Category Archives: Uncategorized

03Nov/18

A Veterans Day Story

My close friend and colleague Eric Arauz died in March. I wrote about him everyday for one month. Others followed suit. I took a bunch of the stories and made them into a book, which was published last month. Eric served in the Navy during Gulf War I, back in the 1990’s. He described himself as “a poor sailor but a great veteran.” He loved talking to other veterans and he was an excellent advocate for them, especially those with mental health and/or addiction issues.

Near the end of October, I traveled to the Psych Congress annual conference in Orlando. I was invited by the organizers to come down and talk about Eric. They honored him by naming the kickoff keynote after him and also creating an award in his name. Very cool. I read a few sections from the book. Before I closed with my chapter on Eric at Elizabeth High School, I mentioned how I really would have liked to tell him the story about an Army veteran that I met a week earlier in Philadelphia.

Independence Blue Cross of Pennsylvania put on an all day event about the Opioid Epidemic at the Kimmel Center in Philadelphia. There were four panel discussions and a keynote speaker. I was impressed with the event, and every panel had at least one truly impressive person. The keynote took place just after lunch. The speaker was retired U.S. Army Master Sergeant (MSG) Justin Minyard.

MSG Minyard is a big guy (over 6’5″). He wore a suit, no tie (I approved). His hair was short but he had grown a beard. MSG Minyard began his talk with an apology. “I had a traumatic brain injury,” he said, “and there are times that I can’t get my mouth to say what I am thinking. As frustrating it is for you to watch me pause and stumble, it is even more frustrating for me. Please bear with me.” It was a powerful introduction, and my heart went out to him. I think that most of the audience had a similar reaction.

MSG Minyard was stationed near Washington, DC in the late 90’s and early 00’s. He was on details for both President Clinton and President Bush II, and he also had the honorable task of guarding the Tomb of the Unknown Soldier. Within a couple of hours of the attack on the Pentagon on 9/11, MSG Minyard and his unit were at the site trying to rescue people trapped under the rubble. “I was trying to reach a woman who was trapped under three floors of debris and while trying to reach her a load bearing wall collapsed on me and I had spinal damage and had to have several discs removed.” He was 21 years old.

MSG Minyard was a good soldier but a terrible patient. He cut his physical therapy time by more than half and demanded to be returned to the field. He served multiple tours in Iraq and Afghanistan (at least five) and was injured on several occasions. He told a story about how he and a half dozen other special forces operatives were tasked with attacking a bunker in a city. The helicopter was 60 feet above the target. Just as MSG Minyard jumped out of the chopper and went to grab the rope to repel down, they took incoming fire and the helicopter swerved. MSG Minyard was not able to grab the rope and he fell the entire 60 feet. To compound matters, the soldiers that came after him (down the rope) landed on him, exacerbating his back injury.

To deal with the pain and trauma, he was prescribed Oxycodone and Valium. During his speech, MSG Minyard filled a glass with his daily drug cocktail. Then he filled up a glass vase with his monthly dosage. It was a powerful effect and the audience gasped. He lived this way for almost three years. It devastated his wife and his daughter.

“It got to the point that when my four year old daughter asked me to read her a bed time story, I would respond to her with the worst words possible at the highest volume, just inches from her face. Because if I read to her, that was 15 minutes that I could not spare because the CVS would close and I would not be able to get my medication and I’d go into a horrible withdrawal.”

Silence. And then, “I did that. I’m responsible for that. I can never undo what I put my ex-wife and daughter through.”

He talked to therapists and doctors. More than two and half years into his prescribed addiction, someone talked to him about alternative ways to deal with pain. “Why am I just hearing about this now?” he asked.

More silence. And then, “Think about this. I’m just a big dumb Army guy, but I did guard two Presidents and the Tomb of the Unknown Soldier. I was deployed multiple times and worked on highly important missions. I had access to care and support. If this can happen to me, it can happen to anyone around America.”

MSG Minyard was given spinal cord stimulation and got off his pills. The recovery process was difficult. He has been clean and sober for about eight years and now works for Boston Scientific (the company that developed the spinal cord stimulation technology). He said that he still has pain, but it is mostly manageable. He finished by talking about his 11 year old daughter and how she still wants to hang out with him (“at least for another year and a half”). He takes her to “an expensive park in Orlando” and they walk around all day and evening. The all day walking causes him pain, but he does it for his daughter.

He earned a standing ovation, even from me (I rarely do that). I left my seat and forced my way backstage, past staffers and security. MSG Minyard was drinking water and was guarded by two off-duty Philadelphia police officers. I went up to him and introduced myself. We shook hands. I told him what I do and I thanked him for his talk.

And then I asked him if he wore cufflinks. He said yes.

“Do you have a pair of Army cufflinks?” I asked him.

“No.”

I started to take mine off. He saw what I was doing and said, “Sir, I can’t possibly take those.”

“Sergeant, you’ve earned them. Wear them with gratitude and pride.”

One of the cops turned towards MSG Minyard and said, “You have to take them. He outranks you.” Then the cop turned to me and saluted.

With tears in our eyes, we all shook hands. I gave him my card and told him that I’d like to connect and possible bring him to Rutgers for a talk. As I started to walk away, my first thought was that Arauz would have loved that guy’s speech and my gesture. It was a resurrection story.

A Veterans Day story.

 

03Nov/18

Bearing False Witness: American Addiction Centers’ Client Outcome Studies

Image result for false witness

By Andrew Walsh

Edited by Frank L. Greenagel II

 

In February of 2018,  American Addiction Centers (AAC) released a report that summarized three years of patient tracking and patient outcomes research. It was full of distortions and lies. Their press release falsely bragged, “American Addiction Centers is breaking new ground in addiction treatment with the release of its first patient outcome studies.”[i] AAC then offered an even more farcical utterance: the patient outcome studies show that 63% of AAC clients maintain abstinence one year after treatment. I was shocked to read that such a high percentage of clients stayed sober (this was actually the greatest treatment outcome claim I had ever heard). AAC continued to fluff themselves when they reported that the national benchmark for other treatment providers one year after treatment was only 30%. Intrigued by the news release which painted AAC in such a positive light, I dug into the report to learn more (editor’s note: What he found was horrifying).

The patient outcome studies began in 2015 and were the result of a partnership between American Addiction Centers and Centerstone Research Institute (CRI). AAC is a large, publicly traded, for-profit organization that provides[ii] substance abuse treatment in several different American states. CRI is an independent, non-profit research organization. Working together AAC and CRI conducted three studies. They started with a sample size of 4,399 patients. Patients from five different AAC inpatient locations were included in the study. The size and scope of the studies seemingly addressed any potential for geographical influences on data (i.e. the study was so large and spread out that the results should have been representative of the U.S. overall). The study was designed to include regular follow-up intervals (two months, six months, and 12 months) with clients after they discharged. This allowed AAC to track how patients did after they completed treatment.

They released the results of their studies in a 76 page report. The layout and design is visually stunning. The graphics included are clear, crisp, and informative. To a casual observer, this report portrayed AAC as one of the best treatment providers in the world. I could not reconcile this with recent news[iii] regarding American Addiction Centers[iv].

How was the company I was reading about in the report (portrayed as producing the best outcomes I had ever seen) the same company accused of fraudulent drug testing, with a history of lawsuits ranging from SEC violations to patient deaths, and who previously had five employees (including the former company president) charged with murder following the death of a client? Initially in reviewing the report, I thought AAC had moved on from its troubled past[v] and was producing tremendous patient outcomes. However, the more I delved into the report, the more disappointed and outraged I became.

There are several areas of concern I discovered after reading and analyzing the report multiple times[vi]. In particular, I am troubled by two bold statements in it. Additionally, I am concerned about one important section that is missing. I have provided an analysis below.

 

Statement 1: “At 12 months, 63% of patients were abstinent from all substances”[vii]

Seemingly with this statement AAC, is saying that 63% of their patients were still sober 12 months after completing treatment. However there are several problems with this statement:

  1. It does not mean that patients have been sober for 12 months. It only means that 63% of patients who were surveyed 12 months after discharge had been sober for at least 30 days.[viii]
  2. Per the report, 48% of clients had stayed sober since discharge (12 months sober). This is still an incredibly high percentage. Why report a misleading higher statistic (63% sober at 12 months) instead of just reporting the still industry leading statistic (48% of clients remained sober for at least 12 months after discharge)? That answer is provided below.
  3. These statistics (as are all the stats in their report) are based on patients’ self-reports. This means that none of the answers provided by the patients have been verified with drug tests, or speaking with study participants’ families, friends, and loved ones.
  4. These statistics are based on a sample size of only 80 patients out of the 4,399 patients who were included in this study. Why state the study included 4,399 patients but only include 80 for calculating the key statistics?[ix]

 

Statement 2: “Over a 3-year period, more than 4,000 people enrolled in the study”

I have taken several graduate level research courses and have professional experience in designing and running clinical trials. I have partnered with various universities including Princeton University, The University of Pennsylvania, and The University of Arizona to conduct clinical trials involving human subjects (editor’s note: He knows a bit about study designs and sample size).

Initially, when I read about the sample size used in this research (4,399 clients), I was impressed. A large sample size is ideal because it decreases the margin of error (it means that the results are likely accurate).

Including five separate locations across the U.S. was also smart because it eliminates geographical differences from impacting the data. For instance, West Virginia and Kentucky have incredibly high rates of opioid abuse. If clients in the study were only from those areas, they would artificially inflate the number of people abusing opioids and seeking treatment at AAC. By using multiple locations across the U.S., the study reduced the likelihood of skewed statistics.

At first glance, the size and scope of this study seemed to be legitimate. The further I dug into the study design and statistics, the more the flaws were exposed. AAC stated they had 4,399 clients in the study, which is a massive sample size. However, this large sample size was not included in generating the statistics AAC cites as proving how amazing their program is. The chart below shows the actual number of clients include in the study at the different follow-up points.

Time Point Eligible Completed Follow Up Rate
2 Month 4,399 1,133 26%
6 Month 1,852 515 28%
12 Month 221 80 36%

 

The chart content and location raised several questions and concerns for me:

  • Why cite a sample size of approximately 4,399 clients but not make it readily known that not all of those clients were used to generate the statistics referenced in the study?
  • Why is there a discrepancy between eligible patients and completed patients?
  • How were the statistics (such as the 12-month abstinence statistic) calculated?
  • Why was such an important chart buried in the report on page 46?

The more I read the America Addiction Centers’ report, the clearer the answers became. AAC included and cited such a large sample size because it sought to give the public the impression that this was a very serious study and that the results found were legitimate.

Per AAC, they were not able to contact all patients who were enrolled in the study upon the regularly scheduled follow-up intervals. This is understandable and a common occurrence in almost all studies that include a follow-up component. Many study participants move or get new phone numbers or just disappear. However, AAC press releases conveyed that all 4,399 participants were followed up with 12 months after their discharge. In reality, only 1.8% of the 4,399 participants responded to follow-up at the 12-month mark[x].

The 12-month abstinence rate was calculated based on the number patients who responded to the follow-up. At the 12-month mark, 80 patients responded and 51 of them reported that they were abstinent for at least 30 days. 51/80 = 63%. While this math is relatively simple, AAC went against research norms and ethics when calculating it.

In the bottom row of the chat we see that while 221 clients were eligible to participate, AAC was only able to get in contact with 80 of them. The 141 clients AAC could not get into contact with are referred to as loss to follow-up. A common question is; how important is loss to follow-up? Simply put loss to follow-up is extremely important if patients lost to follow-up have different outcomes than those who completed the study. AAC was very proactive in following up with patients. Per the report, an average of 10 phone calls, 4 emails, 6 text messages, and 1 letter were sent over the course of a month to each study participant. What is the likelihood that 141 participants (those who did not respond) moved and changed both their phone numbers and email addresses? There is a very low likelihood that this is the case. Therefore, we need to look at alternative explanations. Based on my experience working with substance abusers as well as conducting clinical trials, I believe it is more likely that a high percentage of these 141 participants most likely relapsed and chose to not report their relapse to AAC.[xi]

Now that we have determined that loss to follow-up is important, we need to look at how it is calculated (editor’s note: bear with him here. I don’t like reading this math either, but this is a really important point. Read it a couple of times if you need to). With an eligible population of 221, 141 clients failed to follow up. We simply take the 141 and divide it by 221 (the eligible population) to get a percentage of 72.8% (the loss to follow-up rate).

Now a good standard is that when a loss to follow-up rates exceeds 20%, it poses serious threats to the validity of the study. AAC’s study has a loss to follow-up rate of 72.8%, which is 3.5 times greater 20% rate that threatens validity (editor’s note: the whole study is invalid. I would fail a college junior for turning this in).

I employed a common research technique to address the follow-up rate problem: treat every patient lost to follow-up as a worst-case scenario (patient relapsed). AAC claims to have a 63% abstinence rate. However, when we included the 141 people in the calculation and coded them as having relapsed, we get a abstinence rate of 23%. This is shockingly lower than the 63% reported. Based on standard practices in conducting clinical trials and studies, the AAC study has significant cause for concern regarding the validity of the findings.

 

The Third Major Problem: Conflict of Interest

Reporting conflicts of interest in publications is a standard best practice. However, this does not always occur. In reviewing the report, I noticed that there were no disclosures regarding conflicts of interest.  They want the reader to assume that there must not be any conflicts. In researching American Addiction Centers, I made an interesting discovery: AAC hired the CEO of Centerstone Research Institute (CRI) in 2016, in the middle of the studies. Throughout the report CRI is depicted as an “independent third-party non-profit research center.” CRI was theoretically employed in this capacity to ensure the integrity of the data. By hiring the CEO of the company who was supposed to provide independent analysis AAC has threatened the integrity of the study.[xii]

Conclusion    

Taken alone, any one of the concerns I have outlined is troubling:

  • American Addiction Centers crowed about their 4,399 person study but used as few as 80 people for some of their key statistics.
  • American Addiction Centers sought to distort the public’s perception by presenting the data in manner in which it could be easily misinterpreted.
  • The company (CRI) that conducted the study was billed as an independent non-profit, but the CEO was hired by AAC before the study was completed. It is a vicious conflict of interest.

Examining all three concerns while simultaneously taking into account recent events involving AAC including locking out employees at its NJ facility in 2017 and a $7 million dollar jury verdict following yet another patient death in February 2018 , an apparent and devastating pattern starts to emerge. American Addiction Centers has a long and well-documented history of putting profits before patients. With gleaming websites, shining brochures, and a visually beautiful report, AAC portrays themselves as a strong treatment program. The websites and brochures hide the dirty reality. The report is invalid, though it is not useless. It gives a first hand account (written by them) of the fraud and lies that they regularly and willfully engage in.

____________________________________________________________

[i] https://finance.yahoo.com/news/american-addiction-centers-releases-findings-144200689.html

[ii] Provides is used very loosely here. I also thought of adding (substandard) ahead of “substance abuse treatment services” but decided that you already probably knew that.  – Frank Greenagel

[iii] https://www.nevadacurrent.com/2018/08/02/former-rehab-worker-everything-is-about-saving-money/

[iv] https://www.usatoday.com/story/news/nation/2018/10/03/patients-drug-addiction-treatment-centers-opioid-epidemic-crisis/1358894002/

[v] “moved on from their troubled past.” Andrew must have been joking here. We mean to show that lies, distortions, death, stealing and dozens of other ethical and legal violations are baked into American Addiction Centers’ DNA. – Frank Greenagel

[vi] He really did. The first time he read it, he gave me a summary. I said we needed an article on it. He went back and read it again and provided more details to me. We then discussed how he should take AAC’s report down, blow-by-blow. This required several readings and copious notes. – Frank Greenagel

[vii] https://americanaddictioncenters.org/outcomes-study/

[viii] What a horrific distortion. – Frank Greenagel

[ix] A few brutally honest answers before you get to Andrew’s more measured response: their substandard programs produce terrible results, so they need to cherry pick their data, manipulate figures, distort perceptions and sometimes straight up lie. They assume that most people won’t read all 76 pages, so they bury these problems deep within it. – Frank Greenagel

[x] https://www.youtube.com/watch?v=SjbPi00k_ME

[xi] Let us speculate a step further – American Addiction Centers knew that the clients relapsed and then cut them from the study in order to improve their reported percentages of sober clients. – Frank Greenagel

[xii] Andrew is too kind here. The integrity of the study wasn’t threatened. There is no integrity. The people that conducted the studies are either inept or evil, and possibly both. – Frank Greenagel

_______________________________________________________

Andrew Walsh is a Project Manager and Director of Clinical Trials for Carrier Clinic. Carrier Clinic is one of the largest private non-profit psychiatric facilities in New Jersey. He earned a Master’s Degree in Social Work and a Master’s Degree in Human Resource Management from Rutgers. Prior to working in the behavioral health field, Andrew worked in the Gulf of Mexico oilfield as an internal business consultant focused on innovation and improving the efficiency of people, processes, and procedures. He eventually decided to return to NJ to practice innovation in the behavioral health field. In his free time, Andrew enjoys hiking, cooking, and reading.

He has written previous articles about Addiction HotlinesMedicaidMedicareA Fix For Addiction Hotlines, and how treatment programs keep clients rather than sending them to get appropriate care.

20Oct/18

Profits Before Patients: “We own that client!”

By Andrew Walsh

Edited by Frank L. Greenagel II

Image result for we own you

 

Jessica’s[i] family was extremely concerned about her. Jessica was 24 years old and was abusing alcohol, marijuana, and opiates. Driven by the fear of what would happen to their daughter, Jessica’s parents researched all options for help for their daughter. With the support of her family, Jessica contacted a for-profit partial hospitalization program (PHP) and intensive outpatient program (IOP) in Central New Jersey[ii].

During the course of Jessica’s phone assessment, it became clear to the PHP/IOP that Jessica needed detox first, which was a service that they did not provide. The program made arrangements for her to attend a for-profit detox facility in Northern New Jersey. Upon completion of detox, Jessica would then return to the PHP/IOP she originally contacted.

Over the course of seven days at the detox, it became clear to the treatment team that in addition to substance abuse, Jessica was also suffering from extreme anxiety. The treatment team also learned that Jessica had a significant trauma history stemming from multiple sexual assaults.

The treatment team at the detox found themselves in a quagmire. On the one hand, the program in central New Jersey did not have the appropriate capabilities to treat Jessica’s severe anxiety or her serious trauma history. Jessica needed a program that was licensed to provide dual diagnosis services. Additionally, Jessica would greatly benefit from a program that has extensive trauma programming and experience in treating clients with sexual assault histories. On the other hand, the referring PHP/IOP program owned Jessica. If the detox did not send Jessica back, the PHP/IOP would be upset and would eventually stop referring clients to the detox. In recent months, the treatment team at the detox had been experiencing significant pressure from administration to keep increasing revenue.

The treatment team caved to the pressure from administration and from the referring PHP/IOP. Upon completion of her detox, Jessica returned to the PHP/IOP where she received treatment for her substance abuse. However, the PHP/IOP did nothing to treat her severe anxiety or her history of trauma and sexual assault. Quickly Jessica’s progress stagnated because her anxiety and trauma were not addressed. She ended up developing a relationship with a fellow patient and they left treatment together and relapsed.

Jessica eventually was able to end the unhealthy relationship she developed with her fellow patient and again sought help. She contacted the same PHP/IOP in central New Jersey she had attended previously.

Contacting the same facility had several advantages for Jessica. She was able to speak with the treatment team she worked with before and who knew her case. The team was aware of Jessica’s severe anxiety and history of trauma and sexual assault. Those professionals were also aware that these factors significantly contributed to Jessica’s relapse.

However, there were several negatives that Jessica was not aware of that outweighed the advantages. The treatment team was still unable to treat Jessica’s severe anxiety, trauma, and sexual assault history. Additionally, the treatment team had been experiencing significant pressure from their administrative team to keep increasing revenue by keeping the number of patients in the program as high as possible.

The thought of referring Jessica to a more clinically appropriate program rarely crossed the minds of the treatment team. After all, Jessica belonged to them.

The cover of USA Today on October 3, 2018 reported a similar story. Cody Arbuckle died at an American Addiction Center facility in Nevada last July.

A coroner listed the cause as toxicity from loperamide, an ingredient in the anti-diarrhea drug Imodium A-D.

His mother has filed a lawsuit against AAC in the Clark County District Court. Kathryn Deem, Arbuckle’s mother, is represented by Jeremiah Lowe’s San Diego law firm, Gomez Trial Attorneys. According to Deem’s attorneys, staff at the Solutions Recovery house reported that Arbuckle was under the influence of drugs. But rather than transporting him to a hospital, they say in a lawsuit, they sent him to a “non-medical residential detoxification house” in Las Vegas.

Arbuckle was supposed to be under 24-hour monitoring, the lawyers say in the lawsuit, but he was not checked over 14 hours overnight. He was found dead the following morning. The lawyers say in the lawsuit that AAC kept Arbuckle “in their non-medical program for business reasons, because they did not want to let go of their paying client.”

He became the seventh patient who died shortly after entering an AAC facility, the attorneys say in the lawsuit[iii].

These stories highlight a common occurrence in the substance abuse field that is incredibly troubling: treatment providers owning clients. In the past few years, I have been fortunate enough to work with thousands of clients at the Carrier Clinic. I have interacted with the majority of treatment providers in the tri-state area. On a weekly basis I would receive referrals from treatment providers with clients who needed to detox before they could attend the treatment providers’ program (I worked in Carrier’s call center for one year).

These treatment providers would always call me and happily refer their clients to our program. They would go as far as obtaining insurance authorizations and providing transportation to Carrier (no small feat). As a nonprofit, this additional business helps keep the lights on and the program running. However, there was one small stipulation from the referring treatment providers regarding these clients; “Send me back my client when you are done, they are mine.”

The current state of affairs of the substance abuse treatment field is troubling. There are many treatment providers that unintentionally are ill-equipped to provide clinically appropriate services to clients. Often and terribly, there are treatment providers that are consciously aware of the lack of clinical appropriateness and still treat those patients because they put profits before people. One commonality among the majority of treatment providers though is their belief that clients belong to them. This damaging mentality is pervasive throughout the industry and is incredibly destructive.

Jessica’s story highlights a troubling dyad in the substance abuse treatment field:

  1. Detoxes will not refer clients to PHPs/IOPs who do not refer clients to them
  2. PHPs/IOPs will not refer clients to detoxes who do not refer clients to them

Caught in the middle of this dysfunctional relationship between treatment providers are the Jessica’s and their families. Clinical appropriateness is now competing with profits, and the focus on profits outweighs the significance on clinical appropriateness in the decision making process.

Further contributing to the disservice to clients is that the majority of treatment providers are not equipped to provide clinically appropriate services for co-occurring psychiatric disorders or trauma. The majority of treatment providers are licensed to provide substance abuse services. However, they are not licensed, nor have the necessary staff with necessary credentials, to provide psychiatric services.

On a weekly basis marketers would come in to my facility and talk about their program. They would show us glossy brochures and talk about the specialized programs they have for first responders and trauma populations. However, very few of these programs were licensed to provide dual diagnosis services. Whenever I inquired about their ability to take clients who had co-occurring substance abuse and psychiatric disorders, they always assured me that they had the capabilities, as long as the client’s psychiatric disorder was not too acute. Almost every presentation from these marketers ended with some version of the following: “We will definitely send our patients to you for detox and then as soon as they are done you can send them right back to us.”

Having worked with clients with substance misuse disorders, I feel confident in my assertion that occasionally clients change their mind. I firmly believe in my clients’ right to self-determination. When working with clients on their discharge plans, they would occasionally elect to attend a different program instead of returning to the program that referred them. Seeing clients start to take responsibility for their treatment was encouraging because it showed buy-in.

Once the referring facility realized that the client they referred to us was not returning to them they would become upset. Phone calls would pour into our marketing department and clinical team complaining, “Why didn’t you send back the client? That was our client. They are mine.”

The majority of the conversations that I had with these upset treatment providers were with people who did not have the requisite education, experience, or licensure to make clinical determinations. It was not, and is not, uncommon for unqualified marketers to state that the clients they refer to my program are clinically appropriate to return to their program upon completion of their detox.

I would return to the clients I was working with. However, a few days later a message would be passed along to our treatment team that if we didn’t send the patients back to the referring facility in the future, the referring facility would stop sending patients to us. We ended up right where we started: revenue versus clinical appropriateness. The client belongs to the referring facility[iv].

Here are three solutions that clinicians should follow in order to address this problem and put patient care back at the forefront of practice.

  1. Adhere to the standards of your profession
    1. If you are LSW or LCSW, adhere to the Social Work Code of Ethics:
      1. Section 2.06 (A) Referral for services – social workers should refer clients to other professionals when the other professionals’ specialized knowledge of expertise is needed to serve clients fully
    2. If you are a LCADC, adhere to the Ethics for Professional Substance Abuse Counselors:
      1. Standard 2 – Client Self Determination (8): the addiction professional will refer a client to an appropriate resource when the client’s mental, spiritual, physical, or chemical impairment status is beyond the scope of the addiction professional’s expertise
    3. If you are a LPC, adhere to the ACA Code of Ethics:
      1. Section A.11(a) – Termination and Referral: if counselors lack the competence to be of professional assistance to clients, they avoid entering or continuing counseling relationship

 

  1. For practitioners who feel pressured by their program administrators to make clinically inappropriate decisions for fiscal purposes, report your program to the attorney general’s office at NJ CARES or email Deputy Attorney General Sharon Joyce at Sharon.Joyce@law.njoag.gov.

 

  1. Develop a list of programs that can provide clinically appropriate services to clients (focus on identifying programs that are specific for trauma populations, first responders, LGBTQ, and co-occurring populations).

The substance abuse field has poor reputation because practitioners and programs have been acting horrifically. In a medical practice, if a patient died because a doctor refused to refer the patient to an appropriate level of care for appropriate services, the doctor would be charged and (hopefully) convicted of medical malpractice. A defense of, “This is what everybody does in the field and what my administration wanted me to do,” would not be valid. Medical professionals take an oath to do no harm to the chargers in their care. Practitioners and treatment programs would be better off if they lived by the ethics and values they so highly tout on their websites and brochures.

The for-profit treatment programs (looking at you American Addiction Centers and Recovery Centers of America) are not going to change without significant pressure from advocates and the government (editor’s note: we are working on this). Our immediate hope rests with the clinicians and techs that work in those programs. Tell your bosses that they are acting unethically. Remind the clinical director(s) about the various codes of ethics. If that doesn’t work, report your bosses and your companies. You can contact the NJ Attorney General’s Office (if you are from another state, start with your Attorney General’s Office) or you can email Frank Greenagel. The reckoning is coming.

_____________________________________________

[i] Jessica is not her real name. It has been changed to protect her identity.

[ii] The author and this website cannot publish the name of the company unless Jessica and/or staff members went on the record.

[iii] We think that there may be more than that. We are currently investigating American Addiction Centers.

[iv] To be very clear, the Carrier Clinic did not send people back to referring programs that could not address the psychiatric, physical or trauma issues that we discovered. This has made us an outlier in the field.

____________________________________________________

Andrew Walsh is a Project Manager and Director of Clinical Trials for Carrier Clinic. Carrier Clinic is one of the largest private non-profit psychiatric facilities in New Jersey. He earned a Master’s Degree in Social Work and a Master’s Degree in Human Resource Management from Rutgers. Prior to working in the behavioral health field, Andrew worked in the Gulf of Mexico oilfield as an internal business consultant focused on innovation and improving the efficiency of people, processes, and procedures. He eventually decided to return to NJ to practice innovation in the behavioral health field. In his free time, Andrew enjoys hiking, cooking, and reading.

He has written previous articles about Addiction Hotlines, Medicaid, Medicare, and A Fix For Addiction Hotlines.

14Oct/18

On Death and Grieving

In early October, a very close friend reached out to me via text to tell me a friend of his had died that day. Just 39 years old, the man had succumbed to his substance misuse disorder after many years of complete sobriety. When my aforementioned friend lost someone very close to him in 2014, I sent an email out about what he (and others) might want to do in both the immediate and long-term aftermath. He asked me for that advice again. I sent him a longer version, which I’m posting here for the public (I’ve edited out the deceased name).

What you should do:

  • Write down everything you can about him/her. Things he said, things you did together, jokes played, things that pissed you off and little gestures. Your mind will be flooded with memories over the next two weeks, and then they will slowly fade. You will never remember him as well as you do right now. Write it down. Also…it will help you grieve. Do this every day, for 30 days, without fail.
  • Keep up your exercise routine. If you don’t exercise, you should start.
  • Consider seeing a therapist who specializes in grief and loss.

What you should avoid:

  • Avoid isolating after the first 24 hours. Humans (and animals) have a tendency to crawl into a hole when injured or sad and avoid contact. It is a terrible instinct for grieving. Having people around, even if you don’t discuss the death, is helpful. Maybe not 24/7, but certainly daily. I am incredibly grateful for my friends who realized that they should stop by for a meal or watch baseball or just hang around during my various periods of grieving.
  • Do not take in more caffeine or nicotine than usual.
  • Be aware of your eating. Some of you may have no appetite, while others will seek comfort in food. Both options have negative consequences. Try to keep up your regular diet.
  • If you are someone who uses eating, drinking, drugging, sex, gambling or shopping to feel good or self-treat, be very wary over the next three months. If you are in recovery from one or more of these issues, consider talking to friends who are also in recovery or upping your support group attendance.

What you should be aware of:

  • I was angry at Fraser for dying and then I would feel bad about being angry at my dead friend. It was confusing. It took me a while to reconcile all of those feelings.
  • You have the right to talk with who you want about this, and you can also tell people that you are sad and just need some space. I found that I talked about it a lot with a couple of close friends, shared about it at every meeting I went to and discussed it in therapy. But I didn’t have it in me to talk to everyone. Some people just pissed me off or didn’t “get it.”
  • Everyone grieves differently. Everyone. Don’t fight with those close to you because you don’t like the way they grieve.
  • Remember that his/her family’s pain is worse than yours. Writing a letter to them about how much he meant to you, as well as some funny/good stories will be valued more than you can possibly know.

I’ve written a lot about death and grieving over the last four+ years. I have provided some baseline advice in this article, but for more specific situations, you might want to check one or more of the pieces below.

In the spring of 2014, Rutgers published a story about my work and how I was inspired after the death of my childhood friend Fraser Curry. I wrote a follow-up piece about my reaction to his death and what people can do if they have a friend or family member with a drug problem: http://greenagel.com/what-to-do-when-your-friend-or-family-member-has-a-drug-problem/

When my friend Pat died, I wrote this in 2014: http://greenagel.com/our-friend-pat/

This is a (near) copy of a speech I gave at an Overdose Vigil to 350+ parents who lost a child to addiction: http://greenagel.com/to-the-parents-who-have-lost-a-child/

A long-time patient of mine died in December of 2016 and I wrote this for myself and other counseling professionals: http://greenagel.com/on-the-death-of-my-patient/

A cousin of mine lost a baby in 2017 and I wrote this: http://greenagel.com/to-the-parents-who-lost-a-young-child/

I lost one of my closest friends (and my closest co-worker) this past March. I followed almost all of the advice that I’ve laid out (I didn’t work out for three weeks and I over ate). My writing turned into a book and it was released on October 8th on Amazon. It is titled The Book of Eric and it provides an example of how to deal with loss and grief.

06Oct/18

American Addiction Center’s Unauthorized, Unethical and (perhaps) Criminal Behavior

Earlier this week, I googled my name* and discovered that the first link was for a link to drugabuse.com. That is a website that is owned by American Addiction Centers (AAC), which is a for-profit treatment company that has been in the news a lot because of variety of problems at their centers, but most significantly because multiple employees have been indicted for murder of their clients. That’s right: multiple employees from American Addiction Centers have been indicted for the murder of their clients. I have contacted my lawyer and will be pursing a few different legal actions against them.

Question: Why would American Addiction Centers pay for the search engine optimization (SEO) use of the name “Frank Greenagel” and why would they then link the name to drugabuse.com?

Great questions.

1) On June 5, 2017, I wrote an article about how an AAC treatment center in NJ locked out its employees and transferred its patients to other facilities. The article received over 20,000 hits in the first week.

2) On February 24, 2017, I published a piece by Andrew Walsh about the unethical (and probably illegal) behavior of addiction treatment hotlines. While AAC was never mentioned by name in the article, one of the hotlines that engaged in the horrific and unethical behaviors that Mr. Walsh wrote about is owned by AAC.

3) On February 11, 2018, I wrote an article where I linked to the lock-out piece and also taught my readers to ask three questions of treatment programs. At a conference earlier this year, I spoke to two therapists who work at an AAC facility and both of them emphatically stated that the treatment program they worked at could not answer any of those questions satisfactorily. I encouraged both of them to contact the State Attorney General’s Office and to quit.

I believe that none of those articles caused American Addiction Centers to move against me. I firmly believe that my next two points enraged someone there and then AAC unethically used my name without authorization.

4) On August 28, 2018, I posted this on my Greenagel Counseling Services Facebook page:

American Addictions Center is the company in this story. While they have many sub-sub standard treatment programs and sober homes, they are fairly typical of the field. Because they are such a large player in the market and advertise so much, they are even more to blame. A reckoning will eventually come.

The article is good.

_______________________________________

That price tag of more than $3,300 a day buys recovering addicts group therapy sessions during the day, conducted by interns according to Lapina, not licensed professionals. At night, clients are transported in vans to free 12-step program meetings throughout the valley.

“Mental health counseling, which most of their addiction clients need, would cut into profits, so they rely on Alcoholics Anonymous or Narcotics Anonymous because they are free,” says Lapina, who detailed the daily routine of Solutions’ clients. “They even buy generic cola, not even Coke. Everything is about saving money.”

Lapina has received the green light from the Equal Employment Opportunity Commission to sue Solutions and its parent company, American Addiction Centers. She’s filed a claim in federal court for employment discrimination.

Lapina, who is now a licensed drug and alcohol counselor, says the vast majority of house managers are former clients who have little to no training and are paid just above minimum wage.

“The house managers have traded one drug for another — power. They bully people. I was asked by clients to protect them from house managers,” she says. (and then I linked to this article)

5) On September 10, 2018, I posted this on my Greenagel Counseling Services Facebook page:

Straight up, American Addiction Centers is shit.

SHIT.

They own these websites: recovery.org, rehabs.com, projectknow.com and drugabuse.com. They are set up as community help, but they steer clients towards themselves. And their programs are rife with problems. (and then I linked to this article about their websites)

6) In the post referenced in point #5, I included three more articles:

a) complaints filed against American Addiction Centers through the Better Business Bureau

b) this piece about a dead American Addiction Centers client and how multiple employees have been indicted for murder

c) this lengthy article in the New York Times about the numerous professional, ethical and legal troubles that American Addiction Centers have

I believe that sometime after the September 10th post, American Addiction Centers or one of their subsidiaries or one of their contractors purchased the use of my name (without authorization) to be linked to their website. This behavior should be added to the long list of reasons why you should never, ever send someone to a treatment center owned, staffed or run by American Addiction Centers.

Image result for prison

All too often, America is incarcerating the wrong individuals, particularly when it comes to issues around drugs. Someone who is caught with $200 of heroin goes to jail while no one from a company that knows doctors are overprescribing opioids serves any time. That needs to change. Furthermore, I’m a strong advocate for the incarceration of bad actors within the substance abuse treatment field.

________________________________________

* update: I checked this on 10/20/2018 and found that the link to drugabuse.com no longer appeared and had been replaced by a link to SAMHSA. This piece was read by over 5,000 people in less than two weeks. Many of the readers are in government or the treatment industry. I have no doubt that AAC decided to remove the link after recognizing they walked into a wolf trap. By removing it and linking it to SAMHSA (their lawyers must have thought it was a good idea), it is tantamount to admitting they did something wrong. I have saved some screen shots to show what it looked like when AAC was engaging in their wildly unethical behavior. Here is one:

14Sep/18

A Soldier and a Wonderful Leader

 

 

 

 

Master Sergeant Greg Spadoni. Served in the United States Army for 35 years. Our time in the NJ Army National Guard lasted from 1996 to 2002. This is a brief tribute that will not nearly say enough about the man.

I met him in September of 1996 when I joined my NJ National Guard Unit, fresh out of Ft. Knox. He introduced himself as a friend of a family friend and told me to find him if I had any questions. “Or if anyone bothers you,” he said.

“Why would anyone bother me? We’re all in the Army together,” I replied.

He knowingly smiled. “Well, just in case.”

He was the NCOIC (non-commissioned officer in charge) of the Battalion S-2 (they handle Intelligence). I had been assigned to the Battalion S-3 (training and the Tactical Operations Center (TOC)). Our sections worked very closely, and we usually shared the same tents. Whenever I could, I spent time with him in his section or when he hung around the TOC.

When he wasn’t serving in the Army, Greg taught middle school math in Easton, PA. He talked about his students, other teachers, and gave me an entertaining view of what the job was like.

It seemed liked we were always in the field. We camped when it was 30 degrees and when it was 100 degrees. The food was awful. The tents were loud and musty. People got up early. To this day, I’m pretty much ruined for camping. Greg would entertain me with his life’s wisdom. He told funny stories. He would bring a piece of carpet and a coffee pot into the field. The carpet was for his feet in the morning and the coffee was for all of us. “Creature comforts, Frankie, creature comforts. It makes all of this easier. Don’t forget it.”

I haven’t.

Eventually, I ran into problems with other soldiers. Sometimes it was busy body NCOs, other times it was officious officers. I occasionally brought some of it on myself, but usually it was those motherfuckers. Greg would step in. Calm things down. Later, he’d say, “Frankie, you can’t say stuff like that. You have to go with the flow sometimes.”

I would listen to him. You know why? Because he was smart and competent and funny and I knew he cared. He was a great leader.

By the time he retired, he had been an E-8 for 18 years. Years before I joined, he had been the First Sergeant (1SG) of Headquarters Company (HHC). Everyone told me that he was the best 1SG they ever had. He took a lateral assignment as a Master Sergeant (same rank, but he was in charge of six people rather than 150). Whenever we got a new company commander, they inevitably went to Greg and would ask him to move back to the 1SG role. He would say, “I’ll do it if you let me kick out 10 people. We have a truck driver that can’t drive because of his DWIs. We have all kinds of people that shouldn’t be here.” The Captains always said no, because our unit was always below strength (not enough people). Later, he would tell me, “I can be in charge of you or 150 people. Being in charge of you is a better job.”

The first photo is from November of 2001. Our unit had been activated after 9/11. Our Battalion was assigned to monitor and guard the Hudson River Crossings (the GW, Lincoln Tunnel, Holland Tunnel and Journal Square in Jersey City). The command center was back in Port Murray. I was tasked around the other crossings for part of it, but I got to spend some time at the command center. Greg was in charge of one of the 12-hour shifts. Being in the TOC exposes you to everything the unit does and the high ranking officers. When VIPs visit, they usually come to the TOC first. Greg was doing such a bang-up job that a colonel came by and pretended to pin an officer rank on him. I insisted on capturing it with a photo. It shows his good humor.

Don’t be mistaken though. He could rip people apart. When he was in Cuba in 2004, he was in charge of a Joint Task Force full of Sailors, Airmen and Marines. I heard stories. One time, an E-6 in the Navy gave him some shit about a task and Greg ordered his superior to stand before him at 0600 the next day. Greg tore into him. The Chief Petty Officer was aghast and promised that his sailor would cause no further problems. A Marine colonel heard all of this and came in after the the ass chewing was over. “Jesus, I have never heard anyone rip into people like you. What I don’t get is that everyone still loves you.”

It’s easy. Because he was smart and competent and funny and everyone knew he cared.

Don’t worry. He’s still alive. This ends well.

I drove out to Easton, PA to see him today (9/11/18). We got lunch. I updated him about my life. We talked about other soldiers and what happened to everyone. We commiserated over the fallen and for those whose families fell apart. We also told jokes and laughed. At one point, Greg looked at me and said, “It’s great that you don’t have your cell phone out on the table. Everywhere I go, people are on those fucking things.”

“I know. Then they wonder why they are isolated and feel bad. Our culture is so fucked up that I’m going to be able to work forever. This is why I drove out here. To talk in person. Nothing beats that.”

Then we moved on to other stories. I let out my full throated cackle.

“There it is,” he said, “There’s that crazy laugh.”

28Aug/18

An Easy Fix for Addiction Hotlines

by Andrew Walsh

 

A few months ago I was invited to speak to a class of students at Rutgers in the addiction certificate training (ACT) program at the Graduate School of Social Work. I shared my experiences from graduate school and working in the field of substance abuse. While I was with the students, I was prompted to share some of the writing and undercover work I have done in the field of substance abuse treatment.

For a year and a half, I did full-time work and full-time graduate school. While my schedule was hectic, I was able to compare what I was learning in the classroom with what I was experiencing in the field. I was horrified.

Under the guidance of Professor Greenagel, I set out to start documenting and writing about the ever widening gap between best practices and what was actually occurring in the substance abuse field. One of the first subjects I tackled was addiction hotlines. My previous piece on addiction hotlines can be accessed here.

I found that the majority of the hotlines ranged from negligent at best to operating illegally. One of the main takeaways from my undercover work with the addiction hotlines was the lack of consideration that people with Medicare, Medicaid, or no insurance received. When I posed as a 27 year old with insurance seeking substance abuse treatment I could not get my phone to stop ringing. However, when I posed as a 26 year old with seeking substance abuse treatment with Medicaid, I could not get a phone call to last more than three minutes.

I was thoroughly convinced that the horrors of the substance abuse field would cause some of the students to reconsider their career paths.  A few months passed and unexpectedly one of the students from the class contacted me. She posed a simple question that stopped me in my tracks. She asked

With state treatment facilities in a state of stagnation due to lack of beds for Medicaid, Medicare, and the indignant, how can private centers work to meet this need for people with Medicaid, Medicare, or no insurance?

I recognized that I left my previous work half-complete. I did a mournful job of illustrating and summarizing the problem but I did not provide any solutions.

I set out to remedy the situation and decided that I first needed to quantify the demand for substance abuse treatment among Medicaid recipients, Medicare recipients, and those with no insurance. After quantifying the demand, I then sought out to quantify the services available; i.e. where can these people go to get help. My work on the Medicare population can be seen here and the piece on the Medicaid population can be accessed here. The main takeaway was that the demand for substance abuse services for these populations far exceeds the supply.

I spent one year working in the call center of a psychiatric hospital. Working as an addictions triage specialist, I took anywhere from 50-100 calls a day from potential clients or their family members looking for substance abuse services. I was fortunate that Medicare was accepted for treatment at that psychiatric hospital. However, I still received dozens of daily calls for patients with Medicaid or no insurance seeking services. After I did some research, I began to end those conversations by saying, “We can’t provide services to you here but if you get a pen and paper I am happy to give you the name of the facilities that can and their phone numbers.”

Inevitably, the callers would express sincere gratitude with some variation of: “Thank you so much. I have been calling around everywhere but I couldn’t figure out who could help me.”

I hold advanced degrees, have a few years of direct practice experience with substance abusers, and am familiar with the majority of substance abuse providers in the tri-state area. All of my experience and research has made it possible for me to know which facilities accept Medicaid, Medicare, and those with no insurance.

When I reflect back on my work, education and directed research, I come to two clear conclusions:

  1. The demand far exceeds the supply of services for Medicaid, Medicare, and those with no insurance
  2. Services exist but substance abusers and their families get worn down trying to find the programs that will accept them

I am a social worker, which means I am an idealist. But I am also a pragmatist. Ideally, I would like to see an expansion of offerings for the Medicare, Medicaid and uninsured populations. Pragmatically, I know this will take a long time. Additionally, it is unrealistic to hold private facilities responsible for expanding services to those populations.

That written, I believe private treatment providers can help clients access the services that do exist. The best practice would be for these private entities to call the appropriate facilities with the client and do a warm hand-off to the appropriate party. Pragmatically I realize that this causes a significant burden on the private entities and will be met with significant opposition. The practice that will encounter the least resistance from the private treatment providers but still produce a significant effect is providing the clients they cannot treat with the names of the facilities that can help them. As my previous work has shown, these lists are relatively small and should not take more than two minutes to share with these clients.

While I am troubled by the fact that there are waiting lists for Medicaid, Medicare and those with no insurance, I am horrified that people cannot even find these facilities to get on the waiting list. Private treatment provider hotlines are often the first point of contact for many substance misusers and their families. Even if they cannot provide services directly to these clients, ethically they should refer the clients to the facilities that can provide the services. With people dying because they can’t even get on the waitlist to keep the flame of hope alive, treatment providers that fail to refer clients are in essence saying a life may be worth less than two minutes.

_____________________________________________________

Andrew Walsh is a Project Manager and Director of Clinical Trials for Carrier Clinic. Carrier Clinic is one of the largest private non-profit psychiatric facilities in New Jersey. He earned a Master’s Degree in Social Work and a Master’s Degree in Human Resource Management from Rutgers. Prior to working in the behavioral health field, Andrew worked in the Gulf of Mexico oilfield as an internal business consultant focused on innovation and improving the efficiency of people, processes, and procedures. He eventually decided to return to NJ to practice innovation in the behavioral health field. In his free time, Andrew enjoys hiking, cooking, and reading.

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27Aug/18

The Five Ways You are Most Likely to Die

Thanos is not real. Therefor, you need not fret.

 

 

 

 

 

 

Every Thursday for many years, I’ve run a multi-family group in an addiction treatment center for young adults and their families. Last summer, I wrote this list on the board and asked them to guess its significance:

  • Car crash
  • Hiking
  • Shoveling snow
  • Heart Attack
  • Cancer

People were dumbfounded and mostly had no response. I told them that these were the mostly likely ways that I would die (in no particular order). We’ll come back to that group. A few days later, I offered up the same list to my friends, parents, and my ex-wife. Only two friends got it right. My ex-wife figured it out after hearing just the first three.

One family member in the group exclaimed that it was a morbid topic. Another played into my hands by asking me how I arrived at that list. I explained to the group that I often drove above the speed limit and that there is a high correlation between speed and accidents. I discussed how I am hiking higher and higher mountains and have recently started hiking in winter conditions including deep snow and on sheets of ice. My driveway is over 100 feet long and opens into a large parking area – I shovel it alone and it often can take three or four hours. While I exercise and neither drink alcohol nor smoke cigarettes, I do have a diet high in red meat and I avoid vegetables. I have a sweet tooth and also smoke cigars. There is no known history in my family of cancer, but there is one for heart attacks. After explaining my list, I stated that I could lessen the chances of dying those ways by engaging in the following behavioral changes:

  • Drive slower. Never text or eat while driving.
  • If I’m taking a dangerous hike or going in extreme conditions, always have a guide or a partner.
  • Take breaks every half hour while shoveling snow. Don’t make speed a point of pride.
  • Eat a bit healthier. Lose some weight.
  • Eat a bit healthier. Reduce sugar intake. Cut down on cigars.

I have fully committed to items 2 and 3. I am slowly addressing items 1, 4, and 5 (ironically, those are the most likely ways I’ll die). I had every group member silently write down their list of the five ways they are most likely to die. Then I had them break up into smaller groups and share their lists. They were instructed to discuss what behavior changes they could attempt in order to reduce. After a half hour, I brought everyone back into a big circle. Their most common answers: drug overdose, car crash, cancer, heart attack, respiratory disease, and suicide. These are six of the ten ways that most Americans die (a note on the four group members who mentioned suicide – none of them had active suicidal ideations but they all had a history). The talk surrounding how to reduce these outcomes was lively and suggestions included: quit smoking, see a therapist, keep going to 12-step meetings, stop texting while driving, eat more vegetables, and take medication as prescribed.

Three other answers stood out. An older father listed diabetes. It developed from drinking and he has to monitor his blood daily, take insulin shots, and get regular medical checkups. Most of the clients did not know that heavy drinking could cause diabetes. A 2016 Cato Institute Study reported that diabetes is actually a top-ten killer of Americans.

Three people listed either “getting shot” or “getting killed.” They were clients in their 20s with long drug histories. One woman expressed fear about an ex-boyfriend who was currently incarcerated. I suggested talking to her counselor and a lawyer and to consider a restraining order. The two men who said they might “get shot” did not have a particular person in mind but each had dozens of friends who had either overdosed or were killed as a result of their lifestyle. Both agreed that remaining drug free and avoiding their home town greatly increased their life expectancy.

Three others listed “terrorist attack.” I addressed this issue from the flank. I wrote down the lifetime odds of Americans that die via falling (1 in 133), motorcycles (1 in 949), poison (1 in 1,355), fire (1 in 1,454), heatwave (1 in 10,745), and animal attacks (1 in 30,167). I wrote down the number of Americans killed in America by foreign born terrorists between 1975 and 2015. The Cato Institute reports the number is 3,024 and the lifetime odds are 1 in 45,808.  I asked the group why some people would be more concerned about terrorism, shark attacks and lightning strikes over problems caused by speeding, alcohol use, prescription drug abuse, smoking, and lack of exercise. A 23 year-old male who was five months clean replied, “We don’t want to acknowledge the problems that are our fault and have to make changes. It is easier to be afraid of things beyond are control and that are on tv a lot, like terrorists and shark week.”

It was the kind of statement that group therapists strive for – I couldn’t have put it better and it was much more impactful coming from him. There are a number of lessons here, and I would like readers to jot down their own list and discuss it with their friends and/or family members. And figure out what you can change so that you can live a little bit longer.

This could kill you

You might say that work or waiting is killing you, but that is almost certainly hyperbole

 

 

 

 

 

 

31Jul/18

Epigenetics and the Treatment of Substance Misuse Disorders

Danielle Victoriano interned at Carrier Clinic this summer, where she worked on clinical trials. She learned under the direction of Andrew Walsh. During some down time, she labored on a series of research projects and articles. This piece on Epigenetics is the second one to be published.

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In recent years, the growing number of substance abusers in the United States has become a topic of national discussion. As the death toll from overdoses continues to skyrocket—with about 63,600 deaths in 2016, a number 21% higher than in 2015—substance abusers, family members, substance abuse counselors, and scientists are desperately searching for solutions that would help curb this national crisis. From all this turmoil has arisen a potential aid in the fight against substance abuse: epigenetics.

The topic of epigenetics cannot be breached without a better understanding of DNA, the material inside cells that serves as the language of life. DNA is the command center for why we look the way we look, and sometimes, why we behave the way we behave.

DNA or deoxyribose nucleic acid can be broken down to four bases: Adenine, Thymine, Cytosine and Guanine. Each of these bases are attached to a phosphate group and a sugar, and this combination of bases, sugars, and phosphate groups form the double-helix ladder that often comes to mind when we think about DNA.

Image result for dna

However, this viewpoint is wholly incomplete. It must be understood that the DNA ladder also actually wraps itself around proteins called histones.  The tightness from the wounding around these histone proteins regulate which parts of the gene are expressed and repressed. The closer the histone proteins are to each other, the tighter the DNA is wound, and thus, the harder it is for the DNA-encoding machinery to access the DNA material. The further away the histone proteins are to each other, the looser the DNA is wound, which means that it is easier for gene expression to occur.

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The distance by which histone proteins are from each other and the tightness of the DNA wounding around these proteins is determined by two chemical groups. Attachments of methyl groups on either the DNA itself or on the histone proteins are associated with repressing, or turning off the expression of a gene, while acetyl groups are associated with expression, or turning on the expression of a gene. Methylating the DNA and/or methylating the histone proteins tightens up the DNA-protein interaction, while acetylating the histone proteins opens up the gene and allows for expression.

To think about it more simply, imagine a flashlight that’s been turned on. Now, imagine a hand covering it. To open up the fingers over the flashlight means that light will pass through. To close the fingers over the flashlight means that light will not be able to pass through. This is similar to how epigenetic modifications to the human genome works. The light represents the fact that the DNA material will be there, it is whether or not the hand is open or closed that will factor in to if the gene is actually repressed or expressed. When the hand is open, there is expression, and when the hand is closed, there is repression.

Thus, epigenetics is the study of how the human genome is modified not through changes in the base pair sequence, but how the structure of DNA and protein is modified through attachments of chemical groups that alter the configuration.

The blossoming field of epigenetics has paved the way to discovery of epigenetic markers brought by substance abuse. By epigenetic markers, this means that genes have been identified to be methylated or acetylated differently from the norm.

One substance misuse disorder that is of high importance to public policy is the abuse of opiates. According to the Center for Disease Control, in 2016, around 66% of the 63,600 drug-overdose related deaths involved opioid use.

Researchers have found that in opioid addictive patients, there is more expression of a certain neuro-excitatory gene, GRA1, that would account for the addiction’s withdrawal symptoms such as restlessness, muscle twitching, and dilated pupils. This overexpression can be attributed to hyperacetylation of the neuro-excitatory gene. Hyperacetylation means that the gene is constantly being expressed, which leads to more expression than usual.

Alcohol is yet another substance misuse disorder that has been identified to have epigenetic markers. With alcohol use, researchers have found dysregulated amount of protein factors in the brain through abnormal methylation and acetylation patterns in some genes. In turn, during the active influence of alcohol, there is high concentration of the protein Arc, which is associated with decreased levels of anxiety and stress. This relationship results in alcohol-dependence to combat negative emotions that can be seen in many individuals with alcohol misuse disorders.

Knowing the existence of these epigenetic markers, and being able to identify and locate where they are in the human genome opens up a whole new realm of opportunity in terms of treatment options in substance abuse recovery. Potentially, the current rates of relapse that follow inpatient detoxification treatments could be curbed. As of 2015, it is reported that more than 85% of substance misuse patients relapse and return to substance use within a year following treatment. Since withdrawal symptoms are a trigger for relapse, imagine being able to control and limit those symptoms by targeting the epigenetic markers that caused the symptoms in the first place. Imagine being able to de-acetylate the neuro-excitatory gene, GRA1, that is constituently turned on in those with opioid abuse. This would most likely make early recovery easier, less painful, and less daunting.

Medications that are currently being examined to combat substance abuse are histone deacetylase inhibitors (HDAC inhibitors) and DNA methylation inhibitors (DNMT inhibitors).  These medications would attempt to re-regulate the imbalance that have been produced by epigenetic modifications in the body, by reversing or inhibiting the effects of methyl groups and acetyl groups.

Though research is still in its infancy, with no current research on how these medications affect humans, results have shown to be promising. One research study looked at the effects of having histone deacetylase inhibitors in rats with alcohol addiction and found that with HDAC medication, these rats are less likely to seek out or self-administer alcohol.

In terms of non-medication related treatments, there has been a promising finding that exercise can be used to reverse some of the epigenetic modifications made from chronic alcohol abuse. It has been found through rat studies that exercise has restored the brain physiology that has been altered by chronic drinking. Alcohol-addicted mice that were treated with regular exercise had improved memories and brain activities when compared to the non-treatment group.

Despite these success stories in controlled environments, there is still a lot more that needs to be done before this new technology can be used in humans. Currently, we simply do not have the technology to selectively choose genes that are specifically targeted by different addictive stimuli. However, we are hopeful that this new field will take off. With growing interest from research institutes in the national and global arenas, we can hope that the awaited future of epigenetics is not that far.

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Danielle Victoriano is a member of the Princeton University Class of 2019. She studies Ecology & Evolutionary Biology and plans on going to Medical School. She can be reached at dzv@princeton.edu

 

30Jul/18

Epigenetics

Daniel Shen interned at Carrier Clinic this summer, where he worked on clinical trials. He learned under the direction of Andrew Walsh. During some down time, he labored on a series of research projects and articles. This piece on Epigenetics is the first one to be published.

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The National Suicide Prevention Lifeline is a 24-hour suicide prevention network that takes 1.5 million calls per year nationally, or roughly 4,000 calls per day[1]. Following the tragic deaths of celebrities Kate Spade and Anthony Bourdain earlier this June, this number rose by 65% for several days, an increase of more than 2,500 calls per day[2]. Such spikes are typical following media coverage of celebrity suicides; similar statistics were reported after musician Chester Bennington’s death in 2017, and in the months following actor Robin Williams’s death in 2014, national suicide morbidity rates increased by nearly 10% according to a recent study from Columbia University[3].

Regardless of the precise psychological and sociological factors behind the so-called “celebrity-suicide effect”, clearly these high-profile incidents seem to touch a painful hidden nerve within our nation. According to the National Institute of Mental Health, one fifth of all Americans, or nearly 45 million individuals, are currently struggling with some form of mental illness[4]. When news of Ms. Spade and Mr. Bourdain’s deaths broke, conversation within the media focused particularly on an alarming CDC statistic reporting a 30% increase in the national suicide rate since 1999[5]. (For reference, the national population grew by only 16% since then[6].) Yet despite the prevalence and severity of these illnesses, nearly 60% of suffering adults do not seek treatment, and if the caller volume spikes following Ms. Spade and Mr. Bourdain’s deaths are any indicator, this statistic likely suffers from under-reporting[7]. The minority that do seek treatment are nearly always prescribed medications that often come with a litany of adverse side effects – nausea, drowsiness, weight gain, and muscle tremors, to name a few – that add further stress to an already difficult situation.

Epigenetics is a growing area of biological research which has rapidly gained the attention of medical researchers within the past two decades and is now being considered as a potential strategy for devising effective psychiatric treatments. Promising developments have already begun in other arenas; recently elucidated epigenetic mechanisms behind some cancers have already led to the creation of novel cancer drugs, and similar progress is being made for many other non-communicable diseases[8].

In basic terms, epigenetics can be defined as the study of the biological mechanisms behind gene expression – that is, how cells can switch certain segments of DNA on or off in order to perform specific functions. For instance, although your skin cells and brain cells all contain the same DNA and thereby the same genes, your skin cells do not sprout dendrites and your brain cells do not secrete oils/sweat because both cell types have switched off the gene segments encoding for inappropriate and unnecessary features. Proper gene expression is essential for an organism’s growth and survival, and many diseases are the result of switches being in the improper state: some gene is turned off when it should be on, or vice versa. For example, many cancers arise when genes encoding for crucial DNA repair/proofreading proteins become switched off, leaving cells more vulnerable to cancer-causing mutations. This leaves medical researchers with a tantalizing prospect: if the onset of a certain disease is due to improperly switching on/off certain genes, could treatment simply be a matter of reversing the switches back to normal?

Psychiatric epigenetics research is based on the hypothesis that psychiatric disorders such as major depressive disorder (MDD) and schizophrenia have epigenetic markers – that is, these diseases are the result of either overexpression or underexpression of certain genes within brain cells, resulting in altered brain activity and behavioral symptoms. Furthermore, these markers can be either hereditary or environmentally triggered, and by reversing the pathological gene switches back to normal, the disease can be mitigated. Encouraging findings from cancer research and other non-psychiatric disciplines have already shown this to be a promising hypothesis8. MDD, schizophrenia, and generalized anxiety disorder (GAD) rank among the most common mental disorders in America, and consequently have been of primary interest for epigeneticists searching for markers[9]. Due to the sheer complexity of the brain, progress has been slower in the psychiatric realm compared to non-psychiatric arenas, as evidenced by the relative dearth of literature on the topic. Nevertheless, studies from animal models and post-mortem tissue studies have already yielded encouraging results; a few of these studies are highlighted below.

Major depressive disorder

Several lines of evidence have implicated brain-derived neurotrophic factor (BDNF), a protein responsible for healthy neuron function, as a key factor in the onset of MDD, with decreased expression of BDNF in the hippocampus being associated with depressive symptoms[10]. In 2009, a team from the University of Alabama used rat models to investigate whether or not the gene encoding for BDNF experienced any epigenetic alterations in depressed individuals[11]. They did so by subjecting a group of rat pups to abusive conditions such as social deprivation and maternal maltreatment to induce depressive behavior, then comparing their brain cells with those of a control group. What they found was that in the depressed rats, the BDNF gene exhibited signs of increased DNA methylation, a chemical modification of DNA that acts as an off-switch for gene expression. Furthermore, experimental treatments with a DNA methylation inhibitor, designed to undo this chemical modification, yielded promising results. Crucially, this epigenetic marker appeared to be heritable between generations as well: when female individuals from the depressed rat group were allowed to mate, their offspring also exhibited the same methylation patterns and the same behavioral symptoms. This suggests that epigenetics may offer a sobering framework by which the long-known hereditary aspects of mental illness can be understood.

Schizophrenia

 γ-aminobutyric acid, or GABA, is a neurotransmitter responsible for reducing neuronal excitability in the brain, among other functions. It has been hypothesized that for individuals suffering from schizophrenia, the mechanisms driving GABA production are defective in certain neurons, resulting in increased neural activity and pathological behavioral symptoms[12]. In 2005, a team of Harvard researchers looked for markers at the RELN gene within GABA-producing neurons, hypothesizing that defects in RELN production are a major factor behind GABA deficiencies[13]. Comparing post-mortem brain tissue between schizophrenic and non-schizophrenic individuals, they indeed found evidence of DNA methylation – an epigenetic off-switch – at this gene within brain cells of the frontal lobe in the schizophrenic samples. Moreover, their results were consistent with a previous study examining RELN expression in patients with bipolar disorder[14]. Given the similarity of psychosis symptoms between these two illnesses, this link suggests that epigenetics may provide a window by which the mechanisms behind these diseases can be better understood, leading to more effective treatments for a multitude of conditions.

Anxiety disorders

The hypothalamic-pituitary-adrenal (HPA) axis is a complex system consisting of the hypothalamus, pituitary gland, and adrenal glands and can be thought of as the “stress-system” of the body, forming the link between brain activity and hormone production. Corticotropin-releasing hormone receptor 1 (CRHR1) is a crucial protein that contributes to activating our bodies’ stress response via this system. A recent 2016 study from the Weizmann Institute of Science in Israel used rat models to investigate whether or not the gene encoding for CRHR1 was affected in rats with anxiety disorders (induced through various means)[15]. They found that for anxious rats, the CRHR1 gene was under-methylated compared to healthy rats, suggesting that this protein was being overexpressed in anxious individuals and resulting in overactivation of the stress response. When they treated the anxious mice with an experimental drug designed to restore methylation, they found that many of their symptoms subsided, demonstrating that epigenetics can indeed be a promising avenue for designing new pharmacological therapies.

Next steps

The above studies all present a positive correlation between specific epigenetic signatures and the onset of psychiatric disorders, suggesting that epigenetics research is indeed a promising direction for future diagnosis and treatment methods for these disorders. Nevertheless, the field of psychiatric epigenetics is still very much in its infancy, as evidenced by the relative dearth of literature on the subject compared to other disease studies like cancer. Moreover, all of the drugs that have been developed thus far (including the cancer drugs), promising though they may be, have been pan-inhibitors – that is, they affect the entire genome rather than specifically targeting one gene, raising concerns about potentially dangerous side-effects that are not fully understood. Reaching the point where epigenetic treatments can act with specificity and accuracy on single genes requires a more extensive understanding of our cells’ epigenetic mechanisms in all of their complexity, which is beyond our current knowledge. Given that our cells regularly erase and re-write epigenetic markers on their own as part of normal functioning, elucidating these mechanisms is certainly possible, and the moment we gain the ability to selectively modify epigenetic markers on single genes will herald a paradigm shift in medicine and human history.

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Daniel S. Shen is a member of the Princeton University Class of 2019 and studies within the Department of Music. He is planning on going to Medical School. He can be reached at dsshen@princeton.edu

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[15] Evan Elliott, Sharon Manashirov, Raaya Zwang, Shosh Gil, Michael Tsoory, Yair Shemesh, Alon Chen. Dnmt3a in the Medial Prefrontal Cortex Regulates Anxiety-Like Behavior in Adult Mice. Journal of Neuroscience 20 January 2016, 36 (3) 730-740.