Monthly Archives: June 2016

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.

01Jun/16

Two Great Drug Policy Bills

State Senator Joe Vitale, the Chair of the Senate Health, Human Services and Senior Citizens Committee

On June 6, the NJ Senate Health Human Services and Senior Citizens Committee will meet on in the State House Annex in Trenton at 1 pm to discuss seven new bills. Two of them are excellent attempts to address the opioid epidemic.

S-1266Vitale Establishes permanent sterile syringe access program; appropriates $95,000.

When I was working on my Masters in Social Work, I wrote a long research paper on the international history of needle exchange programs. I was dismayed to find out that NJ was one of the states that did not have a widespread program – it was blocked by then (and current) State Senator Ron Rice, a Democrat from Newark. One of the reasons for his opposition to the needle exchange programs was that he believed it encouraged drug use (the other was that he was unhappy that inner city treatment programs are underfunded, which was and is a legitimate gripe).  Research from around the globe and US unequivocally shows that needle exchange programs greatly reduce new HIV and Hepatitis C infections while not causing new people to pick up drugs (“hey free needles, I should use drugs now”).

NJ has had pilot programs in a few cities, but Senator Vitale’s bill would create a permanent and broader reaching program. The meager funding for it is farcical, but passing this is the first step. Increasing the funding can be broached later.

S-2035Turner Restricts initial prescriptions for opioid drugs to seven day supply.

Senator Turner’s bill will probably not pass the State Legislature, but even if it did Governor Christie would surely reject it. This is an excellent idea to help address the overprescribing by doctors and forcing MDs to do a better job of monitoring how the painkillers they prescribe are being used and how they are effecting their patients. Patient advocates argue that this causes an undue burden by requiring additional visits that they can’t afford, and doctors cry that they should not be regulated and told how to practice medicine. One only needs to look at these charts to see how opioid overdoses are continuing to increase to see that additional regulations are needed. This not burdensome.

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I urge anyone who is interested in these issues to write a letter to one or more of the committee members. If your state senator is on the committee, then consider calling him/her on top of submitting a letter. To see a list of the members of the committee, click here.