S1 E13: Dr. Kevin McCauley on America’s Criminalization of Addiction

Meadows Senior Fellow Dr. Kevin McCauley shares the journey he’s traveled from the heights of the US Navy to the depths of a prison cell and explains how that experience drives him to push for changing the justice system’s punitive approach to addiction.

Podcast Transcript

Dr. Kevin McCauley. Hello. I’m Dr. Kevin McCauley. I’m one of the senior fellows at The Meadows.

David Condos: Thank you, Kevin, for being with us today. It’s so good to have you.

Dr. McCauley: My pleasure.

David: Well, we’ll launch right into your story, introducing us to yourself as a person. I know you have an especially compelling journey you took to get here.

Dr. McCauley: Sure.

David: We’ll start with that.

Dr. McCauley: I think my story is unique because I really wasn’t a drug user in high school or college or anything like that. I wanted to be a doctor and I wanted to go into the Navy. When I graduated from medical school, I joined the Navy and I became what’s known as a flight surgeon. I was the doctor who took care of the pilots in the Marine Corps.

David:  It’s a very specialized job.

Dr. McCauley: It was fun. It’s a bit like being a small-town doctor because you get to know everybody, you get know the CEO, you get to know the most junior enlisted and you make house calls. It’s part of the safety factor because you know the personal lives of all the aircrew. That actually makes it a bit for the flight surgeon to pick up problems, should there be any. Then I had to have surgery, you can’t take any medications and fly. I had this surgery. At the end of that surgery, they gave me a big bottle of Percocet. I’m actually the first patient that I know of who got addicted to opioids after surgery. Now, that’s a very common entry into addiction. That’s a superhighway into addiction.

David: This was about how long ago?

Dr. McCauley: This was a good 24 years ago. I think 1996, ‘97.

David: Less common at that time?

Dr. McCauley: Yes, and this is what’s interesting about opioids is that they have a very different effect on different people. A minority of patients, there’s such a powerful antidepressant effect from the opioid, that it really gets its hooks in you, and it did. It didn’t happened all at once, but over a period of about six months I started to become a weekend user of opioids. That involves the crossing of personal boundaries up to and including forging prescriptions and things like that.

David: Because you were a doctor, you had that access?

Dr. McCauley: Right, I did. I had what’s called a DEA Form 222, and you can order pretty much anything you want. I knew that this was wrong. That was another gift I was given is that from day one I knew that this was not good, but what really shocked me was I couldn’t stop. I really had the motivation to stop it desperately, wanted to stop, and I always seemed to just end up in a relapse. Finally, I called the Medical Board of California because they had what’s known as a diversion program that you could go to treatment and then be monitored and still keep your license, but because I was in the military, I really couldn’t just go to the Betty Ford Center and take 30 days for my little opioid problem. That just wasn’t going to work. No one really knew what to do with me. I tried hard to stay sober, but then I would relapse and then I’d stay sober a little bit longer. Then I relapse. During one of these relapses, I got caught.

David: You were still practicing medicine in the Navy this whole time?

Dr. McCauley: I was, and it wasn’t necessarily that I was using every single day or strung out or anything like that, but I was impaired. I was petrified, quite frankly. The Navy, fortunately, they knew precisely what to do with me in ways that the Medical Board of California didn’t. They just stuck me in Leavenworth for years, I was court-martialed and sentenced to a year of confinement.

David: Just for people don’t know, that’s like a military prison? How would you describe it?

Dr. McCauley: The nation’s maximum-security military prison is what’s called the United States Disciplinary Barracks at Fort Leavenworth, Kansas. At the time I went there, it was an old building that was built in 1911 every brick mind and hold and set by inmates, as they call it the castle because it was this giant rotunda with all these wings coming out of it. It looked like it had bats flying around it. It was really pretty spooky. Over the hill, you could see the federal prison at Leavenworth. Leavenworth, it’s got four prisons in that town. Now, today, they have a much more modern facility and the castle has been torn down, but it definitely makes an impression on you when you get there.

David: You were sitting there in prison, probably a place you never expected that you would be– Talk us through what was going through your head.

Dr. McCauley: Well, what’s interesting is I didn’t go to Leavenworth first, I went to the Camp Pendleton brig first, and I spent the first 90 days of my sentence in solitary confinement. That definitely didn’t help. Let’s just put it that way.

David: A shock to the system?

Dr. McCauley: Right. I am an advocate for removing that confinement, especially for people who have mental illnesses.

David: Why were you put in there? Was that just a standard protocol?

Dr. McCauley: Most people are in solitary confinement in the United States. Not necessarily for disciplinary reasons, they’re there for administrative reasons. I was an officer, and they didn’t want me in the general population. It’s a bit of a crisis of faith in the Marine Corps when an officer goes to the brig. They just wanted me away from everybody. That was the reason that I wasn’t [crosstalk].

David: They didn’t want the other people to know that you were there?

Dr. McCauley: Yes, in a sense. It wasn’t a secret, but it doesn’t help. I can understand that, I was not exactly helping the military with its mission at that point, but it doesn’t take more than about a week or two and your mind starts playing tricks on you in solitary confinement. Once that was over and I got to Leavenworth and I was more in a normal prison situation, you’re absolutely right, there’s certain existential questions like, “How did I get here? I loved my career, why would I put it at risk? What does this say about me? What does it say about my future?”

What I decided to do was tried to learn everything that I could, about addiction, everything, to learn all the history, all the law, all the medicine, all the science, all of it. This was the year 1997. Back then you could still learn everything that there was to know about addiction, I was still possible to do that. Today it’s not possible in one human lifetime to learn everything.

David: Because there’s so much more resources?

Dr. McCauley: Exactly. The research and the knowledge has just exploded over the last two decades. I just started to read. I started to order books and journal articles. I think the prison mailroom was a little concerned that I was getting all these books on drugs. Maybe they thought I was going to make meth on my toilet or something like that, but I just read and read and read. I acted like your typical medical student, “Let’s see if I can study my way out of this problem.”

David: Yes, because that’s how your life had been.

Dr. McCauley: It’s all I was good at, at that point. As I read this stuff, it just became clear to me that this was extremely important information, far more important than just what it had to say about addiction and then what to do with people who had an addiction. When you study addiction, you really start to untangle some of the secrets of how does free will work in the brain, how do people make choices, how’s that process constructed, and how can it break down in a disease process.

At that time, there was still holes and gaps in the research, people couldn’t really link this to that, and no one really saw how it all kind of fit together, but that’s changed. Now today, we have a very coherent model of what makes people with addiction different, what are the risk factors, and what are the factors that predict recovery.

David: It’s interesting thinking about you were a doctor, you had gone through all the medical school, and you apparently had never learned this before that. At that time or even now, is that part of the training?

Dr. McCauley: I think it’s increasingly becoming part of the training for a number of reasons. A, the sciences there, and from that science have come a number of treatments, and they’re in the work. The opioid epidemic has also made people much more interested in the problem. Yes, I think the curriculum that a medical school could create around addiction is much greater today, many are, but when I was a medical student, there was no set-aside lectures on addiction or the neuroscience of addiction or how to how to speak to people with addiction or anything like that.

I think that now we understand a little bit more about which messages actually work when you’re trying to prevent addiction and healthcare professionals. [music]

David: I imagine that this whole experience of this fall from grace almost as it were and being thrust into prison and all this, I imagine that really changed the way you thought about criminalization of addiction. How did that unfold?

Dr. McCauley: I think all of this started in medical school when it was very clear that there was a certain way to treat patients who showed up at the hospital who were addicted to drugs. There was really one treatment, which is to kick them out. Very early on, the prejudice against patients with addiction was modeled and I think absorbed, especially by me. I’d love to tell you that I rebelled immediately at that and I felt the injustice of it and felt a deep kinship with people who were truly struggling. No, I can’t claim that, but it quickly became clear to me as I was in a carceral setting, what the public health implications were for the people who are my peers and for myself too, I was very concerned for myself.

That now has grown into an entire area of public health to try to understand the effects of incarceration, not only on individuals but also on communities, which are damaged to when an individual is incarcerated. That’s quite fascinating. Now I think that that’s really started just in the last year, that’s getting more traction, because now we’ve got all these white kids-

David: Right, from the opioid crisis, yes.

Dr. McCauley: – whose parents just outraged that they’re now a target essentially a full profit criminal justice system and they’re not going to have it. We didn’t seem to worry too much when it was people on the fringes of society or people of color. That’s a theme in the way diseases have evolved. The same was true for HIV. It was when people knew someone that they cared about, that they loved who had HIV, that the world started to change its image a little bit of what the person with HIV looked like and what we wanted to do about it. What I find interesting is now we seem to be stepping in those same footsteps, which is definitely progress of a sort.

David: Yes, it’s following the same path of these other crises that came before it.

Dr. McCauley: Yes.

David: Continuing with that criminalization topic, how do you feel the justice system and our culture should change the way they look at addiction and approach addiction?

Dr. McCauley: I’m pleased that everyone is thinking about the fact that when you incarcerate someone, that’s not the end of it when they’re done with their sentence, that there are lifelong problems that can emerge from that, for instance, solitary confinement. It’s a very high rate of suicidality in people who now have to live with that experience. I think the increasing awareness of that is critical, and I think it’s going to change a lot of the way we deal with these problems. The fact that we’re trying to divert people who have nonviolent drug charges out of the prison system entirely. I certainly applaud that.

What concerns me is that we still have this fundamental belief that if the punishment is great enough or if the punishment is less severe but swift enough, that that will deter addictive behavior. I think that one of the key diagnostic features of addiction is that as the addiction progresses, negative consequences don’t seem to stop the pattern of use. They don’t affect it at all. That’s a fundamental misunderstanding that I still see in very well-meaning criminologists who believe that, “Okay, if we just adjust the punishment a little bit, then we should be able to deter drug use and people will be more successful in probation.”

I’ve never believed that punishment, however you want to shape it, is what motivates people to get sober. What get people sober is high degrees of social support, opportunities at different life courses and the ability to find something that’s deeply, personally meaningful to that individual and associate with peers who also believe the same thing.

That’s a concern. I think that it’s going to take us a little longer because what’s happening right now is now that it’s unfashionable to just straight out punish people with addiction, we’re starting to incorporate the punishment into the treatment. I think that that’s going to have very limited access, and when people realize that it’s not working, then they’re going to become more and more disenchanted and pessimistic about anybody’s chances of getting sober. Whereas if you support the individual, recovery is very likely. People get sober all the time.

David: Yes, but that punishment approach just does not jive with the scientific way that we understand addiction.

Dr. McCauley: Yes, it’s not just a political position. It’s not just that I have an ax to grind. Yes, that’s what the data shows. Even criminologists will tell you that. I’ve spent the last two decades trying to explain carefully to all kinds of audiences and some of them quite hostile, that punishment may look like it’s working, but what makes addiction so interesting is it’s different from the normal population. In the normal population, the deterrence of the prison or the punishment is 100% successful.

Everybody say, “I’m not going to do that because I don’t want this to happen.” What happens in addiction is that the punishment works probably the majority of the time, but there are periods at which it starts breaking down and you cannot rely on only count on the punishment to deter the behavior. The brain has entered a different state where it gives such value in such immediate value to drug use that it’s not processing consequences at all. That’s I think an insight that still has to seep in to the policymaking world.

David: Yes, that’s interesting you talked about like the audiences that you’re delivering this to and there’s still some hostility. How do you describe the reaction that you get?

Dr. McCauley: It depends. The toughest, but really the best audiences for me are district attorneys, officers. They’re world weary. They’re tired of trying this out of the other thing. They actually have the agenda of protecting the public and ensuring justice because I think this is important to just state, people with addiction do bad things and they harm people. I certainly did. I’m not saying every person with addiction does that, but if you’re in the game long enough, yes, there are going to be some people who get burned along the process.

It’s not that I don’t respect the mandate of the prosecutors. Trying though to explain that there are variations in intent in the criminal state of mind bent on doing bad things, that’s not really very well understood in our legal traditions. It’s much better understood in England where diminished capacity has quite a bit of tradition to it, but trying to separate the criminal act, what lawyers call the actus reus from the criminal intent, the mens rea is not something that we necessarily are very good at, but I do think that this new neuroscience of addiction will point us in a direction where we can more effectively do that and then of course, deliver justice in a more accurate way.

Other audiences would be– I think the one that really matters to me are parents, families. I now have a better understanding of exactly what I put my family through. I feel an obligation to make amends. I craft my lectures to specifically answer questions that routinely come up from families, that that helps them understand what’s going on and really feel some hope because I think overall that is the story of all this neuroscience that it’s very hopeful. The people do get better and most people who stick with the recovery thing, they eventually find it.

Daid Condos: Dr. Kevin McCauley is an author, speaker and senior fellow with The Meadows based in Sedona, Arizona. He’ll join us again in the next episode as we continue our conversation on the neuroscience of addiction. You can find more about his work at www.drkevinmccauley.com.

To check out more episodes of this podcast and find all kinds of other resources and tools for Meadows Behavioral Healthcare, visit www.beyondtheorypodcast.com. Finally, thank you for listening, and I hope you’ll join us again next time for another episode of Beyond Theory.