28Sep/16

The Insurance Denial Disaster

Frank Jones and I co-wrote this article between May and June of this year. We found that it was far too long for a newspaper op-ed and that treatment professional magazines did not want to print this. The insurance industry is powerful, as they buy a lot of advertising and contribute to thousands of politicians on both sides of the aisle on both the federal and state levels. I expect that this article will hurt my consulting business a little, but the moral and social imperatives demand that this issue be properly addressed. Mr. Jones’s biography can be found at the end of this piece.

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For over a decade, both of us have seen many insurance companies deny payment for addiction treatment services (one of us is a licensed clinical social worker, while the other operates a boutique insurance agency) to hundreds of individuals. The denials by insurance companies to pay for opiate detoxification, in-patient addiction treatment or intensive outpatient counseling have increased in the last few years, even as more and more people are abusing opiates, overdosing and dying.

This isn’t a new problem, but it has been getting worse in recent years. In 1996, Congress passed the Mental Health Parity Act. It stipulated that insurance companies must pay for mental health treatment in the same way that they would pay for physical health treatment (Kevin Sabet states that it took Congress decades to take the radical position that the brain is part of the body). The law was rife with exceptions and carve outs and was ultimately quite toothless. Addiction treatment was not covered in the law, despite the desire of the bills’ sponsors to include it, because of the stigma associated with substance use disorders. In 2008, the Mental Health and Addiction Parity Act was passed and it attempted to fix a number of faults in the 1996 law, as well as provide equal coverage for addiction treatment (this linked article notes that the MHPAEA did not mandate mental health or substance use treatment, but if treatment for these conditions is included as a benefit, plans have to provide it under the same terms and conditions as other medical treatment). In 2010, the Affordable Care Act improved upon the 2008 law by directing that all insurance plans cover mental health and addiction treatment. Despite all of these laws and the vast amount of media attention that is now paid to the heroin epidemic and the rich and famous people that are dying, insurance companies are still often denying addiction treatment. This urges the key question: how are they able to do it? The answer is horrifying: many states do not have an enforcement mechanism to ensure compliance and wading through the federal bureaucracy requires more time and skill than the average person possesses. In the rare cases where insurance carriers have been found to be in violation, they have not been fined. They have just had to pay for the appropriate level of care. This is the epitome of a toothless law and weak enforcement.

Ed Brazell’s family has been struggling to help his son for several years. He has Anthem Blue Cross/Blue Shield, which is considered to be an excellent health care plan. When his son went to Seabrook House in NJ to deal with his severe substance misuse disorder, he had to pay an additional $5,000 on top of the insurance. It was tough and required the family to scramble, but the alternative was grave. His son stayed clean for a bit, but he relapsed and quickly was using 25 bags of heroin a day. When his son agreed to go to a detox, the insurance company told them that “should stay in bed and take Tylenol.” Ed was aghast, and asked to talk to the doctors and counselors that Anthem Blue Cross/Blue Shield utilizes to make those decisions. “I wanted to know about their decision making process and they refused to talk to me.” Ed’s son went to Florida where he received a form of inpatient care (level 3) that was billed to the insurance companies as intensive outpatient (level 2) – this is known as the Florida Model, and while it is sometimes rife with problems, it sprung up as a reaction to the fact that insurance companies are either paying for limited treatment or not paying at all.

The American Medical Association, American Psychiatric Association, and the World Health Organization have characterized addiction as a chronic medical problem. It seems that this assertion from those esteemed bodies has not made its way to the insurance carriers who apply coverage limitations to addiction and mental health treatment modalities, which are not applied to treatment modalities tied to physical or medical disease categories. Increasingly, carriers are lowering reimbursement and shortening the benefit periods for those afflicted with addiction and in need of recovery treatment.  This behavior seems to be contrary to the aforementioned Mental Health and Addiction Parity Act and the Affordable Care Act.

Unrealistic demands are made on the treatment centers, such as the requirement that progress must be demonstrated within three days of admission, or further coverage will be denied. A person so afflicted for years, prior to finally seeking treatment, is highly unlikely to progress in just three days.  This coverage model has not yielded successful, sustained treatment outcomes (one treatment center executive we spoke with said, “It is almost as if they are trying to create a system that is denied to fail”). As an example, some carriers will allow for 12 days of outpatient coverage with no coverage for in-patient treatment. It is quite clear that people with opiate addictions have better outcomes with a full continuity of care: a week of detoxification services, a week to a month of inpatient treatment and then a few months (at least) of outpatient treatment.  Several years ago, 30 days was allowed for in-patient addiction recovery treatment and five days per week for intensive outpatient treatment.

Like oncologists who are far more equipped to diagnose and treat cancer than insurance carriers, diagnosing and treatment for those in addiction should be more influenced by the treating clinicians. Instead, the physicians and therapists that are employed by insurance carriers have a much stronger role in determining what level of care (or if any) a patient gets (this is almost always done sight unseen; the professional employed by the insurance company reviews a file and only occasionally talks on the phone with a patient). Some argue that the insurance professionals’ primary goal is managing costs instead paying for the proper services – if they are recommending a lower level of care or denying coverage than is medically indicated, then that is a true conflict of interest as the physician potentially benefits directly from turning down treatment. This raises a second question: what criteria are they using to limit or deny treatment?

These claims we are leveling against insurance carriers are not new. Nor is it the first article that details the insurance denial disaster. On their website, Aetna writes that they use the American Society of Addiction Medicine’s (ASAM – full disclosure: Mr. Greenagel is an associate member) criteria, which states that the proper level of care is “the least intensive, but safe, level of care.” This ambiguous wording is open to interpretation and is used as a shield to defend insurance companies against claims that they are denying proper coverage. Unfortunately, this vague wording and loose criteria are taken from a medical professional organization and is legal for the insurance companies to use in this way.

Patricia Rogers’s experience was similar to Ed Brazzell’s, but with a far more devastating outcome. She had Horizon Blue Cross/Blue Shield of NJ and experienced denials for her son at least three times in 2010. She paid out of pocket costs and unpaid claims of over $60,000. She wrote about her experience:

We found out about my son’s addiction over the holidays in 2009. He was using alcohol, marijuana and heroin. We tried to get him to willingly go to treatment. He refused and eventually ended up in Union County Jail. He agreed to go to a treatment facility, but insurance at the time would only approve IOP but through some grace of God he was able to live at a facility in Florida (and it was only considered IOP through insurance – the Florida Model). That was the first of many rehabs my son attended, along with many detoxes and halfway houses. He was considered to be dually diagnosed with mental illness as well. Over the course of his fight with this chronic medical illness and he was denied treatment too many times for me to remember. There were also times where his treatment was cut short and I gladly paid out of pocket for his care. His fight ended on May 27, 2011, when he died from this chronic medical illness.

Many treatment programs are not getting paid by the insurance companies that had previously agreed to pay for the treatment. Post payment and prepayment claim reviews are conducted by Recovery Audit Contractors (RACs), Medicare Administrative Contractors (MACs) and the Zone Program Integrity Contractors (ZPICs) who work for the insurance carriers and the Center for Medicare and Medicaid Services (CMS) respectively.  The purpose of the audits is to uncover fraud, waste and abuse, the audits aim to ensure that payments are made correctly the first time and to identify, investigate, and recoup payments made in error. Ostensibly, it is a program which will save millions, and potentially, billions of dollars. In reality, it is a program heavily dependent on the use of intimidation and strong-arm tactics to achieve much of that savings. Treatment approved in advance by the insurance carriers, for which payments are received by the treatment centers, are too often identified as an overpayment by RAC reviewers with a demand for repayment, under the guise of “medical necessity”. The auditors are rewarded (9-12% of the recoupment) for their efforts based on the amount, which gets returned to the carrier or CMS. Much like the physician employed by the insurance company, the auditors have a financial misalignment of interests, as they benefit from denying coverage and/or withholding payments. It is a bad policy and terrible ethical position.

We have hundreds of stories about insurance denials just in NJ (though there has not been much data collection on a statewide or national basis on insurance denial disaster). Another harrowing tale is by a woman who asked to remain anonymous. Her insurance was Anthem Blue Cross/Blue Shield, and she has detailed their three denials:

I learned of Z’s drug use sometime in March 2014.  The insurance company website was of little to no use in trying to find treatment.  I learned of an addiction doctor in Merchantville, NJ (Dr. Lance Gooberman) who provided an opiate inhibitor.  In addition I tried to find counseling for my son.  This was all new to me and my husband and we quickly learned how naïve we were in fighting this on our own.  In June, Z attended IOP at Rehab After Work.  The counselor told us he needed inpatient care or he would die.  Our first try to get Z into a rehab was in July 2014.  He was denied but given approval for outpatient treatment.  We tried again in August at Seabrook House in Bridgeton, NJ.  Z was told verbally that the insurance was denying.  I do not know if he ever received written confirmation of this.  In September, he hit bottom and once again tried to enter an inpatient facility.

On September 20, 2014, we took Z to Livengrin in Bensalem, PA.  Since it was a Saturday, the facility could not get in touch with our insurance.  Z remained.  By Monday, he was denied, and Livengrin went through the appeal process 3 times.  All were denied and Z returned home on September 24.  He returned to Dr. Gooberman for Vivitrol injections.  He remained clean for 3 months.  On December 27, 2014, I found him dead at home in his music studio.  The detective told me he found 2 bags from heroin.

Legislation to address these issues is imperative, as it would have a profound effect on the outcome of recovery for millions of Americans (1) battling this chronic medical illness(6).  We urge you to consider advocating for and supporting legislation to respond to these national needs. We are currently working with members of Congress to introduce such legislation, and we hope to attract the attention of the White House. The legislation would:

Address the adverse determinations by insurers. The systematic coverage denial position the hired carrier physicians take result in prohibiting necessary care to the patients. A bill to address and correct this practice should permit decisions of continued or extended care be deferred to the judgment of the treating physician.  This would almost certainly have a positive effect on treatment, as long-term addiction treatment provides overwhelmingly better outcomes for this chronic medical illness. Similar legislation has passed in Massachusetts and Pennsylvania, but it is greatly needed nationwide.

Address the wanton payment audit practices of the carriers, and of the Recovery Audit (RAC), Medicare Audit (MAC) and Zone Program Integrity (ZPIC) Contractors. There must be limitations and mutually beneficial regulation of the billing audit process, of the strong-arm practices of the contractors and the at-will financial hostage situations created by the carriers and audit contractors.

Last week in New York, Governor Cuomo and the NY legislature announced bi-partisan legislation that begins to address some of these problems. Three of the seven major bills/programs address the failings of the insurance companies and provide very clear directions:

1) It ends prior authorization by insurance companies for inpatient or outpatient treatment. The first review by the insurance companies can only take place after 14 days of treatment (as we have already discussed, reviews currently happen after 2 or 3 days)

2) It addresses insurance coverage and how insurance companies are not paying for treatment, despite the legal requirement to do so as dictated by the 2008 Mental Health and Addiction Parity Act and the 2010 Affordable Care Act.

3) It mandates that insurance plans pay for Naloxone (the anti-overdose drug)

Our final story involves Valerie and her family. She has been a NJ public school teacher for many years. Her youngest son has been in and out of treatment programs for most of the last decade. Her insurance company is Blue Cross/Blue Shield and they used Magellan for Behavioral Health Services. Her son’s treatment was often denied or cut short, despite having a reputed Cadillac insurance plan. She and her husband have paid out over $100,000. She explained her family’s story in a lengthy letter to us:

We have spent the past five years working through the labyrinthine process of receiving denials and writing appeals; of requesting and wading through medical records; of phone calls and emails; of preparing and presenting our sons’ cases for hearings or External Review. All while responding to both sons’ treatment needs and legal issues, as well as one son’s multiple relapses. And yes, going to work every day.

We learned that our insurance company uses the American Society of Addiction Medicine (ASAM) criteria and dimensions to determine medical necessity. As we went through the letters of denial we wondered whether they were actually referring to our sons or their history at all. Both boys were adolescents at the time – by ASAM’s own definition – which meant they needed to fulfill 2 of the 6 ASAM dimensions to meet medical necessity for approval for treatment. Yet, our insurance determined them to be adults which meant they had to meet all 6 dimensions.  Despite the fact that our sons’ medical records revealed that they did in fact meet all 6 dimensions, our insurance company ignored those facts and misapplied and misrepresented the ASAM criteria to deny life-saving treatment.

Valerie has organized a large number of these families into a group and they are hoping to effect an investigation on the state level. They are also advocating for insurance reform through legislation. Valerie’s grandmother was a suffragist and worked very hard to get women the right to vote. Now, Valerie has taken up the mantle in an equally important fight in our time.

We have a health crisis in the United States which is not being adequately addressed, despite the soundbites uttered by politicians and the constant media attention.  We need addiction to be recognized and regarded by the carriers as the chronic medical illness that it is. We need mental health and substance disorder clinicians to have the same role in defining treatment for their patients as medical doctors have in defining treatment for their patients with physical illness. Most significantly, substantive penalties need to be put in place in order to ensure compliance with the existing laws that mandate coverage. The costs associated with inactivity on this critical point are both high and disastrous. Advocates, professionals, politicians and even private citizens have both a vested interest and an obligation to push for insurance reform. And if you don’t have insurance, the results are even worse.

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Frank Jones, Partner, Mints Insurance – a 20 year insurance leader who advocates for the medical industry and a government affairs professional. He operates a national boutique insurance agency with a focus on medical risks, and a special niche in mental and behavioral health operations and medical malpractice. He can be reached at Frank@mintsinsurance.com.

 

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Frank Greenagel, MPAP, LCSW, LCADC, ICADC, ACSW, CJC, CCS, is a clinical social worker who specializes in addiction & recovery treatment.

Frank is an adjunct professor at the Rutgers School of Social Work and an instructor at the Center of Alcohol Studies. He writes a blog at greenagel.com. He conducts trainings and delivers keynote speeches around the country. He completed a Master in Public Affairs and Politics in 2015.

He has served on the NJ Governor’s Council on Alcohol & Drug Abuse (GCADA) since 2011 and was also the Chairman of the NJ Heroin & Other Opiates Task Force. In 2014, 10 years after he was granted an honorable discharge, Frank was directly commissioned into the Pennsylvania Army National Guard as a First Lieutenant. He helps soldiers that have experienced PTSD, substance abuse issues and tries to point them all in a positive direction. He can be reached at flg2@aol.com.

25Sep/16

People Attack Me About Marijuana

I recently wrote an article about how NJ recently approved the use of marijuana to treat people with PTSD. To be clear, I am against it. A number of people responded negatively on either Facebook, Linked In or via email. Several messages attacked me on a personal level, and more than one person accused me of taking money from Big Pharma. Last April, I wrote about the different kind of statements that people make when they disagree with me. I have found that most people are set in their ways and views on the topic of marijuana, and usually do not want to have a discussion with someone with a different view (they usually just engage in shouting, insults, and a number of other fallacies). As an educator, I strive to help people understand and sometimes change the process of how they arrive at their conclusions. I adore discussions where people have different backgrounds, beliefs and philosophies, but I expect the discussion to be free from fallacies. I’m going to highlight three fallacies: agrumentum ad ignorantiam (argument from ignorance), red herring (bringing up a different topic than has been addressed) and arugmentum ad hominem (you engage in personal attacks).

1) Do you have PTSD?

I’m not sure how this is relevant. If I answer no, then I assume I’ll be accused of not personally understanding the issue. If I say yes, I figure I’ll be told that I am too close to the topic and while marijuana may not have been a treatment answer for me, it works for others. Or perhaps I’ll be told that my mind is addled.

I have treated people with PTSD for over a dozen years though. I care so much about soldiers (and other service members) and veterans that I rejoined the Army as a medical officer in 2014 after having been out of the service for over 10 years.

To answer the PTSD question: no, I do not have, nor have ever had, PTSD. I have had an easy life.

 

2) Are you satisfied instead with big pharma pushing life destroying, highly addictive, narcotic analgesics? (I added the commas).

 

I have been an extremely vocal critic of Big Pharma in my professional talks, in my college classrooms, in my writing, and in my service on the NJ Governor’s Council. I recently wrote an article about the problems with big pharma here. If someone accuses me of taking money from the pharmaceutical industry, it shows that they are guilty of conducting little to no research or background checks.

That said, the discussion of prescription opiates is a red herring when talking about marijuana for PTSD. I am assuming that you are arguing for marijuana to treat pain instead of prescription painkillers. That is a different argument. As I just wrote, I am critical of Big Pharma and the overprescription of painkillers (I suggest you read the NJ Heroin and Other Opiate Task Force Report from 2014). If you have clinical, controlled studies on how marijuana helps people with pain without causing psychological side effects, I would be thrilled to see them.

 

3) Have you not done even the smallest modicum of research? The overwhelming evidence of numerous studies has already definitively PROVEN the many many positive effects and benefits of medicinal marijuana for ptsd!

Sadly sir, you are mistaken. The studies that some people cite (you mentioned none, just that there are numerous ones) do not pass scientific muster. Most people have a hard time differentiating good from bad studies. Additionally, many pro Marijuana for medicine reports are funded by the for-profit Marijuana industry.

Here are some of my other opinions on marijuana:

  • I would like to see it decriminalized in every state. I don’t want to see people get arrested for using it in private spaces. I have no problem with a person who is 21 or older using marijuana in their home.
  • I caution people who use it on the amount and frequency though. With full legalization, American marketing power would be brought to bear, which would encourage people to large amounts of it, in order to maximize profits.
  • I am against full legalization, which allows for advertisements on the internet, TV, radio, and billboards. I am against marijuana candy being sold in convenience stores. I am against lawsuit shield protections for marijuana producers.
  • Marijuana is currently a schedule I drug (highly addictive, no medical value). I support rescheduling to level II. This would federally allow it to be given to people with late stage cancer, HIV/AIDS, and glaucoma. It would also allow for federal funding of studies on the effectiveness of marijuana as a medical treatment for other conditions.
  • I am deeply concerned about the use of marijuana by people who drive or operate any kind of machinery. Studies have shown that coordination and reaction are affected over 24 hours after using marijuana.
24Sep/16

Dr. Herb Conaway, the 2nd Worst Person in NJ Politics

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In a state rife with some awful people on both sides of the political aisle, Dr. Herb Conaway ranks as the second worst person on my list (if you don’t know who the first is, than you haven’t been paying attention). Dr. Conaway is a Democratic Assemblyman out of Burlington. He is well educated: undergrad at Princeton, law degree from Rutgers, and a medical degree from Thomas Jefferson. He served as a Captain in the Air Force medical corps for four years. He is clearly smart, hardworking, and has had some valuable experiences. This is what makes his opposition to bills that combat the opiate epidemic and his support of medical marijuana so concerning.

Earlier this week, a devastating article about Dr. Conaway was written by Ken Serrano for the Gannett papers (it was pushed off the front page by the bombings in Seaside and Chelsea). Some highlights:

1) Limiting the amount of opioids a physician can prescribe to seven-day supplies is seen as a way to cut into the heroin and painkiller epidemic. The Centers for Disease Control and Prevention encourages limitations. But a proposed law that won approval in the state Senate hasn’t advanced in the Assembly, where Conaway, the chairman of the Health and Senior Services Committee, stands in the way. A proposed law eventually dies if it isn’t posted by the chairman of a committee for a vote. Conaway told the Asbury Park Press Friday he will not post the seven-day supply bill because it will hurt some patients.

2) From 2006 through 2013, Conaway’s reelection committees were the second biggest beneficiary of contributions to state candidates in New Jersey from the pharmaceutical industry, out of 127 candidates. His campaigned received a total of $41,750.

3) Another anti-abuse bill would require doctors and others prescribing opioids to minors to warn parents about the dangers of addiction and counsel them about alternatives to opioids, amid mounting evidence that those under 25 who have taken prescription opioids are more susceptible to addiction. Last year a different version of the bill that required that all patients being prescribed opioids be advised of their risks. The Senate version, S2366, passed 36 to 1, but the bill died when Conaway refused to post the Assembly version, A3712, in the Assembly health committee.

Back in 2014, the NJ Heroin and Opiate Task Force recommended that the Prescription Drug Monitoring Program (PMP or PDMP) become mandatory – that is that all doctors must enter opiate prescriptions in a central data base and that both doctors and pharmacists should check patients’ histories before writing and dispensing those opiate painkillers. A voluntary PMP is only used by medical professionals who are responsible and aware of the problem. About 20% of the states have mandated PMPs, and they have shown that doctors prescribe 30% less opiates when they are being monitored. Dr. Conaway has opposed expansion and mandating the PMP every step of the way – he often states that government should not get tell doctors how to do their job.

Dr. Conaway has also blocked parental notification laws about the dangers of opiates. He says that this would “open the door to further legislators governing doctors how to behave.” But there are many instances where doctors are required to inform patients about the risks of medication, surgery or other procedures. Dr. Andrew Kolodny, the Chief Executive Medical Officer Phoenix House, explained Conaway’s behavior thus:

Any efforts that would really be effective at addressing the opioid crisis will generally result in reduced prescribing. The manufacturers of opioid painkillers don’t want to see their prescriptions go down, so they are blocking efforts to promote more cautious use.

I’m just one of many people who are critical of Dr. Conaway, but the general public is unaware because they spend two out of every four years worrying about who is going to be President and little to no time monitoring their state governments. The entire interview with Dr. Kolodny is a good read.

Dr. Conaway is bright and well educated. It’s not that he can’t read scientific studies, look at reports or understand data. He can. His actions to block bills that hurt the bottom line of Big Pharma have brought many people to question his motivations, and they usually arrive at the same conclusion – that he takes money from Big Pharma and it has influenced him in their favor.

I have to take a number of ethics trainings every year at Rutgers, for the Army, at the Governor’s Council and to maintain all of my professional licenses. Over and over, conflicts of interest are explained and how that not only impropriety is bad, but the appearance of impropriety is also a huge concern. I can not say for sure that Dr. Conaway has killed bills that would help curb the opiate epidemic because he has taken thousands and thousands of dollars from Big Pharma, but it sure looks that way.

18Sep/16

Stoned Wrong in NJ: Marijuana and PTSD

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Last week, a Democratic bill was signed into law by NJ Governor Chris Christie that will allow people with PTSD to get medical marijuana. This expands upon the original NJ medical marijuana law, which was passed by the legislature and signed by Gov. Corzine in January of 2010. Previously, only diagnoses of cancer, glaucoma, HIV/AIDS, multiple sclerosis, seizures, and crohn’s disease had been approved for medical marijuana in NJ. I have no comment on the aforementioned conditions – I am not a medical doctor and the treatment of those problems fall far outside of my scope of practice.

However, I have been treating a large number of both veterans and civilians with PTSD for over a decade, and as I have noted many times before, I have grave concerns about giving marijuana to those with PTSD.

1) The only evidence that marijuana helps people with PTSD has been anecdotal stories by people who claim it helps them. The unscientific, non-clinical studies that have been conducted with multiple individuals usually ask people after they’ve smoked if they feel better. The studies aren’t looking at how marijuana affects them 12 hours later, 24 hours later, multiple days, or weeks later.

2) The Veterans Administration (VA), which I am sometimes critical of, has the greatest experience and expertise treating veterans for PTSD. So many of the people that work in the VA care deeply for veterans and are willing to try anything in order to help them. The VA’s official position on marijuana for PTSD is this:

Marijuana use for medical conditions is an issue of growing concern. Some Veterans use marijuana to relieve symptoms of PTSD and several states specifically approve the use of medical marijuana for PTSD. However, controlled studies have not been conducted to evaluate the safety or effectiveness of medical marijuana for PTSD. Thus, there is no evidence at this time that marijuana is an effective treatment for PTSD. In fact, research suggests that marijuana can be harmful to individuals with PTSD.

3) My experience treating people with PTSD  has shown that marijuana sometimes momentarily alleviates acute symptoms, but when the psychotropic effects wear off the symptoms return and often get worse.

4) Studies have shown that smoking marijuana causes decreased lung function, chronic respiratory track problems (wheezing, shortness of breath), a strong link to obstructive lung disease, increased bronchitis episodes, possible acute cardiovascular issues and a higher likelihood for cancer (but we need more studies on that specific item).

5) Studies have also shown that marijuana use may cause an earlier onset of psychotic illnesses. Long term heavy users (defined as 3x a week or more for a period of over 6 months) show impairment in memory and attention. Marijuana use causes withdrawal symptoms such as irritability and insomnia, and often makes symptoms of depression and anxiety worse.

6) There are currently four states where recreational use of marijuana is legalized:  Colorado (2012), Washington (2012), Alaska (2014), Oregon (2014), and Washington DC (2014). All five legalized marijuana much earlier: Alaska, Washington and Oregon passed medical marijuana laws in 1998; Colorado in 2000 and DC in 2011. The establishment and expansion of medical marijuana laws are a gateway to legalized recreational marijuana. Once recreational marijuana becomes legal in a state, for-profit marijuana corporations get a true foothold and start lobbying politicians and donating to their campaigns

7) If, IF, there are medical benefits from marijuana use (reduction of nausea, stimulation of appetite), they are caused by the CBD chemical in marijuana. The THC chemicals do not have medical benefits, but are popular because they lead to the psychoactive high. THC content in marijuana was between 2 and 5% from the 60s thru the 80s. A few years ago, the strongest marijuana was 19%. Two years ago, the winner of a competition was 29%. The strongest THC content available in Colorado now is 41%. (THC wax is over 90% and THC Vaping can be over 99%). NJ could have pushed for medical marijuana to be CBD concentrated with a maximum amount of THC content at 5%, but they chose not to do this.

8) NJ politicians from both political parties said that they had passed this law because veterans were in such dire need. We are seeing an ever-increasing use of veterans and 9/11 to justify legislation (and sell products). I wrote about this in the spring. There is an organization in Oregon called Grow for Vets. It is non profit whose sponsors are all, surprise, for profit marijuana companies. They use their supposed support of veterans to curry public favor.

This NJ law was introduced and sponsored by Senator Joe Vitale (D-Woodbridge). I have worked with him on a number of issues and I have often applauded him for the work he has done in the areas of addiction and recovery. For several years, he has been my favorite NJ politician. He still remains so, but on this we disagree. It is my hope that NJ will collect data on everyone with PTSD that is prescribed marijuana so we can monitor their condition. If the evidence shows that marijuana helps those with PTSD, I’ll publish a retraction. If however, the evidence shows that marijuana does not help those with PTSD, I hope that this law gets reversed.

31Aug/16

The Public Cost of Big Pharma’s Opioid Drugs

Back in December, CNN reported that “deaths from drug overdoses reached an all-time high in 2014″ and that “deaths from overdoses of prescription drugs and heroin continue to be the leading cause of unintentional death for Americans, rising 14% from 2013 to 2014.” The chart from the National Institute on Drug Abuse (NIDA) details the horrific increase in overdose deaths between 2001 and 2014. State and national figures for 2015 have not been released yet, but I expect that they will show that there has been no abatement.

These deaths and the permanent grief and loss that accompany those deaths can not be measured. I have written about the pain of parents, how some of them have desperately tried to help others, and how some of them have influenced policy. Regardless of the wonderful work that many of them engage in, they have all told me how the sorrow has not dissipated.

Other writers and wonks have discussed the high costs of incarceration and treatment. Those are two areas of enormous public and private expenses that are well known. While it is fairly easy to see the link between the marketing of pharmaceutical painkillers and the modern opiate epidemic, it is probably impossible to force Big Pharma to shoulder some of the costs of incarceration and treatment (this is something that parents and advocates often argue for at round table discussions, conferences – I think their energy might be applied better to other goals…read on).

But it is very clear that Big Pharma has contributed to this epidemic and has also greatly profited from it. Sam Quinones and I discussed the role of Big Pharma in creating the opiate epidemic, and one of my students wrote about how the Pharmaceutical Industry used continuing medical education sessions to influence doctors into peddling their drugs.

To be sure, there are other tolls. On June 23, 2013, the New York Times reported on the workplace costs associated with opioids. Those workplace costs included worker’s comp and treatment expenses (they did not factor in lost production):

  • The average claim without opioids was $13,000
  • The average claim with short-acting opioids was $39,000
  • The average claim with long-acting opioids was $137,000

These costs hold true for public workers. In June of 2014, the California counties of Santa Clara and Orange sued five pharmaceutical companies for “false advertising, unfair business practices and creating a public nuisance.” (you should click on the link, as I wrote about it back then – another lawsuit was also filed by the City of Chicago that month against many of the same pharmaceutical companies for similar reasons). It is well known that state, county, city and municipal budgets are struggling all around the United States (you can see this in the reduction of services, the increase in charges – even in the increase in traffic fines). Chicago, Santa Clara and Orange Counties crunched the numbers and clearly saw that opiate addiction had hurt public worker production and increased the costs associated with employing those workers. These cases have not been resolved, but I expect to see more and more suits filed by other municipal, county, city and (perhaps) state governments.

Last month, the LA Times published a brilliant article about how Purdue Pharma knew that their drug, Oxycontin, was being diverted and abused and chose not to report it to authorities. The article is damning:

A Los Angeles Times investigation found that, for more than a decade, Purdue collected extensive evidence suggesting illegal trafficking of OxyContin and, in many cases, did not share it with law enforcement or cut off the flow of pills. A former Purdue executive, who monitored pharmacies for criminal activity, acknowledged that even when the company had evidence pharmacies were colluding with drug dealers, it did not stop supplying distributors selling to those stores. Purdue knew about many suspicious doctors and pharmacies from prescribing records, pharmacy orders, field reports from sales representatives and, in some instances, its own surveillance operations, according to court and law enforcement records, which include internal Purdue documents, and interviews with current and former employees.

The article inspired two California congressmen to call for a House investigation on August 29. Congressman DeSaulnier said he was “concerned that Purdue seemed to have escaped any repercussions for the way it handled the information it collected on suspect doctors and pharmacies. How do you get people to do the right thing when there are no consequences?”

Regardless of how one feels about people who use or abuse or are addicted to drugs (read the comments on news articles – it’s often disgusting), there are financial costs that are undeniable. Even if you believe that drug abusers are terrible, weak willed people who did it to themselves and that their parents should have done a better job, one can’t deny that it costs society an enormous amount of money. Some of these expenses should be recouped, and when the evidence of wrongdoing is as clear as it has been in the case of Purdue Pharma, everyone should write their Congressperson in support of investigating, fining and prosecuting them.

Please write your Congressperson or call them. To find your Congressperson, click here.

 

15Jul/16

Why CARA Is a Failure and How Recovery Advocates Were Duped

On Wednesday, the Comprehensive Addiction and Recovery Act (CARA) passed the Senate 92-2 and was sent to President Obama’s desk. Advocacy groups lit up social media with praise for the bi-partisan legislation which expands Naloxone training for first responders, provides more funding for buprenorphine for people with opiate disorders, and grants some meager funds to find alternatives to incarceration.

While the bill offers up a few good solutions, it’s far more of a failure than a success.

1) The Senate version of the bill called for a mandated prescription drug monitoring program (PMP). The House rejected it after doctors and pharmacists lobbied that it would be burdensome. The final language just suggests that doctors and pharmacists use it. “Suggests” has not worked when it comes to public policy and addiction treatment issues.

2) Case in point. CARA calls for over $900 million to go towards expanded buprenorphine for individuals with opiate misuse disorders. It does not address the key flaw regarding buprenorphine, which I have been writing about for years. Buprenorphine has proven to be effective when combined with weekly therapy sessions and weekly drug screening. The Drug Abuse Treatment Act of 2000 introduced buprenorphine to America and despite the trials and evidence, merely suggested it be accompanied with therapy and drug screens rather than required it. As a result, buprenorphine has been less effective in America than in other countries and has gotten a bad reputation in some treatment programs and 12-step rooms because it is viewed as swapping one drug for another. Without a requirement for drug screens and counseling, it isn’t medication assisted therapy. It’s just medication.

3) The $1.1 billion bill has little funding. This is a political trick. Pass the bill. Get applauded by people in recovery, family members and advocates. Congress will now go on break for the next seven weeks and everyone’s attention will turn elsewhere for the rest of the summer. Advocates will calm down. Then Congress will return after Labor Day. At that point, schools will be back in session, the NFL will be on TV, and the Presidential election will be in full swing. Voting on funding for CARA will most likely be buried. Even if CARA does not get funding, 92 Senators in June and 400 House members in March voted in favor of it. One third of those Senators and all of the House members are up for reelection this fall. Even without funding the bill, they can all claim that they voted for CARA and that they really, truly, deeply care about addiction.

Maybe (hopefully) I’m wrong about the third point and Congress will somehow find the $1.1 billion to make it work. Even so, it would still fail on points one and two.

 

09Jul/16

In Defense of Teachers, Muslims and Cops

I try to limit my writing to subjects that I have an obvious expertise in (addiction, recovery, military, education, criminal justice, public policy) or intense interest (comics, baseball). I’m concerned enough about the current public discourse regarding teachers, Muslims, and cops that I’m going to write about them, but only within a very limited framework. I do not know what the fixes are for these problems; rather, I am just offering up a few of my viewpoints and experiences. A quick background on me: politically, I’m a centrist. I’m a registered independent voter. Family members, friends and students of mine that are conservative view me as a liberal while liberals often express a frustration with some of my conservative viewpoints.

Teachers

I taught high school English from 2006 to 2009. My mother was a high school English teacher for 31 years. My grandmother taught English in the 1930s and my great grandmother taught every subject in a K-12 school house in a small farming community about 50 miles outside of Minneapolis, Minnesota. Teaching is not only in my blood and a way of life, but a deep, enduring passion. I have tried to encourage a number of my high school and college students over the years to pursue a career in teaching, and I’m thrilled when I hear them talk about their students when they “got” the lesson or hear a story about how a kid made them laugh.

Over the last dozen years, I have read (at least what seems to be) at least one story a week on NJ.com about teachers who are accused or convicted of having sex with their students. I did a quick google search, and it appears that teachers make the news more for having sex with their students than anything else. It’s distressing, and I have had more than a few people in my personal life ask me about the “teacher-student sex problem.” While I am always distressed to hear about these stories, I think it is neither an epidemic nor endemic of the teaching profession. There is a tiny percentage of teachers that do this, but because of the “if it bleeds it leads” mindset, this is what we hear about. On top of this, Governor Christie has continually demonized teachers (along with police officers and other public workers) since he took office. Attacking the teachers’ union made for popular soundbites and youtube vidoes, both of which increased Christie’s popularity during his first term. Partly (I’m quite sure but can’t prove) because of the negative publicity and Christie’s attacks, the number of young people who report wanting to become a teacher has gone down.

Muslims

Each time there has been a mass shooting the last couple of years and before we find out who pulled the trigger, an old friend of mine asks me if I think it is either a “rural white Christian who feels economically and culturally left behind or a radical Muslim with foreign ties.” It’s an awful question, but it seems to me that liberals hope it’s the white Christian while conservatives want it to be the radical Muslim (the whole business of hoping it’s someone from (or not from) a particular group is ugly, and each side ultimately tends to use it as a talking point to push their world view or limited political agenda). Again, I don’t know what the fixes are for addressing the grievances of either group, but it seems to me that Muslims in America are constantly asked to answer for the heinous crimes of a tiny percentage of 1% of American Muslims.

I have served in the military with Muslims; just like members of every other religion or race, a couple were great soldiers, some were good, most were ok and a few were sub-par. I’ve had dozens of Muslim students over the years (both at Essex County College and Rutgers), and I found them to almost always be polite, studious, punctual and usually a bit quieter than my other students. Unless they discussed a particular issue involving their faith, I could not tell that they were Muslim through their writing. A former colleague of mine at the Rutgers Newark Counseling Center is Muslim, and he is a prime example of a wonderful American: calm, smart, wise, kind, humorous and hardworking. He is also a Cowboy fan, which caused me to ask him when we met, “Wait…you are a Cowboy fan? How do you reconcile that with being a psychologist, a Muslim and a teacher of young people?”  He grew up with many of the same cultural experiences I did (trading lunch items in school, cartoons on weekday afternoons). He invited me to observe services in a mosque, and I took a number of my recovery students there on a few separate occasions. I felt welcome and safe there every time (just as I have felt when I have gone to Catholic, Protestant,  Baptist, or Jewish services with friends). Rany Jazayerli is a dermatologist from middle America who is a life-long Kansas City Royals fan. I have been reading his work with Rob Neyer, at Baseball Prospectus, at Grantland, at Five Thirty Eight, and on his own site for almost 20 years. He is a married father of three and a Muslim.

Not every Muslim I know has been an ideal American citizen though. I have also worked with Muslims in jails and rehabs. Some of them drove drunk, sold drugs, stole from family members and engaged in a variety of other drug related crimes. Like people of every other race, religion, and class in America. (When I was working in Thailand, Muslim leaders despairingly talked to me about the drug use among their young people and how it was devastating their families. They expressed the same sadness, fear and powerlessness that I’ve heard from Americans the last dozen years)

Cops, State Troopers, and Other Law Enforcement Officers

I started writing this piece before Alton Sterling and Philoton Castillo were shot this week. In their immediate aftermath, I wrote this: “The number of cops that engage in excessive violence (and in even fewer instances, murder) are a tiny percentage of law enforcement overall. My fear is the legitimate grievance regarding the higher statistical likelihood of black people being searched, arrested, beaten or shot will continue to be used to ascribe all law enforcement with racism and evil. The sadness and anger felt by Americans will be fueled by the echo chamber in which it seems that most of us live and end up motivating some deranged individuals to attack police officers, which in turn will further drive a wedge in society. And it will probably be captured on camera.” I wrote that a few hours before the five police officers were killed in Dallas on July 7th.

I have two friends that are cops. One is a guy I served with in the Army from 1997 to 2001. His father was a State Trooper and from everything I heard from other troopers in the NJ Army National Guard, a wonderful man with great sense of humor. My buddy is a married father of three and an easy going sergeant. Over the years, he changed his views on drug arrests. When he was younger, he was quick to arrest and charge people with simple possession. As he aged, he realized that it was a numbers game and that it was detrimental to the people he was arresting and not a good use of his time (that said, he takes a very strong stance on driving while under the influence of any substance). I met my other friend in college in 1996. We went to Rutgers together. He was a Maryland State Trooper for a few years before transferring to a municipal force in NJ. He has been in law enforcement since 2004. He joined to protect people and catch bad guys. On the morning of July 8th, he left home to go to work. His wife cried and begged him to be safe and make it home. His two children watched this interaction. Because we are so close, we’ve talked about drug problems and drug arrests for years. Long before the Good Samaritan Law was passed in NJ, he understood that drug users do better with treatment than incarceration, and at lower costs to society. He has taken people to the hospital and referred them to treatment for years. And it has gone completely unnoticed and unreported.

In April, I watched one of my former students from Elizabeth High School graduate from the Maryland State Trooper Academy. The Colonel of the Troopers was there, and in his speech to the graduates he said everything that one would want to hear. I’m going to quote him from memory as best I can:

We are a paramilitary force with specialized training. You must remember that we are not a military force. We are not going out there to engage the enemy, but rather be part of the community and protect society. If you use excessive force, we will get rid of you very quickly. Please watch your words and actions at all times – do not be one of those troopers who give all of us a bad name. Do not be discouraged by what a few bad officers do that causes a media frenzy.

My former student is a young man (25) of color. He has been assigned to a barracks in Baltimore. Unlike my buddies from the Army and college, I worry about my student. I’m not just concerned about the usual work, but I’m afraid that someone will take a shot at him because he’s in law enforcement. He has been on my mind throughout much of the last few days.

At the start of June, I gave a keynote speech at the NJ Juvenile Justice Officer Convention. I talked about a variety of illegal and prescription drugs, as well as criminal justice reform and other public policy issues. I also talked about the failure of D.A.R.E., and how not only does it not work, but kids that go through D.A.R.E programs are more likely to use and abuse drugs. Afterwards, I spoke with dozens of cops, both in person and via email. Some of them were D.A.R.E officers. They asked me to see that data on their ineffectual programs and then for advice on what they could do better. Many of them expressed frustrations within their units, schools or communities. It seemed that all of them cared a great deal about the work they do.

I have been hired by other law enforcement groups for trainings or to engage in group or individual counseling sessions. I always ask why they become cops. Usual answers include “it’s the family business” and “good benefits” and sometimes “a cop saved my life.” By far though, the most common answer is this: “I want to catch bad guys.” I then ask them if they joined for any of these reasons:

Possibility of getting killed. Lots of paperwork. Long shifts. Nights, weekend and holiday work. Dealing with the worst people. Working with old and broken equipment. Bosses who are out of touch. Pressure to make arrests. Investigating sex crimes.

Of course no one entered law enforcement to deal with those problems, but they are part of the job. It’s a rhetorical question and one of my bonding and teaching strategies. Add to these problems the shift in public perception about cops – many feel unappreciated, blamed and attacked. Morale is low. The data on cops and troopers is pretty clear. They have more sleep problems, higher rates of first marriage divorce, higher rates of alcohol abuse, higher rates of stress, a high likelihood of PTSD, higher suicide rates, and shorter life expectancy. I tell them that their job might be killing them (much like how military jobs and child welfare workers jobs cause them to have all kinds of personal and health problems). This is a point that I must emphasize strongly – there are some jobs that we ask people to do that are detrimental to their physical and mental health, as well as the well-being of their families. Again, the data on this is clear.

One unit I work with focuses on sex crimes. What they deal with and see is beyond horrible. Someone will work in that unit for at least 3 years, but many work in it 10 or more. They see thousands of horrendous pictures of sexual acts committed against 6 month olds, toddlers and small children. And it’s not a bad day at work. They see this every day. For years. It does a number on them. It effects their families. These officers often don’t take sick days or vacations, because time is of the essence and any time off to them means “bad guys are doing bad things.” And they are haunted by the images of those bad things. I am thankful for the work they do and feel a sense of desperation to help them.

When military members came home from Vietnam, they not only had to deal with physical injuries and psychic wounds, but a hostile public that sometimes spat at them and called them baby killers. The burnt out and disillusioned Vietnam Veteran was so common that he became an American archtype, and we can all think of books and movies and TV shows where they are represented. The perception of the military and veterans changed after Gulf War I concluded in 1991, and soldiers (and marines and airmen and sailors) came home to yellow ribbons, parades and thanks. This respect for servicemembers and veterans has continued through 2016. I don’t know how it flipped (nor can I find a reasonable theory on it), but law enforcement needs and deserves a similar public perception change.

From what I’ve learned about the Dallas Chief of Police, he seems to be the ideal type of individual to help address the problems of modern policing and current perception in America. Even before the recent and well publicized problems between the black community and police blew up on the American radar (one might argue that it entered the national dialogue with Ferguson in 2014), Chief Brown had been working on engaging the community and training his officers to use restraint. A veteran of over 30 years, his son killed a police officer and was then killed by another cop shortly after Mr. Brown became the Chief in 2011. He’s also black, which is particularly significant and potentially impactful because of the level of distrust between many members of the black community and law enforcement.

The Importance of Language and How We Say Things

All of this written, I don’t have policy proposals to deal with teacher-student sex, Muslims who shoot people in America or the rampant fear that other Americans have towards Muslims, how to fix the disparity of arrests and violence against black Americans by law enforcement, nor how to improve the perception of the vast number of cops who try so hard to do the right thing all the time. What is obvious and painful to behold is that teachers, Muslims and cops are all being maligned for the actions of a few deranged individuals that share a profession or religion with them.

I’m an Orwellian. That means that precise language is extremely important to me and that I try to avoid understatement, exaggeration, hyperbole, and inflammatory language. I am so disappointed and frustrated by the words I hear people use to argue their positions. People threaten, curse, yell, exaggerate statistics, and misstate facts to make their points. People on both the right and left, conservatives and liberals, Republicans and Democrats, are guilty of this. We surround ourselves with people that think and speak like us and choose to read media that reinforces our opinions. We get fired up on social media by the latest outrage and unfriend those that have a different viewpoint.

President Obama spoke at the Rutgers graduation this year, and he criticized the administration, faculty and student body for pressuring Secretary Rice to not speak at the 2014 graduation.

I don’t think that’s how democracy works best, when we’re not even willing to listen to each other. If you disagree with somebody, bring them in and ask them tough questions. Hold their feet to the fire, make them defend their positions. … Don’t be scared to take somebody on. Don’t feel like you got to shut your ears off because you’re too fragile and somebody might offend your sensibilities. Go at them if they’re not making any sense.

A number of liberal writers said he was wrong, and that Rutgers community was justified in denying Secretary Rice a chance to speak. I strenuously agree with the words of President Obama. We need to be able to talk to and more importantly, listen to each other. If you are a conservative, ask yourself if you have any liberal friends or liberal views. If you are a liberal, do you have any conservative friends or conservative views. Do you talk in specifics or generalizations? Are you in a constant state of rage and agitation? Can you have a conversation without getting nasty or raising your voice? These are points I implore you to consider and questions to ask yourselves.

22Jun/16

The Recovery Coach Problem

Two weeks ago, I received a notice from the NJ Addictions Professionals Certification Board that they have created a credential called the Certified Peer Recovery Specialist. This replaces the terrible Recovery Mentor credential, and is just the latest term for a Recovery Coach. Two years ago, I wrote about Recovery Coaches and it has been of the most read articles on my site.

My biggest concerns about Recovery Coaches are that they are uneducated, untrained, unlicensed and unsupervised people that are collecting a fee for services to a very volatile and vulnerable population. The people who act as a Recovery Coach are usually in recovery themselves and often well meaning, but neither is a proper sole qualification to engage in this work (more on the Life Coach disaster below*). Many of the Recovery Coaches that I have come across cut their teeth in 12-Step programs and cite God as a profound force in their ability to recover. This is problematic at best, even moreso than typical “this way worked for me so therefore you should follow” it strategies. One should not infer that I don’t like 12-Step programs – I do – but I don’t want to see people use their AA or NA experience to give people advice on medications, family dynamics, suicidal thoughts or educational guidance. Another problem is that Recovery Coaches are, more often than not, against Medication Assisted Therapies and I know some proclaim that if you take Suboxone that “you are still getting high.”

All that written, having a certification that requires training, limits scope of work and requires supervision is a good start to fixing the Recovery Coach problem. The Certification Board described the credential as such:

This credential is available to Peers seeking to learn Peer Support skills in order to foster the recovery of others affected by addiction and co-occurring problems.The CPRS is not a private practice credential, as they are only licensed by the NJ State Division of Law and Public Safety, Division of Consumer Affairs.The CPRS will replace the Recovery Mentor. Please note that this is not a counseling certification (italics are mine), but rather a Peer Recovery credential that allows the holder to perform the following domains:

1) Advocacy

2) Ethical Responsibility

3) Mentoring and Education

4) Recovery/Wellness planning, within a supervised professional agency.

As of now, the training has only been approved to be provided by CARES in MorrisCounty. Their website states that the credential was inspired by the “Peer Specialists (that were placed) in hospital emergency rooms anytime someone is saved from an opioid overdose with Naloxone. The Peer Specialists meet with the patients in the ER with the goal of getting them into treatment and hopefully long term recovery.”

As long as the peer specialists (or recovery coaches or recovery mentors) are limited to this role and are not speaking out against medication** to those with addiction issues, this is a positive development. Like so many other programs and public policies though, it’s a good first step. There is more work to be done on this, and I still urge people to get a licensed therapist over a recovery coach.

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* Life Coaches are another group that seek to circumvent education, training, licensing, supervision and experience in order to collect a fee and act as therapists. The counseling professions are a bit of a disaster (far less than 20% are competent, in my wide experience), but that still should not open the door to anyone who can get someone to listen to them to become a pseudo-therapist. One wouldn’t hire a legal coach, medical coach, financial coach (well…I’m not sure why anyone would get a financial advisor that wasn’t a fiduciary, but I digress), or marriage coach, but for some reason life coaches caught on. From the dawn of civilization until present day, there have always been charlatans, hucksters, carnival barkers and snake oil salesman. Then as now, they are best to be avoided.

** In reading this and other articles by me, one might assume that I am wildly pro-medication. I am not. I believe that medication can be effective to help people with severe addiction issues, as well as people with depression, PTSD, anxiety, bi-polar disorder and a variety of other medical problems (heart disease, diabetes, HIV). I just don’t believe in medication first, but rather after a series of behavioral changes (proper sleep, proper diet, regular exercise, quitting smoking) have been legitimately attempted. I am quite wary of Big Pharma, and have written about the problems of over or improper medication extensively.

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6/23/2016 Correction: An earlier version of this piece stated that the NJ Division of Mental Health and Addiction Services (DMHAS) had been involved with the creation and approval of this certification. After communicating with officials at DHMAS this morning, I was informed that they were not involved in the process at all and that the Certification Board erred in its statement (please note that CARES has not made this false claim).

22Jun/16

Governor Christie’s Heroin Failure

Last week, Governor Cuomo and a number of legislative leaders announced a series of bills and initiatives to counter the heroin crisis in New York state.  This bi-partisan legislation was announced at a big press conference in Albany on June 14, 2016. The highlights of their work (which I’m quite impressed with) include:

1) the first time opioid drugs are prescribed, they can only be a 7 day supply (this means that Oxycotin, Percocet, Percodan, and Vicodin can no longer be handed out in 60 and 90 pill quantities to first time patients)

2) it mandates all prescribers (MDs and Advanced Nurse Practitioners) get training on pain management

3) increased the number of funded inpatient treatment beds by the state by 270

4) increased the number of funded outpatient slots by the state by 2,335

5) it ends prior authorization by insurance companies for inpatient or outpatient treatment. The first review by the insurance companies can only take place after 14 days of treatment (previously, reviews would happen after 2 or 3 days – think about that…someone from an insurance company would ask the treatment provider if the treatment has been working and how the client is doing after 2 days…and also think about how much time these treatment providers have to spend on the phone with the insurance companies, every few days)

6) it addresses insurance coverage and how insurance companies are not paying for treatment, despite the legal requirement to do so as dictated by the 2008 Mental Health and Addiction Parity Act and the 2010 Affordable Care Act.

7) it mandates that insurance plans pay for Naloxone (the anti-overdose drug)

All seven are good, but 1, 5 and 6 are incredible. What is particularly impressive is that Governor Cuomo was able to work with the NY legislature, whose leadership has continually been in trouble for years (click here, here or here for the horrid and sordid details).

Governor Christie’s failures in dealing with the heroin and opioid epidemic are lengthy. He delayed the Task Force report by 18 months and then did not take any action on the recommendations. He has failed to mandate the PMP in NJ. He vetoed the creation of more recovery high schools. He got a standing ovation at the Statehouse in January when he announced a $100 million for addiction prevention and treatment, but he never put the money aside (so there are no programs – but he still got his ovation and media attention).

The successes that have happened while he has been Governor happened in spite of him, rather than because of him. Advocates like Linda Surks, Patty DiRenzo, Paul Ressler; politicians like Senators Vitale and Lesniak, and the members of the Camden County Freeholders; former Deputy Attorney General Calcagni and hundreds of other hard workers have been the driving forces behind the Good Samaritan Law, Narcan Expansion, the Recovery High School, prescription drug drop off boxes, and the stunning fact that law enforcement officers carry Narcan and look at addiction as more of a public health issue than a criminal one.

NJ Assemblyman Joseph A. Lagana of District 38 introduced a number of bills last week that seeks to combat the heroin epidemic in NJ (none of them are as forward thinking as the aforementioned NY laws). His four bills (I’m taking all of this from an email he sent out last week):

The first bill would establish a process that would allow an individual to petition the courts for the involuntary commitment of another individual for treatment for substance use disorder.

Specifically, the bill would provide for a “petitioner” who is the spouse, civil union partner, relative, friend, or guardian of an individual to submit to the court a petition for the involuntary commitment of the individual to treatment for a substance use disorder. The petition must be accompanied by a guarantee obligating the spouse, civil union partner, relative, friend, or guardian of the individual to pay all costs for treatment of the individual that is ordered by the court.

“Many drug users want help, but are rendered helpless by their addiction,” said Lagana. “Addiction not only hurts the people using, but those close to them. People who have the best interest of these individuals at heart should have the option to get them treatment.”

The second bill would require that every prescription for a controlled dangerous substance, prescription legend drug, or other prescription item be transmitted electronically using an electric health records system. This requirement would take effect one year after the date of enactment.

The third bill would add naloxone hydrochloride, and other opioid antidotes, to the list of prescription drugs that are to be monitored as part of the state’s Prescription Monitoring Program. While the PMP focuses on monitoring the dispensation of controlled dangerous substances in the state, and although opioid antidotes are not considered to be controlled dangerous substances, the sponsor noted that information related to the dispensation of opioid antidotes is nonetheless relevant to determinations regarding the prescription and dispensation of controlled dangerous substances.

The bill, called “John Wagner’s Law, is named after the son of former Assemblywoman Connie Wagner who lost his battle with opioid addiction. Lagana holds the seat vacated by Wagner. Lagana said the bill came about after hearing from local law enforcement and addiction specialists that they needed naloxone deployment data to help with their prevention efforts.

The fourth bill would require certain health care professionals to meet continuing education requirements on topics related to prescription opioid drugs as a condition of renewal of a professional license, certification or registration. Under the bill, health care professionals with the authority to prescribe opioid medications, including physicians, physician assistants, and dentists would be required to complete one continuing education credit on topics that include responsible prescribing practices, alternatives to opioids for managing and treating pain, and the risks and signs of opioid abuse, addiction and diversion. Health care professionals without prescribing authority would be required to complete one continuing education credit on alternatives, risks and signs of abuse. The credits required under this bill would be part of a professional’s regular continuing education credits and would not increase the total number of continuing education credits required. (this is my favorite of the four)

When I spoke with the Assemblyman at a panel discussion last week, he admitted that it was an uphill battle and that many of these would not pass the legislature or if they did, that Christie would almost certainly veto them. And that gets to the heart of the problem here in NJ – while Governor Cuomo passes meaningful legislation in NY by working with a historically crime-infested legislature, Governor Christie shuts down bridges, goes to Cowboy games, and campaigns for Trump. While he dithers, people die.

06Jun/16

How Big Pharma Gets Doctors to Push Its Drugs

This piece on Continuing Medical Education Units was written by Anthony Gallo, a student of mine last year at the Rutgers School of Social Work. Anthony graduated with his BASW last month. He is now enrolled in the Rutgers MSW program and is interning this year for the NASW-NJ.

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Continuing Medical Education (CME) units are the professional educational requirements for renewing a doctor’s medical license. The requirements differ from state to state: Arkansas requires 20 CMEs in a 2-year cycle while Washington requires 200 (to search your state’s requirements, click here). According to the Accreditation Council for Continuing Medical Education (ACCME) they are intended to help physicians by improving “their practice and delivering high-quality, safe, effective patient care.” They are generally designed to influence physicians’ practices in positive ways, but this is not always the case.

CMEs can cost several hundred dollars for a six hour class, so keeping up with them could potentially cost a thousand to upwards of ten thousand dollars every two years. Conflicting motives arise when CMEs are paid for by companies who can introduce intentional or unintentionally bias. The late Arthur Sackler, co-owner of Purdue Pharma and founder of modern pharmaceutical marketing, was one of the originators of the concept of commercially sponsored CME units. He rightly believed that by influencing medical education he could increase sales of his pharmaceuticals to doctors. This strategy was showcased in the American prescription pain pill boom in the 1990s.

Purdue flew doctors to resorts and conferences where they would hear lectures from corporate sponsored experts on the benefits of prescribing opiates for pain. These speakers would deliver messages that downplayed the risks of these medications and portrayed Purdue’s opiate drug, OxyContin, as a wonder drug that was “virtually non-addictive.” An unnamed CME organizer quoted in Sam Quinones’ book Dreamland described the effectiveness of one of Purdue’s paid speakers, Russel Portenoy:

All you need is one guy to say what he was saying. The other guys who are   sounding a warning about these drugs don’t get funded. They get a journal article, not a megaphone.

In this way CMEs were used to reassure the medical community that opiate painkillers were safe and effective when they were actually overstating the benefits and understating the side effects (including addiction).

In all, the U.S. General Accounting Office reported that Purdue Pharma helped to fund over 20,000 educational programs and their efforts proved wildly successful. Pain pill prescriptions rose from 670,000 in 1997 to 6.2 million in 2002, in part due to their CME programs. This was also before strict regulations governed commercial influence in CMEs.  Many of Purdue Pharma’s statements were false. Several executives eventually faced criminal charges for misrepresenting the dangers of their drug, and Purdue Pharma continues to pay fines to this day. America’s current heroin epidemic was partially created and compounded by the misuse of pharmaceutical marketing and education.

Regulations have been since tightened, limiting the commercial influence on CMEs. CME providers are now required by the Accreditation Council for Continuing Medical Education to be independently structured from “any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.” There are also strict reporting requirements for financial contributions and prohibitions on direct or indirect influence of course material.

The potential for abuse is still real, however, and in the first quarter of 2009 the pharmaceutical company Eli Lilly paid out roughly $44.5 million in speaking fees to company approved experts. One of their highest paid was Dr. Manoj V. Waikar, who received $74,850 for speaking at 51 events for the company. These speeches are generally scripts written by the company.

In 2014 the ACCME reported that 41.4% of CME providers received commercial financial support.  Eleven CME providers received in excess of $10 million from commercial companies. Dr. Michael Steinman, an associate professor of medicine at the San Francisco V.A. Medical Center described the conflict perfectly by stating, “The course providers have a subtle and probably unconscious incentive to put on courses that are favorable to industry because they know where their bread is buttered.”

CME programs are receiving more scrutiny than before. Recent tightening of accreditation standards for CME programs and shifting public opinions have lowered commercial influence. Doctors receiving reimbursements for CME credits dropped from 26% to 12.7% between 2004 and 2009. Doctor’s receiving payments for speaking on behalf of companies dropped from 16% to 8.6% in the same timeframe.

Major universities have taken steps to prevent commercial bias. Stanford recently expanded its ban on faculty involvement in commercially sponsored speaking activities to include adjunct professors as well. Harvard also has strict regulations regarding commercial involvement.

The move away from commercial funding will be difficult and expensive, likely requiring more doctors to pay for their CMEs. Despite the challenges, this change will likely be vital for the unbiased advancement of the medical sciences. The industry has made progress since the early days of OxyContin, but Big Pharma continues to get into trouble for using CMEs to push medications on doctors (you really should click on that). We’ve seen some of the dangers of commercial influence and we must push ahead in fixing the CME funding system.