Category Archives: Uncategorized

15May/14

Medication for Alcoholics and What Most Doctors Don’t Know

There was a nice article in the health section of the New York Times on 5/13/2014. I’ve linked to it here.

The gist of it is that there are medications, naltrexone and acamprosate, that can help reduce cravings for alcohol and increase abstinence rates.

Very few doctors are aware of these types of medications and even fewer are trained on them. If you or someone you love has an alcohol problem, they should see a professional, licensed substance abuse counselor (in NJ, the license is a LCADC: to find a provider in your state, click here). Additionally, they should get a physical exam and see an ASAM doctor. They understand addiction and will prescribe the best medication, if applicable (and more importantly, are less likely to mis-diagnose and falsely medicate some other perceived psychological issue).

Medications should not be taken in a vacuum. They should accompany some type of therapy (individual or group), regularly monitoring, and patients should be encouraged to check out AA meetings and/or Smart Recovery.

There are a number of people in AA who disapprove of medication assistance for alcoholics (or addicts). Those people are wrong and are acting, at best, irresponsibly and at worst, criminally, by telling someone not to take medication if they want to be sober. The only opinion AA has on this is that outside professional help is often needed and that members should not act as doctors.

13May/14

Vermont’s Drug Policies Surpass New Jersey’s

Rebecca O’Brien of the Bergen Record was a finalist for a 2014 Pulitzer Prize in journalism for her reporting on the heroin crisis in NJ. Her most recent article details how New Jersey’s plans pale in comparison to Vermont’s efforts.

I’m quoted in the article several times, and the line that most brings me down is this: “I think we will be a middle-of-the pack state” in regards to our drug policies.

This is an excellent report that you may have missed from the end of 2013. It details what each state is doing, makes a number of findings and issues several recommendations.

(everything below is taken verbatim from the website)

Some key findings from the report include:

  • Appalachia and Southwest Have the Highest Overdose Death Rates: West Virginia had the highest number of drug overdose deaths, at 28.9 per every 100,000 people – a 605 percent increase from 1999, when the rate was only 4.1 per every 100,000. North Dakota had the lowest rate at 3.4 per every 100,000 people. Rates are lowest in the Midwestern states.
  • Rescue Drug Laws: Just over one-third of states (17 and Washington, D.C.) have a law in place to expand access to, and use of naloxone – a prescription drug that can be effective in counteracting an overdose – by lay administrators.
  • Good Samaritan Laws: Just over one-third of states (17 and Washington, D.C.) have laws in place to provide a degree of immunity from criminal charges or mitigation of sentencing for individuals seeking to help themselves or others experiencing an overdose.
  • Medical Provider Education Laws: Fewer than half of states (22) have laws that require or recommend education for doctor and other healthcare providers who prescribe prescription pain medication.
  • Support for Substance Abuse Treatment: Nearly half of states (24 and Washington, D.C.) are participating in Medicaid Expansion – which helps expand coverage of substance abuse services and treatment.
  • ID Requirement: 32 states have a law requiring or permitting a pharmacist to require an ID prior to dispensing a controlled substance.
  • Prescription Drug Monitoring Programs: While nearly every state (49) has a Prescription Drug Monitoring Program (PDMP) to help identify “doctor shoppers,” problem prescribers and individuals in need of treatment, these programs vary dramatically in funding, use and capabilities. For instance, only 16 states require medical providers to use PMDPs.

Key recommendations from the report include:

  • Educate the public to understand the risks of prescription drug use to avoid misuse in the first place;
  • Ensure responsible prescribing practices, including increasing education of healthcare providers and prescribers to better understand how medications can be misused and to identify patients in need of treatment;
  • Increase understanding about safe storage of medication and proper disposal of unused medications, such as through “take back” programs;
  • Make sure patients do receive the pain and other medications they need, and that patients have access to safe and effective drugs;
  • Improve, modernize and fully-fund Prescription Drug Monitoring Programs, so they are real-time, interstate and incorporated into Electronic Health Records, to quickly identify patients in need of treatment and connect them with appropriate care and identify doctor shoppers and problem prescribers;
  • Make rescue medications more widely available by increasing access for at-risk individuals to naloxone and provide immunity for individuals and others seeking help; and
  • Expand access to and availability of effective treatment options as a key component of any strategy to combat prescription drug abuse.
11May/14

College For Prisoners

The concept of providing college courses in prison or helping ex-offenders enroll, attend and graduate from college is a political loser.

Back in February, New York Governor Andrew Cuomo proposed to re-institute college courses for those in state prison. He stated that more than 50% of ex-offenders return to the criminal justice system within 3 years of leaving prison. At a cost of $60,000 a year, that is a terrible return on public money. He said that GED and college programs would cost about $5,000 per inmate per year, and that those that take part in educational programs while incarcerated have a much lower rate of recidivism. Some people applauded the move. Polling showed that the proposal was supported by voters statewide by a 53-43 margin. The Governor engaged in a media tour and gave a strong interview on NPR.

Less than 2 months later, the New York Times reported that it was dead on arrival and that Governor Cuomo had dropped the ball. One legislator said “Hell no to Attica University,” while other representatives proposed a kids before cons act. Even though it made long-term economic sense and had a majority of public support, Governor Cuomo could not get it through the state legislature.

On Thursday, Governor Chris Christie stated that these programs had already been successful in NJ and that he supported their expansion. Unlike Governor Cuomo, Governor Christie did not propose spending any public money on the programs (this is becoming his new move: he supports a program/idea without putting any money behind it – like he recently did with prescription drug monitoring programs). NJ-Step is a privately funded program that provides education to prisoners and helps them transition to two and four year NJ colleges.

The press conference got a lot of coverage and received some of the same backlash as the New York program did. Over 60% of people voted that they were against it in an unscientific poll on NJ.com today. A cursory glance at the comments reveals the antipathy that many feel towards this issue (if one were to gauge the quality, morality, and empathy of humanity by reading the comments on news stories, one would almost certainly be discouraged).

As I wrote in the beginning of this post, the issue is a political loser. Democratic and Republican politicians are not only afraid of losing general elections but of getting picked off in primaries. These programs anger a significant portion of the electorate and are therefor extremely difficult for a politician to publicly support. It will require a skilled politician to rally bi-partisan support. There will need to be a long education campaign, and we will need ex-offenders to be the face of it.

I’ve had the pleasure of working with two of those faces over the last 4 years. Ben Chin will graduate from Rutgers later this month with a degree in Linguistics and a minor in Public Health. He has earned a 3.9 GPA and was selected for Rutgers Skull and Bones. He won the Truman Scholarship in 2013 and the Luce Scholarship in 2014. When you meet Ben, you will be welcomed by his smile, charmed by his personality, impressed with his ability and surprised by his humility. Ben was incarcerated from 2008 to 2010 in the Mountainview Correctional Facility. Ben got sober right before he went to prison in December of 2007. I met him in the fall of 2009 when I took a couple of Rutgers students into Mountainview in order to talk to people about addiction, recovery and education. Ben called me the day he got of prison and after a couple of interviews, we accepted him into the Rutgers Recovery House. In addition to being an exceptional student, Ben has engaged in service work. He has spoken to high school students around NJ, college students around the country and has been a public face of what recovery and education can do for ex-offenders.

NJ-STEP

 

Regina Diamond is another outstanding example. She graduated from Rutgers in 2013 with a Bachelors in Arts & Social Work. She completed her degree with a 3.9 GPA and a number of honors. Later this month, she will graduate from Fordham with her Masters in Social Work. She served several years in prison in her late 20’s because of crimes she committed in order to feed her drug habit. She finally got sober after her sentencing and went to prison in recovery. It would be two years before she could attend an AA meeting while incarcerated (there weren’t any offered). Her hopes were dashed when she was told that she missed the age cut-off to take college classes by a couple of months (that policy has since changed). She did not take any courses while in prison, but immediately enrolled in school upon her release. She has been sober for 10 years now and plans on giving back to society in a number of ways. She does not make any excuses for her negative behavior while under the influence of drugs, and she expresses deep gratitude to all the individuals and institutions that have helped her over the last several years.

Regina_pic

Regina and Ben were the co-keynote speakers at the 2013 GCADA Summit in New Brunswick. They spoke openly about their journeys and earned a standing ovation. Their stories begin with a combination of bad decisions and bad luck and ultimately reach a pit of despair. They found (were led to) recovery and eventually made their way to Rutgers. They have achieved redemption and now seek to improve the lives of others by sharing their stories and serving as role models. Despite the fact that college for prisoners is a political loser and morally off-putting for some people (I do understand that position), it is an economic winner. It’s time to stop wasting money and throwing away lives. I believe in Ben Chin and Regina Diamond. I hope you will too.

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Addendum (6/1/2014): Great article on a NY college in prison program that was featured in the Sunday New York Times.

07May/14

The Bad Science of “The Sober Truth”

The Sober Truth is a book that was published in March of 2014. It is written by Dr. Lance Dodes (a psychiatrist) and his son. It is a polemical attack on Alcoholics Anonymous that is not based on fact, but a series of anecdotal stories.

Back in March, The Atlantic published an article/review of the book that asserted the Dodes’ book as truth rather than opinion. That article made the rounds on social media and was discussed and (slightly) debated within the treatment community. Not surprisingly, it has been used by people who are in treatment programs as a reason why they should not go to AA or NA (it is a good example of confirmation bias).

Yesterday, a more informed review appeared in The New York Times. Dr. Richard Friedman, the author, asserts that The Sober Truth is both biased and bad science:

The Sober Truth asserts that addiction can be treated with psychodynamic psychotherapy, which focuses on unconscious feelings and thoughts. But while there is some scientific data for cognitive behavior therapy in addiction, there is little to no evidence that psychodynamic therapy is effective for any type of drug abuse. The authors’ blanket claim of efficacy for their own cherished treatment, in the absence of credible data, is the very flaw for which they harshly criticize A.A.

But the book’s most glaring deficiency is the authors’ dismissive attitude and misunderstanding about the role of neuroscience in addiction.

Those looking for a scientifically accurate and nuanced understanding of addiction and its treatment will not find it in this book.”

There are some people who get clean and sober just by going to AA meetings. Other people need more help. That includes individual counseling (cognitive behavioral therapy and/or motivational interviewing have the best results), group counseling, family therapy, transitional and/or recovery housing, recovery supports, higher education, vocational training and in some cases, medication. These different types of treatment work very well with 12-step meetings.

We know more than we did 10 years ago, and we knew more then than we knew 30 years ago. The treatment field continues to improve. As we move forward, we will continue to get a better understanding of how the brain works. We need to continue to get more public and private funding for prevention, treatment and especially recovery support services. This can be done by encouraging quality research and reducing the stigma of addiction and recovery. Unfortunately, Dr. Dodes’ work does neither. In fact, he has violated the Hippocratic Oath – he has done harm.

03May/14

Prescription for Disaster

This is an outstanding article in the May 5, 2014 issue of The New Yorker. It’s about a doctor and his medical practice that prescribed thousands of people with opiate painkillers in Wichita, Kansas from the late 1990’s until around 2010.

While he seemed to truly care about his patients, he was clearly naive and under-trained. Most significantly, he allowed his head-nurse/office-manger/wife to make a number of questionable business and medical decisions.

Many of his patients died and he was sentenced to 30 years in federal prison.

A few policy points are clearly re-enforced by this article:

(1) each state should have a mandated prescription drug monitoring program

(2) doctors, nurses and medical office managers should be required to get at least 6 continuing education units (C.E.U.’s) every bi-annual period

(3) pharmaceutical sales reps needs to be reined in…this can partly be done by assessing stiff penalties for making off-label suggestions to doctors about how to prescribe drugs (a salient moment in the article is when a Big Pharma sales rep tells a doctor that there is no difference from “pain caused by cancer” and non-cancer pain; “pain is pain,” so you can prescribe pain killers that have only been researched and approved for cancer patients to non-cancer patients)

01May/14

Why Chris Christie is (mostly) right about marijuana

Chris Christie recently vowed that he will not decriminalize, legalize or expand medical marijuana under his watch.

Here is why legalizing marijuana is a bad idea:

(1) the tax revenues won’t nearly be as high as proponents claim they’ll be

(2) if the tax rate is too high, it will encourage the black market sale of marijuana

(3) if the tax rate is too low, it will encourage  people from neighboring states to come to NJ, buy pot and then go sell it in their state (Colorado is trying to find the sweet spot between points (2) and (3) on my list)

(4) legalized marijuana means more people will do it. this will lead to more people that are addicted to it. I don’t think anyone can sensibly deny that it is an addicting drug

(5) last year, almost 3 million Americans were arrested for underage drinking. if we legalized marijuana, we will see an increase in the number of people arrested for underage marijuana use. this will also require more police. once you hire police, they stay hired (you don’t temporarily hire them).

(6) the underage people that are more likely to get off from their marijuana charges are (drum roll please)….white males from upper middle class (or better) families. this would just reenforce the social inequality aspect of marijuana arrests that proponents are trying to alleviate (and that can be solved much more cleanly by decriminalizing marijuana)

As a clinician, I stand to make more money if marijuana is legalized. I’ll see more people in treatment and have to write more reports for court cases. Despite the fact that I would make significantly more money, I am against marijuana legalization. Many people that are pro-legalization stand to make a lot of money off of it. Be wary of them.

All that said, marijuana has been legalized in Colorado and Washington. There is no need to rush to change the policies in our (or any other) state. Let’s see what happens over the next 3 years in Colorado before we make any public policy changes. We are going to get a lot of data from Colorado. I expect that the tax revenues will not be as high as expected, that there will be an increase in motor vehicle accidents, that more people will be admitted to treatment for marijuana and that more people will be arrested for marijuana. I am willing to admit I’m wrong in the face of good data and will publicly recant my positions. I strongly doubt that will happen though.

24Apr/14

What Is Powdered Alcohol?

On April 21st, the federal government reversed it’s 13 day old decision to give Palcohol “label approval.”  CBS was quick to release a story about the potential health risks from powdered alcohol. To summarize, CBS stated that (1) it was marketed (with a wink) to minors; (2) people would likely try to snort it; (3) people would likely ingest too much of it; (4) people would bring it to places where alcohol was banned (college sporting events, school dances, etc…) and (5) that it could lead to more accidents, including drunk driving.

TIME released an article on the same day that didn’t add much to the story. What is significant is that multiple media outlets reported this story and did a good job explaining the public health risks.

The Palcohol website doesn’t provide much quality information, but does describe the owner’s background in detail and offers their stream-of-consciousness marketing ideas.

By far, the best article I came across was this one by CNN. It discusses how General Foods tried to push powdered alcohol in the 1970’s and how it was blocked by the states.

The good news is that we are unlikely to see this hit the market any time soon. If it were to somehow get full federal approval, I expect that we would see a couple of disasters on college campuses that would lead to a series of state level bans (think Four Loko and the 2010 bans – incidentally, the company that makes Four Loko just announced that it will stop making Four Loko altogether).

22Apr/14

Why Are Prescription Drugs So Expensive?

This is the key point from James Surowiecki‘s recent article in The New Yorker:

“And, across the board, drug prices rise much faster than inflation. The reason for this is that prices for brand-name, patented drugs aren’t really set in a free market. The people taking the drugs aren’t paying most of the cost, which makes them less price-sensitive, and the bargaining power of those who do foot the bill is limited. Insurers have to cover drugs that work well; the economists Darius Lakdawalla and Wesley Yin recently found that even big insurers had “virtually zero” ability to drive a hard bargain when it comes to drugs with no real equivalents. And the biggest buyer in the drug market—the federal government—is prohibited from bargaining for lower prices for Medicare, and from refusing to pay for drugs on the basis of cost. In short, if you invent a drug that doctors think is necessary, you have enormous leeway to charge what you will.”

One of the major problems in the substance abuse treatment field is that many insurance companies won’t pay for opiate treatment drugs like Suboxone or Vivitrol. Even with insurance, these drugs often cost close to a thousand dollars a month. More grist for the mill that drug treatment has become a modern civil rights issue.

16Apr/14

Problems at College Counseling Centers Get Worse

Years ago, very few students utilized the counseling centers on college campuses. In 1980, most people that saw a therapist on campus  did so to discuss relationship problems or academic stress (both great reasons to see a therapist).

College counseling centers began to come under scrutiny after the Virginia Tech Massacre on April 16, 2007. After a couple of years, it became apparent that the Virginia Tech Counseling Center failed on a number of levels:

(1) The shooter first made contact with the center in 2005. Despite the fact that he said his problems persisted, the counseling center did not follow up properly nor get him in for further evaluation and treatment.

(2) The counseling center director took the files home and did not find them until 2009. He was fired soon after the discovery.

(3) (this one isn’t the counseling center’s fault) The school did not have a way of alerting students about an emergency. Afterwards, they made it so people get texts and emails when disaster/tragedy strikes. Numerous other schools have followed suit as well.

Virginia Tech was not the first shooting by a student with mental health problems. There was a 1991 shooting at the University of Iowa. In 2008 at Northern Illinois University, 5 students were killed and 20 more were injured by an alumnus who had mental health problems and stopped taking his medication (I don’t see what could have been done here to prevent this one though). In 2011, Jared Lee Loughner shot Congresswoman Gabby Giffords and killed 6 others in Arizona. He had been suspended from Pima Community College because of his bizarre behavior caused by mental health issues and substance abuse. Here is a list of high school and college shootings from around America. Many of them involved students with untreated (or poorly treated) mental health issues.

Those disasters are not the fault of college counseling centers, but they have brought increased scrutiny to those centers. In some of those incidents, something more could have and should have been done. Unfortunately, schools are now getting very nervous and are sometimes kicking kids out of school instead of dealing with them in a proper way. This is a very relevant article from Newsweek regarding this that was published in February, 2014.

Despite the ever-increasing number of students on-campus and those seeking mental health & addiction treatment, Universities are not adequately hiring new staff members. That recent article for Inside Higher Ed states that the top two reasons why students come in for treatment in 2013 are for anxiety and depression (relationships have dropped to 3rd). In an alarmingly growing trend, 18% of students who access services at college counseling centers claim that they have some thoughts of suicide.

For a little over a year, I’ve been talking about the problems with college counseling centers when I conduct trainings at colleges. Here they are:

(1) At the largest schools, the number of students that attempt to access services increase by 5 to 9% each year (over the last 5 years). Schools are not hiring staff at the rate to deal with it. Most administrators are asking therapists to “do more with less.”

(2) Most clinicians are woefully unprepared to deal with issues involving suicide, alcohol abuse, drug abuse or claims of ADHD. Problems with prescription drug abuse are skyrocketing and most colleges are not handling it well.

(3) Psychiatrists’ schedules are absolutely loaded at schools, and only a select few schools employ addiction trained psychiatrists.So…it’s hard to get treatment, and when one does, it may not be very good.

(4) Waiting lists for counseling at some schools take 4 to 6 weeks. They will deny this to the media. Ask a student at a school of 30,000+ to call the school’s counseling center and see how long it takes to get a triage appointment and then an in-person appointment.

(5) Males access the counseling centers at a much lower rate than females.

(6) Minorities access the counseling centers at a much lower rate than whites.

(7) Veterans are extremely reluctant to go to the college counseling center.

(8) College counseling centers have an over-reliance on individual therapy. Groups, outreach work and getting embedded in the communities are still the exception, rather than the norm. Those three models should become the norm, especially if there are not going to be enough new staffing hires.

(9) Much of college life encourages/supports excessive drinking. Greek life and football games are deemed untouchable by some alumni. Senior administrators are afraid to take on those institutions and the culture that surround them. College counseling centers continually deal with the fall-out. Directors of College Counseling centers seem to have little influence on alcohol, illegal drug and prescription drug policy on campus.

(10) Most college counseling centers or university policies change only after a high-profile death happens. Like this one at Rutgers, or this one in Maryland that happened today, or this one at Lafayette from last year (It’s an easy exercise…see how many examples you can find in a half hour. Email me and I’ll make a new post with all the examples I get). Some of these could have been avoided if there were better policies in place beforehand.

These policy changes, the expansion of programs and the hiring of staff require political willpower and money. Those are two resources in supposedly short supply on most campuses. If you see change happen, it probably took place after item (10) of my list happened.

 

15Apr/14

Study says that “long-term Ritalin use causes brain damage”

A recent article on thefix.com states that ritalin causes long term brain damage.

Ritalin was over-prescribed for the over-diagnosed ADHD starting in the 1980’s. By the late 90’s, Adderall had replaced it as both the prescribed and abused drug of choice for people that claimed they had ADHD. I have publicly stated that we don’t know the long-term effects of Adderall and that the last 20 years of teenagers are Big Pharma’s guinea pigs.  Now it is coming out that Ritalin causes long-term damage. I want to go on the record that it will eventually come out that Adderall causes severe long term brain damage and exacerbates behavioral problems in many of the people that took it for a long time.

Last year, I wrote a policy brief on Adderall that I urge all parents, teachers, counselors and anyone taking (or thinking of taking) Adderall to read. In December of 2013, the New York Times published a long article about the selling of ADHD and Adderall and how Big Pharma is now pushing adult ADHD.

To paraphrase their marketing plan:

“Signs for adult ADHD are said to be: you smoke, you procrastinate, you are restless, you have relationship problems, or you lose things. If you have one or more of these symptoms, you might have adult ADHD and you should get on medication.”