28Jul/14

The New York Times Screws up on Marijuana

Over the weekend, the New York Times called for an end to marijuana prohibition. The link to the editorial is here. I’m going to reprint the entire piece here and address it line by line. I believe that legalization has too many problems, but I support decriminalization. My comments are in red.

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It took 13 years for the United States to come to its senses and end Prohibition, 13 years in which people kept drinking, otherwise law-abiding citizens became criminals and crime syndicates arose and flourished. The lawlessness is correct, but what people fail to discuss is that there was less drinking during prohibition, fewer accidents caused by drinking, and fewer cases of cirrhosis of the liver.  It has been more than 40 years since Congress passed the current ban on marijuana, inflicting great harm on society just to prohibit a substance far less dangerous than alcohol. I agree that marijuana is less harmful than alcohol.

The federal government should repeal the ban on marijuana.

We reached that conclusion after a great deal of discussion among the members of The Times’s Editorial Board, inspired by a rapidly growing movement among the states to reform marijuana laws.

There are no perfect answers to people’s legitimate concerns about marijuana use. Agreed. There needs to be more medical research on marijuana, which requires the Federal Government to move it from a schedule I to schedule II drug. But neither are there such answers about tobacco or alcohol, and we believe that on every level — health effects, the impact on society and law-and-order issues — the balance falls squarely on the side of national legalization. Tobacco and alcohol policy can be instructive here. Both substances are taxed, and yet the money they raise pales in comparison to the medical, criminal justice and social costs that they incur.  That will put decisions on whether to allow recreational or medicinal production and use where it belongs — at the state level.

We considered whether it would be best for Washington to hold back while the states continued experimenting with legalizing medicinal uses of marijuana, reducing penalties, or even simply legalizing all use. Nearly three-quarters of the states have done one of these.

But that would leave their citizens vulnerable to the whims of whoever happens to be in the White House and chooses to enforce or not enforce the federal law. Agreed.

The social costs of the marijuana laws are vast. Agreed. There were 658,000 arrests for marijuana possession in 2012, according to F.B.I. figures, compared with 256,000 for cocaine, heroin and their derivatives. The ironic point here is that if marijuana is legalized, the number of arrests will actually go up (underage use, intoxicated driving). Even worse, the result is racist, falling disproportionately on young black men, ruining their lives and creating new generations of career criminals. Agreed. But…when someone who is under 21 gets arrested for possessing marijuana, who do you think will get off? Who will be charged? (rich white people will get off and poor black people will be charged…so legalizing marijuana won’t change this)

There is honest debate among scientists about the health effects of marijuana, but we believe that the evidence is overwhelming that addiction and dependence are relatively minor problems (this is an irresponsible claim), especially compared with alcohol and tobacco. Moderate use of marijuana does not appear to pose a risk for otherwise healthy adults. Agreed. Claims that marijuana is a gateway to more dangerous drugs are as fanciful as the “Reefer Madness” images of murder, rape and suicide. Agreed.

There are legitimate concerns about marijuana on the development of adolescent brains. Agreed. For that reason, we advocate the prohibition of sales to people under 21. Fine, but please remember my above point regarding arresting underage users.

Creating systems for regulating manufacture, sale and marketing will be complex. But those problems are solvable, and would have long been dealt with had we as a nation not clung to the decision to make marijuana production and use a federal crime.

In coming days, we will publish articles by members of the Editorial Board and supplementary material that will examine these questions. We invite readers to offer their ideas, and we will report back on their responses, pro and con.

We recognize that this Congress is as unlikely to take action on marijuana as it has been on other big issues. But it is long past time to repeal this version of Prohibition.

22Jul/14

John Oliver’s Brilliant, Succint and Funny Take on Prisons and Criminal Justice Policy

On Sunday night, John Oliver devoted 17 minutes of his show to discussing prisons and criminal justice policy. He touches upon:

(1) how Sesame Street is now teaching kids how to cope with a parent that is incarcerated

(2) mandatory minimums for drug offenders

(3) the disproportionate number of minorities in prison

(4) the lack of services for prisoners, including inadequate food

(5) the privatization of prisons

(6) how privately owned prisons look for investors by arguing that they are good investments because of “high recidivism rates”

It’s incredibly well done. To see it, click here.

21Jul/14

The Legalized Drug Market for Opiates

Over the weekend, an article appeared in the New York Times about a doctor who knowingly overprescribed oxycotin (and other drugs) to known drug dealers:

Dr. Li, an anesthesiologist from Hamilton, N.J., ran a pain management clinic one day each weekend in Flushing, Queens, where he saw dozens of patients a day, posted a price list on the wall for drugs that included oxycodone and Xanax and accepted payment primarily in cash. During closing arguments, prosecutors said Dr. Li was driven by greed and ignored warnings from emergency room workers and his patients’ relatives that he was placing lives at risk. His lawyer, Raymond Belair, countered that he was dealing with difficult patients, some of whom misled him about their substance abuse problems.

The case against Dr. Li was unusual because the office of New York City’s special narcotics prosecutor typically charges doctors accused of knowingly prescribing painkillers to drug abusers with criminal sale of a prescription for a controlled substance. Dr. Li was instead charged with manslaughter after Joseph Haeg and Nicholas Rappold, who were under his care, died. Though the tactic has been used in cases in several other states, it is rare in New York.

The story of doctors like the aforementioned Dr. Li are why there are prescription drug monitoring programs (PMP) in 49 of the 50 states. Missouri is the one state that does not have a PMP. Unsurprisingly, Missouri has a huge problem with the illegal acquisition and sales of prescription drugs. Today’s New York Times has a story about Missouri: America’s Drug Store. Foolishly, a few state lawmakers have refused to implement a PMP there:

But while proponents say the vast majority of the Legislature supports the measure, it has been blocked by a small group of lawmakers led by State Senator Rob Schaaf, a family physician who argues that allowing the government to keep prescription records violates personal privacy. After successfully sinking a 2012 version of the bill, Mr. Schaaf said of drug abusers, “If they overdose and kill themselves, it just removes them from the gene pool. There’s some people who say you are causing people to die — but I’m not causing people to die. I’m protecting other people’s liberty,” Mr. Schaaf said in a recent interview in his Senate office. “Missouri needs to be the first state to resist, and the other states need to follow suit and protect the liberty of their own citizens.”

Mr. Schaaf’s steadfast opposition has come under sharp criticism from fellow Republicans, including a United States representative, Harold Rogers, Republican of Kentucky, one of eight states on Missouri’s 1400-mile perimeter. “It’s very selfish on Missouri’s part to hang their hat on this privacy matter,” Mr. Rogers said. “The rest of us suffer.”

History informs us that Senator Schaaf can only impede progress for a time and that Missouri will eventually get her PMP up and running. In the meantime, the state suffers. But there are some interesting characters that have sprung up to fight the lack of a PMP. One of them is Richard Logan (pictured below), a dual-classed pharmacist and sheriff’s deputy.

On his office phone at L & S Pharmacy, Richard Logan listened as a doctor’s office detailed how a patient had just left with her third prescription for painkillers in only nine days — and was quite possibly getting more, illegally, elsewhere.Mr. Logan, 61, holstered two guns, slipped on a bulletproof vest and jumped into his truck. Because in his small corner of America’s epidemic of prescription drug abuse, Mr. Logan is no ordinary pharmacist. He is also a sheriff’s deputy who, when alerted to someone acquiring fraudulent drug prescriptions, goes out to catch that person himself.

“I’m only one guy, and for every person we get to, there are probably 100 who we can’t,” Mr. Logan said. “How many people have to get addicted and die for us to do what everyone else is doing about it?

18Jul/14

What do Recovery Coaches and Sober Companions do? (and why should you be wary of them)

Recovery Coaches and Sober Companions* are in the news lately because of a recent article in the New York Times and the fact that Toronto Mayor Rob Ford has a sober companion. One of the key concerns regarding recovery coaches is that they are not required to have any education, training or licensing (it is harder to cut hair or do nails than it is to be a recovery coach). The article from the July 11, 2014 NY Times described how wealthy New York women that struggled with addiction were employing recovery coaches:

“You get over one thing and you get slammed with something else,” said Ms. Mellon, 47, looking slinky in a crisp white blazer, a high-slit skirt and gladiator sandals. She recalled some of the ordeals: her father’s death, two hostile takeover attempts, taking her mother to court. “It’s a miracle I’m still here,” she said. Her secret to staying sober through it all? Ms. Mellon enlisted the aid of a recovery coach, Martin Freeman, a London-based psychotherapist.

Ms. Mellon’s recovery coach is a psychotherapist (the article does not mention if he is licensed in New York state though). Most recovery coaches are unlicensed and either shoddily or completely untrained. One doesn’t need a license to be a recovery coach; they don’t even need a certification. A person can get a certification in New York state quite easily. To get the certification, one doesn’t have to have a license, or a college degree, or any work experience. A person needs only take 60 hours of training (a week and a half of classes) and to pass a test. The more serious professions require significant levels of education, intense trainings, difficult tests and then lengthy licensure requirements (medicine, law, accounting, counseling, teaching, engineering, plumbing). These barriers to entry keep the fly-by-night charlatans out of those fields as much as possible and also serve to protect the public. The lack of a barrier means that almost anyone can be a recovery coach and that it is difficult for consumers to find viable help. There are websites and organizations springing up to offer credentials in recovery coaching in order to give them the appearance of legitimacy. Here is one of them; it’s clearly not Mensa.

Let’s return to the NY Times article and Ms. Mellon:

“He’s the most enduring relationship I’ve had,” said Ms. Mellon, who keeps her sobriety coach on a retainer to ensure he will be there for morning chat sessions and late-night calls and to accompany her to stressful events. “I’m his one and only.”

There are a few causes of concern here:

(1) how often are these morning chat sessions and late-night calls and how much do they cost?

(2) “the most enduring relationship I’ve had” is an worrisome statement – people in recovery often have poor boundaries and struggle with relationships

(3) “I’m his one and only.” What happens if that recovery coach moved? Or if the coach took on another client? Would Ms. Mellon get angry? Feel hurt? Relapse? Because recovery coaching is unlicensed and unregulated, they are not held to the same standards that psychologists, social workers, licensed drug & alcohol counselors or licensed professional counselors are.

More grist for the mill from the Times:

“Addiction is a disease of isolation,” added Ms. Karr, 59, who has a 28-year-old son (she starts “Lit” with an open letter to him). “I would have loved to have someone come over and help me not get drunk.” It’s not just the extra glasses of pinot or rosé. Cosmopolitan mothers these days are also reaching for Adderall (the multitasker’s best friend), Percocet (the antidote to the taxing trifecta of marriage, children and career) and Ambien (that bedtime staple), not to mention a cocktail of other drugs that high-strung mothers also have at their disposal. And by the time these mothers realize they need help, they don’t exactly have the time or wherewithal to check into rehab or attend 12-step meetings. In addition, they want more privacy, the better to avoid the judgment and stigma that mothers with addiction face.

In addition to alcohol, people are addicted to stimulants, painkillers, sedatives and tranquilizers. They need professional help, not para- or quasi-professional help. Another concern is the line “they don’t exactly have the time or wherewithal to check into rehab or attend 12-step meetings.” It is that kind of self-absorption and denial that makes them a high risk to relapse. If you are addicted, you should go get professional help and probably should enroll in an in-patient or out-patient treatment program. “Who has time for treatment?” is akin to the following ridiculous questions: who has time to sleep, eat, exercise, save money, or engage in other behaviors that increase our health and longevity.

Back to the Times article and Ms. Powers, an untrained, unlicensed recovery coach:

Ms. Powers, 53, a former heroin addict, was an art director at Area, a prominent nightclub in New York during the 1980s, before moving to Los Angeles to get clean. She joined Narcotics Anonymous, where she became a sponsor to help fellow addicts through the program. These days, when she’s not on a tour bus with a rock-star client or on a film set with an actor, Ms. Powers rides her bike from Wall Street to Carnegie Hill, where she weans mothers from Vicodin or Klonopin.

“They’re starved for companionship,” Ms. Powers said. “Today’s pill-popping moms are a far cry from the bored, suburban housewives of ‘The Valley of the Dolls.’ They’re taking opioids, which are dangerously addictive. If you’re trying to withdraw from OxyContin, a doctor might prescribe Suboxone, which is even harder to kick than heroin.”

So we have unlicensed, untrained professionals helping people get off of dangerous drugs and charging money for it. Ms. Powers heart is probably in the right place, and she appears to have had a few success stories. But her dismissal of Suboxone, which is a legitimate medication assisted therapy (MAT), is unfortunately fairly typical of a number of people in 12-step programs. Claiming to be a recovery coach and charging money for her work gives Ms. Power’s medieval views an ill-earned sense of legitimacy. This is a problem.

Rob Ford made international headlines last year as the crack smoking mayor of Toronto. After a series of escalating episodes, Mayor Ford recently went away to rehab for two months. Upon his return to work, he announced that he had a recovery coach, Robert Marier. Mr. Marier is a self-identified former crack addict with a lengthy legal history who claims to be sober for the last 10 years. This is from the July 14, 2014 Toronto Globe and Mail:

Mr. Marier has no formal clinical training, instead using his own experience – a “been there, done that” attitude – when working with clients. Working through a company that hires him out, he said he’s helped hundreds of clients in the five years he’s been coaching.

I hope people are picking up on the theme here: unlicensed and untrained individuals that work with people with addictions and claim to have helped hundreds of people. How do they measure success? Do they keep data? Do they engage in supervision, where they discuss their clients’ issues with other recovery coaches? Are there quality of care reviews? I expect the answer to all of these questions are either “not applicable” or “no” or “no comment.” More on Mr. Marier:

Donny M., a recovering cocaine addict who asked that his last name be withheld, credits Mr. Marier for saving his life. The 24-year-old had seen Mr. Marier around in AA meetings, but in 2010 he was surprised (and irritated) when the grey-haired man approached him in a McDonald’s restaurant.

“He just came up to me and asked me about cleaning my apartment and stuff like that – ‘did you make your bed this morning?’” Donny said. “It’s a Bob thing … addicts, we think we’re too good to do the things that normal people do. We think we’re above it,” he said. Over the next four years, Mr. Marier became Donny’s AA sponsor, showing up at 8 a.m. every Saturday morning to drive him to meetings.

Mr. Marier is both a sponsor and recovery coach; the lines are blurred. I have no doubt that Donny has found Mr. Marrier to be helpful and supportive and that Donny’s life is better for it. But it seems that his life is better because he went to AA and got Mr. Marier as a sponsor…unless Mr. Marier charged Donny money for his efforts. Legitimate professionals do not approach people at McDonald’s looking for work or to haggle them (car salesman and Jehovah’s Witnesses do, but let’s give some respect to the word legitimate). Mayor Ford’s sobriety coach is alleged to have kicked a protester while the mayor was holding a press conference last week. Mr. Marier denies this: “It didn’t happen. We touched each other. It was a grazing, and there was no kicking motion. Absolutely none.”

Why Sober Coaches Earn $1000 A Day was published on thefix.com a few years ago. A couple of different high paid recovery coaches talked about the problems with recovery coaching. One of them is Ms. Powers, who apparently is one of the stars of the field and a media darling.

Unfortunately sober coaches can become as much of a crutch for some clients as the drinking and drugging once was. The onus is on the  companion to maintain healthy boundaries and an appropriate degree of professionalism—a dangerous position, given how many hustlers there are in the game. Schrank notes that the business isn’t regulated in any way: “There are no professional associations or standards of practice,” he says. “So you have a lot of charlatans in this game.”

Powers admits that some sober companions have dubious qualifications for the job. “You are a sober coach if you say you are, so what does that mean?” she asks. “It means there will be people with a good sales pitch and a gift for hustlers using therapeutic jargon—people who may not really be in recovery—selling themselves as sober coaches. If someone is looking for a sober coach,  I’d tell them to really take time to interview several candidates, or better yet, have their therapist speak to them before arriving at a decision.”

There is a company called Sober Champion which has a nice website and attempts to explain what sober coaches and sober companions are and are not, but they still have pretty lax requirements. They advertise that they will “accommodate your lifestyle” and help you “Stay out of jail!”

There was a great article on thefix.com titled I was a paid celebrity sober companion. The author talks about how he was flown out to LA to help out a celebrity for $600 a day. He felt out of place and ran into all kinds of problems because of the celebrity’s status and money. He discovered that he could help the celebrity by coercing him to go to 12-step meetings and getting him to open up during long talks. Eventually, the author returned to NYC and drank again. He didn’t blame his work as a recovery coach as the cause of the relapse, but he acknowledges that it “didn’t help.”

There certainly must be some good recovery coaches out there, but they are few and far between and hard to identify. As a group, they aren’t as bad as the predators who put addicts on television, but it is close.

The concept of the recovery coach is not new. Major League Baseball has had stars with drinking problems since the game was invented, and clubs looking to keep their stars on the field employed recovery coaches/handlers/babysitters over a hundred years ago. They were called “keepers” then, and of course, average or below average players weren’t given keepers. It was only for really good players. Steven Goldman, a NJ based writer who used to be the Editor-In-Chief at Baseball Prospectus, wrote one of my all-time favorite articles in February of 2011 after (future 2-time MVP and triple crown winner) Miguel Cabrera was arrested and charged with driving under the influence in Florida.

Let’s try a real antecedent, Jimmie Foxx. There’s a funny scene in A League of Their Own, the 1992 film about women’s professional baseball during World War II where “Walter Harvey,” a stand-in for Phil Wrigley, lectures ex-player “Jimmy Dugan,” a character inspired by Foxx:

Walter Harvey: You kind of let me down on that San Antonio job.
Jimmy Dugan: I freely admit, sir, I had no right to sell off the team’s equipment like that; that won’t happen again.
Walter Harvey: Let me be blunt. Are you still a fall-down drunk?
Jimmy Dugan: Well, that is blunt. Ahem. No sir, I’ve, uh, quit drinking.
Walter Harvey: You’ve seen the error of your ways.
Jimmy Dugan: No, I just can’t afford it.
Walter Harvey: It’s funny to you. Your drinking is funny. You’re a young man, Jimmy: you still could be playing, if you just would’ve laid off the booze.
Jimmy Dugan: Well, it’s not exactly like that… I hurt my knee.
Walter Harvey: You fell out of a hotel. That’s how you hurt it.
Jimmy Dugan: Well, there was a fire.
Walter Harvey: Which you started, which I had to pay for.
Jimmy Dugan: Well, now, I was going to send you a thank-you card, Mr. Harvey, but I wasn’t allowed anything sharp to write with.

All of which is hilarious until you consider that the great Double X was through as a big-league regular at 33, and would have been through period if not for a wartime encore. Yes, he hit .325 with 534 home runs career, but he also lost a third of his value after his age-31 season and all of it shortly thereafter. He died, miserable, at 59. In John Bennett’s excellent short biography for SABR, the question of when and why Foxx starting drinking is kicked around quite a bit—was it the chronic pain from a devastating 1934 beaning that drove him to it? His daughter dismissed that explanation: “Daughter Nanci believes his drinking problems had a lot to do with the emptiness he felt in adjusting to normalcy once his playing days had ended.”

Who, so gifted an athlete—and Miguel Cabrera is certainly that—would do things that would hasten forth the inevitable end, sending themselves hurtling pell-mell towards the fate that awaited Mantle? “Well, hold on,” you might say. “Alcoholism is a disease. Addiction has both a psychological and biological component.” This is true. Yet, unlike most other diseases, this one can be responsive to therapy and the exertion of human willpower. No 12-step program will cure congestive heart failure or lung cancer, but it just might allow a fellow to lick a drinking problem.

Of course, a problem drinker has to want to get on the wagon. Listening to sports radio last week, I heard several callers question why the Tigers had not assigned Cabrera a handler or babysitter—“keepers” is what they called them in baseball’s rowdy early days—a sober hand who could steer the player safely from ballpark to hotel with nary a saloon stop in between. The problem is, it’s not a new idea and it generally didn’t work.

The Giants tried it with the aforementioned Phil Douglas, a quality pitcher on two pennant-winning teams they would have very much liked to keep dry and focused. His last keeper was a future Hall of Famer, the former left fielder Jesse Burkett. Burkett, nicknamed “The Crab” for his less-than-cheerful disposition, and Douglas made quite the odd couple. “They probably drunk more ice-cream sodas together than any two grown men in history, before Doug got away on his last binge,” a former teammate recalled to John Lardner.

Yet, get away he did, and he drank himself out of the game, albeit faster than did, say, Rube Waddell or Hack Wilson. Wilson, like Cabrera and Foxx a right-handed power-hitter, is another example of a player who invested more in the bottle than in the maintenance of his baseball career, and spent the rest of his short life regretting it. He also had his share of keepers, concerned friends, solicitous managers, and helpful teammates. It didn’t matter. He stopped being interesting at 32,  was out of the league at 34, and died at 48. Or consider Foxx’s post-career fate, pink-slipped from his last job in baseball, as Gene Mauch’s hitting coach for the Triple-A Minneapolis Millers. As Mauch later recalled (again, see Bennett’s SABR bio), Foxx “was seldom at the park on time to be of help. I idolized the man, and kept him away from scrutiny. At the end of the season, [Red Sox GM Joe] Cronin gave him his money and sent him home—it was so sad.” Baseball is a very forgiving game, but not if you can’t handle yourself.

I think there may be some instances where recovery coaches can help, but they need to be educated, trained and licensed professionals. There is too much room to cause harm. As addiction and recovery work there way more and more into the public spotlight (partly because of the 21st century opiate epidemic), more and more people will look to make money off of this problem. I don’t begrudge anyone for trying to make a living, but not at the expense of someone’s sobriety or life. Be wary of the predators. Be wary of recovery coaches, sober companions, sober escorts and sober coaches.

 

* Recovery coaches, sobriety coaches, sober escorts and sober companions are different words for the same quasi-profession. I will use the term recovery coach for the rest of this article for literary consistency

09Jul/14

Frederick Douglass was a Recovering Alcoholic

Frederick Douglass is one of my great heroes. He was born a slave in 1818. He taught himself how to read and write and at the age of 20, he ran away to freedom. He spoke about his experiences as a slave, and how slavery debases both the slave and the slave owner. He would tell how slave owners would act pious in church and in their communities and then come home and yell and beat their slaves. Douglass was such an eloquent speaker that many people raised the question of whether or not he had ever been in bondage. In 1845, he wrote the Narrative of the Life of Frederick Douglass in order to prove to people that he had been a slave. He was very specific with exact names and locations so that people could fact check. He did not want there to be any doubt about his story (the book is 70 pages long and can be bought in paperback for $2 or on kindle for $1…every American should read it).

In Chapter X of his book, he writes about:

(1) How slaves were given the time off between Christmas and New Year’s, and that their masters encouraged them to drink. “It was deemed a disgrace not to get drunk at Christmas.”

(2) Some slave owners would make bets on their slaves to see who could drink the most without getting drunk.

(3) “We felt, and very properly too, that we had almost as well be slaves to man as to rum.”

(4) “So, when the holidays ended, we staggered up from the filth of our wallowing, took a long breath, and marched to the field, — feeling, upon the whole, rather glad to go…back to the arms of slavery.”

One of his great joys in life was teaching other slaves and ex-slaves how to read. It wasn’t enough to be free, but one had to be educated in order to protect one’s freedom and to be a productive member of society.

After his book was published, Mr. Douglass went on a tour of Britain and Ireland for two years. While he was over there, he described himself over and over again as a “sot” in his speeches. Sot is an English word that originated sometime in the 1590′s and means “one who is stupefied by drink.” He would talk about the evils of slavery, the religious hypocrisy of slaveholders, how slaves are encouraged to drink and discouraged from reading. He said,

“There is no freedom from the bondage of slavery without freedom from the bondage of alcohol.”

Frederick Douglass was a recoverying alcoholic* before we had the term. He experienced physical and mental slavery and eventually overcame both. He got educated, traveled, helped others and he talked about his experiences. He was a role model and he helped implement changes on a national level. His story has a number of themes that resonate with people in recovery today (clearly, his journey was harder).

I am not going to be so arrogant and foolish as to say what Mr. Douglass’s positions would be on current issues, other than to say that he probably would have encouraged people with substance abuse problems to not use and all people to get educated.

He’s one of my great role models, and I want to share him with you.

* or use whatever term you are comfortable with: reformed drinker, former drinker, person in long-term recovery, abstainer

06Jul/14

Medication Assisted Treatment for Opioid (Opiate, Heroin, Painkiller) Addiction

Someone who is addicted to heroin or oxycotin often follows a treatment path that looks like this:

(1) trouble at home, school, or work (which may include an arrest (which may or may not lead to jail)

(2) 2-10 days in at a medical detox

(3) rehab (if they have insurance or enough money)

(4) intensive outpatient counseling (again, if resources are there)

(5) 12-step meetings

But this plan (or variations of it) are sometimes just not enough to help someone quit and stay away from opiates. There is an ever-growing body of scientific evidence that Medication Assisted Therapies are effective in helping treat people with opiate addictions. Despite this evidence, numerous people have risen to decry MAT. These opponents include people in 12-step programs, insurance companies and concerned professionals who think they aren’t handled properly at all times (this last group is different from the first two).

Methadone (a schedule II drug) was the first modern MAT and it was created in Germany in the 1930′s and introduced to America  in the late 1940′s. By the 1960′s, it was the defacto treatment for heroin addicts, especially ones in the cities. Critics of it consider it state-sponsored addiction and they have some justifiable points. Many people experienced euphoric highs on methadone and other stayed on for 10 or 20 years, living a seemingly zombie-fied life. It is probably the existence and public experience of methadone that have turned many people against MAT’s.

In 2002, the Drug Abuse Treatment Act (DATA) was passed by Congress and buprenorphine was introduced to the American public as the new MAT for the treatment of opiate addiction. Buprenorphine is better known as Suboxone or Subutex and has had much better success rates than methadone. Patients see a doctor one to five days a week (depending how far along they are in treatment and how well they are doing). Patients are expected to submit weekly drug screens and to get weekly therapy from a licensed substance abuse professional (this is not required by law…but it should be). Buprenorphine is classified as a controlled dangerous substance by the FDA (schedules III, IV and V, depending on the type and dosage) and can only be prescribed by medical professionals who have gone through a very specific multi-day training.

Suboxone diversion concerns some doctors.  These concerns are valid. The best article about buprenorphine I’ve come across appeared in the NY Times last November. Some medical professions are very loose when prescribing it, while others run a very tight ship. I prefer the latter group.

Vivitrol is injectable naltrexone. Because there isn’t any opiate or synthetic opiate in it, it is not a controlled substance. Any doctor can prescribe it. Patients get a shot 1x a month. Vivitrol helps reduce cravings and it mostly blocks the euphoric effects of opiates. When combined with therapy, 12-step meetings and/or other lifestyle changes, it can be quite effective. This is the MAT that I prefer and try first with people that see me.

There have been numerous instances where people in 12-step programs (AA or NA) have told new members that they shouldn’t take medication or that they “aren’t really clean” if they are using medication to assist their recovery. Those individuals are flat-out wrong. Dr. Lou Baxter, the past president of the American Society of Addiction Medicine (ASAM) recently wrote an article about MAT’s. His most recent article refutes false statements by self-appointed people that claim to speak on behalf of 12-step programs that people in recovery shouldn’t take medications to help quit drugs. Dr. Baxter argues:

Although there is no dispute that abstinence from alcohol and other drugs with potential for addiction is the foundation for sustaining recovery in most instances, there are other cases where MAT, especially for persons with co-occurring illnesses, is essential to obtain and sustain term recovery.

In the late 1980′s it was discovered by NIH that addiction was a brain disease. Since that time, medications with FDA approval have been developed to target those areas of the brain. These medications have shown great efficacy in assisting patients into and sustaining recovery. Every other chronic medical disease employs and encourages the use of medications in concert with life-style changes. Addiction medicine should examine the benefit of following suit.

MAT in addiction treatment is not required for everyone, but used in conjunction with 12- step programs and other biopsychosocial interventions, for those that need it, has shown to be invaluable in appropriate cases.

Another barrier to effectively using MAT’s has been that insurance companies rarely pay for them. Stuart Gitlow is the current president of ASAM and has been speaking and writing about the importance of MAT’s for the last several years. Last winter, he wrote an article about the barriers created by insurance companies (and some other impediments as well). Some directly-quoted highlights:

(1) …state governments and insurance companies regularly deny patients access to FDA-approved medications that could help reverse the epidemic of opioid addiction and overdose deaths. A new report released by ASAM examined the effectiveness of opioid medications and found these medications to be effective, safe and cost-effective when used for long-term maintenance treatment.

(2) Restrictions vary widely from state to state and from insurance company to insurance company, with almost none of them adhering to best practices research-based protocols for these medications.

(3) Addiction is a treatable chronic disease with success and relapse rates comparable to other chronic diseases such as diabetes and hypertension.

(4) None of the medications by themselves should be considered effective treatments for opioid dependence.

(5) Treatment professionals need to overcome their own prejudices against addiction medications and begin using them in comprehensive treatment protocols for the disease of addiction.

Bunavail was recently approved by the FDA. It is a lower-dose of buprenorphine that acts more effectively because of some improvements in the delivery method. I’m almost always in favor of coming up with advancements in medication that allow for lower doses. Lower doses leads to less side effects, which leads to better patient compliance. But this is all for naught if:

(1) medical professionals don’t require counseling and drug screens and recovery supports with the medication

(2) people in 12-step programs continue to speak out against MAT’s, pretend they are medical professionals and shame people in recovery who are using MAT’s

and (3) most significantly, insurance companies continue to not pay for MAT’s.

 

 

 

27Jun/14

History of Marijuana Policy

I’ve written a lot of marijuana this year. For the last twelve months, I’ve been speaking at conferences and universities about the history of marijuana policy in America and what the future may hold for us. I’ve focused a great deal of my attention on the recent legalization in Colorado and what I expect the consequences of that poor decision will be.

On December 4, 2014, I’ll be giving a webinar for the National Association of Alcohol and Drug Abuse Counselors (NAADAC). You can sign up for it here.

16Jun/14

What to do when your friend or family member has a drug problem

Last month, a story about me and my friend Fraser appeared on the Rutgers Today website. It is currently featured on the front page of the Rutgers New Brunswick website.

Fraser and I met at Voorhees High School in the the winter of the 1991-92 school  year. We were in honors sophomore English. There were a number of difficult kids in that class, and I still feel a bit badly for our teacher, Peggy Quadrini. Fraser and I spent the next couple of years partying, joking, eating, slacking off, watching sports, arguing and generally getting involved in chaos and mayhem. Eventually, I changed my behavior, joined the Army and went to college. Fraser spiraled downward. He cycled in and out of jails and recovery, bouncing from job to job and house to house. It was a nomadic life. A couple of times a year, he would put 60 to 120 days of continuous sobriety together. Each time he relapsed, I felt despair and anger. My first thought would be, “How could he do this to me?” and my second thought would be, “Why can’t he get it?”

frank better photo with friendfeature

In 2001, Tuffer and I picked him up from the Green Street Jail in Newark. They made us wait 4 hours until he had been there for 12 hours, so that they could bill someone for a full day in jail. After 9/11, Fraser talked his way onto the site at Ground Zero and helped in the rescue and rubble clearing efforts. In 2002, I visited him at the Somerset County Jail. His father had just passed away, and he told me, “The last time I saw my Dad was through the thick, plate-glass window of the visiting room here in jail.”  The last time I saw him was on July 8, 2002 in Clinton, NJ. He was boarding a van to go back to Freedom House (a halfway house that I really like in Glen Gardner, NJ). Eventually, he left it against medical advice. On September 23, I received a phone call from our friend Nat that Fraser had died the night before. We pieced together that he had been drinking and doing drugs. He threw up and choked on his own vomit and died. We suspect that the person he was dating was there at the time and didn’t call emergency services for several hours (because she was high at the time and there wasn’t a Good Samaritan Act then). I cried for days and felt empty. I kept thinking “I could have done more” or “I should have been there.”

Several people pointed out that I couldn’t have prevented his death and that I was powerless over his addiction. I grieved for a long time. Eventually, I realized that I was also angry at him for dying. It was hard being angry at my dead friend. I talked about it with a lot of people. A few months after his funeral, I left for Toyko, Japan. I taught English there for a year and then traveled around Japan and Southeast Asia. I mourned for Fraser and thought about what I was going to do with my life. When I returned to America, I took at job at Integrity House in Secaucus, NJ. A month after I started that job, I also applied to the MSW program at Rutgers.

I have been working in the field of substance abuse for 11 years now. The following is the best advice that I can give people that are concerned about a friend, family member or loved one that you think has an alcohol and/or drug problem:

(1) Don’t drink or do drugs with them

(2) Don’t drink or do drugs around them

(3) Set firm boundaries – don’t let them drink or do drugs around you.

(4) Don’t give them money. For anything. Money you give them for food, rent, clothes, legal fees or something else is very likely to be used for alcohol or drugs

(5) Get into therapy. You need someone to talk to about this. If you are a student in middle school, high school or college, there should be a counselor available at there for you to talk to

(6) Attend Al-Anon or Alateen. At least 6 times. If you go to a meeting and the focus is on the alcoholic or addict, go find a different meeting where the people there talk about themselves, their feelings and their actions (or inaction)

(7) Work with a professional and consider imposing consequences: taking away the car, their phone, kicking them out or even calling law enforcement on them. Encourage (or force) them to go see a licensed professional

(8) Confront them. Express your concerns. Do not yell, curse or name-call. Explain how you see they have changed, how you feel and what you want to be different (a professional can really help you with this). This is extremely important, as one of the criteria that professionals look for is, “Has someone every confronted you about your drinking or drug use?” If multiple people have confronted someone, that can help them get clean years before they might otherwise.

There are other things you can do, but this is a great start. Stop and think about how much time and energy you have spent worrying about your loved one. Do you get distracted during the middle of your day or lie in bed thinking about her late at night? Have you neglected other areas (or people) in your life? Have you made excuses or blamed others (their friends, the school, co-workers, ex’s or cops) for his behavior? If you’ve answered yes to any of those three questions, then you should go see a professional and follow my aforementioned steps. You may or may not be able to help your loved one, but you’ll certainly be able to help yourself.

 

13Jun/14

Heroin: White People and Black People

I read an article on Fox recently with the headline “Face of Heroin Addiction Now Young, White and Suburban” (you can read the article here). The article was written after the release of a small study of people seeking treatment for opiate addiction. The major point of it is this:

Today, the average heroin user is 23 years old and tends to live in a suburban or rural area. More than 90 percent of the study subjects who reported that they began abusing heroin in the past decade were white. However, the study authors acknowledged that their research was limited, since they only analyzed participants seeking treatment for their addiction.

There are two points here, and neither of them should be considered new nor news. The first point is that a lot of young white people are using opiates. When “Glee” star Cory Monteith died last summer, the articles about “the new face of heroin” abounded. We’ve known this for about a dozen years. The proliferation of prescription drugs introduced a new class (and generation) of people to opiates. When those prescription opiates became too costly, they switched to heroin. The second point is that most of the people that get into treatment for opiates are white. On average, white people have more money, better insurance, less stigma and more access to treatment. Of course more of the people in treatment are white people. It’s this second point that really bothers me.

The heroin epidemic is not new. I’ve said so many times. Richard Pryor had a huge problem with cocaine, and it unfortunately played out in the national spotlight in the early 1980′s. He discussed his cocaine problem and how white people got caught up in it during one of his shows:

“Y’all remember?  Y’all used to drive through our neighbor hoods and shit and go, ‘Oh, look at that.  Isn’t that terrible.’ Then you’d get home, right, and your 14 year old’d be fucked up, and you’d go, ‘OH MY GOD!  IT’S AN EPIDEMIC!’..”

For decades, poor and minority communities have been ravaged by heroin use. Little was done to help and the plight of the addicted in those groups got worse. As a result, the economic and living conditions of their communities deteriorated as well. Addicted people are very likely to have addicted kids and the plague spread. Regardless of one’s moral views of this subject (or the value you place on poor and/or minority lives), there can be no mistaking the devastating economic costs of letting addiction spread and thrive. It has effected white suburbia in the 21st century, and now schools, parents, the media, law enforcement and politicians are noticing and attempting to take action.  Richard Pryor saw this happen 30 years ago with cocaine and spoke about it.

Paul Mooney has talked about this type of thing as well, but he gave a more apt-fitting name (or meme) to it:

The great political comedian Paul Mooney made his bones by laying in the cut between American democratic ideals and American behavior.  A mentor and inspiration to his friend Richard Pryor, Mooney’s stock-in-trade is a canny ability to thread the truth between ongoing and established hypocrisies — to make us see the pathologies that are still at the core of our decision-making and societal array.

One of his best routines involves the “nigger wake-up call,” that signal moment when the rest of America finally understands something, and comes to resent and acknowledge that which black and brown America has internalized and tolerated for generations

This last section was copied verbatim from David Simon’s post “The Nigger Wake-Up Call”, which he published last summer after the NSA home-spying revelations.

Regardless of race and class, we need to address the heroin and other opiates epidemic. If we only address it in the white and wealthy communities, then we have done a terrible, terrible job. We need to make sure that we implement sound policies and create excellent programs for all.

————–

Addendum (6/13): Here is a story from today about a drug sweep that recently took place in Northern NJ. As you can tell by the photos, an overwhelmingly majority of those arrested are young and white. Unsurprisingly, they will be offered treatment instead of incarceration. Another salient fact is that despite the changing demographics of heroin use, people travel into desolated inner cities to buy their drugs. If we don’t address the problem in the inner cities, those markets will continue to function and the work that is done in the suburbs will be ultimately fruitless.

The end of the article touches upon another sore subject: for those that live in Paterson (largely poor, largely minority), they don’t get that option. Their option is jail.

09Jun/14

Counties sue Big Pharma over ultra-addictive painkillers and their “campaign of deception”

In the middle of May, the counties of Orange and Santa Clara in California filed a 100 page lawsuit against Big Pharma for “false advertising, unfair business practices and creating a public nuisance.” The LA Times ran a very good article on it. Some highlights:

(1) The lawsuit alleges the drug companies have reaped blockbuster profits by manipulating doctors into believing the benefits of narcotic painkillers outweighed the risks, despite “a wealth of scientific evidence to the contrary.”

(2) The complaint accuses the companies of encouraging patients, including well-insured veterans and the elderly, to ask their doctors for the painkillers to treat common conditions such as headaches, arthritis and back pain.

(3) The widespread prescribing of narcotics has created “a population of addicts” and triggered a resurgence in the use of heroin, which produces a similar high to opiate-based painkillers, but is cheaper, the suit says.

(4) In Orange County, where the lawsuit alleges there is a painkiller-related death every other day, Dist. Atty. Tony Rackauckas said he decided to pursue the case “as a matter of public protection.” The primary goal, Rackauckas said in an interview, is “to stop the lies about what these drugs do.”

The five companies named in the lawsuit are: Actavis, Endo Health Solutions Inc., Johnson & Johnson’s Janssen Pharmaceuticals, Purdue Pharma, and Teva Pharmaceutical Industries’ Cephalon Inc.

The most egregious offender is Purdue Pharma, the company that created Oxycotin in 1996 and has aggressively (and perhaps recklessly) marketed it ever since. In 2007, Purdue Pharma agreed to pay $635 million to settle charges that it had overstated Oxycotin’s benefits and understated it’s addictive qualities. While the fine may seem large, the Wall Street Journal estimates that annual sales of Oxycotin are about 2.8 billion dollars.  The fine amounted to about 20% of one year’s annual Oxycotin revenue. Clearly, this did not dissuade Purdue Pharma from their negative practices. Some other concerns involving Purdue Pharma:

(1) In 2013, the FDA denied generic versions of Oxycotin. This allowed Purdue Pharma to keep the patent and continue to rake in billions of dollars a year.

(2) Also in 2013, Purdue Pharma announced that they had received FDA approval to sell transdermal buprenorphine. Because of the explosion in opiate addiction over the last dozen or so years, there have been more and more people getting treatment and getting medication-assisted treatment. Buprenorphine (most common trade names are Suboxone or Subutex) is one of the best two medications for opiate addiction. Purdue Pharma is looking to capitalize on this market, which ironically (bitterly), they helped to create. If Purdue Pharma was a black male, the headlines would say that Purdue Pharma robs and kills people.

In the beginning of June, Chicago filed a similar suit against Big Pharma as well. It made headlines in NJ because Johnson & Johnson was one of the companies named. Here is a clip of a TV report about if from June 3rd.

Chicago Mayor Rahm Emanuel released a statement regarding the lawsuit:

“For years, big pharma has deceived the public about the true risks and benefits of highly potent and highly addictive painkillers in order to expand their customer base and increase their bottom line…It’s time for these companies to end these irresponsible practices and be held accountable.”

I expect that more counties, cities and perhaps states will follow these examples. Big Pharma is wealthy and employs a number of very smart lawyers. If the battles against the deceptive and negative practices of Big Tobacco provide a template, than this fight may be played out in the courts for  the next 5 to 20 years. It won’t help the person who is addicted or about to get addicted, but it might benefit kids born in 2014.