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.”

14Apr/14

The Problem We All Live With

(with thanks to Norman Rockwell for the title)

Politicians from both sides of the aisle are beginning to recognize that spending $55,000 a year to incarcerate individuals in NJ has given us a very poor return on that money.

A little over 50% of individuals that are released from prison or jail* return to the criminal justice system within the next 3 years. We are neither rehabilitating people nor deterring crime.

Since the end of WWII, Democrats have been afraid of appearing that they are soft on crime, so they have supported harsh drug laws, mandatory minimums and the building of large public (and private) prisons. Some Democrats are aghast at the lack of ROI and the data that shows that drug problems are only getting worse. They have finally stood up to be heard.

But change is actually being pushed by Republicans, who are just now realizing that a large part of our state and federal budgets are paying to incarcerate Americans in astronomical numbers – the US has 25% of the world’s prison population. They are beginning to talk about how we should reduce our prison population, look at alternative options and spend this money on other projects.

Sound drug policy that pays for adequate drug treatment (which is FAR cheaper than incarceration) is a good start. This recent op-ed covers an upcoming bi-partisan summit here in NJ.

I was not interested in criminal justice policy until I began working in the drug and alcohol field (and then again when I worked at the largest inner city high school in America). Education, drug policy and the criminal justice system are intertwined, and any discussion of one of them should touch upon the others. We continue to lock up our poor and minorities at a much higher rate than wealthy and/or white people.

*prison is for a year or more and is run by the state or fed; jail is run by the county or municipality and people generally stay there 364 days or less

Addendum: CNN report of the aforementioned criminal justice summit in NJ

08Apr/14

New York State Takes On Insurance Companies

Here is a heartwarming (for me) story about how the New York Attorney General is going after insurance companies that don’t pay for addiction treatment.

One of the biggest problems in drug treatment has been that insurance companies are either (a) denying coverage completely, (b) paying for a lower level of care than is recommended by professionals or (c) paying for a shorter period of treatment time than is professionally recommended. Despite the passage of the Affordable Care Act and parity laws that state that insurance companies must pay for mental health and addiction treatment when required, many (most) insurance companies are still not paying.

It is very easy to find stories about how insurance companies are denying coverage. Here is an example. Here is another. And it is not new…this story is from 2002. It’s gotten so bad that HBO has a page on their site that tells you how to hold your insurance company accountable.

New York State has been far ahead of NJ on a lot of the drug policy laws. This is just the latest example.

07Apr/14

Consumers’ Guide For Treatment Programs

Tom McLellan is the head of the Treatment Research Institute (TRI) in Philadelphia. He made headlines on NBC News this week as the expert who lost his son that has a plan. TRI has released a consumers’ guide for treatment programs – think consumer reports reviews rehabs.

McLellan worked in the White House for 2 years on drug policy, even though he thinks government work “makes you stupid.” Despite being a national expert with a PhD, he was not able to stop or save his own son from dying from addiction six years ago.

He testified before the NJ Heroin Task Force in 2012 and he was an incredible witness with brief, insightful points.