31Jan/17

A Deeper Reflection on Governor Christie’s Drug Policies

On January 10, 2017, Governor Chris Christie uttered his seventh and final state of the state address at the statehouse in Trenton. In the early years of his administration when the Governor was popular and strutted across the national stage, seats at these speeches were extremely difficult to come by. On January 6th, Christie’s staff was still sending out email invitations in order to fill up the room (I declined)

The Governor’s approval ratings hover in the teens, and politics clearly mirrors life in this simple fact: people don’t show up to unpopular peoples’ parties (unless the food is really good).

Mr. Christie is a historically unpopular politician who is serving out his last year in office. NJ is facing a cascade of economic problems: slower job recovery than the rest of the region, declining home sales, high property taxes, crumbling infrastructure, companies moving out of state, and one of the worst cases in the country of underfunded pension obligations. Despite statements to the contrary, the Governor has been unable (or unwilling) to address those aforementioned issues (he has also overseen a record number of state credit downgrades), and they will be passed on to the next person who takes over in January of 2018.

These difficult economic issues and his resounding unpopularity may have influenced the focus of this year’s state of the state address. The Governor fell back upon a topic that he has forcefully and eloquently talked about for years: drug addiction. He spent over 2/3 of his speech discussing policies and programs around addiction and recovery (this was not historic – the Governor of Vermont devoted his entire State of the State to addiction in 2014). This is a subject that has bi-partisan support and one that can still get him positive media coverage. The day after his speech, a member of his staff sent out a self-congratulating email with links to glowing coverage from the area papers as well as the Governor’s appearance on “Fox and Friends” that morning.

To the average citizen with a cursory understanding of addiction and recovery, it appeared that Mr. Christie is a visionary with several incredible and well-meaning policy proposals. Advocates, those deeply ensconced in substance misuse policy, and other politicians know the real story, and we’ve been sharing it with various media outlets over the last three weeks.

Some of my friends and colleagues have asked me why I have been so critical of the Governor when he is finally focusing more attention on this issue. Two analogies: (1) You work very hard at a job. You put in long hours. It’s clear that you are vital to the organization. Other people of less skill and work get raises. After seven years, you finally get a 3% raise. While you are happy for the money, you think, “Why did it take so long and why so little?” (2) You do a majority of the housework in your home (more than your spouse/kid/parent/sibling). After three years, your spouse/sibling takes out the garbage and cleans the kitchen sink. Once. How much praise do you give them?

During his speech, Governor Christie announced or asked for the following:

  • That he wants a bill from the legislature that mandates insurance coverage of inpatient treatment for six months. Senator Joe Vitale introduced a bill that would cover three months last September. Six months is unlikely to pass and even if it does, would be subject to a massive pushback on the state and national level by insurance companies. The Governor did not address whether or not this would apply to people on Medicaid or those without private insurance. If it did apply, it is something that the state could not currently afford.
  • He announced a one-stop number for people to call about treatment – 1-844-REACH-NJ. This is redundant. On July 1, 2015, the state created and funded the NJ Addiction Hotline. That number is 1-844-276-2777. Either Governor Christie is creating a redundant program or is changing the number in order to get some press for a program that has been around for 18 months.
  • He ordered the creation of a curriculum on opioids and other prescription drugs for school children of all ages. The NJ Heroin and Opiate Task Force suggested this in its report back in 2014, and the NJ legislature has tried to pass legislation regarding this for the last few sessions.
  • He talked about Narcan saves, but he did not say that he would ensure that first responders received the additional funding required in order to have Narcan. Gov. Christie was slow to support Narcan, and its presence, use and expansion in this state is largely due to the front line work of advocates like Patty DiRenzo and Paul Ressler, both of whom last their sons to this epidemic.
  • Christie said he would instruct his Attorney General to limit initial opiate prescriptions to 5 days. Seven day limits have passed in NY and Massachusetts in the last couple of years. This is a sound policy and a major departure from the Governor’s lack of motivation of regulating doctors (he refused to mandate the Prescription Drug Monitoring Program, require medical providers to be trained on addiction, or require doctors to warn parents of those under 18 about the dangers of opiate painkillers when prescribing them).
  • The Governor did not discuss needle exchange programs, the NJ Recovery High School in Union, the importance of medication assisted therapies (and much needed regulation that would require them to be accompanied by urine screens and counseling), or the various programs that police are trying to utilize to address what happens after an overdosed person is revived.
  • A few days later, Governor Christie announced the creation of yet another Task Force to study the problem. He largely ignored the report of the first Task Force (which I chaired in 2012). The co-chairs of the second Task Force were at the statehouse for his speech. Advocates, policy advisors and politicians have made the issues very clear. There are many other states that have implemented good programs and strong regulations. It is hard to fathom why we need a third Task Force.
  • Perhaps most significantly, he has not commented at all on President Trump’s plan to repeal the Affordable Care Act and gut the Medicaid expansion. Thousands of New Jersey citizens were able to get access to treatment with that expansion, and many in the future will be cut off. Despite his big talk about wanting to address this issue in a bi-partisan way, the Governor has shown himself loathe to criticize the President. That isn’t leadership. Breaking with Trump and stating the very obvious fact that Medicaid expansion helped treat thousands of people (and saved a lot more money in the criminal justice system and health care) would be leadership.

Within the first year of taking office, Governor Christie supported expanding drug courts as an alternative to incarceration (which is costly and largely ineffective in addressing addiction). I was excited to hear him talk, and I believed that a Republican Governor who had been a US Attorney had a much more real shot at meaningful criminal justice reform and overhauling the treatment industry than a Democrat (who would be accused of being soft on crime, wasting tax dollars, and suffering from a bleeding heart). Despite talking about expanding drug courts, he didn’t significantly increase their funding. This is a pattern he has oft-repeated over the last 7 years. Mr. Christie is quick to talk about new laws, effective programs, tougher regulations and increased funding, but when it comes time to sign the dotted line, he hems, haws, delays and under-delivers. But by that time he has already basked in the sunlight of media attention and public adoration, and the citizens of NJ are either too busy or too apathetic to notice that he has accomplished very little.

12Jan/17

Broken Promises, Announcing Old Programs, Taking Credit For Others’ Work and Hyperbole: The Self-Serving Bombast of Chris Christie’s Drug Speech

Image result for chris christie

At at little after 2 pm yesterday afternoon, Gov. Chris Christie gave his seventh and final state of the state address. After a brief review of other policies, the Governor used most of his time to address drug addiction. He appeared on the front page of papers around the state today, and received a lot of fawning coverage. Jeremy Rosen, a member of his staff, sent out an email to members of the state and national media this morning about all the positive press and highlighted Mr. Christie’s appearance on Fox and Friends this morning.

Ken Serrano of the Asbury Park Press called me immediately after the speech and asked for my opinion. His write-up can be read here. Michael Hill of NJTV news interviewed me in my home this afternoon (click here to see it). With my media appearances concluded, I wanted to write out a blow-by-blow response to Mr. Christie’s speech.

The Good

1) Mr. Christie stated that drug addiction affects kids, schools, health care, law enforcement, jobs and even your family. Agreed.

2) He said we can’t “arrest, jail, or pray” ourselves out of this problem. Agreed.

3) The Governor talked about the prison program that will open in the spring. He talked about it at last year’s address. I have heard from people setting it up that the plans are moving smoothly. I hope high hopes for this and expect that this will be his greatest legacy.

4) Mr. Christie railed against legalized marijuana and mentioned that if you legalize it, more people will use. He said that one of the biggest predictors of someone becoming an addict was starting to use substances at a young age. I am against legalized marijuana. Mr. Christie’s point about age of first use is correct. But while the Governor wants to continue criminalizing marijuana and locking people up for using it, I want to see it decriminalized.

5) He said that insurance companies must pay for up to six month of inpatient treatment and eliminate pre-authorizations and early medical reviews. New York passed a similar bill last summer. Senator Vitale recently introduced a bill covering these very issues but it only required up to three months of inpatient treatment. Gov. Christie took it further. This was the highlight of his speech. If this happens, I will stand up and clap for him and praise him on this achievement.

Taking Credit For Work Others Already Did

6) Mr. Christie announced a one-stop website and phone number for people to call to get information and find treatment. The number is 1-844-REACH-NJ. NJ already has a one-stop phone number. The NJ Addiction Services Hotline is 1-844-276-2777 and began to take calls on July 1, 2015. It has 22 full time staff members and is run by Rutgers Behavioral Health Care. Over 85% of the phone calls they have received are from people with no insurance or on medicaid. This new number is a redundancy – a true waste of tax payers’ money. When I called it today, the automated menu put me on hold. After a long wait, I told the person on the phone that I had a friend with no insurance. They referred me to the NJ Addictions Services Hotline.

7) The Governor said that 18 and 19 year olds would be considered youth when it came to mental health and addiction treatment, allowing them to get more funding and better services. Commissioner Alison Blake has been advocating and working on this plan for the last three years. It is a good idea that should have been implemented years ago. More lives could have been saved.

8) Mr. Christie said that we needed a new curriculum on opioids and other drugs for kids of all ages – different programs for kindergartners, middle school kids, and high school students. Great idea, but it was suggested years ago. The NJ Heroin and Opiate Task Force suggested this back in 2012 and included it in its paper in 2014. Last fall, Senator Joe Vitale introduced legislation covering this very thing.

9) He talked about all the saves from Narcan and how law enforcement officers around the state are administering it. This is wonderful. Governor Christie delayed the wide scale use of Narcan back in 2012. When the bill allowing for it finally passed in 2013, he did not provide funding for police departments. Grass roots activists like Patty DiRenzo and Paul Ressler pushed this issue to the forefront of municipalities and police departments and helped raise public money to train civilians and first responders on it. More lives would have been saved had Christie not delayed the release and engaged in a massive push of funding for police officers from the beginning.

10) The Governor talked about counselors helping those that have overdosed. They are not counselors, but rather Recovery Specialists. They have a little training and a small scope of practice – they meet with individuals who have overdosed and through sharing their personal stories and reducing stigma, have better outcomes at getting addicts to go to treatment. This program was created by the Ocean County Prosecutor several years ago.

11) Mr. Christie talked about the role of recovery dorms on college campuses. He said he would increase the funding for these vital programs fourfold. Senator Vitale sponsored a law that passed in the fall of 2015. It mandated that all colleges with over 5000 students living on campus must have recovery housing in the next four years. Christie signed the bill into law but did not provide funding for it. A fourfold increase does not even support the current existing programs, much less help the other schools establish this new required housing. Usually Mr. Christie likes to talk about specific numbers, but he didn’t do so in this case because the numbers are so small.

12) People without a deep knowledge of this issue were impressed by the time he gave to addiction and praised him for being out in front on this issue. Gov. Pete Shumlin of Vermont devoted his entire 2014 state of the state address to addiction and then followed through on his plans. Advocates around NJ had been begging Christie to do the same thing. It would have been more effective had he done it a couple of years into his reign when he had a 54% approval rating. He has done it much too late – his number hover around 12% and he has only a year left in office.

13) He instructed the Attorney General to issue a special rule that limits initial opiate prescriptions to 5 days. NY and Massachusetts have laws with a seven day limit on the books. We have tried to get this passed in NJ, but Democrat Herb Conway kept killing it in the Assembly Health Committee. If this actually happens in NJ, it’s great news. We asked for it ages ago. Until this happens though, I am skeptical. Big Pharma donates a lot of money to NJ politicians. 

The Horrifying

14) The Governor said that we need more sober living and recovery houses, and that he would push to deregulate them. Sober living and recovery houses are not regulated in NJ. This is a huge problem. I have fought to have these houses regulated. They need to have (a) 24/7 staffing; (b) urine tests two times a week; (c) a curfew; and (d) reasonable access to 12-step meetings and treatment. There are no requirements like this right now. There have been a number of deaths in NJ sober living houses because of a lack of oversight. The lack of regulation of sober living is such a problem that Florida has created a Task Force to shut down programs. There is nothing to deregulate in NJ. This is particularly upsetting because it is well known and has been well reported that Mr. Christie has rich friends who have made a lot of money from running half way houses for people coming out of the criminal justice system. And they have run them very poorly. I am afraid that Mr. Christie is looking to give his friends another financial windfall at the expense of the suffering.

15) Mr. Christie spoke movingly about AJ Solomon, a young man who worked in his office and had a drug problem. While I am happy for Mr. Solomon that he has found recovery, I am deeply concerned that he is opening a private treatment program next month in Camden. He is 26 years old and less than three years sober. These are the exact kind of experiences and qualifications that individuals often have when they open up the kind of for-profit facilities with problems that I mentioned in point 14. Being in recovery does not mean one has an understanding of treatment or recovery support services.

The Unmentioned

16) Needle exchange programs reduce the rate of new Hep C and HIV infections. This saves lives and money. NJ has only a few small exchanges that have survived on private funding. Gov. Christie approved $200,000 for those programs last summer. But they need to be both continually funded and expanded.

17) The Governor said he would crack down on doctors who profit off of pills and the industry that supplies them. He did not say how he would do it. He did not say he would take away medical licenses, push for fines or throw doctors or pharmaceutical executives in prison.

18) He still has not mandated the NJ Prescription Drug Monitoring Program.

19) Mr. Christie did not talk about the NJ Recovery High School. Nor has he helped raise funds for it, nor provided for it in his budget. The school has been supported by Senator Ray Lesniak, a Democrat of out of Union who has had a long-term antagonistic relationship with the Governor. That is probably why Mr. Christie has neither visited it nor supported it. He has let petty politics get in the way of helping addicted children.

 In Summation

Many of Mr. Christie’s announced policy plans are positive. But most of them have come much later than they should have – the number of overdose deaths have increased significantly under his watch, and he was advised on these issues years ago. I am concerned about whether or not these laws will be passed or if the programs will be funded (and if they are funded, will it be a one-off or will they be continually provided for). The timing is problematic. The Governor is deeply unpopular. He has no political capital and the treasury is not only bare, but horrifically in debt. Mr. Christie has a year left in office. He was quick to tout the reception of his speech on go on Fox to talk about it. It seems that he has once again fallen back on this public health issue to address his dreadful poll numbers and try to engage in a comeback. Despite my distrust of the man and his history of disappointing me, I hope that some of these policies and programs will come to fruition. But I fear that we will all be fooled again.

“Meet the new boss. Same as the old boss.” – The Who, 1971.

07Jan/17

On the Death of My Patient

Yesterday afternoon I found out that a  young man that I knew quite well had died. Bobby (not his real name) had been an individual patient of mine, off and on, from 2010 through most of 2016. I’ve spent much of the last 24 hours thinking on him.

Bobby was referred to me by another therapist. That therapist started treating him when he was 17 and saw him for several years. Bobby was a very bright kid from a good family. He used substances a little bit, had a penchant for minor crimes, and often used his wit to lessen his consequences. In his early 20s, he discovered crack cocaine and his life spiraled downward. Within two years, the drugs had severely impacted the functionality of his brain. Bobby’s sharp mind had been permanently dulled. His therapist thought he should see a drug expert, but also found it brutally difficult to see Bobby in his newly diminished capacity.

I met with Bobby and his parents  during our first session. It was clear that they were kind and loving and desperate for their son. They were frustrated too. Bobby would put together a month or two of living substance free, and then would spectacularly relapse and sell his things (he went through several laptops). Bobby had been seeing a psychiatrist and was on a heavy regimen of a variety of medications. He had also begun to experience a bit of religious psychosis. Despite all of this, Bobby was able to get and maintain good part time jobs that paid well. We worked out a plan.

Bobby and I met weekly. Because of his mental state, he no longer had any friends that he hung out with. I tried to get him to reach out and engage with others, but he had little desire to and perhaps not much ability. Every session, he would ask me a very painful question: “When will my brain heal?” Despite doing significant damage to his cognitive functions, he was aware of the fact that he was changed. I refused to lie to him. I told him that he may have done permanent damage to his brain, but that we wouldn’t know for sure until he had a few years clean from drugs and allowed it to heal if it could. This would register, but he always asked me the same question the next week. It was heartbreaking.

Bobby had a kind heart. We would talk about the needs of other people. He had vast empathy for not only his family, but strangers. He eventually put together 11 months clean. He was saving money, occasionally attending 12-step meetings, and was slowly repairing his relationship with his parents. Then he disappeared for a few days. His Mom tracked him down in a dumpy motel. He expressed remorse and got clean again. He was 30 credits or so shy of a degree, so he went back to school part time (and worked part time too). He relapsed after a little more than a year. His parents cut him off and after a few months of a vagabond lifestyle, he checked himself into one of the indigent treatment centers in NJ. He got out after six months and called me up. He said he had no money but wanted to see me. I had folded up my private individual practice in order to focus on all of my other work, but I felt a deep obligation to Bobby. He offered to pay a small fee once he got a job and I agreed.

We met off and on over the next two years. We worked on a plan for meetings, exercise, family communication, work, school and in a few other areas. He would often cancel for one reason or another, and eventually I figured the best way to get him to keep his appointments was to meet him outside of his apartment. Occasionally he still cancelled. The last time I saw him was in the summer.

When I found out he died, I was not surprised but it still jolted me. My first thought was “I should have done more.” That was also my first thought when my friend Frazer overdosed and died in 2002. Then I thought about his Mom. And his Dad. And his other family members. I called his Mom an hour after I found out. I hadn’t spoken with her in three years. She told me that he had been home for the holidays and died in his sleep. She said he went peacefully. And then she started to cry. Heavily. I told her that there are no adequate words of comfort. I told her I mourned with her. I also said that I knew hundreds of parents that had lost their children, and that I would like to put her in touch with them, if and when she was ready. She thanked me and told me how much Bobby liked me. Even in this moment of ultimate despair, she was trying to soften the blow for someone else.

I’ve worked with a lot of people that have since died. Some were students, but most were clients that were in some kind of rehab or outpatient group. A man who was very dear to me died from complications around his relapse and liver cancer four years ago. That was awful (I still carry around the prayer card from his funeral). I’ve trained and supervised many therapists who have lost a patient. They always grieve the loss, and they often beat themselves up for missing something or not doing it differently. I tell them that working in mental health and addiction is brutal, and that death is horribly common aspect of our work. I tell them that it is a reminder of how limited our powers are.

When a patient was sent to prison in 2004, my first real supervisor told me that I couldn’t wear the successes and failures of my clients, because I was (a) not that powerful or responsible and (b) that I would burn out. He told me I had to focus on the process. It was my duty to listen, to educate, to inform them about resources, to model healthy communication and behavior, and to provide honest and forthright feedback. I have shared that story with every counseling student and supervisee since then. I did all of those things for Bobby. And he still died. I spent hundreds of hours with Bobby talking about the most intimate aspects of his life and mind. I liked him. I hoped and rooted for him. And now I mourn him.

 

03Jan/17

Why Most New Year’s Resolutions End in Frustration and Failure

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I avoided the gym today because I wanted to avoid the resolution tourists that plague it on National Gym Sign Up Day. Most of the newly signed (gym general managers call them rubes but count on them to turn a profit) are long gone by the Super Bowl, but the monthly deductions from their bank accounts may last the rest of the year.

New Year’s Resolutions are not new. There is evidence that Babylonians, Romans, and millennia of Jews and Christians vowed to make changes at the start of a new year (the wikipedia article is quite interesting). If there is such a long history of resolutions and people really mean it when they make them, why do so many fail?

1) Too vague – I’m going to lose weight. I’m going to start working out. I’m going to drink less. I’m going to save money. None of these are specific. I’m going to lose 15 pounds by May. I’m going to work out three times a week for at least a half hour each time. I’m going to have five drinks or less a week. I’m going to save $500 more a month. These are much more specific. They are also measurable.

2) Too ambitious – I’m going to lose 50 pounds by March. I’m going to work out every day for at least 90 minutes. I’ll never drink, smoke, or gamble again, and I’m also going to give up sugar and caffeine. I’m going to save 40% of my gross income. Failure is not only almost certain, but probably immediate. Set reasonable, specific, and measurable goals.

3) No plan – Plans are specific and set up a course of action. If you want to quit smoking, you should talk to other people who have quit. You should investigate different medications, gums, patches, and cessation groups. You probably should avoid other smokers (when they are smoking…this is really important for anything you are quitting). You may need to carry gum (I suggest Wrigley’s) or toothpicks or a squeezey ball (to squeeze when people irritate you and you feel like smoking).

4) People don’t track/measure them – You are far more likely to succeed with exercise, weight control, saving money, planning a trip, or quitting smoking if you measure the progress of your plan. Daily. That means writing things down. In the same place (not on scraps of papers, napkins or on your phone).

5) An utter lack of support – Alcoholics Anonymous works because people are trying to make a major change with the support of other people who are either (a) just making that change themselves or (b) made the change a long time ago and offer wisdom and support. This is the major key to Weight Watchers. It is also why most people do better with a workout partner (at least early on). There will be a day (in week 2 or week 5 or month 9) where you want to give up. Or cheat a little. Having another person or group you are accountable to helps you stay on your new path.

If you do all five, you still aren’t guaranteed success. But, it will be much more likely. And here is where it gets really cool. Once you’ve changed,other people will eventually see it (in the long run) and then you can help them change too.

30Nov/16

Guest Commentary: Our Failing Mental Health Policies

I am on a number of email lists and newsletters. This came to my attention this morning. I have worked in a number of fields for many years on both the micro and macro levels, and I'm often aghast at the treatment that is offered and the governmental policies that fail to direct or regulate or (at times) pay for those services. Dr. Lieberman wrote the following piece for other healthcare professionals. It was so nice to read the words of someone else so that I know that I am not alone in my frustration. I received his permission this afternoon to repost this, and I'm thrilled to pass it on to the readers of this site.
_____________________________________________________________________


Jeffrey A. Lieberman, MD
November 23, 2016

Hello. This is Dr Jeffrey Lieberman of Columbia University in New York City, speaking to you today for Medscape. Lately I have been feeling as though I am becoming more of a curmudgeon. I have been irritable and intolerant, and things get me more upset than they used to. But maybe it is for good reason.

I owe my current distress to several events that underscore the continued neglect, inattention to, and prioritization of issues of clear need and benefit to the American people that we have not acted upon. When I say "we," I am referring to our government, the media, the healthcare system, and even the population at large, which should demand its rightful due in the way of services, policy, legislation,
and funding.

I am specifically talking about mental health care and mental illness. Mental illness has always been neglected and given short shrift. Psychiatry and mental health care are what I call the Rodney Dangerfield of medicine—they do not get the respect they deserve. As we become more and more aware of the deleterious consequences of this, one would think corrective actions would be taken, but they
are not or they are happening much too slowly. Several recent occurrences dramatically highlighted this and, frankly, ticked me off.

Missed Legislative Opportunity

This summer, a piece of legislation that could be transformative for mental health care in the United States was finally passed by the House of Representatives. I have talked about this in previous blogs. The Helping Families in Mental Health Crisis Act, HR 2646, was initiated by Congressman Tim Murphy and Congresswoman Eddie Bernice Johnson in the aftermath of the massacre of children by Adam Lanza in Sandy Hook, Connecticut. It was meant to bring about sweeping changes in the way that mental health services are coordinated and financed by the federal government.

This bill slogged its way through the political process for 3 years; in July it was finally approved by a nearly unanimous vote of 533 to 2. The Senate version, the Mental Health Reform Act, S 2680 (formerly S 1945), is a far cry from the House bill, and if passed, it would need to be reconciled with the House bill. Unless some measures of the House bill are incorporated into the reconciled bill, the whole
exercise will not be nearly as effective as it could be.

The opportunity to pass this meaningful legislation is running out of time, and the political challenges are particularly concerning to me, not least because Congress adjourned for the election and will return afterwards only for a lame duck session. If nothing is done before the end of this Congress, then the process has to start all over again the next year. This is a missed opportunity—big time.

Agenda for Mental Health Care Ignored

On August 29, 2016, in the midst of the presidential campaign, Secretary Clinton released an agenda for mental health care. When was the last time a presidential candidate—not a president but a presidential candidate—ever released a thoughtful, potentially comprehensive position statement on mental health care? I cannot think
of any. There have been presidential commissions, but not a position statement by a candidate in advance of an election. That is noteworthy. 

The Clinton campaign released this agenda on a Monday, the beginning of the week, clearly hoping for continuing media attention during the rest of the week (in contrast to releasing something at the end of the day on a Friday before a holiday weekend, which would be buried). But what really got my dander up is that it got no attention. An August 31, 2016, editorial[1]in the Washington Post took note, saying
essentially that the Clinton agenda was released and no one was talking about it. It got next to no play in the media, which tells you how much interest the media believes the public has in this topic. Shameful.

Psychiatrists Overlooked After Hinckley Released

Ten days later, on September 10, news came that John Hinckley Jr, the would-be assassin of President Ronald Reagan, was being released from St Elizabeth's Hospital in Washington, DC. After he tried to murder President Reagan, a court found him not guilty by reason of insanity and he was remanded to St Elizabeth's, and presumably has been getting better for 35 years. He does seem fit to be released back into
society, meaning that he is better and out of danger, and whatever punitive action was intended by his mandated residence at St Elizabeth's has been accomplished.

The real issue is whether he really is better and is not a danger. I have no opinion about that because I do not know his mental status, his diagnosis, the treatment, and aftercare. In the wake of that announcement with all of the media coverage that attended it, there was commentary by lawyers, police, and criminal justice experts.
No commentary by psychiatrists was included among those opinions. Psychiatrists presumably would be an integral, if not essential part, of any consideration of how such a case should be handled given the primary question: Is he better? Does he possibly continue to be a danger? How do we ensure that he is not a danger by providing the necessary treatment? No commentary by psychiatrists. What does that
say about the way the media views this and the credibility of input from psychiatrists? Not much.

The Displaced With Mental Illness

A week later, on September 18, the New York Times published a very interesting article,[2] written by a journalist who had been stationed in Asia for the past 25 years. He and his family had finally returned to the United States and he was assigned to cover a beat in northern California. The article was about returning to
his home country and his impressions after having been away for more than a quarter of a century.

Among a number of very interesting reactions, the author's dominant impression was of walking through the middle of San Francisco and seeing the homeless on the street, including large numbers who were displaced persons with mental illnesses. He commented that, despite the poverty and the much lower level of development in the many Southeast Asian countries he covered, he had not seen the kind of human detritus strewn through those communities that he saw in San Francisco, one of the richest metropolitan areas in the world. How could this happen in a country with the resources and the level of development of the United States?

Awareness Is Growing but Policies Remain Shortsighted

In the aggregate, these four developments, occurring within a relatively short period of time, point to a social problem that has existed historically yet has not been accorded the importance and the attention it deserves. This is how our society cares for people with mental illness, provides for them in terms of mental health care, and finances the social policies that govern how mental health care is
provided and made accessible to people. Although awareness of the scope of the problem is growing in terms of the statistics, costs, epidemiology, and awareness of the consequences, particularly the burden of illness, our government does not act. This burden includes the monetary costs to society and the egregious social pathologies that crystallize in our society as a result of this neglect—homelessness, prisons crowded with persons with mental illness, rising rates of addiction, increasing demographic groups with suicidal behavior, and the mass violent incidents, some of which are perpetrated by individuals with untreated mental illness.

It is infuriating. I hate to believe that I am becoming less tolerant and that my emotional response is disproportionate to the perceived problem. I do not believe that is so in this case. I simply have an acute awareness that appreciates how self-defeating and shortsighted our policies are. Rather than be discouraged and walk away from this, throwing up our hands, becoming angry and having a tantrum, I
encourage you, as myself, to stay the course, redouble our efforts, and continue to try to make people appreciate the scientific, clinical, and social reality of mental illness. We must underscore our ability to provide evidence-based care that is effective and will reduce the burden of illness and the consequences and costs to
our society. And we must press for change.

Change will come. We will be using our ability full force to provide mental health care. The rate-limiting factor will be how quickly legislation, financing, and social policies will change. That will happen; the question is, when?

Thank you for listening.

Dr, Jeffrey Lieberman of Columbia University,

References

1.      Editorial Board. Clinton just made a very important announcement — and
hardly anyone is talking about it. The Washington Post. August 31, 2016.
https://www.washingtonpost.com/opinions/clinton-just-made-a-very-important-announcement--and-hardly-anyone-is-talking-about-it/2016/08/31/5379ddfe-6ef5-11e6-9705-23e51a2f424d_story.htmlAccessed
November 10, 2016.

2.      Fuller T. What San Francisco says about America. The New York Times.
September 18, 2016.
http://www.nytimes.com/2016/09/18/opinion/sunday/what-san-francisco-says-about-america.html?_r=0
Accessed November 10, 2016.
11Nov/16

So Your Friend Voted For the Other Candidate

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After a mind numbingly long 18 month election season, many of us hoped to return to a regular routine that involved less reading, discussing, and arguing about politics. Three days after the election, people are still debating the election, protesting, gloating, and generally extending what has already been an overly long process. Whether it was your candidate that won or lost, you might be more than a bit irritated with family members, friends, co-workers or facebook friends that voted for the other candidate. I have fielded a number of texts, messages, emails and calls from people that say something to the effect that “I don’t know if I can be friends with XXXX anymore.”

Very simply: you can and you should still be friends with that person (or people) in your life who voted for the other candidate. Here is a quick guide to help you get through this:

1) Spend less time on Facebook and other social media.

2) If there are people who voted for the other candidate that are gloating, arguing, complaining, protesting, attacking, or just posting a shit ton of political articles, you can unfollow them for a while. In a few weeks or months, you can refollow them as facebook returns to normal and they post annoying holiday photos of their children, write about how cold it is, share memes that aren’t funny,  promote some event that no one wants to go to, and perhaps, just perhaps, share a heartwarming story or glorious photograph.

3) Take a few minutes and recognize why you are associated with the individual in question in the first place. Don’t cast them off just yet if they meet any one of the following criteria: if you have common blood; have broken bread together; suffered through war, incarceration, early recovery, freshmen year or a terrible boss together; one of you attended the funeral of the other’s loved one; you’ve gone on vacation together; there is a picture of the two of you smiling. If they are someone that you have no connection to other than you like to collect facebook friends, then by all means, purge them from your life.

4) Focus on those above mentioned commonalities rather than your profound irritation with their horrible political choices.Throwing that relationship away as you choose to surround yourself with people who only share your worldview is the move of a small and close minded individual. The ability to listen to those that you disagree with is a good one, and will help you deal in your professional and personal relationships (particularly in romance).

5) Before you blow off point #4 with “But they are so fucking stupid and annoying,” ask yourselves what other differences in people you have accepted. For example, I really disagree with the following lifestyle choices:

(a) eating vegetables

(b) those that think Eli Manning is even close to a Hall of Fame quarterback

(c) people who give me shit for smoking cigars

(d) people who thought Titanic was a good movie

(e) anyone who follows the Kardashians

(f) tattoos

(g) dogs – they are like babies that never get better

(h) skateboarders

(i) not showering

(j) people who talk on their phone in public

(k) people who walk while looking at their phone

My curmudgeon list can get really long. I think I have a friend or a family member that believes or engages in every one of those ridiculous choices. And I still like them (and in a few cases, love them). My point is that almost all of us have accepted differing beliefs from people in our lives.

6) I have an uncle who has not talked to me for eight years because he disagrees with my politics. That was his choice, not mine. Of his four niblings (that term covers nieces and nephews), I was the one who sent him gifts most often and made a point to visit him when I was in California or he came to the East Coast. I accept the fact that he chose to end our relationship based on differing political beliefs, but I would not do that to someone else. Here is the tragedy of that relationship: other than politics, we got along really well. We like a lot of the same foods, books, movies and sports. He made me laugh and was really good to me when I was a teenager. The whole situation is sad.

(7) Over the next few weeks do some (or all) of the following:

(1) exercise more

(2) spend time with friends and laugh and don’t discuss politics

(3) go for hike in the woods

(4) plant bulbs for the spring

(5) binge watch whatever horrific shit of a tv show you like

(6) attend some kind of community event or service (religious, AA, bowling league, PTA fundraiser, etc…)

(7) Read that book you bought two years ago but never got around to reading

(8) organize your closet

(8) And if you really care about politics, then stop thinking that posting or liking articles on facebook or engaging in hashtag activism makes a difference. It doesn’t. It creates an echo chamber where you turn off those that disagree with you and are supported by those that already agree with you. Go get involved. Contact your local Republican, Democratic, Green, Socialist, Libertarian, Pirate, or Sith party and start doing real work. Pick an issue you really care about and become an expert in it. Advocate for it on the local or state level. Shit, run for office. All sides of the political map need good people.

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* This does not apply to the netherworld of Twitter. Those are horrible people.

10Nov/16

Why Social Work: A Student’s Life and Studies Leads to Work with the Latino Community

The piece below was written by Cynthia Diaz. She was my student at Rutgers during the 2015-16 school year. She graduated with her BASW in May and is working on her Masters at Fordham. She is currently interning at Advocates for Children in New York City. I asked her to write an article for me about her life, why she chose social work and what she hopes to do with her degree.

After Tuesday’s presidential election, I expect that Latino families will experience more of these problems and will have a harder time accessing services. Cynthia’s childhood serves as a reminder about the struggles that many members of the Latino community experience.

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As a daughter of low-income Latino immigrant parents, I experienced a great deal of adversity growing up. I was surrounded by people who believed in a patriarchal society and domestic violence was a norm in my household. I witnessed my mom struggle with depression and endure domestic abuse. I never understood why this was or why she let it continue. It made me resentful and angry. Throughout elementary school, my mother struggled to help me with my homework; she only completed elementary school and did not know any English. I’ll always remember my mother sitting next to me with a Spanish- English dictionary as she translated the instructions for my homework. These struggles are common for Latino families. Unknowingly, I prepared for a career in social work as a child. As soon as I was fluent in both English and Spanish, I became the translator for my family and friends. I attended others parent-teacher conferences and went along to social service agencies to help my older cousins get help for their children.

I was the first person in my family to apply to college.  My parents did not see any value in it so they did not support me. My mother wanted me to go to a county college so I could continue to look after my sister. I chose to attend Rutgers instead. Right before moving into the dorm, my father kicked me out of the house and forbid me from coming home. Leaving my hometown and being estranged from my father was quite stressful. It was difficult to maintain a good relationship with my mother after this because I was so hurt that she did not stick up for me. If I wanted to visit my mother and sister, I would stay at a friend’s house and only stop by when my father was not around. I felt lost and alone during my first two years of college, and I turned to alcohol instead of talking to people about my problems. I skipped class and did terrible my first year. I never thought about seeking help.

My little sister was growing up fast and I realized I had to change my lifestyle. I recognized that a business degree was not for me. I spent a summer working for AMARD&V (Artists Mentoring against Racism, Drugs, and Violence) and witnessed the numerous obstacles that Latino students have. I identified with problems they were facing but had no idea how to help them. Many of them had problems at home and did not feel safe. Some of them were only 11 years old. I did what I could – I listened to them and provided them with a safe place to go. This experience made me think about how my life was growing up, and how different my home life, education and relationships could have been if I had someone who understood and guided me.

After that summer, I realized that I could use my experiences to help others. Maya Angelou said, “You may encounter many defeats, but you must not be defeated. In fact, it may be necessary to encounter the defeats, so you can know who you are, what you can rise from, how you can still come out of it.” My experiences with domestic violence, lack of educational support, familial estrangement, and heavy teenage drinking could help me relate to others. I went to the School of Social Work to talk to the director of the BASW program. It was obvious that I should pursue a social work degree. The director and my professors made it clear that I could not just rely on my experiences to help others – that I would need to develop clinical skills, learn about social service resources, and maintain healthy boundaries with my clients.

I graduated with my Bachelor’s in Social Work last spring. It was a great accomplishment that I am very proud of. But I knew if I wanted to make a real difference that I had get a Master’s degree. I’m currently enrolled in Fordham University’s School of Social Service in the leadership and macro practice concentration. I’m interested in policies regarding children, families, and the Latino community. I want to advocate and help those who feel as if their voices can’t be heard. But I can’t just advocate for them – I know that I have to help them advocate for themselves. I hope to learn how to take leadership roles as both a female and a Latina. My life is just getting started. There is so much I want to see and do, and so many people I want to help. I have a strong urge to dive in and help people wherever I go. My professor and supervisors help me understand the big picture. They have taught me about the importance of education, training, consultation, supervision, healthy boundaries, and self-care. I’m 23 and they caution patience. I listen because I want to do this for the long haul.

20Oct/16

The Many Disappointments, Failures and Scandals of Governor Chris Christie

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If it weren’t for the Presidential Election, the Bridgegate trial would be front page news around America. Even my fellow Garden Staters are not giving it the attention it deserves. Gov. Christie’s approval rating sits at 21%, an all time low for him. The ledger of Governor Christie’s disappointments, failures and scandals started long before Bridgegate – long before he became Governor in fact, and I’ve compiled a list of my choices for his worst moments below.

Gov. Christie’s Worst Hits

1) Christie falsely stated that his opponent was being investigated by the Morris County prosecutor’s office during his first campaign for Morris County Freeholder in 1994. Two years after he won the race, he was ordered by the court to apologize for the lies he told. His opponents won a defamation suit against him (the amount of money that Christie paid out was never disclosed). To learn more, click here.

2) Christie raised $350,000 for Bush in 2000 and was named the US Attorney for NJ as his reward. This was despite the fact the Christie had no experience as a prosecutor. Over the next several years, Christie made a name for himself going after corrupt Democrats (and some Republicans). But he went after corrupt politicians that were weak, while giving strong ones that might help him later a pass. To read more about it, click here.

3) Todd Christie, the Governor’s brother, was part of a trading firm that was accused of taking advantage of its own clients. Many of the traders were indicted, but Todd Christie was not. He settled with the SEC in 2008. There has been a great amount of speculation that Chris Christie made a deal to spare his brother. This was one of the major reasons that the Romney campaign decided to pass on Christie for VP in 2012. To learn more about Todd Christie, his financial problems, and his brother’s help, click here.

4) NJ has had budgetary problems long before Governor Christie took office (NJ is required by law to have a balanced budget, but lots of programs are underfunded) and state aid to counties and municipalities has been cut under his leadership. This has led to a series of budget crises on the local level. Governor Christie has spoken about the need to examine the contracts, benefits and pensions of public employees (teachers, cops, firemen and other state workers). While there is no doubt that difficult conversations need to take place with a responsible eye towards revenues and expenses, Governor Christie has often insulted and demonized public workers. He is not the first politician to do this, but that is not an excuse. Gov. Christie’s harshest words are for the public workers’ unions, and while it is easy to find things to criticize within those organizations, it damages the negotiations regarding salaries, benefits and pensions. And it contributes to a negative and nasty climate. Click here for Christie on the teachers’ unions and here for Christie on a police union.

5) Governor Christie has used bullying language, put downs and wishes for violence when he talks about other politicians, opponents and even a veteran. Christie asked the media to “take the bat out” on Loretta Weinberg, a 76 year old Democratic legislator. He called a veteran an “idiot” at a town hall meeting. Last year, NJ.com created a section on the site that has an extensive list of Christie insults.

6) Senator Frank Lautenberg died on June 3, 2013. Cory Booker decided to run to replace the departed Senator that fall. Gov. Christie held a special election a mere 20 days before the regular November 5th general election. It cost the state $24 million dollars. Governor Christie said the reason why he approved the special election was that he did not want to deprive the people of NJ a duly elected representative. Others claimed that despite vetoing other programs and elections based on costs, Christie wanted to keep Booker off of the Nov. 5 ballot in order to increase the margins of his anticipated Gubernatorial reelection. To read more about this, click here.

7) When he was a teenager, Chris Christie knocked on future Governor Tom Kean’s door in the 1970s and found a political mentor and friend that lasted until 2013. Their relationship soured when Gov. Christie attempted to unseat Tom Kean Jr. as the the State Senate Minority Leader by replacing him with someone who would rubber stamp all of his proposals. The move failed and Kean Jr. stayed in power. Gov. Kean viewed it as a huge betrayal. It’s a clear example of both the opportunism and lack of loyalty that make up Gov. Christie’s character. To learn more, click here.

8) The NJ State Ethics Commission is supposed to be a non-partisan, independent office that examines the actions of elected and appointed public officials to ensure integrity at all levels of NJ government. The last two executive directors were Christie appointees, which while not illegal, went against the nature of the commission (who typically appoint their own commissioner). His appointees were both people that were friendly to his office. This reeked of impropriety. One must read the lengthy article about this issue at NJ Spotlight.com.

9) NJ’s credit rating has been downgraded 9 times under Gov. Christie. Job growth in NJ has been much slower than other states in the region since the Great Recession.

10) ExxonMobil caused a great deal of environmental damage in NJ. The company was found liable at the end of the decade long trial. In February of 2015, Governor Christie announced a settlement of $225 million. NJ’s attorneys had been seeking $8.9 billion, and while they may not have won that award, one is hard pressed to find someone who thought the $225 million settlement made sense (it was 3 cents on the dollar). ExxonMobil did donate $50,000 to the super PAC that was supporting Gov. Christie’s presidential bid. It will be interesting to see if Christie or any of his family members get a job with ExxonMobil after he leaves office.

11) In 2010, Bennett Barlyn, Hunterdon County’s Assistant Prosecutor, brought a 43-count indictment against then Sherrif Deborah Trout, Undersheriff Michael Russo, and investigator John Falat. They were charged with official misconduct and falsifying documents. They were Christie people. Paula Dow, the Attorney General at the time, threw the indictment out. Barlyn complained to his superiors that it seemed politically motivated. Barylyn was fired. He filed a wrongful termination suit. After several years, he won. He was awarded $1.5 million. Christie didn’t pay for it. The NJ taxpayers did. Under terms of the settlement, details of the case can’t be released and Barlyn is not allowed to discuss it. In a vacuum, this is disturbing. When discussed as part of the overall portrait of Governor Christie, one must wonder at how many other times his office squashed cases against his allies and unfairly pursued those that defied or opposed him.

12) State officials and reporters have asked “why did NJ miss out on $300 million of Hurricane Sandy relief aid?” the last few years. In 2014, the Star Ledger reported that Christie used $6 million of Hurricane Sandy recovery dollars to build a senior center in Belleville, NJ. The problem is that Bellville did not suffer much damage due to the hurricane. Meanwhile, other towns that were devastated did not get the funds they were supposed to. The Federal Government has been investigating Gov. Christie since 2013 about a potential misuse of the relief funds NJ received.

13) He has been a major disappointment in the area of drug prevention, treatment and recovery services. He delayed the NJ Heroin and Opiate Task Force Report for almost 2 years, has not supported the NJ Recovery High School, did not immediately come out in favor of Senator Vitale’s 21 bills in the fall of 2014, did little as other states passed meaningful legislation in 2016, advocated giving marijuana to veterans with PTSD despite a lack of evidence that it helps, and failed to work on a number of suggestions while he spent two years campaigning for President.

14) His subordinates have been accused of shutting down the George Washington Bridge in September of 2013 because the Mayor of Fort Lee would not endorse him for Governor. David Simon brilliantly wrote about it when the story broke. Christie is not on trial (for now), but a number of his former subordinates are. Christie has denied knowing about this, and is letting them twist in the wind (again, the issue of loyalty surfaces). David Wildstein, a high school classmate of Christie’s whom he has since disavowed, said that he had a “one constituent rule,” which meant that his only job at the Port Authority was to make Gov. Christie happy. Christie’s people used the Port Authority as a political slush fund to reward those that supported him. The trial has been going on for over a month, and every day some new revelation emerges about impropriety and potential misconduct.

This list is incomplete. I’m sure people can think of a lot more examples of Gov. Christie’s disappointments, failures and scandals. As time goes on, more and more will be revealed. A friend of mine said that Gov. Christie and the Bridgewate trial is our generation’s Nixon and Watergate. I disagree. Despite some of his obvious character flaws, President Nixon opened the door to China, signed the Clean Air and Water Acts, and actually did a few good things when it came to drug policy. Gov. Christie can not point to similar achievements.

18Oct/16

Rutgers Announces Free Trainings for Police about Heroin, Substance Abuse and Community Policing

I’m posting this press release from the Rutgers Center of Alcohol Studies. Please share. To get a copy to distribute, click here.

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RUTGERS CENTER OF ALCOHOL STUDIES TO OFFER FREE ADDICTION TRAINING PROGRAM TO ENHANCE COMMUNITY POLICING EFFORTS AND COMBAT THE HEROIN AND OPIOID EPIDEMIC

PISCATAWAY, NJ (October 13, 2016): The Rutgers Center of Alcohol Studies (CAS) announced today that it has created a free training program to improve community policing efforts related to heroin and other substances of abuse. This community-based recidivism prevention project is being made possible through the generous support of the Smithers Prevention Endowment. The trainings will cover new strategies for engaging and helping individuals under the influence of alcohol and drugs, identifying those with substance use disorders who are in need of immediate treatment, de-stigmatizing substance misuse by understanding how the brain becomes hijacked by drugs and alcohol, and intervening to help move a person towards treatment. The training will be delivered at police stations in New Jersey, New York and Pennsylvania by Frank L. Greenagel Jr.

Dr. Marsha Bates, the acting director of the Center of Alcohol Studies, said, “Frank Greenagel is one of our long time professional development instructors who has nationally recognized expertise in the area of heroin and opioids. His ties with the addiction community and local law enforcement makes him ideal to provide these new trainings. Police departments in NJ and beyond have valiantly tried to address the opioid epidemic in recent years, for example by being trained to administer Narcan. Officers on every level have been asked to change their approach to those with substance use problems, often without significant training by licensed professionals. The Rutgers Center of Alcohol Studies is proud to offer this community service by supporting law enforcement officers in their efforts to combat the opiate epidemic.”

Mr. Greenagel stated, “One of my closest friends is a detective and one of my best students is now a state trooper. Both of them have talked to me about the large volume of drug related situations they deal with and how their peers are tired of low-level drug arrests and giving the same individual Narcan multiple times. I have such a deep appreciation for cops and the work that they do. I am excited to assist them to help break the cycle of substance use problems. I have worked with the Center of Alcohol Studies to develop a training program that will help change this by moving away from arrests and towards treatment.”

Frank Greenagel, a clinical social worker licensed in 3 states, specializes in addiction and treatment. He provides lectures and trainings at Rutgers and throughout the tristate area to increase awareness of the heroin epidemic and provide concrete strategies to end it. In 2012, he served as the Chairman of the NJ Heroin & Other Opiates Task Force. He serves on the Board of Directors for Hazelden-Betty Ford in NYC and the NJ Governor’s Council on Alcohol & Drug Abuse (GCADA). Mr. Greenagel has a long history of working with law enforcement officers and soldiers, particularly related to PTSD and substance use issues.

The Rutgers Center of Alcohol Studies is a leader in the field of addiction research and education. Its mission is to increase understanding of alcohol and drug actions, reduce stigma, and improve the lives of people affected by substance misuse. The Center has trained generations of psychologists, social workers and other mental professionals in addiction prevention and treatment. Its Summer School of Addiction Studies celebrates its 75th anniversary next year.

Law enforcement agencies interested in this program should contact the Rutgers Center of Alcohol Studies at 848-445-4317 or cas_ed@rutgers.edu.

10Oct/16

The Need for Continuing Medical Education (CME) to Combat the Opioid and Heroin Epidemic

On Thursday, October 13, 2016, the NJ State Senate Health Committee will hold their monthly hearings on a number of bills. S-2419 would require medical professionals to receive 1 hour of training on Opioid Prescribing every 2 year cycle. I have submitted a brief to the State Senate on this issue. You can download the pdf version here.

The highlights of my piece are:

Two major suggestions:

  • Each medical professional should be required to attend a minimum of 3 hours per 2-year cycle
  • These courses should neither be designed nor funded nor provided by the pharmaceutical industry. Allowing Big Pharma to be involved in these CME courses in any way could potentially poison the purpose of this bill. Legal written language should be put in place to ensure that does not happen.

Big Pharma not only gives money to individuals and businesses, but also to a number of professional organizations. One can justifiably argue that that the pharmaceutical industry benefits from the ignorance of prescribing doctors. Doctors and their professional organizations make claims that mandated CMEs are burdensome, that regulation can hurt their practice, and that government should not get involved in the regulation of medicine. They are using these assertions to hide the real reason for their opposition: Big Pharma gives them money and legislation like this threatens Big Pharma’s profits. This bill is not burdensome. It is about consumer and patient protection, which is a key role in the purpose of government. NJ does not have burdensome CME requirements, and lags behind many other states in mandating training specific to this issue.

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The full piece is below.

Policy Brief regarding the Mandating of Continuing Medical Education (CME) about Opioid Prescribing

October 8, 2016

This was written in regards to NJ State Senate Bill 2419. The bill “requires issues related to prescription opioids to be included in continuing educations courses for certain health care professionals.” It requires the following hours for various medical professionals:

Midwives                                 1                      Advanced Practice Nurses      6

Dentists                                   1                      Physicians                                1

Physician Assistants                1                      Nurses                                     1

Pharmacists                            1

Two major suggestions:

  • Each medical professional should be required to attend a minimum of 3 hours per 2-year cycle
  • These courses should neither be designed nor funded nor provided by the pharmaceutical industry. Allowing Big Pharma to be involved in these CME courses in any way could potentially poison the purpose of this bill[1]. Legal written language should be put in place to ensure that does not happen.

It is important to note that most individuals with an opioid problem started on prescription pills. According to the American Society of Addiction Medicine[2] (ASAM):

  • Drug overdose is the leading cause of accidental death in the US, with 47,055 lethal drug overdoses in 2014. Opioid addiction is driving this epidemic, with 18,893 overdose deaths related to prescription pain relievers, and 10,574 overdose deaths related to heroin in 2014.
  • From 1999 to 2008, overdose death rates, sales and substance use disordertreatment admissions related to prescription pain relievers increased in parallel.
  • The overdose death rate in 2008 was nearly four times the 1999 rate; sales of prescription pain relievers in 2010 were four times those in 1999; and the substance use disorder treatment admission rate in 2009 was six times the 1999 rate.
  • In 2012, 259 million prescriptions were written for opioids, which is more than enough to give every American adult their own bottle of pills.
  • Four in five new heroin users started out misusing prescription painkillers
  • 94% of respondents in a 2014 survey of people in treatment for opioid addiction said they chose to use heroin because prescription opioids were “far more expensive and harder to obtain.

Dr. Nora Volkow, the head of the National Institute on Drug Abuse (NIDA), testified before a U.S. Senate Caucus on International Narcotics Control in 2014 and said this regarding the education of doctors:[3]

Education is a critical component of any effort to curb the abuse of prescription medications and must target every segment of society, including doctors. NIDA is advancing addiction awareness, prevention, and treatment in primary care practices, including the diagnosis of prescription drug abuse, having established four Centers of Excellence for Physician Information.  Intended to serve as national models, these Centers target physicians-in-training, including medical students and resident physicians in primary care specialties (e.g., internal medicine, family practice, and pediatrics).  NIDA has also developed, in partnership with the Office of National Drug Control Policy (ONDCP), two online continuing medical education courses on safe prescribing for pain and managing patients who abuse prescription opioids.  To date, these courses have been completed over 80,000 times.

Dr. Vincent Beswick-Escanlar, a Preventative Medicine Resident at the Uniformed Services University in Bethesda, MD, succinctly summed up the case[4] for mandating CMEs:

Continuing education for medical providers is one way we might be able to improve opioid prescription practices, and in turn, reduce misuse and overdose deaths. By making sure that everyone who prescribes an opioid – doctors, dentists, nurse practitioners, physician assistants, and so on – has the training to decide when opioid medications should and shouldn’t be used, prescribers might be able to limit these drugs to only those patients who will therapeutically benefit from them, and avoid prescribing them when other pain management options might be more effective. It’s not just about finding the right drug and dose – it’s also about considering alternatives, dispensing just the right number of pills at a time, avoiding side effects, recognizing misuse, and so on. Although continuing education is not a replacement for foundational education – like at medical or nursing school – it might help prescribers stay up-to-date with the latest guidelines and best practices, as well as the needs of their communities.

I am certain that neither Dr. Volkow nor Dr. Beswick-Escanalar would agree that 3 hours that I have suggested are sufficient to address these issues, but we must set a minimum limit. You will hear (or read) testimony from doctors and professional groups that will argue against any bill that mandates CMEs about opioid prescribing, pain management or substance abuse. In 2014, the pharmaceutical and medical device industry paid out $6.49 billion to doctors[5]. While some of that money was for research, some of it was also given out to encourage doctors to prescribe the drugs the pharmaceutical industry produces. A variety of recent studies have shown that doctors are more likely to prescribe a medication if they get a free lunch from the pharmaceutical company.[6] Big Pharma not only gives money to individuals and businesses, but also to a number of professional organizations. One can justifiably argue that that the pharmaceutical industry benefits from the ignorance of prescribing doctors.

The American Medical Association (AMA) has opposed mandating CMEs for opiates. That organization has been behind on this epidemic since the beginning (at various times, the AMA has fought against PMPs, 7 day only first-time opiate prescriptions, mandated patient warnings regarding opiates, and requiring medical students take a course about substance abuse). The American Academy of Family Physicians (AAFP) also opposes mandating CMEs. Both organizations argue that mandatory training causes a burden for doctors.

The claim that it causes a burden in false:

  1. Doctors have to take CMEs, and many states have 0 or only 1 mandated topic. NJ has 1 to 2 mandated courses (at most, NJ doctors are forced to take 8 hours of specific coursework every 2 years – the other 92 hours are up to them).
  2. There is a free online HHS training at health.gov: “Pathways to Safer Opioid Use.”

Some doctors and their professional organizations complain that they fear litigation from patients who feel they have received inadequate treatment for their pain. They also cite that some insurance companies tie their reimbursement to patient satisfaction. In short, they are arguing that not prescribing opioids or suggesting alternatives will damage their practice.

3. It is difficult to understand how these are arguments against CMEs about prescribing opioids. In fact, they are compelling arguments for this exact type of course. Those aforementioned doctors may benefit from learning how to talk to their patients about pain and the different kinds of alternatives to medication.

Doctors and their professional organizations make claims that mandated CMEs are burdensome, that regulation can hurt their practice, and that government should not get involved in the regulation of medicine. They are using these assertions to hide the real reason for their opposition: Big Pharma gives them money and legislation like this threatens Big Pharma’s profits.

Big Pharma is also paying close attention to legislation such as this current bill. From 2006 to 2015, the pharmaceutical industry has “donated more than $880 million nationwide on lobbying and campaign contributions.[7]” Only 34% of US States require a course in either addiction, pain management, or opioid prescribing (NJ currently requires none of these). Those donations are used to fight legislation like this from passing, or to ensure that legislation that does pass is weak (like a 1 hour course mandate on opioids).

This bill is not burdensome. It is about consumer and patient protection, which is a key role in the purpose of government. NJ does not have burdensome CME requirements, and lags behind many other states in mandating training specific to this issue.

The number of CME hours per two year cycle varies from state to state. Arkansas requires only 20, while Washington State mandates 200. NJ makes doctor complete 100 CME hours every two years.  Of those 100 hours, doctors have a great amount of leeway. NJ medical professionals are required to get 2 hours on end of life care each cycle. Those licensed prior to 2005 must also get 6 hours of cultural competence every two years. NJ does not currently mandate CMEs regarding chronic pain, opioid prescribing, controlled substances or substance abuse. As of October 1, 2016, 17 other states mandate CMEs in at least one of those areas.

States with mandatory CMEs regarding opiates:  Maine, Maryland, Massachusetts, New York, North Carolina

States with mandatory CMEs regarding the treatment of chronic pain: California, Iowa, Nevada, Oregon, Rhode Island

States with mandatory CMEs regarding controlled substances and substance abuse: Florida, Kentucky, Mississippi, Oklahoma, South Carolina, Tennessee, Vermont

 

Frank L. Greenagel Jr.

MPAP, MSW, LCSW, LCADC, ACSW, ICADC, CJC, CCS

Adjunct Professor – Rutgers School of Social Work

Instructor – Center of Alcohol Studies

Governor’s Council on Alcoholism & Drug Abuse

1st LT – PA Army National Guard

[1] http://greenagel.com/how-big-pharma-gets-doctors-to-push-its-drugs/

[2] http://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf

[3] https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse

[4] https://health.gov/news/blog/2016/06/could-state-laws-around-opioid-continuing-education-help-tackle-the-national-opioid-epidemic/

[5] http://www.bloomberg.com/news/articles/2015-06-30/doctors-got-6-5-billion-in-14-from-drug-device-makers-in-u-s-

[6] http://well.blogs.nytimes.com/2016/06/20/drug-company-lunches-have-big-payoffs/

[7] http://bigstory.ap.org/article/86e948d183d14091a80f5c3bfb429c68/drugmakers-fought-state-opioid-limits-amid-crisis