RFK Jr. Says Drug Addicts Need Tough Love. Is He Right?

A former heroin addict, the HHS nominee has special insight into how to solve the nation's drug crisis. Sally Satel sorts the good ideas from the destructive.

Published in The Free Press on January 01, 2025.

If Robert F. Kennedy Jr. is confirmed as the secretary of the Department of Health and Human Services in the Donald Trump administration, and if he carries out even part of his agenda, he will be a consequential—and controversial—cabinet secretary. I have deep concerns about some of his stances, including his record of objecting to vaccines, many of which are lifesaving. But in other areas, starting with addiction, his vision and values could transform lives.

Kennedy has declared that a priority of his is addressing the U.S. drug addiction crisis, which has killed nearly a million people since 1999. The lion’s share of these deaths occurred in recent years as fentanyl—the most potent drug ever used in epidemic proportions—burst onto the black market.

I am a psychiatrist who specializes in addiction. In addition to researching this subject, I am the medical director of a methadone clinic in Washington, D.C. So I have a vested interest in Kennedy’s policy suggestions. As does Kennedy himself.

He has lost a brother and a niece to overdoses. Kennedy’s own heroin addiction began when he was a teenager, following his father’s assassination. It ended when he was arrested at age 29 for felony possession and given two years’ probation. He spent time in rehab and in the decades since has regularly attended 12-step meetings.

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 (and some of my own suggestions).

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.”

Tough love is the opposite of “harm reduction,” a philosophy and practice that does not put pressure on drug users to quit. (The classic harm reduction policy is needle exchange, which is an important public health service.) But at the more radical end of the spectrum are the policies in liberal cities that allow street encampments and open-air drug markets.

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. Even blue states are now recognizing this. In 2024, the California legislature increased penalties for both shoplifting and drug charges. Oregon reversed a measure decriminalizing possession of small amounts of illicit substances such as fentanyl and methamphetamine. Such possession is now a misdemeanor.

I support an option—also covered in Kennedy’s documentary—that now exists for people charged with or convicted of committing a crime to support an addiction: drug court. This gives criminal defendants the chance to enter rehabilitation programs where they are held accountable. In the nation’s 4,000 drug courts, judges mandate a form of treatment for a period of, say, one to two years during which the addicted individual is not incarcerated but instead closely supervised, including via routine urine testing.

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.

What’s Kennedy’s Other Option?

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.”

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, many such programs forbid residents from taking prescription medications for addiction, such as methadone or buprenorphine. I believe the programs would be greatly improved by allowing medication.

Still, I am drawn to the idea of the immersive rehabilitation experience. Some people need physical containment in an environment without drugs to help them break the cycle.

Medications to Treat Drug Addiction

Kennedy has been quiet on gold-standard anti-addiction medications like methadone and buprenorphine. But his condemnation of psychiatric drugs such as Adderall and SSRIs has caused patients to worry about losing access to these pharmaceuticals. (Kennedy did not return a request for comment.)

Methadone, a mainstay medication that has been widely used for more than 60 years, reduces overdose deaths by about half. It is not a cure, but it effectively suppresses opioid withdrawal and reduces cravings, allowing patients to begin the arduous work of recovery.

Similarly unclear is Kennedy’s attitude toward buprenorphine, another popular and helpful anti-opioid medication, 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 and access 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.

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 at least be grudgingly tolerant of methadone and buprenorphine.

Fixing a Ridiculous 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 payment 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 championed by RFK’s well-meaning uncle President John F. Kennedy to prevent the warehousing of 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 up much-needed treatment beds to people who are severely addicted or have serious mental illnesses that make them dangerous to themselves and others.

What About GLP-1 Treatments?

Kennedy is a fierce advocate of lifestyle changes over pharmaceutical measures, including the new wave of GLP-1 weight loss drugs such as Ozempic and Wegovy. Last October on Fox News he derided the idea that a GLP-1 drug “is going to cure drug addiction or alcoholism.” He also said that if Americans ate decent food daily, they wouldn’t be obese and therefore wouldn’t need a drug to suppress appetite. Two months later, days after a clash with Elon Musk, who has taken Wegovy, Kennedy softened his stance on the value of GLP-1s, stating that they “have a place” (at least in regard to weight loss).

I hope this change of heart is sincere, because these drugs do show some promise for reducing problem drinking, smoking, and the use of other addictive drugs. More clinical trials are needed, though, and while I doubt GLP-1s will surpass current treatments for opioids, we have no medications to treat addiction to drugs like cocaine or methamphetamine, and only mildly successful medications that are FDA-approved for alcoholism.

Marijuana and Psychedelics

Not only does Kennedy advocate the legalization of marijuana, he also favors the legalization of certain psychedelics and using those tax revenues for the “healing centers” described above.

I strongly advise caution on the sale of high-potency cannabis, as the evidence of harms is accumulating. More research is essential, with special emphasis on the risk to teens, who can develop psychosis and suffer other potential damage to brain development after consuming these products.

Kennedy has also criticized the FDA for its “aggressive suppression” of psychedelics. This refers to the contentious decision last summer to withhold approval of MDMA-assisted therapy for people with PTSD. Kennedy strongly supports psychedelic therapy for veterans.

In June 2023, Kennedy said that he’s not looking for “blanket legalization” of psychedelics—“but we need to make it easy for psychiatrists and therapists who are trained to be able to use this on their patients [as] an experiment and see if we get good results.”

I am guardedly optimistic that psychedelics hold promise for a variety of conditions, but rigorous and replicable research must be conducted before general clinical use can begin.

A Fix for Nicotine Addiction

Kennedy’s October announcement that “FDA’s war on public health is about to end” could mean many things. But I hope it means that he will commit himself to saving the lives of millions of smokers by fixing the monumentally onerous regulations surrounding e-cigarettes.

Vaping is a technology that delivers nicotine without combusting tobacco. E-cigarettes help people break their addiction to cigarettes, which contains much higher levels of deadly tar and toxins than e-cigarettes.

Kennedy must streamline the regulatory process and costs for responsible manufacturers who seek authorization for their products. Only then will we stanch the flood of illicit Chinese vapes that now dominate the market.

Kennedy was seen recently carrying a can of Zyn—small oral pouches containing nicotine. That’s an indication he understands the value of safer nicotine products.

My Concluding Thoughts

Kennedy sees addiction as 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. If Kennedy is confirmed, I hope that when it comes to drug treatment, he will use his power to fortify the existing array of clinically proven interventions and support high-quality investigations into new approaches.