Dreamland is the “true tale of America’s opiate epidemic. It was written by Sam Quinones, a journalist who lives in Southern California, and published in 2015 by Bloomsbury. Mr. Quinones’s book examines the whole swath of the heroin problem, and he goes into minute detail to explain the roles played by the pharmaceutical industry, doctors, politicians, researches, drug traffickers, law enforcement, addicts and their families.

I was skeptical when I first heard about the book, because only a few people that I’ve spoken with have been able to see how a multitude of institutions are involved and effected. I have been exceedingly impressed by Dreamland. I will be interviewing Mr. Quinones on December 14th and that interview will be published (on another site) later next week. Both Mr. Quinones and Bloomsbury have granted me permission to publish a chapter from his book on this site. It is called “The Poppy” and it provides an excellent, four-page account on the history of opium and the rise of heroin use in America. Readers might shudder when they see the parallels between heroin at the start of the 20th century and Oxycotin at the dawn of the 21st century.

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“The Poppy”

The story of the opium poppy is almost as old as man.Opium was likely our first drug as agricultural civilizations formed near rivers. Mesopotamians grew the poppy at the Tigris and Euphrates. The Assyrians invented the method, still widely used today, of slicing and draining the poppy’s pod of the goo containing opium. “The Sumerians, the world’s first civilization and agriculturists, used the ideograms hul and gil for the poppy, translating it as the ‘joy plant,’” wrote Martin Booth, in his classic Opium: A History.

The ancient Egyptians first produced opium as a drug. Thebaine, an opium derivative, is named for Thebes, the Egyptian city that was the first great center of opium-poppy production. Indians also grew the poppy and used opium. So did the Greeks. Homer and Virgil mention opium, and potions derived from it. The expanding Arab empire and later the Venetians, both inveterate traders, helped spread the drug.
Early civilizations saw opium as an antidote to the burdens of life— to sorrow and to pain—and as an effective sleep inducer. They also knew it as lethally poisonous and intensely habit-forming. But its bene- fits made the risks easy to overlook.

In the early 1800s, a German pharmacist’s apprentice named Friedrich Sertürner isolated the sleep-inducing element in opium and named it morphine for Morpheus, the Greek god of sleep and dreams. Morphine was more potent than simple opium and killed more pain.

War spread the morphine molecule through the nineteenth century. More than 330 wars broke out, forcing countries to learn to produce morphine. The U.S. Civil War prompted the planting of opium poppies in Virginia, Georgia, and South Carolina for the first time, and bequeathed the country thousands of morphine-addicted soldiers. Two nineteenth-century wars were over the morphine molecule itself, and
whether China could prevent the sale on her own soil of India-grown opium. The drug provided huge revenues essential to the British Empire and was one of their few products for which the self-sufficient Chinese showed an appetite. That it lost two of these Opium Wars to the British explains China’s infamous and widespread opium problem in 1900 where only moderate numbers of addicts existed in 1840.

In 1853, meanwhile, an Edinburgh doctor named Alexander Wood invented the hypodermic needle, a delivery system superior to both eating the pills and the then-popular anal suppositories. Needles allowed more accurate dosing. Wood and other doctors also believed needles would literally remove the patient’s appetite for the drug, which no longer had to be eaten. This proved incorrect. Wood’s wife became the first recorded overdose death from an injected opiate.

In the United States, more opium came with (newly addicted) Chinese immigrants, who smoked it in back-alley dens within Chinatowns in San Francisco and elsewhere. Opium dens were outlawed, and after Chinese immigration was made illegal, the practice of smoking opium eventually declined, too. Morphine replaced it.
Patent medicines with morphine and opium, meanwhile, were sold as miracle cures. These elixirs were branded with names evoking quaint home remedies. Opium was the active ingredient in, for example, Mrs. Winslow’s Soothing Syrup, which was used to pacify children. These remedies were marketed aggressively in newspapers and popular media. Patent medicines sales exploded, rising from $3.5 million in 1859 to almost $75 million by the twentieth century.

In London in 1874, Dr. Alder Wright was attempting to find a nonaddictive form of morphine when he synthesized a drug that he called diacetylmorphine—a terrific painkiller. In 1898, a Bayer Laboratory chemist in Germany, Heinrich Dreser, reproduced Wright’s diacetylmorphine and called it heroin—for heroisch, German for “heroic,” the word that Bayer workers used to describe how it made them feel when Dreser tested it on them.

Heroin was first believed to be nonaddictive. Heroin pills were marketed as a remedy for coughs and respiratory ailments. With tuber- culosis a public health threat, this was no small point. As junkies ever since have discovered, heroin is an effective constipator and was thus marketed as an antidiarrheal. Women used it, on doctor’s orders, for menstrual cramps and respiratory problems. Doctors didn’t have much else to prescribe for pain or disease. Thus addiction exploded—to a drug that people believed was safe because doctors said so.

This aroused U.S. public opinion, which forced the passage of the Harrison Narcotics Tax Act of 1914. The law taxed and regulated opiates and coca-leaf products, while allowing doctors to use them in the practice of medicine. But it was transformed into America’s first prohibition statute when police started arresting doctors for prescrib- ing opiates to addicts. Addiction was not yet considered a disease, so an addict technically wasn’t a medical patient.

Physicians soon stopped prescribing the drugs. People with real pain were left to endure. Addicts, meanwhile, turned to crime. “[Because the addict] is denied the medical care he urgently needs,” one medical journal reported, “he is driven to the underworld where he can get his drug . . . The most depraved criminals are often the dispensers of these habit-forming drugs.”

A government campaign demonizing “dope fiends” followed, aided by a compliant media. The addict was a deviant, a crime-prone, weak- willed moral failure. This idea stuck and informed the view of junkies for decades. The mythic figure of the heroin pusher also emerged. He supposedly lurked around schoolyards and candy stores, giving youths habit-forming dope, hoping for future customers.

With slight medical benefits compared to its high addiction risk, heroin ought to have passed into history. Instead, heroin replaced morphine on the streets. It thrived because it was tailor-made for dope traffickers. Heroin was easy to make, and cheaper than morphine. It was also more concentrated, and thus easier to hide and more profitable to dilute. The highs, and the lows, too, were quicker and more intense than those of other opiates. An addict craved heroin several times a day, and physically had to have it to function; so he was a terrific customer.

Traffickers and mafias made heroin’s career. New York established itself as the country’s heroin center in part because the drug’s early manufacturers were located there. Once heroin was made illegal, it came clandestinely through the city’s port from Europe and Asia. New York’s immigrants sold it on the street: Chinese and European Jews, among them, and much later, Puerto Ricans, Colombians, and Dominicans. The logic of heroin distribution allowed New York to remain the nation’s principal heroin hub through most of the twentieth century. While the drug came mostly from Asia, the Middle East, or Colombia, the drug was taken in at New York’s port, distributed by endlessly replenished immigrant or black gangs, and from there sent up and down the East Coast and into the Midwest.

Marijuana, like wine, has been hybridized into endless varietals. But heroin is a commodity, like sugar, and usually varies only in how much it’s been cut—that is, diluted—or how well it’s been processed and refined. Thus, to differentiate their product, dealers learned to market aggressively, and New York City is where they learned to do it first.

Italians apparently led the way. In the 1930s, “an aggressive new generation of Italian gangsters began infiltrating the drug traffic, replac- ing other groups, notably the Jews,” wrote historian David Courtwright in Dark Paradise, his history of opiate addiction in America. “Not only did the price increase, but the level of adulteration as well.”

New York’s Italians pioneered heroin pushing, giving free samples to new customers. Their weak dope made injecting it popular. Injecting heroin sent what little heroin was in the dose directly to the brain, maximizing euphoria. Injecting begot nasty public health problems— among them, later, ferocious rates of hepatitis C and HIV. (Mexican black tar added to them. Because tar is a semiprocessed, less-filtered form of heroin, the impurities that remain in the drug clogged addicts’ veins when injected. Unable to find veins, addicts shoot it into muscles. “Muscling” black tar heroin, in turn, leads to infections, rotting skin, botulism, even gangrene.)

In the 1970s, East Coast heroin dealers, mostly blacks by then, began printing brands on glassine bags broadcasting the supposed potency of the drug inside, or the headlines of the day: brands like Hell Date, Toxic Waste, Knockout, NFL, Obamacare, Government Shutdown.

Over the decade the drug that square America despised became the choice drug of despised America: urban outcasts, wandering con men, homosexuals, pickpockets, artists, and jazz musicians populated the early heroin world. Underground classics such as William Burroughs’s Junky described its nonconformist denizens, and mesmerized later generations intent on rebellion.

But heroin was never about the romantic subversion of societal norms. It was instead about the squarest of American things: business— dull, cold commerce. Heroin lent itself to structured underworld businesses. Addicts had no free will to choose one day not to buy the product. They were slaves to a take-no-prisoners molecule. Dealers could thus organize heroin distribution almost according to principles taught in business schools, providing they didn’t use the product. And providing they marketed.

Stories about selling opiates quickly became tales of business models and the search for new markets.

Yesterday, an article I wrote about Naloxone expansion on college campuses was published by HECAOD at Ohio State University. Naloxone is the name of the drug that is sold as Narcan by Amphastar Pharmaceuticals. Over the last three years, many states have pushed for its widespread use among emergency medical technicians and police officers. Thousands of lives have been saved by giving Narcan to people that are in the middle of an opiate overdose. Many officials, families and policy wonks have been advocating on behalf of Narcan for several years.

Last fall, Amphastar doubled the price of Narcan. It appeared to be a blatant money grab just at the moment that it was being used more. I appeared on NJTV in November of 2014, along with a police officer, to talk about the consequences from the price increase. The officer complained about how the price increase would put a strain on the town’s budget and how it might limit its use. Other advocates throughout the country concurred. While I agreed with that sentiment, I stated that “another company may enter the market and that will lower the price.”

I’m pleased to report that the FDA approved an easier to use version of Naloxone yesterday. Adapt Pharma has released an easier to use nasal spray that is also far cheaper than Amphastar’s.  From ABC News:

The Irish company said it will price Narcan at $37.50 per dose for all government, community and educational organizations, including law enforcement, fire departments and schools. That compares to prices ranging from $75 to $100 for existing injectable versions of the drug, though many buyers negotiate discounts.

Two weeks ago, I announced that I would be publishing the work of other individuals on my site. The first article was by Regina Diamond and detailed her addiction, incarceration, recovery and redemption.

This is the second article by a guest. Glenn Duncan is the Executive Director of Hunterdon Drug Awareness (HDAP), an outpatient treatment program located in Flemington, NJ. I worked there from 2005 through the end of 2010. I learned a lot from Glenn. He is a self-less leader, does an excellent job of delegating, is a funny and intelligent presenter, and he runs the best staff meetings I have ever attended (informative, humorous and most importantly, mercifully brief). Glenn will be co-presenting a course at the Rutgers Center of Alcohol Studies with me on January 21, 2016 on “The History of Reimbursement.”

At the beginning of the month, I appeared on the Brian Lehrer show on NPR to discuss Gov. Christie’s speech on addiction in New Hampshire that went viral. I spoke how the Governor has given this speech before and that while it sounds wonderful, he often doesn’t sign off on the policies that the NJ legislature puts in front of him that would better treat addiction (and mental health). Nor does the Governor provide adequate funding to the programs that he claims to support (he is not alone in this, many other politicians are guilty of this empty rhetoric as well). Mr. Duncan reached out to me with his experiences (and opinions) about how NJ does not adequately reimburse treatment providers that help poor and middle class people with addictions, and I asked him to write an expanded article about it. He exceeded my expectations. It is packed with details. It is best suited for politicians, advocates, policy makers, journalists, executive and clinical directors, and wonky nerds.

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While politicians are quick to say that addictions treatment is a top priority and while they are expanding some treatment dollars (e.g., the drug court initiative) they are shrinking others. How are they shrinking others? They are in the process of doing away with slot based treatment contracts and replacing them with fee for service (FFS) rates. These rates do not match the cost expenditure to do business in NJ for those people who have an inability to pay. This is due to the low fee for service rates which they pay out. For example, in the current FFS payment structure, individual counseling is paid $49 per hour, group counseling is paid at a rate of $23 per hour and Intensive Outpatient Treatment (IOP) is paid at a rate of $71 per day. If you were to compare this rate of pay to private commercial insurance company rates of pay, it is roughly half of the price insurance companies pay for the same services provided to their clients. In other words if a client with Aetna, Horizon, Cigna or any other private insurance provider comes into my organization we will get reimbursed $90 for individual therapy, $50 for group and $125 for IOP.

As a case study to flesh out the actual cost of a given service versus the reimbursement rate, let’s use the example of 1-hour of individual counseling, which is reimbursed by the State of NJ FFS initiatives (Drug Court, Driving under the Influence Initiative) and Medicaid at $49 per hour. The average licensed clinician earns a salary of $55,000 per year, which breaks down their hourly rate (with a 35 hour work week) to $27. On this surface this looks to be a profit of $22 for that hour of service. Unfortunately we haven’t taken into account that this licensed clinician works in an organization that has a myriad of expenses to support that hour of therapy. Expenses that don’t seem to be taken into account when setting rates, and at the very least are certainly are not reimbursable. These are expenses such as rent, utilities, phones, supplies, liability insurance, maintenance and repairs, equipment rental, salaries and fringe benefits for support staffing (secretaries, bookkeeping, and other administrative staff, or what is commonly called “management and general”), clinical supervision, case management services (talking with, or writing reports for, probation, DCP&P, EAPs, family or anyone else involved with the client), and fringe benefits (health insurance, payroll taxes, etc.). To roll all these expenses into 1 hour of services you would have to take the annual cost of them all (for my organization this amounts to $350,000) and then narrow that down to an hourly rate of $192 per hour on top of the clinician’s rate of $27 per hour. Since the $192 is a shared hourly rate we would have to have 8 clinicians doing individual therapy (at $27 an hour each or a cost of providing those services of $408), while the reimbursement for those 8 clients at $49 an hour would be $392. Thus it would take 9 clinicians doing individual therapy each hour to start making a profit.

Thus individual therapy is a losing proposition, no matter who the payer is, so the money must be made elsewhere in an outpatient treatment clinic. This would include group therapy and IOP. Some organizations know this hourly individual therapy reimbursement rate is a money loser and make it less of a priority as there is higher potential for a profit in group therapy and even a better profit potential in IOP (group therapy is usually 1.5 hours at $23 per group which adds up to $46 for 3 hours, whereas IOP is reimbursed at $71 for the same 3 hours). However, IOP is a higher level of care, and clients are in this level of care for a shorter time as they stabilize and not need the intensive services. So with the same clinician running group, at a total hourly cost of $217 (salary and all other supportive costs), we would now need at least 10 people in group ($230) during that time to barely do better than breaking even.

Why are these services rates so low? When will the rates be changed to a more competitive level to match today’s costs for running a business of providing treatment to those who have no insurance or who have Medicaid? What will those new rates be? The Division of Mental Health and Addiction Services (DMHAS) have been “studying” this issue since 2013 and paying an independent firm to come up with what those new FFS rates should be. The provider community was first told that the new rates were coming in the first half of 2014, then this was pushed back to the second half of 2014, then late spring of 2015, then the fall of 2015, and this fall providers were told that these rates would be announced sometime in 2016.

How much the state has spent on the company responsible for studying the new rates is unknown or why new rates have taken nearly 3 years without any resolution is also unknown. For all this time, however, providers are supposed to take these lower rates … and survive. By the way Medicaid used to reimburse treatment at a cost of $8 per group and $16 for individual therapy and they didn’t pay for IOP until July 1, 2015 when they adopted the rates of the other DMHAS FFS rates. However, the new rates only apply for those Medicaid clients who are eligible for the affordable care act version of Medicaid, called the alternative benefits plan. In my organization this accounts for about 75% of all Medicaid clients with the other 25% still not having Medicaid pay for treatment. When will Medicaid do a “true-up” or make all clients who have Medicaid able to be reimbursed for treatment? The same day DMHAS changes their FFS rates … which, if you read this far, you know is now going on its 3rd year of no news.

So while those in power say addictions treatment is high on their funding radar for those clients who are either uninsured or underinsured, is not currently reimbursed at sustainable rates for non-profits to treat people with proper group size and qualified staff. This will lead to one of many possible options:

1) this could lead to non-profits either being unable to serve this needed population and close its doors;

2) this could lead to organizations servicing clients poorly (i.e., larger group size than should occur, or organizations where everyone suddenly needs IOP, under-utilization of the most expensive modality which is individual therapy, staffing patterns of less qualified staff who are not properly certified or licensed for the purpose of cheaper labor costs); or

3) this could lead to more organizations doing a total reorganization and changing their mission statement from one of helping anyone who needs treatment regardless of their ability to pay, to a for-profit treatment center model that takes only clients who can afford a much higher for-profit rate for similar services (individual, group, IOP) and pay cash and those clients with private commercial insurance.

What have we done at HDAP to not fall into one of these 3 options? We do 3 fundraisers per year, we attempt to get funding from corporations and foundations to help pay for services because the rates of pay are not sustainable by the State of NJ and Medicaid, we provide other unique services such as servicing inmates in the Hunterdon County Correctional Facility by getting eligible inmates out of jail and into treatment programs where they are better served. However, we also have recently had to lay off administrative staff, putting a larger burden on existing administrative staff so that we have fewer expenses while not cutting into clinical services. My staff have not gotten a pay raise in three years and I have personally cut my own salary by 12% for the past three years in order to help ensure I don’t have to cut staff salaries. That is how we are surviving in this current reimbursement climate without resorting to 1 of the 3 options listed above.

While I don’t have the statistics to back this up, anecdotally it appears (in the past 10 years) that for every 1 non-profit startup with a similar mission statement that Hunterdon Drug Awareness Program has (to treat any Hunterdon County resident regardless of their ability to pay), there have been 5 – 10 for-profit treatment centers starting up. If the State of NJ and our politicians are truly behind properly funding addictions treatment, they will make sure non-profit organizations don’t fade away as they are in serious danger of doing so in today’s FFS treatment reimbursement climate.

Glenn Duncan, Executive Director
Hunterdon Drug Awareness Program, Inc.
http://www.hdap.org
[email protected]

I served in the Army as a tanker. I got out in 2004 and then rejoined in 2014 because I felt an obligation to help service members get better mental health and addiction treatment. I am proud of both my past and current military service, and I have a strident hope that I can raise awareness about problems and influence military/veterans’ policies. I can be a harsh critic of how the government has treated veterans, and I am also concerned about how the Army celebrates alcohol. I recently wrote a piece about the relationship between divorce and suicide in the military.

People send me articles, share photos, tell me stories, ask for advice, seek guidance on resources, and express gratitude for what I am doing.Today, I will answer a few questions from the proverbial mailbag.

I hear people say “Thank you for your service” to veterans a lot. I read an article that said “Please don’t thank me for the service.” I don’t want to offend anyone. What should I say or do?

“Thank you” or “Thank you for your service” and offering a handshake is a wonderful gesture. I always appreciate it. Most veterans do too. On the rare occasion that a veteran responds negatively, I suggest you say, “Sorry. I did not mean to offend.  While I can’t understand or fathom what you’ve done or been through, I just wanted to express appreciation.”

Are there resources you recommend for helping service members and veterans?

Yes. This is a link to my page on resources. It can help with medical care, treatment, education and housing. If there is something that you can’t find or need help with, email or call me and I’ll do everything I can to assist you.

Why is it ‘Veterans Day’ and not ‘Veterans’ Day’?

Awesome question. Just amazing. Grammar nerds are doing a little dance. The VA’s Office of Public Affairs has a great answer to this:

Veterans Day does not include an apostrophe but does include an “s” at the end of “veterans” because it is not a day that “belongs” to veterans, it is a day for honoring all veterans.

Their website also answers a host of other really good questions.

Are businesses being supportive of veterans?

Very much so. Uber and Lyft are offering free rides to veterans to job interviews. Dozens of national chains are providing free food, coffee, haircuts and other services on Veterans Day. A lot of businesses give discounts of 5 to 15% for service members and veterans throughout the year (I bought some trees and plants at Barton’s Nursery in Edison, NJ on Monday and they took 15% off). It takes about five seconds to ask someone if they provide a discount to veterans – if you are a veteran, I urge you to ask.

What do you think about the Department of Defense paying professional sports leagues to celebrate soldiers?

For those of you that are unaware about this sad topic, Vocativ can fill in the blanks:

The Department of Defense spent a total of $6.8 million in taxpayer money on sports marketing contracts since fiscal year 2012 that included items labeled “paid patriotism,” according to a recently-released joint oversight report by Sens. John McCain and Jeff Flake. In total, American military services reported a whopping $53 million in spending on marketing and advertising contracts with sports teams from 2012 to 2015, with more than $10 million of that paid to NFL, MLB, NBA, NHL and MLS teams.

(Senators) McCain and Flake found that the majority of contracts they analyzed included “paid patriotism” items ranging from on-field color guard and national anthem performances to ceremonial first pitches and wounded warrior tributes.

The whole thing embarrasses, saddens and angers me. I like being at a stadium and watching a young girl hug her father after he surprises her by  returning home. It’s an awesome moment. Now I have to wonder if the NFL teams did that to be part of the community and celebrate the US Armed Forces or were they paid. It is tremendously disappointing and increases my cynicism (and I don’t like being cynical).  Senators McCain and Flake (both Arizona Republicans) recently introduced legislation that would ban the tax-payer funding of “paid patriotism.”

Any books or TV shows or movies that you think are accurate and would recommend?

I’m a huge fan of Band of Brothers and Generation Kill. I thought American Sniper handled the return home exceptionally well.

Phil Klay wrote a fantastic collection of short stories entitled Redeployment. It won the 2014 National Book Award for fiction. This is from my review of the book on Amazon:

Mr. Klay is from Westchester, NY and went to Dartmouth. He was a Marine Captain and served in Iraq during the surge. After he left the military, he got his MFA from Hunter College. This is a collection of 12 short stories that all deal with America’s last two wars and how they affected the soldiers and their families.

From “Redeployment,” the first story in the collection:

“Most everybody else stays orange, all the time. Here’s what orange is. You don’t see or here like you used to. Your brain chemistry changes. You take in every piece of the environment, everything. I could spot a dime in the street twenty yards away. I had antennae out that stretched down the block. It’s hard to even remember exactly what that felt like. I think you take in too much information to store so you just forget, free up brain space to take in everything about the next moment that might keep you alive. And then you forget that moment, too, and focus on the next. And the next. And the next. For seven months. So that’s orange. And then you go shopping in Wilmington, unarmed, and you think you can get back down to white?”

There are several other top notch short stories, but my favorite is probably “Money as a Weapons System.” Major Zima is a supporting character in it, and he steals the show with his realpolitik solutions. He is an absolute all-time classic character.

Dr. Ben Carson is a Republican candidate for President and a retired neurosurgeon. As of 11/10/2015, he is the front-runner for the GOP nomination (without digressing too much into the nomination process, I believe Dr. Carson and Mr. Trump only have minuscule shots at the nomination. In the end, the Republican establishment will coalesce behind someone who is more acceptable to them). Dr. Carson recently made the Sunday talk show rounds and was asked what causes addiction and what is the best way to treat it (you can watch his response here). Despite my belief that he has an infinitesimal chance at the nomination, I feel forced to respond to his comments regarding addiction and treatment because he is on TV and he is effecting the national conversation on addiction and treatment. This is a bit of a low-hanging fruit, but sometimes I can neither hold my tongue nor restrain my pen.

John Dickerson: What’s the human side of addiction? Where does it come from? How should it best be treated?

Dr. Ben Carson: Usually addictions occur in people who are vulnerable, who are lacking something in their lives. We have to really start asking ourselves, what have we taken out of our lives in America? What are some of those values and principles that allowed us to ascend the ladder of success so rapidly to the very pinnacle of the world and the highest pinnacle anyone else had ever reached, and why are we in the process of throwing away all of our values and principles for the sake of political correctness.

He did not even attempt to answer the question about how we should treat addiction. As far as where it comes from, he did not really answer that either, instead choosing to talk about political correctness and values. While there are many vulnerable people who become addicted, there are some who have all the advantages in the world and still become addicted. I wish Dr. Carson was aware of three Presidential families and their struggles with addiction.

John Adams was a Harvard educated lawyer, had an incredible wife and was the second President of the United States. His eldest son, John Quincy, was elected as the sixth US President in 1824. His son Charles died from alcoholism at the age of 30 in 1800. His father occupied the White House when he died. Charles had every advantage possible and yet still succumbed to alcoholism. He was not vulnerable. And, I’m sure, he was raised with outstanding values. And he still died from alcoholism.

Theodore Roosevelt was born into a wealthy New York family in the middle of the 19th century. He had outstanding parents and received a fantastic education. He became President in 1901 when William McKinley was assassinated. President Roosevelt had a younger brother named Elliot, who also enjoyed all the advantages of that family. He was Theodore’s best man at his 1880 marriage.  Elliot had an awful drinking problem and attempted suicide in 1894 by jumping out a window. He survived the fall but died a few days later. His daughter was ten when he died. Her name was Eleonore Roosevelt, and she would grow up to be the most famous first lady in US history.

In 1978, two years after her husband lost his re-election bid, Betty Ford went to treatment for her addiction to alcohol and opiate painkillers. She got sober and helped reduce the stigma around addiction and raised awareness about the issue as much as anyone else in American history. By all accounts, she was an amazing woman. She was neither vulnerable nor had bad values.

Dr. Carson decided to talk about the heroin epidemic, but focused on border issues rather than treatment.

Dr. Carson: There is a transportation of heroin through our southern borders that is unimaginable. This is not a good thing for us. We need to not give up on this war on drugs.

This is a disastrous and embarrassing answer. I did not expect him to speak about how doctors have some responsibility for the opiate epidemic, but he could have talked about mandating prescription drug monitoring programs in every state, expanding the use of suboxone (and requiring its use be accompanied by drug screens and therapy) or how the federal government can better enforce the 2008 Mental Health and Addiction Parity Act (incidentally, all of these are policies that many doctors and experts in the American Society of Addiction Medicine (ASAM) support (full disclosure – I’m a member)).

The media and the public need to do a better job in holding politicians and political candidates to a strong standard of (a) understanding about addiction; (b) belief in the value of recovery and (c) supporting meaningful programs and policies that will save money in the long run, and more importantly, save lives.

I received a mass email from Rutgers President Francis Barchi today that started off with: “Today, Charter Day, officially begins our yearlong celebration leading up to the milestone 250th anniversary on November 10, 2016. We mark the day in 1766 when a charter was signed to establish a small private college that would eventually become Rutgers.”

The school is airing a 30-second spot which celebrates its history. You can see it here. I’m particularly proud of ADAP and the Rutgers Recovery House, the Mountainview Program, the Center of Alcohol Studies and the fact that we have Dr. Wise Young, one of the leading stem cell researchers in the world. Rutgers Newark is the most diverse campus in the country and has a recovery program as well.

Our University is not without flaws: the athletic programs hemorrhage money and constantly embarrass us, while the frats are a blight on the landscape. But our university has far more positive aspects and programs than negative ones.

I earned my BA in history and English from Rutgers College in 2001 and returned to get my Masters from the School of Social Work in 2006. I worked at the counseling centers from 2009 to 2014 and completed a Masters in Politics and Public Affairs from Bloustein in 2015. I have taught at the Summer School of Alcohol Studies since 2008 and the Rutgers School of Social Work since 2011. I am a proud alumnus and I love teaching there. I met at least half of the most important people in my life at Rutgers, and I chose to buy a house less than a mile from campus. It is woven into the fabric of my being and my life. The value of my degrees continue to increase. Coming to the banks was easily the 2nd best decision I ever made. Happy Birthday Rutgers.

I am happy to present the first article on my site by someone other than me. For a long time, I’ve thought about the importance of offering up other voices and perspectives. I have known Regina Diamond-Rodriguez for several  years and am extremely impressed and proud of her. I reached out to her a few months ago and asked her to write her story.

Regina abused drugs and went to prison. She eventually got clean, attended Rutgers and transformed her life. Her story appears below. It’s timely, as President Obama came to Newark, NJ this past Monday and celebrated the drug treatment that is offered at Integrity House and the criminal justice reforms that have been pushed by professionals at Rutgers Newark (I am a proud former employee of both). Here are a few questions that I want you to think about as you read her story:

(1) What kind of support was available at critical times? Is this institutional support or purely personal (family & friends)? Are both necessary?  (2) Could that support/opportunities/encouragement have made a difference if it had been there earlier? or in a different form? (3) Are there flaws or impediments in the available social services that impede the success?

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Regina Diamond-Rodriguez, LSW, MSW

I had a typical happy New Jersey childhood. As a child, I played softball and basketball. I loved going camping and spending my summers at the beach. I have loving parents, who did the best they could. Despite my happy childhood and loving parents, I began to feel like an outsider in my early teens. I developed a smart mouth and a rebellious attitude. I felt insecure and angry most of the time. I tried alcohol at the age of 14 and attempted suicide at 15. I was regularly smoking marijuana at 17, and I eventually tried a number of drugs soon after that. I was arrested for possession and being under the influence of LSD at 18; instead of jail, I was hospitalized. I received pre-trial intervention (PTI) and the charges were eventually dismissed. For the next six years I was in and out of therapy and outpatient rehabs, but somehow managed to get decent jobs. I even became a licensed broker’s assistant (obtaining the Series 7 license); however, my life was unstable and I couldn’t hold a job for more than nine months.

In 2003, at the age of 25, I was in the grips of a near-fatal drug and alcohol addiction. I was unable to maintain employment, healthy relationships, or housing — any semblance of a functioning life. I became unemployed, homeless, and had few friends. I felt so lost and alone. Drugs were the only thing that made me feel ok, and it was always just temporary. As my life spiraled downward, my substance use increased. I was arrested for possession of drugs and credit card theft. I spent a few weeks in the county jail and was homeless upon my release. In a moment of drug-induced desperation, I robbed a small store. I went armed with a water gun, demanded money, and ran out with cash in hand. The police were called and I was arrested within an hour of committing the crime. I spent five months in the county jail before I received my first offer for a plea deal: 15 years in state prison. I eventually agreed to a five to ten year sentence with a mandatory 85% and five years parole upon completing the sentence. The final deal would be determined by the judge on sentencing day.

I knew I had to get sober. During the time I was out on bail, I successfully completed detox, a 28-day inpatient program, and ten months in a halfway house. I attended hundreds of Alcoholics Anonymous meetings, got a sponsor and worked the 12 steps. I was inspired by the laughter in those rooms and the stories of redemption. It was difficult though, especially because no matter how well I did I would still be going to prison. I never wanted to live the way I was living when I committed those crimes – desperate and alone, a slave to my addiction. I hurt so many people while I was active in my addiction, including my family, my friends, myself and the victims of my crimes. I cringed with shame whenever I thought about it.

Sentencing day was August 5, 2005. The courtroom was packed with family and friends. I was sentenced to five years in prison. Tears filled the courtroom, and my mother had to be escorted out because she couldn’t stand up. I ached to see her like that. And then the five year sentence hit me, and I could not imagine how I would survive the next four and a half years.

After the shock and grief passed, I decided that I must stay focused, continue working a 12 step program, and obtain a college education. I was moved from county jail to Edna Mahan Correctional Facility for women. After a few months of settling in and searching for productive things to do, I came across a sign-up sheet for a college math class. I enthusiastically signed up. I relished the idea of taking some college courses while I was incarcerated. I could begin to turn my life around while I was locked up. I was devastated to learn that college level courses were only offered to women under the age of 26, and I had just turned 27. I was angry and hurt and confused. The time seemed to stretch on forever. I spent two years in the maximum security and found very few ways to improve my life. I played handball and cards, learned how to cross-stich and cook. The AA and NA meetings were inmate-led and were nothing like the meetings I was accustomed to on the outside. I was on the brink of despair. But I didn’t use.

In 2007 I was moved to minimum security and to a behavior modification program within the prison. I struggled in this program; the model was confrontational and punitive. I was already sober for nearly three years and had the experience of getting sober in a supportive and nurturing environment. I managed to get through the program and was moved to a halfway house in 2008.

While in the halfway house, I took some basic computer skills training. The class was run by a woman who also worked at the local community college. She and Mr. Fletcher, the Director of Education at the halfway house, suggested that I register for classes through the Next Step Program at Essex County College (ECC). I was excited at the thought of this new opportunity. Mr. Fletcher introduced me to Dr. Roden, a history professor at Rutgers. Dr. Roden came to meet with me at the halfway house and told me about the Mountainview Program, which consisted of a small group of formerly incarcerated students who were registered on the Rutgers New Brunswick campus. He suggested that I get a few semesters under my belt at community college, and then apply to Rutgers University. I was thrilled! This was what I had been hoping and searching for during my incarceration.

On June 2, 2009, I was released from the halfway house and returned to the community. I decided not to move in with my family, but instead moved to the county where I went to rehab and got sober before going to prison. I lived with my sponsor, who had sponsored me throughout my entire prison term. I attended AA meetings nearly every night, got a full time job in a local deli, and attended Bergen Community College as a part time student. I loved being back in the classroom, but I definitely felt different from the other students. I was 30 years old and in classes with people who were mostly in their teens that probably would shutter if they knew I had been in prison. I had difficulty with social situations during the first year after being released. I was extremely anxious and insecure. I could not wait to get out of prison, and now that I was out I felt awkward and self-conscious. It was frightening and frustrating.

The first year was a huge transition for me. I lived with my sponsor for the first six months, and then I stayed with my parents for six weeks, and finally moved in with my partner whom I met in prison two years earlier. She had already completed the Next Step program, and was enrolled as a full-time student in the Rutgers Mountainview Program. I completed my second semester at community college, and applied to Rutgers University through the Mountainview Program. I began as a full-time Rutgers student in September of 2010. The Mountainview students were linked with various resources on campus for support. Our main point person was Chris Agans; at the time he was the Director of Student Support Services (SSS). During orientation we were introduced to the staff at the counseling center (CAPS) and also the advisors in Equal Opportunity Fund (EOF). I believe that the support I received through those three programs – SSS, CAPS and EOF – was what helped me to maintain my sanity and sobriety, successfully navigate college life, and eventually graduate with a 3.9 GPA three years later. Through EOF and SSS I received one-on-one academic advising, tutoring and workshops. I also received a work-study job. At CAPS I met with a counselor regularly for emotional support and guidance. Transitioning to Rutgers was not nearly as difficult and overwhelming as the transition home from prison due to all the support and encouragement I received from non-judgmental staff who were genuinely interested in seeing me succeed. A critically important component of the Mountainview Program is the sense of community and encouraged interaction amongst students in the program. Being around other people who went through similar situations and were on the same path as me tremendously increased my sense of belonging. One of my fellow Mountainview students put me in contact with some sober women in AA and I began attending local meetings, some of which are held on campus and some in the surrounding areas off campus. I attended meetings regularly and gained a network of support.

During my second year at Rutgers, I declared my major as social work. I took summer classes each year with the goal of graduating in May of 2013. During my third and final year at Rutgers, I completed my internship at the Rutgers for Social Justice & LGBT Communities, which is where I met Jenny Kurtz, the Director at the time, and now one of my mentors. During my internship I facilitated a support group for LGBT students and served as a liaison for the New Jersey SPEAK (Students Promoting Equality, Action, and Knowledge) Summit. I volunteered as a mentor to first year Mountainview students and also worked as a tutor for EOF.

In January of 2013, I applied to Columbia University, Fordham University, New York University, Rutgers University and University of Pennsylvania to pursue a Masters in Social Work. I was accepted to all five schools and I chose Fordham. I completed my internship at a care management organization working with children who have mental, emotional and behavioral issues. I was referred to the agency by my field liaison from Rutgers; she knew my story yet was still willing to vouch for me. I was hired as a full time care manager, and graduated with my Masters in May of 2014.

In June 2014, I completed parole. I had been involved in the criminal justice system for over a decade, and now I was done. It was surreal.

I continued to work as a care manager for another year. I stayed involved with the Mountainview Program, which had flourished on the New Brunswick campus. Many students were graduating and several had won prestigious academic awards, scholarships and fellowships. I learned about NJ-STEP (NJ Scholarship and Transformative Education in Prison) which is a consortium of higher education institutions that partners with New Jersey Department of Corrections to provide college classes for students (now for people of any age) while they are still incarcerated and assists in the transition to college upon their release. Rutgers Mountainview Program is part of this consortium. Several Rutgers Mountainview alumni are currently employed with NJ-STEP. I learned that the Mountainview Program planned to expand to the Rutgers Newark campus, so I applied for the role of Program Coordinator. I was hired. Amazing! I now work to serve others, act as a role model, give them hope, and help them navigate to becoming sober, educated, upstanding citizens. I have been so lucky and I owe so many people a great deal of thanks.

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I’m not sure if Regina’s substance abuse problem could have been avoided or stopped in her early teenage years. That said, I think it is imperative that we have more (and better) prevention education at the middle school and high school levels. She would have been a good candidate for drug court, and I hope to see NJ and the USA continue to expand those programs. Drug courts cost a fraction of incarceration and have better results – participants are less likely to recidivate. She reported that the 12-step meetings she attended in prison were weak – that is appalling. The State of NJ’s corrections department is in dire need of volunteers to bring in meetings to the prisons (if you are in recovery, please consider doing this).

Regina had a difficult transition to the outside world after her release from prison; this illustrates the need for aftercare/transition services for people that have left both jail and prison. Former Gov. Jim McGreevey runs a transition program in Jersey City that helps get ex-offenders education, treatment, housing and job training. We need more programs like this (regardless of what you think of ex-offenders, these programs save money by reducing recidivism). She attended classes at Rutgers and enjoyed a number of social and academic supports that are provided by that university. If more schools and states replicate these programs, we’ll have far more stories of recovery, redemption and productivity like Regina’s. Right now, Regina is a rare success story. If we implement the correct policy changes, we can have hundreds of thousands like her.

Last week, I received a phone call from a childhood friend who is a Marine Corps Officer. He told me that another man whom he was deployed with a few years earlier recently took his life. My friend expressed anger, sadness, frustration and regret. He proceeded to tell me that a number of fellow Marines that he has served with have taken their own lives in the last few  years. The first question I asked him was if his friend was divorced. “He was in the process of it,” he responded.

When I talk to law enforcement professionals*, members of the military and veterans about PTSD, depression and suicide, I always ask about alcohol/drug use and divorce because both of them are positively correlated with suicide (you should keep these two questions in the back of your mind, whenever you read or hear about a suicide attempt).

In the last several years, the military has been doing a better job about spreading the awareness of PTSD, depression and suicide among service members and veterans. However, they are not addressing alcohol abuse (misuse, dependence…you can pick your own clinical wording) and relationship problems nearly enough. During a month-long training for Army medical professionals this summer, my class was repeatedly told “if you are married, stay married.” This was particularly in reference to weekend activities. At no point were relationships and marriage discussed in depth. No attention was given to time spent together, communication, fair fighting, family planning or overcoming adversity together.

Marriage is difficult – it takes a lot of continual work. A lot of people take their partner for granted or say things like, “I don’t want to have to work at my relationship.” The stark reality though is that it takes constant work; some are far better at it than others (there are those that say they correct their mistakes in a second marriage, but the statistics are pretty clear that the divorce rate for second marriages is higher than for first ones). People have different needs and expectations, and they grow and change at different rates. Add in job stress, health problems, deployment, financial issues, kids, or perhaps a substance abuse problem, and the chances of marital difficulties, separation and/or divorce increase. Service members lives are often rife with the aforementioned problems.

Addressing relationships in the military requires a change in policy. It means early and ongoing instruction/support. There are existing family programs and support groups, but they are clearly not working. We need more therapists that are working with the military (both as embedded military members and as civilians) that help them learn how to select partners, have quality relationships, fight fairly and work through difficulties. I believe that this will reduce suicide attempts by service members and veterans.

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* I recently had lunch with a number of law enforcement officials. We got to talking about PTSD, depression and suicide in their profession. I asked them what was the percentage of divorce in their field. While they couldn’t give me a global figure, they told me that their organization had a 70-75% 1st marriage divorce rate. Those that are divorced, they said, have higher rates of alcohol problems and suicide.

This past Saturday, I spoke at the Vigil in Camden County, NJ. There were over 200 people in attendance, and many were there to remember one of the 274 individuals who died from an overdose whose names were read at the event. A number of people have asked for a copy of my speech; that’s quite a compliment, but alas, I only speak from an outline rather than a full script. I’ll cover some of the key points here, as well as list a few more resources that may be useful to the parent who has lost a child to an overdose (I’m not going to cover all of the current policy problems listed in my speech or review the positives from the last year or list my own policy goals, because I write about those issues here on a regular basis and it would also quadruple the length of this article).

I was going to be a Shakespeare professor, but then my friend died in late-2002 and I decided to work in an in-patient treatment program in Northern NJ. I engaged clients in individual counseling, group work, psychoeducation, family therapy and multi-family groups. I took them to 12-step meetings and on activities in order to teach them new ways to have fun. My work as a drug counselor led me to pay more attention to drug policy. One can’t look at drug policy without also looking at criminal justice policy. I am often exasperated with our state and country’s drug and criminal justice policies. I am angry with a number of different individuals, forces, companies and institutions.

I am angry at Big Pharma for pushing providers to expand diagnoses so they can increase their market share.

I am angry at Insurance Companies that refuse to pay for the appropriate level of care, or stop paying in the middle of treatment or decline to pay for any kind of treatment all together.

I am angry at those who tell me that it is “God’s will” that someone died.

I am angry about advertisements for drugs on TV and in print media.

I am angry at politicians who say they support forward thinking policies but then refuse to supply funding for said programs.

I am angry at people who write horrible things about those that have died from addiction and hide behind the anonymity of the internet.

I would like to yell and curse and mock and belittle and put-down and threaten and perhaps beat those that I am angry with. But not only are those behaviors ineffective, they are actually counter-productive. We must follow the example of Dr. King and win over those that stand against us with love, patience and the sharing of our personal experiences. In 2013, I spoke at the the NASW-NJ conference in Atlantic City. I talked about how Narcan can save lives by reversing overdoses, and how another social worker said something to the effect that we “should not encourage people to take drugs by having the safety net of Narcan.” Rather than yell and curse and belittle her, I showed her the picture of a mother and her son who died from an overdose and said, “I’d like to give her 3 more days with her son or even 4 more hours.” We need family members to show up at public events, speak at schools, talk before legislative committees and go to treatment programs and tell their stories. I encourage you to wear shirts with the pictures of your loved ones who passed from an overdose. Those shirts are devastating to look at and impossible to deny. You may find that people will say you were a poor parent, that your kid was a bad apple, that addiction is a choice, or that we need to clean up the gene pool. You will get angry. And I need you to respond with patience and tolerance. If I can do it, you can do it.

I have worked with people for a dozen years, and helped them through major life events like the death of a loved one, the end of a romantic relationship, job changes, money problems, moving, and health problems. I have suffered losses in my life as well: the deaths of family members, the aforementioned overdose of my friend Fraser, a divorce, and my sister’s battle with breast cancer (she is alive and well, but it was a doozy of a year for our family). During those stressful events, time slowed down and I would walk aimlessly around my house and stare at nothing in particular. I know other people do that too. At last year’s vigil, I met a woman who buried her daughter that morning. I wanted to comfort her and make everything better, but that is beyond my powers and abilities. But I do have some unsolicited advice for the parents who have lost a child:

1) Attend a meeting of GRASP or Parent-to-parent

2) See a professional grief counselor

3) Spend time with other family members

4) Engage in your hobbies, even if you take no joy in them

5) Get out of your house each day

6) Find a purpose. Last year, I wrote an article about what people can do to help (it’s a good starting point). Paul Ressler decided his purpose was to expand the use of Narcan. Others might want to talk to the parents of a young adult who is in the midst of her addiction. A few of you might want to become a therapist. The point is that there are many options, including work outside of the addiction and mental health fields.

This work often leaves me saddened, angry, cynical, skeptical and frustrated. But I continue to look for hope, help others, and work towards meaningful policy changes. Things are better than they were a year ago. They can get better still. Please join me.

While Governor Christie continues to flirt with his no-shot bid at the GOP presidential nomination, dithers on meaningful policy, and blusters on about meager funding for treatment, local leaders in NJ are the ones making an actual difference in the Garden State.

Patty DiRenzo and the Camden County Addiction Awareness Task Force continue to lead the way on implementing innovative drug policies at the municipal and county levels. Ms. DiRenzo was one of the many vocal forces behind the passage of the 2013 Overdose Protection Act and then fought for Narcan expansion last year. Narcan is an anti-overdose drug that is “nonaddictive, nontoxic and easy to administer through nasal, intramuscular or intravenous application. It reverses the effects of an opioid overdose by essentially blocking the opioid receptors that are targeted by heroin and many prescription painkillers.”*  People that would otherwise die can be saved. Since its expansion in June of 2014, the application of Narcan has saved over 300 lives in Camden County alone. It is now available without a prescription at CVS in 12 states, including NJ.

I spoke about the advantages of Narcan at the 2013 NASW-NJ conference, and one audience member asked me if it was “a good idea to encourage people that we can bring them back from an overdose?” A few friends of mine were in attendance, and they half expected me to flip out. I wanted to (a brief aside here…I deal with idiocy, selfishness and figurative blindness at most public events that I attend or speak at, but I am wise enough to know that yelling, cursing, belittling or mocking are not the correct response).

I paused, looked at the woman and said, “I assure you the alternative is grim. I have met with hundreds of parents whose kids have died. If we could give them 1 more day, heck, 3 more hours with their kid, they would take that time and treasure it. The only time that it is too late to change the course of your life is when you are dead. We are social workers. We know this.”

Over the last two years, others have asked me more nuanced questions. The best ones sound something like, “So we save them with Narcan but then don’t help them get more services. That doesn’t make sense. Can’t we send them to treatment so that we aren’t just giving them Narcan and then releasing them back to the street?”  That is an excellent point, but it requires policy change, willing partners, treatment beds and funding.

On October 7th, Camden County announced Operation Sal, a local initiative that has $150,000 in funding to help people revived on Narcan go to detox and then attend treatment. All four hospitals in Camden County are participating, law enforcement has been alerted and is on board, and patients will be sent to Delaware Valley Medical. This is the ideal next step after Narcan. Kudos, Camden County, and thank you.