All posts by fgreenagel

05Jun/17

A NJ Treatment Center Locked Out Its Workers and Transferred All Its Patients

On May 23, Sunrise House, an alcohol and drug inpatient treatment center in Lafayette, NJ, locked out all of their staff and transferred all of their clients to other facilities (until the Wall Street Journal printed a story on it last week, the New Jersey Herald was the only media outlet that covered it).

I worked at Hunterdon Drug Awareness from 2005 to 2010 and at the Rutgers Counseling Centers from 2009 to 2014. During that nine year period, I referred more people for inpatient treatment to Sunrise House than any other inpatient program. I did so because it was a non-profit treatment program that took almost every client I had ever sent them, regardless of ability to pay and they provided them with quality care. I also had some students that interned there, and they reported that it was a good place to work and that they usually received decent supervision.

In 2015, after a few years of suffering some financial problems, they were bought by the American Addiction Centers (AAC), a large for-profit corporation that has been buying up many inpatient and outpatient treatment centers around America. They are one of several large companies that have been gobbling up small programs (Recovery Centers of America is another such company). The investors behind these programs entered the market because of (1) the explosion of new customers (people addicted to opiates) and (2) the increased source of funding those customers have (the Affordable Care Act). National Public Radio made a harrowing piece about these large companies in 2016:

Linda Rosenberg, president of the National Council on Behavioral Health, which represents non-profit addiction treatment programs, worries that private investors are too focused on the profitable inpatient beds and will neglect the services that help patients re-enter society. “After rehab, you come back to your family and your family knows very little,” Rosenberg says. “You need a job, you need health insurance, you need medication-assisted treatment for addiction, you need counseling.” She says there’s very little private investment in all that. “I think that’s the biggest danger,” she says.

And that’s exactly what Tamasi found. When he met with the first group of investors, he learned they only wanted to buy Gosnold’s money-making programs — inpatient detox and rehab. “A detox setting or a rehab program, they have a much wider stream of where revenue can come from,” Tamasi tells Shots. “They’re covered by insurance, people are willing to pay for it if they have the resources to pay for it.” The investors didn’t want the prevention programs, the long-term care or the school-based programs. They didn’t want to invest in the recovery managers that help people get back on their feet once they get out of rehab.

Within a  year of the American Addiction Center’s purchase of Sunrise House, I noticed two major changes: (1) clients were coming out of that program having less quality treatment than the 2005 -2014 period; and (2) student interns told me that the supervision was infrequent and that most staff members felt overworked and ignored.

The workers were apparently upset by the lack of security, understaffing, lack of supervision, inflexible schedules and the general degradation of services and morale at the facility. Last year, the workers at Sunrise House joined the Health Professionals and Allied Employees (HPAE), a labor union of over 12,000 healthcare professionals in NJ. HPAE were engaged in negotiations with the American Addiction Center management for nine months and planned to strike on May 24. The evening before the strike was to take place, the AAC locked out all the workers and transferred all of their clients to other facilities. HPAE has claimed that the lockout was illegal (I do not know enough about labor law to know if this claim is true, nor do I know if the union’s strike was legal). On May 30, NJ Gubernatorial candidate (and probably the next Governor) Phil Murphy stood arm and arm with the union outside of Sunrise House.

A few thoughts:

    1. Anne Fletcher wrote Inside Rehab, a book about the treatment industry. She reported that workers around the country were generally overworked, underpaid, and undersupervised, and that had a direct impact on the lack of successful outcomes.
    2. American Addiction Centers and other large for-profit companies have accelerated this problem, as they have reportedly cut staffing and supervision to dangerous levels in search of higher profits.
    3. AAC (and other large for-profits) want to see this union fail. If it succeeds, it has massive implications for all of their other programs around America. More staffing, higher wages and more supervision mean diminished profits. This must be terrifying for them. They have drawn a line, and it has led to a lock out and transfer of clients.
    4. The therapeutic alliance between counselor and client is a big key to success. One of biggest predictors of treatment failure is if a client’s counselor quits or leaves while the client is in treatment. Even if they terminate in a healthy way, it is still leads to decreased outcomes. It is often difficult for patients with a substance misuse disorder to get comfortable in treatment or trust a therapist. The fact that AAC discharged or transferred every client in their facility rather than settle with the union illustrates how they have put profits ahead of patient care. The public will almost certainly never be able to truly know what the treatment outcomes were like for all of the affected clients that were forced to leave Sunrise House as a result of this dispute.
    5. I am quite sure that the AAC does not want this case to go before the National Labor Relations Board in the near future. Currently, the NLRB only has 3 of its 5 spots filled. President Trump has not nominated anyone for the other two. AAC may seek to delay this as long as possible in hopes that the President appoints anti-labor people.
    6. The dearth of local and national press attention is incredibly disturbing.
    7. Regardless of what happens between the treatment program and the union, it is clear that this scene will play out again in the future.
05Jun/17

The Medicaid Addiction Treatment Problem in NJ

This article was written by Andrew Walsh and edited by Frank Greenagel. Andrew is a grad student of mine at the Rutgers School of Social Work. This is the second article that he wrote under my guidance this year (his first piece was on addiction hotlines).

___________________________________________________________________

Addiction is a very popular topic in New Jersey. Television commercials focus on individuals who struggled, got help, and live a redeemed life. Radio ads discuss addiction and assure that help is only one phone call away at a variety of 24/7 hotlines. Glossy print ads show pristine facilities, smiling patrons, and families that are enjoying improved days. Governor Christie pushed for legislation that increases access to treatment. He has created new phone lines to provide guidance, expanded the number of in-patient beds, and signed legislation mandating a minimum of 14 days in-patient for addiction. At first glance, New Jersey appears to be poised for significant strides forward.

New Jersey has a population of approximately 9 million residents. Of the 9 million, 1.8 million are Medicaid recipients (half of whom are children). Conservative studies estimate that substance use disorder among NJ Medicaid recipients occurs at a frequency of 16.5%. By these estimates, New Jersey has at least 150,000 Medicaid recipients who suffer from substance misuse disorders.  Even with this conservatively low number, New Jersey has enough Medicaid recipients suffering from addiction to fill Yankee Stadium three times over.

For Medicaid recipients in NJ, options for in-patient detox are limited. At this time there are only seven facilities that accept Medicaid for detox. The largest is Bergen Regional, in Paramus, which has 90 beds for detox with an average waitlist of 5-14 days. St. Clare’s, in Boonton, has 16 beds for detox with a waitlist of approximately 14 days. Christ Hospital is located in Jersey City, has 8 beds for detox with a waitlist of 3-7 days. Hunterdon Medical Center is in Flemington and has 14 beds available for detox. Princeton House, located in Princeton, has a total of 27 beds across two programs for detox.  Steps is a program offered by AtlantiCare in Atlantic county (we could not confirm the number of beds available). Finally, Straight and Narrow, located in Paterson NJ, has 20 beds for detox, though we have been told that they are only for people aged 18 to 21 (the same age limitation exists for New Hope and Maryville).

Between the seven facilities there are a little over 175 beds available for detox. A typical detox stay will last five days. Each bed can provide a 5-day detox for 73 patients per year. If each bed available for detox for Medicaid recipients in NJ was filled every day of the year, approximately 1 out of every 14 Medicaid substance abusers would be able to get in-patient substance abuse detox.  However, while there are 175+ beds available for Medicaid recipients for detox, not all beds are specifically designated for Medicaid detox. The 90 beds at Bergen Regional as well as the 20 beds at Straight and Narrow are for Medicaid and Medicare recipients, as well as indigent population. The 14 beds at Hunterdon Medical Center as well as the 8 beds at Christ Hospital are for substance abuse detox as well as emergent psychiatric patients. The 27 beds available at Princeton House are for individuals with private insurance as well as Medicaid. Taking all of these factors into account, on any given day there may be only 100 beds available for Medicaid detox. Accounting for these changes alters the ratio of bed per patients increases from 1 in 14 to 1 in 20. To sum this up, it is very hard to get a Medicaid detox bed in NJ.

With so few beds, the wait-lists at the seven facilities has grown in length. Due to surges in requests for services, waiting for a bed can sometimes take weeks. A quick look at state alcohol related deaths and overdoses shows the danger associated with waiting. Excessive alcohol consumption and abuse resulted in 1,754 deaths in 2013 in New Jersey. Overdose deaths in New Jersey increased 30% from 1223 in 2012 to 1587 in 2015. The increase in overdose deaths is driven by heroin overdoses and fentanyl deaths, which increased 61% and 890% respectively from 2012 to 2015. Opioid overdoses are shown in the chart below. Additionally, benzodiazepine deaths  are commonly found in deaths associated with opioid overdoses. In 2013 3090 NJ residents suffered alcohol-related deaths and drug overdoses.

 

Year Total Opioid Death Heroin Fentanyl Prescription Painkillers and Benzodiazepines
2012 1223 596 42 585
2013 1336 749 46 541
2014 1304 776 142 386
2015 1587 961 417 209

 

Every day an average of nine New Jersey residents die from drug overdoses and alcohol abuse.  New Jersey has an adult population of 6.5 million. Statistically 52.7% of adults drink alcohol, with 10.39% of those that drink exhibiting substance use disorder. This translates in 355,909 adults abusing alcohol. Stephen Stirling of the Star Ledger wrote that New Jersey has at least 120,000 residents that are addicted to opioids. Between alcohol and opioid use disorder, the total is 475,000 New Jersey residents with a potentially life threatening substance use disorder.  Based on these calculations, 6.5 substance abusing adults per 1000 die per year. Applying this mortality rate to the Medicaid population with substance use disorders, an estimated 975 New Jersey Medicaid recipients with substance use disorders die per year. This means that every day, 2.75 Medicaid recipients die from substance use disorders. Over the course of a week, nearly 20 Medicaid recipients will die from substance use disorders. Based on the limitations of available beds and the length of the wait-lists, it is inevitable that many will die while they are waiting for a bed.

New Jersey has approximately 2400 in-patient beds for psychiatric services. To increase access to treatment for New Jersey residents, the NJ Department of Health called for the creation of 864 new beds for substance abuse in New Jersey. While adding new beds for in-patient substance abuse treatment is positive, only 5% these new beds are specifically earmarked for Medicaid recipients. With the addition of 43 beds for Medicaid recipients, the ratio of patients to bed on a yearly basis drops from 1 in 20 to 1 in 15. While this is an improvement, those beds will do little to decrease the length of wait-lists at the few facilities that actually accept Medicaid.

A common reason cited for the lack of Medicaid beds is the low reimbursement rates from Medicaid for substance abuse. Historically, reimbursement rates were so low that facilities lost money for every Medicaid recipient they took. While this argument may have had some validity in the past, it is not as relevant anymore due to recent changes. In 2016 Governor Christ Christie announced a $127 million allocation to increase reimbursement rates for Medicaid substance abuse treatment. The allocation is built on the premise that increased reimbursement rates will be attractive to service providers. The day rate for Medicaid in-patient detox was doubled from $204 to $408. At the new reimbursement levels, the reimbursement rate is no longer a barrier to entry for service providers. The big concern is that 85% of the allocation comes from a federal block grant (if the Feds cut the grants, then these Medicaid programs are in massive danger).

The lack of Medicaid beds for in-patient substance abuse is the direct result of a law signed 50 years ago that is still in existence today. The Medicaid Institutions for Mental Disease (IMD) exclusion was signed as part of the Social Security Act in 1965. The IMD exclusion prohibits the use of federal Medicaid financing for substance abuse treatment in residential facilities that have more than 16 beds if 50% of the patients had psychiatric disorders. Based on the Diagnostic and Statistical Manual of Mental Disorders (DSM), substance use disorders are classified as mental disorders. Therefore, any rehab facility that only treats substance use disorders must still abide by the IMD exclusion.  The intention of the IMD exclusion was to shift responsibility for the cost of addiction treatment from the federal government to the state governments and to combat institutionalization. The unintended consequence of the IMD exclusion is that the 16-bed cap has created a significant barrier to entry for service providers looking to expand into Medicaid. With the cap so low, coupled with the low profit margin, it is not fiscally in the interest of service providers to expand services.  With the recent expansion of Medicaid through the Affordable Care Act, the number of Medicaid recipients has grown. However, the IMD exclusion continues to maintain its strangulation hold on access to in-patient beds, thereby not allowing service providers to leverage the number of beds.

Possible changes to the IMD exclusion are limited because it is a federal statute. Even if states wanted to expand Medicaid offerings for substance abuse, they would be unable to without significant legislative efforts. There are a number of options to expand Medicaid offerings for addiction treatment. One option is for Congress to fully repeal the IMD exclusion. However, as the IMD exclusion has not been updated since 1988, it is high unlikely that Congress will repeal it when they have not pursued easier path of updating it. Additionally, repealing the IMD exclusion is not fiscally viable and therefore is unlikely. Another option is to increase the bed limit beyond the current cap of 16. While this option is promising, increasing the bed limit without increasing federal funding, resources would be exhausted early in each fiscal year. The most promising reform approach is for the states to file a section 1115 innovation waiver. This waiver allows states to design their own Medicaid programs as long as the programs provide equivalent benefits as those offered in the Federal Medicaid program. There are a number of states that have successfully filed section 1115 innovation waivers. These states include New York, California, Maryland, and Massachusetts. Several other states have filled the section 1115 waiver and are awaiting a ruling.

Filing for a section 1115 innovation waiver is the best option at this time to increase access to substance abuse services for Medicaid recipients. However, pursuing the waiver is not without potentially significant drawbacks. There is cause for concern that the current president will cut funding for Medicaid services. If the waiver is approved and service providers expand their offerings, they will have significant exposure if the funding is cut. Additionally, if the Affordable Care Act is repealed, almost 556,000 New Jersey Residents will lose their Medicaid coverage. With such a drastic cut, the number of beds required will still need to increase but not nearly as much as before. Service Providers that expand their offerings may be caught with increased overhead costs without any increase in revenue due to a much smaller client population to serve.

Substance abuse services need to be dramatically increased for Medicaid recipients in New Jersey. Every week some die while they are waiting for a bed. Even if current offerings were streamlined for maximum efficiency, only 1 in 14 would be able to get a bed for treatment. Increasing the Medicaid reimbursement rates makes providing services financially viable for organizations. Filing for a waiver increases the number of beds accessible. Repealing the Affordable Care Act is a threat to substance abuse treatment for Medicaid recipients. Additionally, funding cuts will threaten any progress made. Overall, treatment services for Medicaid recipients need to improve. Every dollar spent on treatment saves approximately seven dollars that would be spent on jail, court fees, attorney fees, and emergency room services. With the Medicaid population being so large and having such a frequency of substance abuse, extensive changes need to be made immediately.

_________________________________________________

Andrew Walsh, MHRM, MSW Intern, is an addiction triage specialist for
Carrier Clinic. He is currently pursuing his MSW and LCADC at Rutgers
University. Prior to returning to Rutgers, he worked in the Gulf of Mexico oilfield as an internal business consultant. Andrew is a lover of books, cuisine, and theater.
26May/17

A Plan to Regulate Sober/Recovery Housing

There has been all kinds of terrible news about the problems caused by sober/recovery homes in NJ, PA, FLA, OH and a number of other states. These concerns have existed for years, and they include overcrowding, a lack of expertise, workers that are using drugs, and death. These programs are neither licensed, nor regulated, and rarely supervised in any way by a true substance abuse expert. I sent this letter to the NJ State Senate Health Committee on May 13, 2017, and I am publishing a copy of it now in the effort to further the discussion and help the public.

________________________________________________________________

 

To the NJ State Senate Health Committee:

I am writing regarding  S-3161 (recovery housing).  Many states around the country have had problems with their sober/halfway/recovery houses. Florida created a certification that went into effect last year, but most of them have still not earned it. They are still mired in problems. Ohio created a voluntary certification (that is overseen by the industry) and the state also provided 2.5M to support the expansion of services. Because of the voluntary nature of the certification, the Ohio sober houses are still rife with problems (no curfew, people using, little to zero accountability, client brokering).

I suggest the following:

  • A state certification or license be required to own/operate a sober/recovery house
  • All staff must submit to a criminal background check
  • 24/7 staffing required, particularly overnight
  • A minimum urine screens of at least 1x a week (self reporting abstinence from substances is not effective). These can be instant tests, rather than send-away lab tests. Screens should test for at least 7 different substances and always include alcohol, marijuana, cocaine, benzodiazepines, heroin, opiates, and methamphetamine.
  • A requirement of a blackout period for the first 30 days. This means that there is a curfew for new residents during that period (10 pm to 7 am, with early morning exceptions for work).
  • At least monthly supervision of all workers by a LCADC to ensure quality control. Despite this not being a clinical setting, there should be some oversight and supervision.
  • Clients that are on medication assisted therapies cannot be denied. Many sober homes are operated by people in recovery, and they often have a bias against medication assisted therapy. Those on medication assisted therapy should be required to adhere to best practices, which mean weekly urine screens and outside counseling of at least 1 hour a week.
  • Reasonable access to 12-step meetings and treatment (with a 1 mile walk) or a van service is provided at least once a day for each.
  • An exemption from ADA compliance, as this can be too costly.
  • Penalties for violations including fines, revocation of license/certificate and possible jail time.
  • Oversight of the programs provided by some state agency.

Owners and operators of these programs will argue that because they are in recovery, that they know better than DMHAS and the state government. Please do not be swayed by arguments that regulation will force them to close. There are a few programs that exist in the state already that exceed my recommendations and they are financially well. Please do not fall prey to their arguments that they can self-regulate and that the industry will watch itself (I can’t think of an industry that does a good job regulating itself).

17May/17

Three Modern American Playwrights That You Should Know About

I attend, on average, about one play a week (some weeks are stronger than others – between May 24 and June 3, I’ll see six plays). I also read one or two plays a week as well. We are currently enjoying a very strong time in American theater, but there are three modern playwrights that I want to highlight.

Lynn Nottage was born in Brooklyn in 1964. She attended Brown and then Yale. Ms. Nottage won the Pulitzer Prize in Drama in 2009 for Ruined, a play set in a war-ravaged African country. Its main characters are all survivors of rape and genital mutilation as a result of the ongoing conflicts. She won the Pulitzer again in 2017 for Sweat, making her the first woman ever to win twice in drama. Sweat takes place in Reading, PA, and discusses the decline of the American working class (and how it has affected all races). The McCarter Theater in Princeton is currently showing her play, Intimate Apparel, which provides a snapshot of New Yorkers in 1905 who are otherwise memoirless. She teaches at both Columbia and Yale.

Stephen Adley Guirgis was born in NYC in 1965 to an Irish mother and Egyptian father. He has some interesting tv/movie acting and writing credits, but it’s his skill as a playwright that sets him apart. He won the 2015 Pulitzer for Between Riverside and Crazy, which features police work, addiction and relationships.I became aware of him about 10 years ago when I saw The Last Days of Judas Iscariot at Rutgers. It is a play that is brutally honest, vulgar, and offers up stunning challenges to authority and world-revered figures. In the next year, the Signature Theater in NYC will show Jesus Hoped the A Train (about prison life), Our Lady of 121st Street (my 2nd favorite play of his after Judas), and it will debut a new play in 2018.

Ayad Akhtar was born in Staten Island in 1970. He is of Pakistani descent. He spent part of his childhood in Wisconsin and attended Brown and then Columbia. He won the 2013 Pulitzer for Disgraced. I read the play last January, and I was so moved by it that I immediately started searching to where it was currently playing (it was the most produced play in America during the 15-16 season). I found that the main character was smart, charismatic, and relatable, and his eventual tragedy was quite upsetting. I discovered that it was playing at the excellent Huntingdon Theater in Boston. Despite a recent heavy snowstorm, I drove up (with my parents in tow) to see it. We saw the play, stayed for the post-play talk with the actors, drove home and arrived in NJ around 4 a.m. We repeated that exact process this past April when we returned to Boston to see  The Who and the What (which is a comedy). In both plays, Mr. Akhtar portrays a Muslim experience in America. Some of his characters are proud of their Muslim heritage, while others challenge it or even outright reject it. Of all the playwrights currently living, there is no one whose future work I am more looking forward to.

 

 

15May/17

Getting Rid of Fraternities and Sororities: The Why and How

Fraternities and sororities are back in the spotlight again after the death of Timothy Piazza, a sophomore at Penn State University, this past February. To date, 18 fraternity members have been charged with a crime (10 with involuntary manslaughter, 8 with lesser chargers). Apparently Mr. Piazza and other pledges were forced to consume massive quantities of alcohol (his BAC was .43). The young man fell several times, including down a flight of stairs. The fraternity members put him on a couch, where he remained for 12 hours before medical services were contacted (he died two days later). Because of the in-house security system, there are videos of fraternity members jumping on his prone body, slapping him in the face, and punching him in the stomach (I expect that the video will eventually be leaked to the press and public).

Penn State officials shut down the fraternity where Mr. Piazza died. They have expressed sadness over this tragedy and vowed to make further reforms. Because this is a national story, other college presidents have weighed in, though many of them have said that because fraternities are private organizations whose property is off-campus, that they have little power to do much.

I wrote about the deaths of three Rutgers students in three different decades back in the fall of 2014. Each time, Rutgers officials stated that this was a terrible event and that their would be changes. Each death happened under a different college presidential administration, yet the words uttered and the lack of action were all eerily similar. Earlier this year, a student died at a fraternity at Miami University. The college president uttered lines from the same ineffectual playbook. This story played out at the University of Florida in 2006 (two students died). Two Greek Houses were permanently suspended at the University of Connecticut in the fall of 2016 after two students died. Six fraternity members were charged with crimes in relation to those deaths.

These are woeful stories. I have long argued that sad stories should not be the central basis of policy formation and changes in American institutions. Data is more important. That earlier mentioned piece on the deaths at Rutgers is one of the top five most read articles on my site. I received a large number of comments and emails after it (many from angry Greeks), and I wrote a follow up piece two months later after several more college deaths. In that article, I included a number of studies about the various problems that Greek life cause on college campuses. There is a large and fantastic (but incomplete) list on wikipedia that details hazing deaths (most of them are caused by college fraternities and sororities, and as you can see, they are increasing). We’ve known about the high rates of rape that are associated with fraternities for decades (here is a 1989 study). In June of 2015, Bloomberg put a brilliant article together about every allegation against (not incident, those are often unreported and sometimes covered up) fraternities and sororities during the first half of that year.

The Greeks and their supporters (this is made up of alumni and people that they pay) argue that Greek life is an essential part of college life and that they do service work. Cheating, excessive drinking, drug abuse, hazing, raping, and death all occur at higher rates with the Greeks than with the non-Greeks on campus. This is demonstrable and irrefutable. Their occasional service work and fundraising for worthy causes do not excuse their behavior.

It is time for College Presidents and the Boards of Trustees to shut down Greek Life. Here is how you do it:

  1. Do not let them use any university facilities for their Greek purposes. They cannot hold meetings or events on campus.
  2. Do not let them advertise any events on campus billboards and encourage the student newspapers to reject advertisements from the Greeks.
  3. Engage in a constant, blistering, fact filled education campaign where students and their parents are told about the problems of Greek life and the high rates of cheating, drunkenness, drug abuse, hazing, rape and death. This should be conducted by college officials and students. Social norming ads should be aired on college TV and radio. Put up warning billboards that are similar to anti-smoking ads.

Membership will plummet, and then continue with a slow but long decline. Fraternities and sororities will be squeezed for money due to the lack of new members. The vast numbers of alumni will die off and not be replaced. The culture will change. Greek Life will continue to survive to some degree, but it will be a vestigial part of college (like men who wear ties to class, dorm mothers, and low tuition costs). The question is this: how many more times will we have to read about tragedies and hear how College Presidents are saddened and outraged before meaningful and permanent changes are enacted?

 

24Apr/17

You are going to ask: where are the lilacs?

We bought a house in 2012. About five weeks after moving in, the seven lilac trees on the eastern border of the property bloomed and filled the afternoon and evening air with their powerful fragrance.  It was both presently wonderful and jarringly nostalgic.

I instantly remembered the last time I had noticed lilacs. There were three huge lilac trees on my grandmother’s property that sat about 15 feet in front of the back door (there may have been more, but three stick out). The three lilacs formed an imposing wall, behind which reigned several large apple and pear trees. There was a four and half foot hole that was between two of the lilacs – it was about five feet deep and it made a perfect pathway for children to the greater lawn and our favorite apple tree. The second photo shown here is from when I was five or six years old. It was taken in front of the base of one of the lilac trees (I regret the Princeton shirt, but my parents didn’t know any Rutgers alumni in 1982).

I was raised to revere Lincoln (my parents didn’t have to push hard). I discovered Walt Whitman in a high school poetry class my junior year, and though “O Captain My Captain” is my preferred Whitman eulogy for our 16th President, I very much like “When Lilacs Last in the Dooryard Bloom’d” (it also reminds me of my father, who mentions it from time to time).

When I was in college, I took an art history class (renaissance art to the present). It was all new and the tests were difficult. The professor encouraged us to take individual trips to the MET to look at various pieces. I fell hard for Claude Monet (there is a room in the Impressionist section that I have a sense of ownership for). Last spring, I traveled to Paris and spent a great deal of time in museums, particularly hunting down the works of Monet and Rodin.

I saw this painting at the Musee D’Orsay (the fifth floor holds the distinction of being my world favorite, so far). Monet painted it in his garden at Argenteuil in 1872. It is titled “Lilacs, Grey Weather” (there is also “Lilacs in the Sun” and it is housed in the Pushkin Museum in Moscow). I stared at it for a long time, both close up and at a distance of over 20 feet. When I returned to NJ, I bought a print of it and hung it in my kitchen so I could see it every day.

When I taught high school English in Elizabeth, I discussed about 75 poems fairly in-depth. One of the poets that received repeat business was Pablo Neruda. His poem “I’m Explaining A Few Things” begins with the line “You are going to ask: and where are the lilacs?” It is devastating. Neruda is known for musing on love and nature. This poem is about the horrors of the Spanish Civil War, the destruction of Madrid and all the slaughtered children he saw. He mourns that markets of fruit & fish and the boxes of flowers that hung in Spanish windows. He cannot smell the lilacs due to the stench of gunpowder and the dead. It is a universal poem, and can be applied to current war torn regions around the world.

I returned from military duty yesterday evening to find my lilacs in full bloom. I can think of nothing better to come home to in the Spring from Army duty, where I had to take a gas mask off in a gas chamber. The scent of lilacs versus the stinging of chemical warfare training adroitly sums up the dichotomy of my life. “Where are the lilacs?” indeed.

Here are my lilacs.

16Mar/17

Policy Brief Regarding the Improvement of Services for Veterans with Substance Misuse Disorders or Veterans in Recovery on College Campuses

There is a PDF form of this on my website as well. You can access it here.

___________________________________________________________________

Policy Brief Regarding the Improvement of Services for Veterans with Substance Misuse Disorders or Veterans in Recovery on College Campuses

March 16, 2017

The Substance Abuse and Mental Health Services Administration (SAMHSA) held a two day conference in Washington, D.C. on March 13-14, 2017, that brought national college leaders together to discuss how to increase the population and improve outcomes of diverse and underserviced populations. I was brought in to facilitate the conversation regarding veterans with substance misuse disorders (as well as veterans in recovery) on college campuses. In addition to veterans, this brief also applies to military service members who attend college while in the National Guard or Reserves.

Challenges:

  • Veterans often only want to associate with other veterans.
  • Veterans that report having positive military experiences are far more likely to access services than veterans who report having negative military experiences. Those that report negative military experiences usually have greater need of services.
  • Veterans and service members often use their military experiences as a cudgel to resist therapy and other forms of assistance by uttering lines such as “you weren’t in (or there) so you wouldn’t understand” or “unless you lived it, you can’t help me.”
  • Veterans are more likely to be older and have families than traditional students. There is a lack of services for their spouses and children.
  • Because they are often older, veterans and service members sometimes report feeling “behind in life.”
  • A lack of coordination between veteran services and other departments on college campuses.
  • Lack of housing for veterans.
  • Lack of ability to identify and treat PTSD on campus.
  • Military and veteran culture usually encourages and normalizes heavy alcohol consumption.
  • Tuition remission, VA payments, and GI Bill moneys are frequently delayed, causing financial hardships which result in late payments to college which results in deregistering from classes
  • Campus professionals have a lack of knowledge of outside services available to service members and veterans.

 

Solutions:

  • Collaborate with veterans center or services on campus. Set up in person meetings between professional staff at least once a semester. You will need to go to them.
  • Approach veterans and service members as if they are in precontemplation on the stages of change model. Provide outreach and educational training on stress and how service members often use negative ways to cope (eating, shopping, gambling, substance misuse, fighting, sex).
  • Currently, 42 college and universities have Peer Advisors for Veterans Education (PAVE) on campus (paveonecampus.org). Start a chapter on your campus.
  • Work with veterans services or center on campus to develop a program that supports families. Using peer support for veterans’ families is cost effective and efficient. Syracuse University has a robust program called the Institute for Veterans and Military Families (IVMF).
  • Use the experiences of veterans and service members to your advantage. Encourage them to engage in your community by putting them in leadership positions, and/or asking them to be of service to other students: they can lead activities such as hikes or captain intramural athletic teams; they can help students with physical fitness; they can tutor others; they can lead service events to soup kitchens and organize clothing drives; and those in recovery can take other people to meetings.
  • Offer yoga (and other services) in your wellness or recovery centers that veterans and service members can attend without signing in. Getting them into your building anonymously will expose them to your building and professionals and may lead to rapport and trust.
  • Having a veteran in your college recovery community will open the doors for more veterans and service members, much like other under-represented populations in CRCs.
  • Work with admissions to identify service members and veterans. Reach out multiple times throughout the school year.
  • Do not allow veterans and service members with substance misuse disorders (and/or mental health disorders) to use their military experience to push away therapists and professionals. This is enabling them. One does not need to have military experience to break through their resistance, but one should get some basic training on military and veteran structure, culture, and issues. Let’s call it Military Cultural Competency.
  • Have a list of on campus and off campus housing options (including for families) handy for those that need it.
  • Talk to the professionals at the veterans service program (if there is one on campus) about not providing alcohol nor normalizing its use.
  • Ensure the counseling and medical professionals on campus are trained in adequate substance misuse disorder and PTSD screening. Ensure that new hires are trained in these areas. Be aware of local services that screen and treat Traumatic Brain Injuries (TBI).
  • Work with financial aid and the registrar’s office to smooth over financial problems that are related to delayed paperwork from military units, VA payments and late GI Bill checks. This is the most common problem that veterans and service members in college and universities complain about.
  • Be aware of local and national services and organizations that can assist veterans and service members. I have compiled a list of vetted services at http://greenagel.com/for-soldiers-and-veterans/

 

 

Frank L. Greenagel II

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

Adjunct Professor – Rutgers School of Social Work

Instructor – Center of Alcohol Studies

NJ Governor’s Council on Alcoholism & Drug Abuse

1st LT – PA Army National Guard

FLG2@aol.com

greenage@rci.rutgers.edu

15Mar/17

Don’t Hit Governor Christie on Healthcare, Medicaid and Trumpcare

The Newark Star Ledger released a blistering editorial on Gov. Christie this morning. They argue that while Gov. Christie dedicated 66% of his recent State of the State address to addiction, has appeared in numerous commercials about drug treatment, and has tried to set himself up as a national figure on addiction, he has stayed silent on Trumpcare and the Medicaid rollback. Drug policy experts and the Congressional Budget Office (CBO) have stated that 1.3 million Americans were able to access drug treatment only after the Medicaid expansion that was part of the Affordable Care Act (ACA).

Gov. Christie was among a handful of Republican Governors (including John Kasich, R-OH) who decided to take the Medicaid Expansion. Last August, Gov. Christie said that “the naysayers were wrong” and that over 500,000 NJ residents became insured under the ACA, most of them from the Medicaid Expansion. When he ran for President in 2015-2016, he touted his record on drug treatment and his willingness to split from the standard Republican position of total rejection of the ACA.

President Trump, Secretary Price and Speaker Ryan recently introduced the American Health Care Act (AHCA). Mr. Trump has said, “We have come up with a solution that’s really, really I think very good,” but both moderate Republicans and Democrats have cited independent and partisan studies that state that over twenty million people will lose coverage in the next 10 years and that this will have a potentially disastrous effect on the heroin and opioid epidemic. Republican Governors such as Mr. Kasich (Ohio), Bruce Rauner (Illinois), and Brian Sandoval (Nevada) have come out strongly against the AHCA. Despite Mr. Christie’s previous praising of the ACA and Medicaid expansion and the examples set by the other Governors, he has not uttered a word about the AHCA.

Here’s the rub: it makes sense for Gov. Christie to remain quiet. He has less than a year left in office, and his best (and last?) hope for a future political position is in the Trump Administration. While there are examples in American history of a President appointing someone who blasted them, it is rare. The passage or defeat of the AHCA will not be impacted at all by Christie’s opinions. While a critique of the AHCA and the Medicaid Rollback would momentarily please newspaper editors and drug policy experts, it makes absolutely no political sense.

I value loyalty. Very highly. I have worked for a couple of excellent bosses/supervisors. We have usually marched in tune together, but there have been rare occasions in which we disagreed on some issue or policy. I never broke with them publicly (those reading this may think about all of my criticisms leveled at Gov. Christie and other politicians that I have worked with, but I have never directly worked for them). On the same vein, I have always wanted subordinates to question and even challenge me, but only behind closed doors. I very much doubt that I would hire someone who publicly challenged or attacked me on a position or issue. Nor would almost anyone else. There is much to hit Governor Christie on, but his failure to criticize President Trump is not one of them.

 

24Feb/17

Con Artists, Grifters and Used Car Salesmen: An Investigation Into For-Profit Addiction Hotline Practices

This article was written by Andrew Walsh. He is a grad student of mine at the Rutgers School of Social Work. This is the first of three articles that he is writing under my guidance this year.

_____________________________________________________________

In response to the increased demand for substance abuse treatment, several facilities have created addiction hotlines as a means of steering clients to their facilities. Over the last two years, there has been a dramatic increase in both print and radio advertisement regarding those hotlines. These advertisements assure the viewers and the listeners that help is a phone call away. This increased focus on advertisement is a response to legislation being drafted in New Jersey that will make substance abuse treatment more accessible and provide longer stays. With the passage of this legislation, substance abuse treatment will become an even bigger business in the state of New Jersey (but to be clear, the abuses by the for-profit treatment industries’ addiction hotlines is a national problem).

To gain an inside perspectives of how these hotlines operate and the services they provide, I decided to call a few, posing as a twenty-seven-year-old individual looking for substance abuse treatment.  Every intake specialist followed a similar script:

  • Seeks to befriend
  • Asks about insurance
  • Asks about substance use
  • Diagnoses as dual diagnosis
  • Asks about family psychiatric history
  • Pressures to get into treatment immediately

 

The first hotline I came across was from a simple google search for “addiction hotline.” I was brought to a website that provided a twenty-four-hour hotline which promised free help. I browsed the website but was unable to determine which facility it was associated with. Having exhausted my search of the website, I picked up the phone. I was not prepared for what followed. As the phone rang I assumed the mindset of an individual who was struggling with alcohol addiction; scared and lost. I was greeted by an individual who identified himself as Jay. He started by asking how he could help me and why I decided to call in. I described how I was struggling with dealing with the pressures of full-time work and full-time graduate school and how my alcohol consumption had increased dramatically in recent months. Within the first two minutes of our conversation Jay was inquiring about whether I had insurance or would pay for treatment out of pocket. Upon verifying my insurance, he informed me that my drinking was not my problem, but rather that alcohol, “was not a bottle in my hand but rather Tylenol.” Jay detailed how I needed a dual diagnosis facility because I was suffering from a substance use disorder and a psychiatric disorder. Jay made this diagnosis after talking to me for less than five minutes. In the next few minutes, Jay went through questions ranging from my history of substance use to my family history of psychiatric disorders. Ten minutes after our conversation started, he was detailing the facilities that they had in New Jersey, California, Florida, Nevada, Louisiana, and Missouri. I expressed a desire to stay in New Jersey, and Jay readily assured me that this was possible. He was thrilled to hear that I was seeking treatment immediately and took my information so he could contact me after speaking with the facility in New Jersey. As our conversation ended, I asked Jay if I would be able to get in the next few days. He assured me that I would, stating, “If it was me I would start doing laundry”. Fifteen minutes after I picked up the phone, I was diagnosed as needing an in-patient stay in a dual diagnosis facility by an individual who I had never spoken to in my life before.

The next company I investigated specializes in recovery villages. Within two minutes of getting onto the website I received a live chat message from an employee. There was a message on top that stated, “Don’t wait another day. Help is a phone call away.” The message provided the hotline number to call. As I dialed the number I again assumed the mindset of an individual struggling with drug addiction. My phone call was answered by Trevor, an intake specialist. As I explained that I was calling because I was struggling with alcohol abuse, he congratulated me for having the courage to pick up the phone. Trevor quickly asked about my insurance and I provided him with the details. He then described the various locations they had facilities: Colorado, Florida, and Washington. Trevor also asked me a list of questions ranging from history of substance use to my family history. He assured me that he was only there to provide options to individuals seeking treatment and that the average length of stay was 30 to 45 days. Trevor believed that the facility in Colorado was a good fit for me and inquired if I would purchase my own airline ticket or whether I would need the facility to purchase my ticket and bill me later for it. He told me that the cost of an airline ticket would not prevent me from receiving treatment at their facilities. Trevor detailed how the staff in Colorado all had master’s degrees and were in recovery themselves. He went as far as to offer to speak to my mother to inform her of how I was struggling and needed an in-patient stay for substance abuse. Our call ended with Trevor telling me how he was proud of me for reaching out for help.

For the final program, I was on the facility website when I received a live chat message from an employee named Chris. As I was browsing the available locations, I decided to engage with Chris and inquired if they have any facilities in New Jersey. He responded that they have facilities all over the country with placement determined by the medical staff. When I told Chris that I was seeking services for myself he stated, “I am so proud of you for reaching out!” I told him that I could not talk on the phone currently but wanted to continue our conversation via live chat. After a delay, he responded that he was happy to continue. At this juncture, our conversation took a negative turn. Chris apparently forgot that I was inquiring about treatment for myself and instead continued to reference the individual looking for treatment as “he.” Chris’s focus moving forward in our conversation was solely based on my insurance coverage. He did not inquire about my substance use, about any psychiatric issues I was struggling with, or any personal information about me. Every message he sent me was about my insurance coverage. I asked Chris explicitly a second time if they had any facilities in New Jersey and he replied, “Remember, we are all over the country. Let’s leave this up to our doctor to determine the kind of care that is needed.” He then wrote, “Trust me, you are in very good hands.” I found this to be both frustrating and alarming since he would not answer my direct question, especially since I had researched the company before our conversation started and knew with certainty that his company did not have any facilities in New Jersey. Chris instructed me to call him later and our conversation ended.

From my conversations, I identified several areas of concerns:

  1. Each intake specialist acted as a friend, quite often exhibiting unprofessional behavior
  2. On every phone call I was relentlessly asked about my insurance coverage
  3. All the intake specialists were quick to diagnosis me after only speaking to me for a few minutes (this brings up another issue: are they qualified to diagnose?)
  4. During the subsequent days following my conversations I received dozens of phone calls, voicemails, and text messages regarding treatment options
  5. Not only were these calls from intake specialists that I spoke with, but also from people and facilities I never spoke with

These trends underscore the take away from this exercise. Every single intake specialist I spoke with and their respective facilities viewed me as a source of revenue instead of as a person.

 

  Act Like Friend Asks About Insurance Within 1st Minute of Conversation Asks About Substance Abuse Diagnosed with Dual Diagnosis Asks About Family Psych History Excessive Follow Up Phone Calls
Facility 1 Yes Yes Yes Yes Yes Yes
Facility 2 Yes Yes Yes Yes No Yes
Facility 3 Yes No Yes Yes Yes Yes
Facility 4 Yes Yes Yes Yes Yes Yes
Facility 5 Yes No Yes Yes Yes Yes
Facility 6 Yes Yes Yes Yes Yes Yes

 

This exercise helped illustrate the behavior of intake specialists working for hotlines. These intake specialists are not acting illegally. Their actions and processes are an industry wide practice. Intake specialists are diagnosing over the phone after a five minute assessment without clear credentials. Interaction with the intake specialists at these hotlines is reminiscent of dealing with a used car salesperson; the client feels that they have been worked over. One last step I took was calling all the hotlines again, this time posing as a twenty-six-year-old with no insurance or money seeking substance abuse treatment. The longest phone call lasted three minutes. I was provided a referral to the SAMHSA hotline. Unsurprisingly, I have yet to receive a voicemail or a text message from any of the intake specialists looking to check in on their “buddy” now that I do not have insurance.

__________________________________________________

Andrew Walsh, MHRM, MSW Intern, is an addiction triage specialist for
Carrier Clinic. He is currently pursuing his MSW and LADC at Rutgers
University. Prior to returning to Rutgers, he worked in the Gulf of Mexico oilfield as an internal business consultant. Andrew is a lover of books, cuisine, and theater.
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.