All posts by fgreenagel


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

Image result for chris christie

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

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

The Good

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

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

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

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

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

Taking Credit For Work Others Already Did

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

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

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

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

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

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

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

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

The Horrifying

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

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

The Unmentioned

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

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

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

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

 In Summation

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

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


On the Death of My Patient

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

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

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

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

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

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

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

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

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



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








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

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

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

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

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

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

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

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


Guest Commentary: Our Failing Mental Health Policies

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

Jeffrey A. Lieberman, MD
November 23, 2016

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

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

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

Missed Legislative Opportunity

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

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

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

Agenda for Mental Health Care Ignored

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

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

Psychiatrists Overlooked After Hinckley Released

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

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

The Displaced With Mental Illness

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

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

Awareness Is Growing but Policies Remain Shortsighted

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

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

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

Thank you for listening.

Dr, Jeffrey Lieberman of Columbia University,


1.      Editorial Board. Clinton just made a very important announcement — and
hardly anyone is talking about it. The Washington Post. August 31, 2016.
November 10, 2016.

2.      Fuller T. What San Francisco says about America. The New York Times.
September 18, 2016.
Accessed November 10, 2016.

So Your Friend Voted For the Other Candidate

Image result for friends fighting

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

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

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

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

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

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

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

(a) eating vegetables

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

(c) people who give me shit for smoking cigars

(d) people who thought Titanic was a good movie

(e) anyone who follows the Kardashians

(f) tattoos

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

(h) skateboarders

(i) not showering

(j) people who talk on their phone in public

(k) people who walk while looking at their phone

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

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

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

(1) exercise more

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

(3) go for hike in the woods

(4) plant bulbs for the spring

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

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

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

(8) organize your closet

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


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


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

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

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


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

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

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

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

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


The Many Disappointments, Failures and Scandals of Governor Chris Christie

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

Gov. Christie’s Worst Hits

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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


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

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

The highlights of my piece are:

Two major suggestions:

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

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


The full piece is below.

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

October 8, 2016

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

Midwives                                 1                      Advanced Practice Nurses      6

Dentists                                   1                      Physicians                                1

Physician Assistants                1                      Nurses                                     1

Pharmacists                            1

Two major suggestions:

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

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

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

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

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

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

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

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

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

The claim that it causes a burden in false:

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

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

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

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

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

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

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

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

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

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


Frank L. Greenagel Jr.


Adjunct Professor – Rutgers School of Social Work

Instructor – Center of Alcohol Studies

Governor’s Council on Alcoholism & Drug Abuse

1st LT – PA Army National Guard










The Insurance Denial Disaster

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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