I am on a number of email lists and newsletters. This came to my attention this morning. I have worked in a number of fields for many years on both the micro and macro levels, and I'm often aghast at the treatment that is offered and the governmental policies that fail to direct or regulate or (at times) pay for those services. Dr. Lieberman wrote the following piece for other healthcare professionals. It was so nice to read the words of someone else so that I know that I am not alone in my frustration. I received his permission this afternoon to repost this, and I'm thrilled to pass it on to the readers of this site.
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Jeffrey A. Lieberman, MD
November 23, 2016

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

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

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

Missed Legislative Opportunity

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

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

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

Agenda for Mental Health Care Ignored

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

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

Psychiatrists Overlooked After Hinckley Released

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

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

The Displaced With Mental Illness

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

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

Awareness Is Growing but Policies Remain Shortsighted

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

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

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

Thank you for listening.

Dr, Jeffrey Lieberman of Columbia University,

References

1.      Editorial Board. Clinton just made a very important announcement — and
hardly anyone is talking about it. The Washington Post. August 31, 2016.
https://www.washingtonpost.com/opinions/clinton-just-made-a-very-important-announcement--and-hardly-anyone-is-talking-about-it/2016/08/31/5379ddfe-6ef5-11e6-9705-23e51a2f424d_story.htmlAccessed
November 10, 2016.

2.      Fuller T. What San Francisco says about America. The New York Times.
September 18, 2016.
http://www.nytimes.com/2016/09/18/opinion/sunday/what-san-francisco-says-about-america.html?_r=0
Accessed November 10, 2016.

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

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

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

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

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

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

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

(a) eating vegetables

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

(c) people who give me shit for smoking cigars

(d) people who thought Titanic was a good movie

(e) anyone who follows the Kardashians

(f) tattoos

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

(h) skateboarders

(i) not showering

(j) people who talk on their phone in public

(k) people who walk while looking at their phone

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

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

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

(1) exercise more

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

(3) go for hike in the woods

(4) plant bulbs for the spring

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

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

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

(8) organize your closet

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

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

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

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

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

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

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

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

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

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

Gov. Christie’s Worst Hits

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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RUTGERS CENTER OF ALCOHOL STUDIES TO OFFER FREE ADDICTION TRAINING PROGRAM TO ENHANCE COMMUNITY POLICING EFFORTS AND COMBAT THE HEROIN AND OPIOID EPIDEMIC

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

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

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

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

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

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

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

The highlights of my piece are:

Two major suggestions:

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

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

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The full piece is below.

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

October 8, 2016

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

Midwives                                 1                      Advanced Practice Nurses      6

Dentists                                   1                      Physicians                                1

Physician Assistants                1                      Nurses                                     1

Pharmacists                            1

Two major suggestions:

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

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

• Drug overdose is the leading cause of accidental death in the US, with 47,055 lethal drug overdoses in 2014. Opioid addiction is driving this epidemic, with 18,893 overdose deaths related to prescription pain relievers, and 10,574 overdose deaths related to heroin in 2014.
• From 1999 to 2008, overdose death rates, sales and substance use disordertreatment admissions related to prescription pain relievers increased in parallel.
• The overdose death rate in 2008 was nearly four times the 1999 rate; sales of prescription pain relievers in 2010 were four times those in 1999; and the substance use disorder treatment admission rate in 2009 was six times the 1999 rate.
• In 2012, 259 million prescriptions were written for opioids, which is more than enough to give every American adult their own bottle of pills.

• Four in five new heroin users started out misusing prescription painkillers
• 94% of respondents in a 2014 survey of people in treatment for opioid addiction said they chose to use heroin because prescription opioids were “far more expensive and harder to obtain.

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

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

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

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

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

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

The claim that it causes a burden in false:

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

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

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

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

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

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

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

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

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

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

 

Frank L. Greenagel Jr.

MPAP, MSW, LCSW, LCADC, ACSW, ICADC, CJC, CCS

Adjunct Professor – Rutgers School of Social Work

Instructor – Center of Alcohol Studies

Governor’s Council on Alcoholism & Drug Abuse

1^st LT – PA Army National Guard

[1] https://greenagel.com/how-big-pharma-gets-doctors-to-push-its-drugs/

[2] http://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf

[3] https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse

[4] https://health.gov/news/blog/2016/06/could-state-laws-around-opioid-continuing-education-help-tackle-the-national-opioid-epidemic/

[5] http://www.bloomberg.com/news/articles/2015-06-30/doctors-got-6-5-billion-in-14-from-drug-device-makers-in-u-s-

[6] http://well.blogs.nytimes.com/2016/06/20/drug-company-lunches-have-big-payoffs/

[7] http://bigstory.ap.org/article/86e948d183d14091a80f5c3bfb429c68/drugmakers-fought-state-opioid-limits-amid-crisis

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

I recently wrote an article about how NJ recently approved the use of marijuana to treat people with PTSD. To be clear, I am against it. A number of people responded negatively on either Facebook, Linked In or via email. Several messages attacked me on a personal level, and more than one person accused me of taking money from Big Pharma. Last April, I wrote about the different kind of statements that people make when they disagree with me. I have found that most people are set in their ways and views on the topic of marijuana, and usually do not want to have a discussion with someone with a different view (they usually just engage in shouting, insults, and a number of other fallacies). As an educator, I strive to help people understand and sometimes change the process of how they arrive at their conclusions. I adore discussions where people have different backgrounds, beliefs and philosophies, but I expect the discussion to be free from fallacies. I’m going to highlight three fallacies: agrumentum ad ignorantiam (argument from ignorance), red herring (bringing up a different topic than has been addressed) and arugmentum ad hominem (you engage in personal attacks).

1) Do you have PTSD?

I’m not sure how this is relevant. If I answer no, then I assume I’ll be accused of not personally understanding the issue. If I say yes, I figure I’ll be told that I am too close to the topic and while marijuana may not have been a treatment answer for me, it works for others. Or perhaps I’ll be told that my mind is addled.

I have treated people with PTSD for over a dozen years though. I care so much about soldiers (and other service members) and veterans that I rejoined the Army as a medical officer in 2014 after having been out of the service for over 10 years.

To answer the PTSD question: no, I do not have, nor have ever had, PTSD. I have had an easy life.

 

2) Are you satisfied instead with big pharma pushing life destroying, highly addictive, narcotic analgesics? (I added the commas).

 

I have been an extremely vocal critic of Big Pharma in my professional talks, in my college classrooms, in my writing, and in my service on the NJ Governor’s Council. I recently wrote an article about the problems with big pharma here. If someone accuses me of taking money from the pharmaceutical industry, it shows that they are guilty of conducting little to no research or background checks.

That said, the discussion of prescription opiates is a red herring when talking about marijuana for PTSD. I am assuming that you are arguing for marijuana to treat pain instead of prescription painkillers. That is a different argument. As I just wrote, I am critical of Big Pharma and the overprescription of painkillers (I suggest you read the NJ Heroin and Other Opiate Task Force Report from 2014). If you have clinical, controlled studies on how marijuana helps people with pain without causing psychological side effects, I would be thrilled to see them.

 

3) Have you not done even the smallest modicum of research? The overwhelming evidence of numerous studies has already definitively PROVEN the many many positive effects and benefits of medicinal marijuana for ptsd!

Sadly sir, you are mistaken. The studies that some people cite (you mentioned none, just that there are numerous ones) do not pass scientific muster. Most people have a hard time differentiating good from bad studies. Additionally, many pro Marijuana for medicine reports are funded by the for-profit Marijuana industry.

Here are some of my other opinions on marijuana:

• I would like to see it decriminalized in every state. I don’t want to see people get arrested for using it in private spaces. I have no problem with a person who is 21 or older using marijuana in their home.
• I caution people who use it on the amount and frequency though. With full legalization, American marketing power would be brought to bear, which would encourage people to large amounts of it, in order to maximize profits.
• I am against full legalization, which allows for advertisements on the internet, TV, radio, and billboards. I am against marijuana candy being sold in convenience stores. I am against lawsuit shield protections for marijuana producers.
• Marijuana is currently a schedule I drug (highly addictive, no medical value). I support rescheduling to level II. This would federally allow it to be given to people with late stage cancer, HIV/AIDS, and glaucoma. It would also allow for federal funding of studies on the effectiveness of marijuana as a medical treatment for other conditions.
• I am deeply concerned about the use of marijuana by people who drive or operate any kind of machinery. Studies have shown that coordination and reaction are affected over 24 hours after using marijuana.

In a state rife with some awful people on both sides of the political aisle, Dr. Herb Conaway ranks as the second worst person on my list (if you don’t know who the first is, than you haven’t been paying attention). Dr. Conaway is a Democratic Assemblyman out of Burlington. He is well educated: undergrad at Princeton, law degree from Rutgers, and a medical degree from Thomas Jefferson. He served as a Captain in the Air Force medical corps for four years. He is clearly smart, hardworking, and has had some valuable experiences. This is what makes his opposition to bills that combat the opiate epidemic and his support of medical marijuana so concerning.

Earlier this week, a devastating article about Dr. Conaway was written by Ken Serrano for the Gannett papers (it was pushed off the front page by the bombings in Seaside and Chelsea). Some highlights:

1) Limiting the amount of opioids a physician can prescribe to seven-day supplies is seen as a way to cut into the heroin and painkiller epidemic. The Centers for Disease Control and Prevention encourages limitations. But a proposed law that won approval in the state Senate hasn’t advanced in the Assembly, where Conaway, the chairman of the Health and Senior Services Committee, stands in the way. A proposed law eventually dies if it isn’t posted by the chairman of a committee for a vote. Conaway told the Asbury Park Press Friday he will not post the seven-day supply bill because it will hurt some patients.

2) From 2006 through 2013, Conaway’s reelection committees were the second biggest beneficiary of contributions to state candidates in New Jersey from the pharmaceutical industry, out of 127 candidates. His campaigned received a total of $41,750.

3) Another anti-abuse bill would require doctors and others prescribing opioids to minors to warn parents about the dangers of addiction and counsel them about alternatives to opioids, amid mounting evidence that those under 25 who have taken prescription opioids are more susceptible to addiction. Last year a different version of the bill that required that all patients being prescribed opioids be advised of their risks. The Senate version, S2366, passed 36 to 1, but the bill died when Conaway refused to post the Assembly version, A3712, in the Assembly health committee.

Back in 2014, the NJ Heroin and Opiate Task Force recommended that the Prescription Drug Monitoring Program (PMP or PDMP) become mandatory – that is that all doctors must enter opiate prescriptions in a central data base and that both doctors and pharmacists should check patients’ histories before writing and dispensing those opiate painkillers. A voluntary PMP is only used by medical professionals who are responsible and aware of the problem. About 20% of the states have mandated PMPs, and they have shown that doctors prescribe 30% less opiates when they are being monitored. Dr. Conaway has opposed expansion and mandating the PMP every step of the way – he often states that government should not get tell doctors how to do their job.

Dr. Conaway has also blocked parental notification laws about the dangers of opiates. He says that this would “open the door to further legislators governing doctors how to behave.” But there are many instances where doctors are required to inform patients about the risks of medication, surgery or other procedures. Dr. Andrew Kolodny, the Chief Executive Medical Officer Phoenix House, explained Conaway’s behavior thus:

Any efforts that would really be effective at addressing the opioid crisis will generally result in reduced prescribing. The manufacturers of opioid painkillers don’t want to see their prescriptions go down, so they are blocking efforts to promote more cautious use.

I’m just one of many people who are critical of Dr. Conaway, but the general public is unaware because they spend two out of every four years worrying about who is going to be President and little to no time monitoring their state governments. The entire interview with Dr. Kolodny is a good read.

Dr. Conaway is bright and well educated. It’s not that he can’t read scientific studies, look at reports or understand data. He can. His actions to block bills that hurt the bottom line of Big Pharma have brought many people to question his motivations, and they usually arrive at the same conclusion – that he takes money from Big Pharma and it has influenced him in their favor.

I have to take a number of ethics trainings every year at Rutgers, for the Army, at the Governor’s Council and to maintain all of my professional licenses. Over and over, conflicts of interest are explained and how that not only impropriety is bad, but the appearance of impropriety is also a huge concern. I can not say for sure that Dr. Conaway has killed bills that would help curb the opiate epidemic because he has taken thousands and thousands of dollars from Big Pharma, but it sure looks that way.

 

Last week, a Democratic bill was signed into law by NJ Governor Chris Christie that will allow people with PTSD to get medical marijuana. This expands upon the original NJ medical marijuana law, which was passed by the legislature and signed by Gov. Corzine in January of 2010. Previously, only diagnoses of cancer, glaucoma, HIV/AIDS, multiple sclerosis, seizures, and crohn’s disease had been approved for medical marijuana in NJ. I have no comment on the aforementioned conditions – I am not a medical doctor and the treatment of those problems fall far outside of my scope of practice.

However, I have been treating a large number of both veterans and civilians with PTSD for over a decade, and as I have noted many times before, I have grave concerns about giving marijuana to those with PTSD.

1) The only evidence that marijuana helps people with PTSD has been anecdotal stories by people who claim it helps them. The unscientific, non-clinical studies that have been conducted with multiple individuals usually ask people after they’ve smoked if they feel better. The studies aren’t looking at how marijuana affects them 12 hours later, 24 hours later, multiple days, or weeks later.

2) The Veterans Administration (VA), which I am sometimes critical of, has the greatest experience and expertise treating veterans for PTSD. So many of the people that work in the VA care deeply for veterans and are willing to try anything in order to help them. The VA’s official position on marijuana for PTSD is this:

Marijuana use for medical conditions is an issue of growing concern. Some Veterans use marijuana to relieve symptoms of PTSD and several states specifically approve the use of medical marijuana for PTSD. However, controlled studies have not been conducted to evaluate the safety or effectiveness of medical marijuana for PTSD. Thus, there is no evidence at this time that marijuana is an effective treatment for PTSD. In fact, research suggests that marijuana can be harmful to individuals with PTSD.

3) My experience treating people with PTSD  has shown that marijuana sometimes momentarily alleviates acute symptoms, but when the psychotropic effects wear off the symptoms return and often get worse.

4) Studies have shown that smoking marijuana causes decreased lung function, chronic respiratory track problems (wheezing, shortness of breath), a strong link to obstructive lung disease, increased bronchitis episodes, possible acute cardiovascular issues and a higher likelihood for cancer (but we need more studies on that specific item).

5) Studies have also shown that marijuana use may cause an earlier onset of psychotic illnesses. Long term heavy users (defined as 3x a week or more for a period of over 6 months) show impairment in memory and attention. Marijuana use causes withdrawal symptoms such as irritability and insomnia, and often makes symptoms of depression and anxiety worse.

6) There are currently four states where recreational use of marijuana is legalized:  Colorado (2012), Washington (2012), Alaska (2014), Oregon (2014), and Washington DC (2014). All five legalized marijuana much earlier: Alaska, Washington and Oregon passed medical marijuana laws in 1998; Colorado in 2000 and DC in 2011. The establishment and expansion of medical marijuana laws are a gateway to legalized recreational marijuana. Once recreational marijuana becomes legal in a state, for-profit marijuana corporations get a true foothold and start lobbying politicians and donating to their campaigns

7) If, IF, there are medical benefits from marijuana use (reduction of nausea, stimulation of appetite), they are caused by the CBD chemical in marijuana. The THC chemicals do not have medical benefits, but are popular because they lead to the psychoactive high. THC content in marijuana was between 2 and 5% from the 60s thru the 80s. A few years ago, the strongest marijuana was 19%. Two years ago, the winner of a competition was 29%. The strongest THC content available in Colorado now is 41%. (THC wax is over 90% and THC Vaping can be over 99%). NJ could have pushed for medical marijuana to be CBD concentrated with a maximum amount of THC content at 5%, but they chose not to do this.

8) NJ politicians from both political parties said that they had passed this law because veterans were in such dire need. We are seeing an ever-increasing use of veterans and 9/11 to justify legislation (and sell products). I wrote about this in the spring. There is an organization in Oregon called Grow for Vets. It is non profit whose sponsors are all, surprise, for profit marijuana companies. They use their supposed support of veterans to curry public favor.

This NJ law was introduced and sponsored by Senator Joe Vitale (D-Woodbridge). I have worked with him on a number of issues and I have often applauded him for the work he has done in the areas of addiction and recovery. For several years, he has been my favorite NJ politician. He still remains so, but on this we disagree. It is my hope that NJ will collect data on everyone with PTSD that is prescribed marijuana so we can monitor their condition. If the evidence shows that marijuana helps those with PTSD, I’ll publish a retraction. If however, the evidence shows that marijuana does not help those with PTSD, I hope that this law gets reversed.