I’ve been giving a keynote speech over the last eighteen months called “The Medical Industrial Complex and the Opioid Epidemic” (the term is mine, though modeled after President Eisenhower’s warning about the Military Industrial Complex in his farewell address). The Medical Industrial Complex is made up of the following:
- Medical Professionals, particularly doctors and their professional organizations (American Medical Association is one example)
- Insurance Industry
- Big Pharma
- The Federal Government (Congress and Executive Branch agencies like the FDA). State Governments also have a role, though it is much smaller.
- The Treatment Industry
I’ll be releasing a series of articles over the next few months about these six groups and how they have each contributed to the problem (if you’ve paid attention recently, you’ll know that the Washington Post/60 Minutes released an expose on the Big Pharma-Government relationship and the New Yorker hammered Purdue Pharma last week).
Even if Big Pharma is reined in, doctors get more training and prescribe opioids less, insurance companies pay for the appropriate treatment and President Trump urges Congress to spend billions of dollars on a variety of programs, it will not improve the outcomes for people in addiction treatment programs.
Treatment programs are often understaffed and focus on paperwork over services. The senior counselors at programs rarely actually see clients; instead, they are monitoring clinical notes. They do this in order to meet standards set up by insurance companies and some state regulators (not all states are regulated). The idea behind this is noble, as documentation of individual, group and medical services let third parties know if and how treatment was provided. In theory. In practice, the notes are almost always better than the actual services provided. Supervisors are often not properly meeting with, training or observing their staff, and they evaluate them based on their notes (I’ll write a lot more about this in the future).
Treatment programs take in money the following ways:
- private pay from clients or their families
- medicaid or medicare
- county or state grants to provide free or discounted services
- private insurance
While most treatment providers would prefer #1 above all others, those kind of clients make up a tiny percentage of the population. Clients with private insurance are essential for for-profit treatment programs, and are highly desirous for non-profit programs to offset the costs of medicare/medicaid recipients and other indigent people. A number of insurance programs will not pay for services rendered by a treatment program (detox, inpatient or outpatient) unless they are certified by either CARF or the Joint Commission (JCAHO). Because they are often the gate keepers to insurance money, treatment programs scheme hard on getting CARF or JCAHO accreditation.
CARF is an international program. It is not a government agency. JCAHO is an American non-profit (don’t be fooled by their tax status folks). I want to spin you back to the housing crisis of 2008 and its aftermath. We learned about how high-interest mortgages were given to people without the means to pay for them, and that those crap mortgages were chopped up and sold as investments with AAA ratings (the highest rating, and often the only ones that state pension and certain retirement funds can buy). These mortgages were highly volatile, but only a handful of people knew that because the rating agencies (S&P, Moody’s, and the Fitch Group) rated B and C investments as AAA. When people couldn’t pay their mortgages, those investment products’ value plummeted. Several banks failed, the insurance companies teetered on the brink and our economy pulled the rest of the world into the Great Recession (for more on this, read “All the Devils are Here” or “The Big Short”). The rating agencies failed to do their job and protect the public.
CARF and JCAHO have failed to properly rate treatment programs. There are terrible programs all over the country that brag about their CARF and/or JCAHO accreditation, and proudly display it on their websites. These are not government agencies, but private companies. Their first goal is money, not consumer protection. Here is how the process works:
- The treatment program contacts CARF or JCAHO.
- The treatment program pays a fee for the inspection and accreditation (this is a classic conflict of interest folks).
- CARF or JCAHO come out for a multi-day inspection. The let the program know in advance when they are coming.
- The treatment program spends the weeks leading up to the inspection getting their notes in order, cleaning the floors, making sure that files are locked, checking fire extinguishers, and getting paperwork signed that says that emergency drills and policy reviews have been conducted.
- CARF or JCAHO visit the agency. They may talk to a couple of clients. They meet with administration. They examine the physical aspects of the program and look at the notes.
- Shortly thereafter, the program is accredited.
- Every couple of years, the program gets reinspected. They get a notice of when the inspectors are coming. They write a check to pay for the re-accreditation.
Neither CARF nor JCAHO certification means that staff are not abusive or neglectful. It doesn’t measure the effectiveness of group or individual sessions, or the ability of the supervisor to monitor and train the staff. CARF or JCAHO certification does not guarantee that there is a decent discharge plan, or that the discharge summary accurately reflects what happened throughout the course of treatment. A program does not need to show if (or how) it evaluates itself or what outcomes are actually achieved.
Some people consider CARF and JCAHO to be scams. They don’t ensure good treatment. They do not protect the public. This is regulation in a terrible form. We need better state and national regulation of treatment programs. This means clearer guidelines, more monitoring and observation, short and long term evaluation and third party outcome studies, and real punishment (huge fines, suspension, forced closing) for those that fail to comply.
When looking for a treatment program, here are some basic questions to ask:
- How long has the clinical and executive director been there?
- What percentage of counselors have at least a masters level license?
- How often do clients get to meet with counselors one-on-one? How long do those sessions last?
- How often do clinical staff get supervision? Is it individual and/or group supervision?
- Does the supervisor observe individual and group sessions by staff?
- How often do techs, housing staff and night workers get supervision? Are they observed?
- How does the program measure success?
- Does the program evaluate itself? Does it have a third party evaluate it?
- Who does the aftercare plans? How do you ensure that the places/professionals you refer to are good?
- Who does the diagnosing? How long do they meet with someone before giving them a substance misuse disorder and/or mental health diagnosis?
Programs can get CARF and JCAHO certification without having good answers to most or all of these questions. It’s the housing disaster all over again, but in the treatment industry.
Last week I took my mother to see an incredible production of A Raisin In the Sun in Red Bank, NJ (it’s really good and there is a Surf Taco nearby, but the show ends on October 8th). Afterwards, we went for an early dinner. At the next table, two older women where talking about a current social/political issue. They lambasted the other side as being selfish and stupid, spouted off incorrect facts and statistics, and proudly clinked wine glass about how they agreed with each other. While I found their comments to be noxious, my bigger issue was with their process. People from both sides of the political spectrum often engage in personal attacks, have a lack of understanding of the issue (economic, historical), have incorrect or cherry-picked statistics, and tend to talk primarily with others that already already agree with them. They kept going on and on, and I found myself growing irritated. My first thought was a Larry David-esque “This is why I can’t go anywhere” and then I made the command decision to not engage them. This decision was made on the basis that (a) they are very entrenched in their position; (b) there were just two of them; and (c) they are old and not going to be voting too much longer anyway.
The first guest lecture I ever gave was to a sophomore honors English class when I was a high school senior. I was invited to talk about A Catcher in the Rye by a teacher who gave me a D a year and a half earlier. I finally read the book a year later after it was assigned and it spoke to me at 17 – it also inspired me to dive deep into other literature. Early on in college, I was invited to talk at both Rutgers and other colleges on the topics of addiction, Shakespeare, or 20th century American literature. By my third year in college, I was substitute teaching in high schools regularly, and I jumped at the chance to give lessons in history and English (ironically, the first class I ever subbed was French 3, which I failed as both a sophomore and senior). After graduation, I taught English to students as young as 12 and as old as 79 in Tokyo for all of 2003. After finishing a social work degree in 2006, I took a job teaching high school English in Elizabeth for the next three years (I’ve written about that before).
In 2008, I started teaching at the Summer School of Alcohol Studies at Rutgers, and have taught there continuously ever since (I also teach seminars throughout the year and have also been training NJ, NY and PA police through the Center for over a year now). In 2009, I started teaching at Essex County College. I taught multiple courses there for three semesters. In 2011, I began teaching at the Rutgers School of Social Work and also started co-teaching a course with Dean Lea Stewart at the Rutgers School of Communication. I have taught 2-4 courses each term between the two departments continuously now for 13 straight semesters.
During my last year of teaching at Elizabeth High School, I used a book titled Poetry 180. Every day, I read a different modern poem to my students and we discussed it. My favorite poem from that book was written by a woman who remembered herself as a high school sophomore writing to her father, “Dad, you are most yourself when you are swimming” it began (along with Shelley’s “Look on my works ye mighty and despair,” it is the two lines of poetry I utter the most). This has led to the question that I ask all of my students and everyone who has since sat in on a training that I’ve conducted – when are you most yourself? To answer this question, you might want to talk to your family, friends and co-workers.
Despite all of the many wonderful relationships and interesting activities I engage in, there is nothing that defines me nor shows me at my best nor makes me happy like teaching. And as much as I like conducting trainings and giving speeches, there is no teaching I like more than my in-person classes at the undergraduate level at Rutgers. This semester, I have 27 students in my Social Welfare Policy Class. I was asked to teach the course in August and it came with a ready-made, departmental syllabus. I’ve found the textbook to be quite good and I’ve kept the assignments but tweaked them a bit (the lectures are all mine). In our lessons on social and cultural issues, I spend a great amount of time talking about the history of the issue, how other states or countries have addressed it, the conservative and middle and liberal positions, and how it both currently and potentially could affect the budget. I have my students read pieces on the importance of listening to people you disagree with, which states take the most money from the Federal government, and a variety of other topics. I’m careful not to teach them what to think, but rather how to look at issues, know the economics, consider your opponents’ view (even if it is personally offensive), and how to talk to people that you disagree with (so basically, don’t be like those two old ladies at lunch last week).
Regardless of your politics, you may be frustrated by the fact that most issues that are topical today were being argued about 20, 50 and even 100 years ago. It takes a long time to finally settle social and political issues (it was 80 years between Seneca Falls and the 19th Amendment). Economic ones are constantly being refought. I’m not a fan of social media activism (though it may be able to swing elections). I don’t see the point of like-minded people sitting around and complaining to each other. Shouting at family or friends isn’t effective either. Change is often a long, slow process (water on a rock…the water eventually wins).
For those of you that are worried, concerned, or even outraged at recent events or regarding a number of social, political or economic policies, take some solace that I’m training these young people to be policy problem solvers. I have 100-150 undergraduate/graduate students a semester for 50 hours of instruction. This is my ninth year of university teaching, so I’ve put my thumbprint on somewhere between 1800-2700 young minds (I hope to do this for another 40+ years).
Some of my former students are now teaching and/or supervising others. For those of you that are horrified with the current state of things, I encourage you to take the long view. If you can, guide, mentor, supervise or teach someone younger than you. Each mind we truly touch eventually reaches out to someone else and thus, we become immortal, as our lessons are passed on long after we’ve shuffled off this mortal coil.
In the last week, three couples that I have some connection to lost a child. Two of the deaths were the end result of a long struggle with severe medical problems, while the other was because of a car crash. I have worked with people on grief for many years, and spoken with hundreds of parents who lost an offspring, usually as a result of a drug overdose. But I have also counseled several who lost a young child or baby, and it is clear to me that burying a child is the most painful of all human experiences. This loss will always be with you, and may, in fact, define you.
This is not an area I specialize in nor claim a particular expertise. Though I have experienced my own difficult losses (my grandmother in 1995, my friend’s overdose in 2002, a divorce a few years ago), they are not as soul-searing as the loss of a child. Still, those losses, a highly developed sense of empathy, and my experience helping people with grief compels me to offer the following advice:
- If you have another child, you should talk to him or her about what happened in clear and honest terms. Do not lie or us euphemisms. Your child or other children know that something incredibly awful has happened – children are incredibly attuned to their parents moods, facial expressions, body language and presence. Even if your other child is 2 1/2 years old, tell them.
- It is also very important that you tell your other child (children) that he or she is not sick nor likely to die. All too often, when kids see this kind of thing happen to a sibling, they wonder if it will happen to them and they never ask or tell an adult what they are worrying about.
- Your friends and family don’t know what to do or say. Some will avoid you completely, because they do not want to intrude or do not know what to say. Others might hang around or call all the time, hoping to comfort you with their presence or some activity. Though this is very difficult, it will help everyone involved (including you) to let people know what you need. And please be aware that what you need during the first week may be different than month three or year two.
- The previous point may be tough to accept. You might think, “Who cares if my sorrow makes other people uncomfortable? Why should I worry about them when I’m the one who has lost my world?” Those are fair thoughts, but you still need other people. As does your family. Being clear that you need space or company or words of condolence or silence will ultimately help you.
- There may be some people who say things like “his time was up” or that “God called her home” or “he is in a better place” or that it “was God’s will.” You may find it consoling, or you might find it incredible offensive and aggravating. People that say this to you mean well. They just don’t know what else to say. If it offends you, let them know and ask them not to repeat it.
- Regarding your spouse, partner or ex: they are the person that also suffers this tragic loss the worst. He or she will grieve differently than you. It may come out as constant crying, silence, rage, withdrawal, throwing oneself into work, talking, some combination of all of the above, or perhaps something else entirely. I have seen couples get angry with each other at how the other grieves. You have each experienced the most terrible thing, don’t compound it by attacking each other.
- Even though you are in a daze, you need to leave your home each day. Whether it is to go to work, school, church, therapy, the gym, grocery shopping or something else, you must venture out into the world. Time is going to feel incredibly slow and miserable, and walking around the house from room to room and staring at the walls or outside will not help. This is extremely common behavior.
- Consider going to a support group or therapy. This may be an anathema to you, but a support group will be filled with people who have the same experience and can show you how they got better or worse. The support groups can be helpful years down the road, when other people have a hard time comprehending that this loss is still very much an active part of your life. A therapist who specializes in grief can provide positive support from a neutral source over a period of months or years.
Waking up each day may be the worst part of your day – as you come to and remember your loss and the wave of pain washes over you. The days will keep coming. I have no special words of comfort – there are no special words. There is the aforementioned advice, which may or may not work. You may not want it to work, but please consider trying.
On August 8th, I toured the Steven A. Cohen Military Family Clinic in Philadelphia. It is located on the University of Pennsylvania campus, just west of Center City. There are other clinics in NYC, San Antonio, Dallas, El Paso, and Fayetville, NC. There are several more slated to open within the next year. To find the contact information for each clinic, click here.
Steven A. Cohen was born in New York. He went to Wharton and made his money on Wall Street. The 2017 estimate of his wealth is around $13B. His son served in Afghanistan. Mr. Cohen and his wife established the Cohen Veterans Network in 2016 with an initial donation of $275M. The clinics currently provide services for veterans, reservists, and National Guard members. They also provide counseling for family members. They see people for one hour a week. If people need a higher level of care, the professionals at the clinic work tirelessly to find appropriate services.
I had the pleasure of meeting with Pete Freudenberger, a social worker who earned his MSW from UPenn. He is also a veteran with a very interesting story. He is the Outreach Manager for the Philadelphia clinic and can be reached at email@example.com.
The Steven A. Cohen Military Family Clinic was featured in an article on Philly.com on June 15. You can read it here.
Social Workers and other helping professionals have high rates of burn out. People in the field will talk about it without describing how to actually look for it. I’ve put together a 20-question self-quiz that professionals can take to evaluate themselves. While it is not scientific, it should give you a good feel for where you are and whether (and what) you need to change (this can be used to gauge burnout in other professions as well, though questions 2 and 18 should be altered or eliminated).
For a printable version of this, click here.
Are You At Risk of Burning Out?
A Self-Test for a Social Worker/Drug Counselor/Preventionist/School Counselor/Advocate
- Are 10% or more of your hours unpaid? (consider work from home, or emails & phone calls outside of your regular work day)
- Do you get weekly supervision of at least one hour per week?
- Do you have a self-care plan?
- Does it take more than 15 minutes for you to fall asleep at least 2x a week?
- Do you wake up in the middle of the night at least 2x a week?
- Do you sleep longer or shorter than you planned at least 2x a week?
- Do you wake up and feel like you haven’t had a restful sleep at least 2x a week?
- Do other people get credit for your work?
- Are you happy with your exercise routine?
- Does your work schedule or stress cause problems with your family (parents, significant other, kids) at least twice a month?
- Do you take an out-of-state vacation at least once a year?
- Do you feel like you have neglected friends?
- Do you feel like you have neglected hobbies?
- Are you in therapy at least 2x a month?
- Do you have conflicts (passive or aggressive) with co-workers at least 2x a month?
- Do office politics interfere with your job?
- Can you talk to someone about work stress other than your significant other?
- Have you had a client or student die within the last year?
- Do you know exactly what is expected of you at work?
- Does your job cause you to compromise any of your values?
+1 for yes: 1, 4, 5, 6, 7, 8, 10, 12, 13, 15, 16, 18, 20
-1 for yes: 2, 3, 9, 11, 14, 17, 19
-3 – -7: You have a very good work-life balance and are a model for others
-2 – 3: A worker with good mental health and decent job satisfaction will fall into this range
4 – 5: Your job is a minor problem. Make a few tweaks to increase your health and possibly productivity
6 – 8: Your job is a major problem. You should talk to your supervisor and therapist about making some major changes
9 – 13: You should consider leaving your job in order to get your sanity back
This article was written by Andrew Walsh that I edited. Andrew is a grad student of mine at the Rutgers School of Social Work. This is the third article that he wrote under my guidance this year (his first piece was on addiction hotlines and his second one on Medicaid in NJ was published last month).
Substance abuse continues to be a topic that receives coverage on both a state and federal level. While the main focus is on opiate abuse and deaths among young adults, there is another population that abuses alcohol and drugs at a higher rate. On January 1st 2011, the first baby boomer turned 65 years old, marking the transition of baby boomers into the older adult population. The United States has a baby boomer population of 76 million. New Jersey has a population of 2.2 million baby boomers, 1.2 million of which are over the age of 65. With the onset of physical and cognitive decline associated with aging, this population will put strain on medical and behavioral health facilities. Unlike prior generations, the baby boomer generation has had extensive exposure to alcohol and drug use growing up. This exposure has created an attitude of acceptance among baby-boomers regarding the continued use of illicit drugs and alcohol later in life. The Substance Abuse and Mental Health Services Administration (SAMSHA) estimates that approximately 17% of this population is actively affected by the misuse of alcohol and/or prescription drugs. In New Jersey this translates into 204,000 older adults actively misusing alcohol and drugs. In 2015, approximately 1678 individuals over the age of 60 received inpatient treatment for substance abuse and misuse. Statistically, less than 1% of seniors who would benefit from substance abuse treatment actually received treatment. Seniors face unique problems with alcohol and drug misuse and abuse:
- Physical and cognitive changes decrease seniors tolerance for alcohol and drugs
- Increased rate of prescriptions places them at risk for adverse medication interactions
- Common symptoms of substance abuse such as unsteady gait or forgetfulness are often mistaken as decreasing physical functions or dementia
- Seniors are less likely to seek professional help for their substance abuse
- Seniors are more likely to be isolated so their substance abuse goes unnoticed
- Health care professionals rarely screen seniors for substance abuse
- Current screening tools are designed for use criteria that is not relevant to seniors such as adverse impact performance in school and work
- Lack of senior specific substance abuse programs
Older adults have significant physiological differences than younger adults that increase their sensitivity to alcohol and drugs. As individuals age, they start to lose lean body mass and water which both decrease metabolism. With slowing metabolic rates, the body’s ability to metabolize alcohol and drugs slows, thereby accumulating in fat stores in the body. Prescription use is very common among older adults. A survey on women over the age of 65 showed that 94% took at least one medication daily, and 57% took five+ medications daily. The same survey showed similar rates among men. Cognitive decline is often associated with aging and can interfere with older adults’ ability to monitor their intake of alcohol and drugs and compliance with their prescriptions.
Older adult substance abusers can be broken down into two distinct groups. One group is comprised of substance abusers who had early-onset substance abuse prior to the age of 60. This group of early-onset substance abusers is typically male and is medically compromised after years of substance abuse. The later-onset substance abuser-group is mostly comprised of women and is less compromised medically due to their short exposure to the harmful effects of substance abuse. Later-onset substance abusers typically start abusing alcohol and drugs following stressful life events such as the death of a partner or friends, retirement, changes in loving situations, and declining physical health.
Pharmacology is used extensively with substance abusers for abstinence purposes. However, the physiological condition of older adults prevents the use of pharmacologic treatments for substance abuse. The medications for alcohol abuse put seniors at risk for dehydration as well as cardiovascular issues. There are opioid blocker medications that are effective in reducing the pleasurable effects and craving of opioids. However, the blocking agents also prevent the relief of pain, which is common and usually chronic with older adults.
In New Jersey, the government is pursuing a number of actions to actively combat substance abuse among the elderly. Governor Christie pushed for legislation that limits the initial prescription of opioids for acute pain to five days. New Jersey has also joined the prescription monitoring program (NJPMP). This system allows doctors to access patient prescription records for the previous two years, thereby decreasing the frequency of doctor shopping. From 2014 to 2016, New Jersey opioid prescriptions decreased 11% while physicians use for patient searches increased from 1.4 million in 2014 to 2.5 million in 2016. Governor Christie has also called for an additional 864 beds for inpatient substance abuse treatment. However, at this time none of these beds are earmarked for Medicare recipients. The NJ Department of Health and Human Services provides educational seminars to seniors about medication management and substance abuse. In 2015, 154 presentations were attended by approximately 3,300 seniors.
Individuals who abuse alcohol and drugs typically experience withdrawal when they stop using. For older adults who are already in a medically compromised physical state, withdrawal places significant stress on an already stressed body. Withdrawal in older adults places significant stress on the respiratory and cardiovascular systems. The safest treatment option for older adult substance abusers is that they use a medically monitored withdrawal management process. However, according to the New Jersey Connect for Recovery hotline, there are only six facilities in New Jersey that accept Medicare for in-patient detox.
The facilities that accept Medicare are Princeton House, Carrier Clinic, Core Health, Summit Oaks, Bergen Regional, and St. Clare’s. Combined these facilities have approximately 200 beds that are available for Medicare recipients for withdrawal management. With the average withdrawal management stay being seven days for older adults, 10,000 older adults will be able to receive substance abuse treatment on an in-patient basis in New Jersey. This means 1 in 20 older adults who need in-patient detox will actually receive it.
However, not all beds available for Medicare recipients are actually earmarked specifically as only for Medicare recipients. Carrier Clinic is the only facility that has beds marked specifically for Medicare recipients. Bergen Regional accepts clients Medicare, Medicaid, and those with no insurance. Princeton House and St. Clare’s accept clients with Medicare, Medicaid, and private insurance. Summit Oaks and Core Health accept those with Medicare and private insurance. This decreases the number of beds available for Medicare detox to approximately 100 beds. This means that 1 in 30 older adults who need in-patient detox will actually receive it.
There are a number of actions to be taken that will help address substance abuse among seniors:
- Expand current DHHS educational seminars to reach more seniors
- Create public service messages geared toward the adult children of seniors to educate on the signs, symptoms, and dangers of substance abuse among seniors
- Expand the number of Medicare beds available for inpatient treatment
- Make the use of NJPMP mandatory
- Use screening tools that do not underreport substance abuse among seniors
- Develop senior specific outpatient programs
- Encourage seniors to attend mutual help groups such as Alcoholics Anonymous or Narcotics Anonymous
Even if all of these changes are implemented, the overall number of seniors who are substance abusers most likely increase as more baby boomers turn 65. The actions described above are meant to produce sustainable decreases over time. As more baby boomers retire and start to decline physically and cognitively, coupled with an utter lack of senior specific services, substance abuse among baby boomers is likely to get much worse. Even if all of these changes are implemented, the design of Medicare reimbursement for doctors on a fee for service basis encourages doctors to spend less time with patients. Unless this aspect of the Medicare system is redesigned, no sustainable progress can be made among seniors with substance abuse problems. A tremendous amount of work needs to be done if there is to be any improvement in substance abuse among seniors.
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.
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:
- 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.
- 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.
- 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.
- 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.
- 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.
- The dearth of local and national press attention is incredibly disturbing.
- Regardless of what happens between the treatment program and the union, it is clear that this scene will play out again in the future.
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|
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.
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).