of public policy and public perceptions that there is a person in recovery who comes from a public health background as the head of the ONDCP. It says to people that the director is a reflection of the policy of the administration.
Bill White: I’ve also thought about what it meant symbolically for recovering people and people seeking recovery around the country to see someone in your position addressing them not only as a national leader, but also as a person in recovery.
Michael Botticelli: Bill, I do hope that gives them a sense of validation. There’s a multiplicity of recovery voices, but I do hope to bring that experience into the work I do. It goes back to my work in HIV and AIDS and the importance of consumer voices being at the policy table. I’m not the only person at the ONDCP who’s in recovery, and there is value in our infusing people who are affected by this disorder and people in recovery with hope and the importance of advocating for and celebrating recovery at all levels.
Bill White: Could you describe what a typical day in the life of the ONDCP director is like?
Michael Botticelli: It’s incredibly varied, which contributes to the sense of wonder that comes with this job. I generally start my day pretty early; I’m here by seven or seven-fifteen to use the quiet time before everyone gets here to get ready for the day. Then, I usually go to the Roosevelt Room where senior staff within the Executive Office of the President do a quick check-in, which is then usually followed by a series of meetings with other federal agencies or outside stakeholders. I try to frame my day and my week around key priority areas that we’re focusing on. I’m also on the road a lot to hear from people around the country who are doing this work and to promote our various policies and programs. It’s really important to us how federal policy is being translated at state and local levels, so I need to be out there hearing from folks about what more we can do, what successes are occurring, and what challenges are being faced. I obviously have been spending a lot of my time helping the federal government and state and local governments increase our collective response to the opioid epidemic, but that doesn’t diminish some of the other areas that we want to continue to promote.
Recovery Advocacy and Recovery Support
Bill White: I’d like to explore some key issues with you related to addiction recovery. In recent years, the US has witnessed the rise of new, historically unprecedented, grassroots recovery community organizations and a new recovery advocacy movement that would have been hard to have predicted in the mid-1990s. What’s your view of the importance of these grassroots efforts?
Michael Botticelli: I harken back to my days working in HIV/AIDS. What changed the conversation on HIV/AIDS and LGBT broader issues in a way that also changed policy was the simple fact that people were out and open about who they were. That has certainly been the case with the recovery movement. We need to increase advocacy around the issues of substance use and recovery. I often say that science and data alone are insufficient to drive and change public policy; it’s people that change public policy. It’s difficult, particularly when you’re dealing with stigmatized issues, to promote individual and policy perspectives when the affected people are invisible. I often feel that we have blinders because we’re so steeped in this work. I’ll often ask people, “Are we really at a tipping point of this advocacy movement?” And I think back to HIV/AIDS and what that did to galvanize communities. I think part of what is driving this is young people in recovery because they live their lives out loud anyway and are really changing the conversation and recovery at a grassroots level. But I also think that the opioid epidemic is mobilizing people for change.
Bill White: Yes, it seems to be creating the kind of urgency that was spurred by the HIV/AIDS epidemic and that mobilized the LGBT community.
Michael Botticelli: Absolutely. Here’s a poignant example. I’m been doing conference calls with parent organizations that have sprung up, largely around the opioid-related death of their children. We have over two hundred parents who are going to be on a call with me today. Young people in recovery are changing the conversation, but so are the parents who have lost a child to addiction.
Bill White: Yes, this is the first time we’ve seen affected parents organize culturally and politically at this level of effectiveness.
Michael Botticelli: And you know we’ve needed it for a long time. I think we will also see some of our constituency groups coming together to form a national advocacy organization. Momentum is continuing to build, not only for locally based recovery support services, but also for national advocacy around recovery.
Bill White: We’ve both witnessed a push to fundamentally redesign addiction treatment from acute care models of intervention to models of sustained recovery management and support. How significant do you think this shift is?
Michael Botticelli: It’s huge and I think the opioid epidemic has highlighted some of the historic challenges that have long existed in the treatment field. Fortunately, I think it comes at a time where there have been significant changes in the field. It is quite exciting that our evidence base around effective prevention and treatment and recovery has just taken off. We have this armamentarium of what we know works, not that we don’t need more research, but we’re not blindly shooting at effective solutions anymore. And we have positive frameworks in place through the Affordable Care Act (ACA) and the Mental Health Parity and Addiction Equity Act (MHPAEA). We are now in a position to move away from an acute and episodic system of care to one that provides a level of prevention, early intervention, treatment, and ongoing care support to mirror how we manage chronic diseases.
Bill White: Do you envision a day when primary care physicians will not only be doing the early brief screening and intervention for alcohol and other drug problems, but will also be doing assertive long-term recovery check-ups and recovery support with their patients?
Michael Botticelli: I do, and I think we’re beginning to see the maturation of some good models for such support within primary care. Bill, I had this great primary care doctor for a long time. Before there was such training for physicians, he knew there was significant addiction in the community he was serving, and he knew I was in recovery. Every time I went to see him, he gave me a recovery check-up. He was great. He asked me if I felt safe and stable in my recovery. He asked me what I was presently doing to support my recovery. Just the mere fact that my primary care physician understood that my foundation in recovery was critical to my overall health speaks volumes. I think we’re beginning to see models around the country of that integration—that both mental health and substance use issues are critical to someone’s overall health. Innovative models are emerging, some spawned by the ACA and its emphasis on the integration of addiction treatment and primary care. A number of states have used the medical home model under the ACA to integrate good primary care and substance use services, while others have been integrating substance use treatment and recovery within community health centers. I think we’re beginning to see the widespread implementation and maturation of such programs within a wide variety of primary care settings.
Bill White: Another area of innovation has been the reintegration of peer recovery support services within the addiction treatment arena and the blending of peer recovery supports with professional interventions.
Michael Botticelli: Everything old is new again isn’t it, Bill? One of the great things that I think the addiction field has historically done and that other fields have more recently incorporated is the role that peers can play in the treatment and recovery processes. We’ve known that for a long time, but there is a renewed emphasis on their value. Many states are now paying for the peer recovery support services within addiction treatment and in many primary care settings. Peers are once again assuming a valuable role within the care team.
Bill White: Yeah. Do you envision a day when peers will be part of the care teams in emergency rooms and primary care physician offices?
Michael Botticelli: I think we are already seeing that, even if it is not as widespread yet as it is likely to be in the future. When I was in Massachusetts, we had a federal SBIRT grant, and we used the Project Assert model that had specialty-trained peers as part of the emergency department team. I know that many states are looking at peers, not only in emergency departments, but also in a wide variety of clinical settings. It’s not without its challenges, Bill. There are certainly cultural issues that you have to get through on how the peer role can best complement other health professional roles. These issues are getting worked out, and I think we will see a continued expansion of peer recovery support services in a variety of settings.
Harm Reduction and Recovery Support
Bill White: I can remember not too long ago when federal officials were banned from even using the phrase “harm reduction” in their public speeches. The ONDCP in recent years has reversed that position through a courageous effort to integrate harm reduction with recovery support services at local community levels. Could you comment on that shift?
Michael Boticelli: Bill, that polarization and divisiveness in the field have always been interesting to me. Many of us who have found our recovery through Twelve Step groups recall the traditions of those programs, that the only requirement for membership is a desire to stop using. Twelve Step programs did not require people to be abstinent before we engaged with them. Does the government fundamentally believe that people with addictive disorders are entitled to care regardless of their compliance with treatment? If that answer is yes, then we have to do everything we can to minimize the harms that are associated with people who have addictive disorders. Clearly we want to move them toward treatment and long-term recovery, but we also have a fundamental responsibility to save their life and to protect them and others from infectious disease while we continue to engage them and move them toward healthier behavior.
New Recovery Support Institutions
Bill White: We referenced earlier the rise of new recovery support institutions—recovery community centers, recovery homes, recovery schools, recovery industries, recovery ministries, and so forth. How important do you think those new institutions are and what do you think the role of the federal government is in helping local communities develop these new institutions?
Michael Botticelli: I’ll start with the latter part. The ONDCP has budget authority over federal agencies critical to the drug control strategy and we have encouraged funding of recovery support services, community-based recovery community centers, collegiate recovery programs, and recovery high schools. Such programs have been critical to our strategy for resolving alcohol and drug problems at the local community level. From a resource perspective, SAMHSA and some of our other funders play a critical role in funding and supporting the development of these services. One of the important things about these programs is the broad recruitment of community volunteers engaged to help deliver services for people seeking recovery. And there’s something about driving down the street and seeing a coffee shop, a drycleaner, and then the recovery support center on Main Street. You know as well as I do that siting of our programs has always been a challenge, but there is something highly symbolic about recovery programs being part of the community that I don’t think can be underestimated.
Bill White: To me, those new institutions mark a transition from figuring out a way to support personal recovery to saying, “Now, we need to create a world in which people can recover in.”
Michael Botticelli: Yes, part of the recovery process is just that. You have to create a community around you that helps support your recovery. And that doesn’t just exist on a personal level; that exists on a community level. Creating these visible recovery communities sends a message to people who are still struggling that a life in recovery is possible and fulfilling. My experience is probably similar to many other people. I knew I had a problem, Bill, and I knew that I had to stop, but part of what prevented me from getting care was that I didn’t see a life on the other side of not drinking. I couldn’t picture that I would be happy, healthy, and would find love. In essence, I thought I would have to isolate myself even more if I stopped drinking. It sends a really critical message to people and to families who are experiencing addiction when they can see this kind of vibrant community on the other side of their pain.
Bill White: Michael, as you look back over this amazing journey that you’ve described, what would you say have been the greatest personal challenges you’ve faced?
Michael Botticelli: Bill, my life in recovery has been incredibly blessed. It’s hard for me to talk about it without getting emotional. I know I’m one person among millions of people who have been so blessed with recovery, but that doesn’t mean that my life has always been easy. It was really hard to be a gay man in recovery watching a lot of my friends die. But I would also watch these people die with dignity and die in recovery. Certainly the death of family members has been challenging, but I’ve been really blessed. The blessings outweigh any challenges I have faced. I’m really lucky to be living the life that people tell you recovery makes possible.
Bill White: You described making this decision to shift careers into this field in the hopes that it would be personally meaningful to you. As you look back today, what do you feel best about in terms of the work you’ve been able to do?
Michael Botticelli: Bill, I’m not just saying this because you’re on the phone. I stand on the shoulders of a lot of people who’ve been doing this work for a very, very long time. There are a lot of other people who have contributed to this growing recovery movement and the growing perception that people with SUDs are worthy of dignity and respect. If I can leave one mark in my time at the ONDCP and in this field it will be my decision to live my life out loud as a person in recovery. Through the work that I have been able to do, I’ve made it easier for people to get care, to get treatment, to be in recovery, and to be open about recovery. If I have been able to achieve those things, I’ll leave this world with something to be proud of.
Bill White: Do you have a short bucket list of things you want to achieve before you finish this work?
Michael Botticelli: I do. I want a major focus of my time at the ONDCP aimed at reducing the burden and the magnitude of the opioid epidemic in the United States. It’s really just tragic the impact that this is having on people and their families and communities. I also want to work on changing the language of the field. As with other stigmatized disorders, language can help perpetuate such stigma and sometimes even the language we use inside recovery circles is to our detriment. We need to forge a new nonstigmatizing language, and I hope to contribute to that.
I think we have an extraordinary opportunity to reduce some of the very real barriers that people in recovery face. No matter where I go, I hear from people in recovery, particularly those with criminal records, the challenges they face in finding things like safe and stable housing and employment. Even though they have done incredible work around their own recovery, they are still hampered by their past and the community barriers they face. Finally, I hope to play a role in criminal justice reform. For way too long, our criminal justice system—our jails and prisons—have been a de facto addiction treatment system. We need to move ahead with our ability under the ACA to get people into care before they intersect with the criminal justice system. We need to continue to forge policies and programs whereby people with SUDs get care and treatment as an alternative to incarceration. And I think we can make substantial progress in these areas in the next few years.
Bill White: Michael, thank you so much for taking this time to explore your career to date.
Michael Botticelli: Bill, thank you for the opportunity.
Acknowledgements: Support for this interview series is provided by the Great Lakes Addiction Technology Transfer Center (ATTC) through a cooperative agreement from the Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT). The opinions expressed herein are the view of the authors and do not reflect the official position of the Department of Health and Human Services (DHHS), SAMHSA, or CSAT.