Frederick Douglass is one of my great heroes. He was born a slave in 1818. He taught himself how to read and write and at the age of 20, he ran away to freedom. He spoke about his experiences as a slave, and how slavery debases both the slave and the slave owner. He would tell how slave owners would act pious in church and in their communities and then come home and yell and beat their slaves. Douglass was such an eloquent speaker that many people raised the question of whether or not he had ever been in bondage. In 1845, he wrote the Narrative of the Life of Frederick Douglass in order to prove to people that he had been a slave. He was very specific with exact names and locations so that people could fact check. He did not want there to be any doubt about his story (the book is 70 pages long and can be bought in paperback for $2 or on kindle for $1…every American should read it).

In Chapter X of his book, he writes about:

(1) How slaves were given the time off between Christmas and New Year’s, and that their masters encouraged them to drink. “It was deemed a disgrace not to get drunk at Christmas.”

(2) Some slave owners would make bets on their slaves to see who could drink the most without getting drunk.

(3) “We felt, and very properly too, that we had almost as well be slaves to man as to rum.”

(4) “So, when the holidays ended, we staggered up from the filth of our wallowing, took a long breath, and marched to the field, — feeling, upon the whole, rather glad to go…back to the arms of slavery.”

One of his great joys in life was teaching other slaves and ex-slaves how to read. It wasn’t enough to be free, but one had to be educated in order to protect one’s freedom and to be a productive member of society.

After his book was published, Mr. Douglass went on a tour of Britain and Ireland for two years. While he was over there, he described himself over and over again as a “sot” in his speeches. Sot is an English word that originated sometime in the 1590’s and means “one who is stupefied by drink.” He would talk about the evils of slavery, the religious hypocrisy of slaveholders, how slaves are encouraged to drink and discouraged from reading. He said,

“There is no freedom from the bondage of slavery without freedom from the bondage of alcohol.”

Frederick Douglass was a recoverying alcoholic* before we had the term. He experienced physical and mental slavery and eventually overcame both. He got educated, traveled, helped others and he talked about his experiences. He was a role model and he helped implement changes on a national level. His story has a number of themes that resonate with people in recovery today (clearly, his journey was harder).

I am not going to be so arrogant and foolish as to say what Mr. Douglass’s positions would be on current issues, other than to say that he probably would have encouraged people with substance abuse problems to not use and all people to get educated.

He’s one of my great role models, and I want to share him with you.

* or use whatever term you are comfortable with: reformed drinker, former drinker, person in long-term recovery, abstainer

Someone who is addicted to heroin or oxycotin often follows a treatment path that looks like this:

(1) trouble at home, school, or work (which may include an arrest (which may or may not lead to jail)

(2) 2-10 days in at a medical detox

(3) rehab (if they have insurance or enough money)

(4) intensive outpatient counseling (again, if resources are there)

(5) 12-step meetings

But this plan (or variations of it) are sometimes just not enough to help someone quit and stay away from opiates. There is an ever-growing body of scientific evidence that Medication Assisted Therapies are effective in helping treat people with opiate addictions. Despite this evidence, numerous people have risen to decry MAT. These opponents include people in 12-step programs, insurance companies and concerned professionals who think they aren’t handled properly at all times (this last group is different from the first two).

Methadone (a schedule II drug) was the first modern MAT and it was created in Germany in the 1930’s and introduced to America  in the late 1940’s. By the 1960’s, it was the defacto treatment for heroin addicts, especially ones in the cities. Critics of it consider it state-sponsored addiction and they have some justifiable points. Many people experienced euphoric highs on methadone and other stayed on for 10 or 20 years, living a seemingly zombie-fied life. It is probably the existence and public experience of methadone that have turned many people against MAT’s.

In 2002, the Drug Abuse Treatment Act (DATA) was passed by Congress and buprenorphine was introduced to the American public as the new MAT for the treatment of opiate addiction. Buprenorphine is better known as Suboxone or Subutex and has had much better success rates than methadone. Patients see a doctor one to five days a week (depending how far along they are in treatment and how well they are doing). Patients are expected to submit weekly drug screens and to get weekly therapy from a licensed substance abuse professional (this is not required by law…but it should be). Buprenorphine is classified as a controlled dangerous substance by the FDA (schedules III, IV and V, depending on the type and dosage) and can only be prescribed by medical professionals who have gone through a very specific multi-day training.

Suboxone diversion concerns some doctors.  These concerns are valid. The best article about buprenorphine I’ve come across appeared in the NY Times last November. Some medical professions are very loose when prescribing it, while others run a very tight ship. I prefer the latter group.

Vivitrol is injectable naltrexone. Because there isn’t any opiate or synthetic opiate in it, it is not a controlled substance. Any doctor can prescribe it. Patients get a shot 1x a month. Vivitrol helps reduce cravings and it mostly blocks the euphoric effects of opiates. When combined with therapy, 12-step meetings and/or other lifestyle changes, it can be quite effective. This is the MAT that I prefer and try first with people that see me.

There have been numerous instances where people in 12-step programs (AA or NA) have told new members that they shouldn’t take medication or that they “aren’t really clean” if they are using medication to assist their recovery. Those individuals are flat-out wrong. Dr. Lou Baxter, the past president of the American Society of Addiction Medicine (ASAM) recently wrote an article about MAT’s. His most recent article refutes false statements by self-appointed people that claim to speak on behalf of 12-step programs that people in recovery shouldn’t take medications to help quit drugs. Dr. Baxter argues:

Although there is no dispute that abstinence from alcohol and other drugs with potential for addiction is the foundation for sustaining recovery in most instances, there are other cases where MAT, especially for persons with co-occurring illnesses, is essential to obtain and sustain term recovery.

In the late 1980’s it was discovered by NIH that addiction was a brain disease. Since that time, medications with FDA approval have been developed to target those areas of the brain. These medications have shown great efficacy in assisting patients into and sustaining recovery. Every other chronic medical disease employs and encourages the use of medications in concert with life-style changes. Addiction medicine should examine the benefit of following suit.

MAT in addiction treatment is not required for everyone, but used in conjunction with 12- step programs and other biopsychosocial interventions, for those that need it, has shown to be invaluable in appropriate cases.

Another barrier to effectively using MAT’s has been that insurance companies rarely pay for them. Stuart Gitlow is the current president of ASAM and has been speaking and writing about the importance of MAT’s for the last several years. Last winter, he wrote an article about the barriers created by insurance companies (and some other impediments as well). Some directly-quoted highlights:

(1) …state governments and insurance companies regularly deny patients access to FDA-approved medications that could help reverse the epidemic of opioid addiction and overdose deaths. A new report released by ASAM examined the effectiveness of opioid medications and found these medications to be effective, safe and cost-effective when used for long-term maintenance treatment.

(2) Restrictions vary widely from state to state and from insurance company to insurance company, with almost none of them adhering to best practices research-based protocols for these medications.

(3) Addiction is a treatable chronic disease with success and relapse rates comparable to other chronic diseases such as diabetes and hypertension.

(4) None of the medications by themselves should be considered effective treatments for opioid dependence.

(5) Treatment professionals need to overcome their own prejudices against addiction medications and begin using them in comprehensive treatment protocols for the disease of addiction.

Bunavail was recently approved by the FDA. It is a lower-dose of buprenorphine that acts more effectively because of some improvements in the delivery method. I’m almost always in favor of coming up with advancements in medication that allow for lower doses. Lower doses leads to less side effects, which leads to better patient compliance. But this is all for naught if:

(1) medical professionals don’t require counseling and drug screens and recovery supports with the medication

(2) people in 12-step programs continue to speak out against MAT’s, pretend they are medical professionals and shame people in recovery who are using MAT’s

and (3) most significantly, insurance companies continue to not pay for MAT’s.

I’ve written a lot of marijuana this year. For the last twelve months, I’ve been speaking at conferences and universities about the history of marijuana policy in America and what the future may hold for us. I’ve focused a great deal of my attention on the recent legalization in Colorado and what I expect the consequences of that poor decision will be.

On December 4, 2014, I’ll be giving a webinar for the National Association of Alcohol and Drug Abuse Counselors (NAADAC). You can sign up for it here.

Last month, a story about me and my friend Fraser appeared on the Rutgers Today website. It is currently featured on the front page of the Rutgers New Brunswick website.

Fraser and I met at Voorhees High School in the the winter of the 1991-92 school  year. We were in honors sophomore English. There were a number of difficult kids in that class, and I still feel a bit badly for our teacher, Peggy Quadrini. Fraser and I spent the next couple of years partying, joking, eating, slacking off, watching sports, arguing and generally getting involved in chaos and mayhem. Eventually, I changed my behavior, joined the Army and went to college. Fraser spiraled downward. He cycled in and out of jails and recovery, bouncing from job to job and house to house. It was a nomadic life. A couple of times a year, he would put 60 to 120 days of continuous sobriety together. Each time he relapsed, I felt despair and anger. My first thought would be, “How could he do this to me?” and my second thought would be, “Why can’t he get it?”

In 2001, Tuffer and I picked him up from the Green Street Jail in Newark. They made us wait 4 hours until he had been there for 12 hours, so that they could bill someone for a full day in jail. After 9/11, Fraser talked his way onto the site at Ground Zero and helped in the rescue and rubble clearing efforts. In 2002, I visited him at the Somerset County Jail. His father had just passed away, and he told me, “The last time I saw my Dad was through the thick, plate-glass window of the visiting room here in jail.”  The last time I saw him was on July 8, 2002 in Clinton, NJ. He was boarding a van to go back to Freedom House (a halfway house that I really like in Glen Gardner, NJ). Eventually, he left it against medical advice. On September 23, I received a phone call from our friend Nat that Fraser had died the night before. We pieced together that he had been drinking and doing drugs. He threw up and choked on his own vomit and died. We suspect that the person he was dating was there at the time and didn’t call emergency services for several hours (because she was high at the time and there wasn’t a Good Samaritan Act then). I cried for days and felt empty. I kept thinking “I could have done more” or “I should have been there.”

Several people pointed out that I couldn’t have prevented his death and that I was powerless over his addiction. I grieved for a long time. Eventually, I realized that I was also angry at him for dying. It was hard being angry at my dead friend. I talked about it with a lot of people. A few months after his funeral, I left for Toyko, Japan. I taught English there for a year and then traveled around Japan and Southeast Asia. I mourned for Fraser and thought about what I was going to do with my life. When I returned to America, I took at job at Integrity House in Secaucus, NJ. A month after I started that job, I also applied to the MSW program at Rutgers.

I have been working in the field of substance abuse for 11 years now. The following is the best advice that I can give people that are concerned about a friend, family member or loved one that you think has an alcohol and/or drug problem:

(1) Don’t drink or do drugs with them

(2) Don’t drink or do drugs around them

(3) Set firm boundaries – don’t let them drink or do drugs around you.

(4) Don’t give them money. For anything. Money you give them for food, rent, clothes, legal fees or something else is very likely to be used for alcohol or drugs

(5) Get into therapy. You need someone to talk to about this. If you are a student in middle school, high school or college, there should be a counselor available at there for you to talk to

(6) Attend Al-Anon or Alateen. At least 6 times. If you go to a meeting and the focus is on the alcoholic or addict, go find a different meeting where the people there talk about themselves, their feelings and their actions (or inaction)

(7) Work with a professional and consider imposing consequences: taking away the car, their phone, kicking them out or even calling law enforcement on them. Encourage (or force) them to go see a licensed professional

(8) Confront them. Express your concerns. Do not yell, curse or name-call. Explain how you see they have changed, how you feel and what you want to be different (a professional can really help you with this). This is extremely important, as one of the criteria that professionals look for is, “Has someone every confronted you about your drinking or drug use?” If multiple people have confronted someone, that can help them get clean years before they might otherwise.

There are other things you can do, but this is a great start. Stop and think about how much time and energy you have spent worrying about your loved one. Do you get distracted during the middle of your day or lie in bed thinking about her late at night? Have you neglected other areas (or people) in your life? Have you made excuses or blamed others (their friends, the school, co-workers, ex’s or cops) for his behavior? If you’ve answered yes to any of those three questions, then you should go see a professional and follow my aforementioned steps. You may or may not be able to help your loved one, but you’ll certainly be able to help yourself.

I read an article on Fox recently with the headline “Face of Heroin Addiction Now Young, White and Suburban” (you can read the article here). The article was written after the release of a small study of people seeking treatment for opiate addiction. The major point of it is this:

Today, the average heroin user is 23 years old and tends to live in a suburban or rural area. More than 90 percent of the study subjects who reported that they began abusing heroin in the past decade were white. However, the study authors acknowledged that their research was limited, since they only analyzed participants seeking treatment for their addiction.

There are two points here, and neither of them should be considered new nor news. The first point is that a lot of young white people are using opiates. When “Glee” star Cory Monteith died last summer, the articles about “the new face of heroin” abounded. We’ve known this for about a dozen years. The proliferation of prescription drugs introduced a new class (and generation) of people to opiates. When those prescription opiates became too costly, they switched to heroin. The second point is that most of the people that get into treatment for opiates are white. On average, white people have more money, better insurance, less stigma and more access to treatment. Of course more of the people in treatment are white people. It’s this second point that really bothers me.

The heroin epidemic is not new. I’ve said so many times. Richard Pryor had a huge problem with cocaine, and it unfortunately played out in the national spotlight in the early 1980’s. He discussed his cocaine problem and how white people got caught up in it during one of his shows:

“Y’all remember?  Y’all used to drive through our neighbor hoods and shit and go, ‘Oh, look at that.  Isn’t that terrible.’ Then you’d get home, right, and your 14 year old’d be fucked up, and you’d go, ‘OH MY GOD!  IT’S AN EPIDEMIC!’..”

For decades, poor and minority communities have been ravaged by heroin use. Little was done to help and the plight of the addicted in those groups got worse. As a result, the economic and living conditions of their communities deteriorated as well. Addicted people are very likely to have addicted kids and the plague spread. Regardless of one’s moral views of this subject (or the value you place on poor and/or minority lives), there can be no mistaking the devastating economic costs of letting addiction spread and thrive. It has effected white suburbia in the 21st century, and now schools, parents, the media, law enforcement and politicians are noticing and attempting to take action.  Richard Pryor saw this happen 30 years ago with cocaine and spoke about it.

Paul Mooney has talked about this type of thing as well, but he gave a more apt-fitting name (or meme) to it:

The great political comedian Paul Mooney made his bones by laying in the cut between American democratic ideals and American behavior.  A mentor and inspiration to his friend Richard Pryor, Mooney’s stock-in-trade is a canny ability to thread the truth between ongoing and established hypocrisies — to make us see the pathologies that are still at the core of our decision-making and societal array.

One of his best routines involves the “nigger wake-up call,” that signal moment when the rest of America finally understands something, and comes to resent and acknowledge that which black and brown America has internalized and tolerated for generations

This last section was copied verbatim from David Simon’s post “The Nigger Wake-Up Call”, which he published last summer after the NSA home-spying revelations.

Regardless of race and class, we need to address the heroin and other opiates epidemic. If we only address it in the white and wealthy communities, then we have done a terrible, terrible job. We need to make sure that we implement sound policies and create excellent programs for all.

————–

Addendum (6/13): Here is a story from today about a drug sweep that recently took place in Northern NJ. As you can tell by the photos, an overwhelmingly majority of those arrested are young and white. Unsurprisingly, they will be offered treatment instead of incarceration. Another salient fact is that despite the changing demographics of heroin use, people travel into desolated inner cities to buy their drugs. If we don’t address the problem in the inner cities, those markets will continue to function and the work that is done in the suburbs will be ultimately fruitless.

The end of the article touches upon another sore subject: for those that live in Paterson (largely poor, largely minority), they don’t get that option. Their option is jail.

In the middle of May, the counties of Orange and Santa Clara in California filed a 100 page lawsuit against Big Pharma for “false advertising, unfair business practices and creating a public nuisance.” The LA Times ran a very good article on it. Some highlights:

(1) The lawsuit alleges the drug companies have reaped blockbuster profits by manipulating doctors into believing the benefits of narcotic painkillers outweighed the risks, despite “a wealth of scientific evidence to the contrary.”

(2) The complaint accuses the companies of encouraging patients, including well-insured veterans and the elderly, to ask their doctors for the painkillers to treat common conditions such as headaches, arthritis and back pain.

(3) The widespread prescribing of narcotics has created “a population of addicts” and triggered a resurgence in the use of heroin, which produces a similar high to opiate-based painkillers, but is cheaper, the suit says.

(4) In Orange County, where the lawsuit alleges there is a painkiller-related death every other day, Dist. Atty. Tony Rackauckas said he decided to pursue the case “as a matter of public protection.” The primary goal, Rackauckas said in an interview, is “to stop the lies about what these drugs do.”

The five companies named in the lawsuit are: Actavis, Endo Health Solutions Inc., Johnson & Johnson’s Janssen Pharmaceuticals, Purdue Pharma, and Teva Pharmaceutical Industries’ Cephalon Inc.

The most egregious offender is Purdue Pharma, the company that created Oxycotin in 1996 and has aggressively (and perhaps recklessly) marketed it ever since. In 2007, Purdue Pharma agreed to pay $635 million to settle charges that it had overstated Oxycotin’s benefits and understated it’s addictive qualities. While the fine may seem large, the Wall Street Journal estimates that annual sales of Oxycotin are about 2.8 billion dollars.  The fine amounted to about 20% of one year’s annual Oxycotin revenue. Clearly, this did not dissuade Purdue Pharma from their negative practices. Some other concerns involving Purdue Pharma:

(1) In 2013, the FDA denied generic versions of Oxycotin. This allowed Purdue Pharma to keep the patent and continue to rake in billions of dollars a year.

(2) Also in 2013, Purdue Pharma announced that they had received FDA approval to sell transdermal buprenorphine. Because of the explosion in opiate addiction over the last dozen or so years, there have been more and more people getting treatment and getting medication-assisted treatment. Buprenorphine (most common trade names are Suboxone or Subutex) is one of the best two medications for opiate addiction. Purdue Pharma is looking to capitalize on this market, which ironically (bitterly), they helped to create. If Purdue Pharma was a black male, the headlines would say that Purdue Pharma robs and kills people.

In the beginning of June, Chicago filed a similar suit against Big Pharma as well. It made headlines in NJ because Johnson & Johnson was one of the companies named. Here is a clip of a TV report about if from June 3rd.

Chicago Mayor Rahm Emanuel released a statement regarding the lawsuit:

“For years, big pharma has deceived the public about the true risks and benefits of highly potent and highly addictive painkillers in order to expand their customer base and increase their bottom line…It’s time for these companies to end these irresponsible practices and be held accountable.”

I expect that more counties, cities and perhaps states will follow these examples. Big Pharma is wealthy and employs a number of very smart lawyers. If the battles against the deceptive and negative practices of Big Tobacco provide a template, than this fight may be played out in the courts for  the next 5 to 20 years. It won’t help the person who is addicted or about to get addicted, but it might benefit kids born in 2014.

I’ve written a lot about ADHD. I have a policy piece about it on my site, which you can read here.

Miami University has taken these criticisms to heart and has created a new policy in which any student that seeks ADHD meds is required to do the following first:

(1) Students at Miami University who seek medication for ADHD must first go through an initial phone screen.

(2) They then attend a “brain booster” workshop, which lasts for 90 minutes. At the workshop, they receive a planner to help them organize their time, and are instructed in how to use it. They receive tips about time management, such as using their cell phone to keep track of appointments.

(3) Students are told how to improve their sleep, hygiene, minimize distractions, and improve their study skills and reduce procrastination. Italics are mine. Sleep problems cause so many other issues. People with sleeping problems are more likely to have physical or mental health problems, and vice versa.

(4) Several weeks after attending the workshop, students fill out a goal completion worksheet to demonstrate how well they have adopted the skills and behaviors they learned.

(5) If they decide to go ahead with an evaluation for ADHD, they attend another hour-long workshop, which is required even for students who have been prescribed ADHD medication in the past. They learn how to keep their medications safe in a college setting, and avoid misusing or diverting them. Only after they have attended both workshops can they see Dr. Hersh. “We slow down the process to screen out the people who just want a quick fix,” he explained.

It’s a fantastic process and I applaud them. I hope more schools follow suit.

You can read the full article here.

Two articles and two books that anyone who is interested in criminal justice policy (or addiction policy…or education policy) should read.

In December of 1998, Eric Schlosser‘s piece The Prison Industrial Complex appeared in The Atlantic. Mr. Schlosser is more well-known for his book (and the 2006 movie) Fast Food Nation (the topic about the food industry in America deserves several posts or another website – in my next life). It paints a disturbing portrait about the move to the privatization of prisons and what that means for people who go to court and the inmates who are incarcerated. It very much predicted situations like this (you should really click on that and read the horrible story about a judge who sentenced kids to a prison in Pennsylvania – he earned kickbacks from the owners of the prison for keeping it full).

The Caging of America by Adam Gopnik was published in the January 30, 2012 The New Yorker. It is what I consider to be the best single article on our prison system to date.

Ted Conover published New Jack in 2000. This review of it by Kathy Robbins appeared in Publishers Weekly:

Stymied by both the union and prison brass in his effort to report on correctional officers, Conover instead applied for a job, and spent nearly a year in the system, mostly at Sing Sing, the storied prison in the New York City suburbs. Fascinated and fearful, the author in training grasps some troubling truths: “we rule with the inmates’ consent,” says one instructor, while another acknowledges that “rehabilitation is not our job.” As a Sing Sing “newjack” (or new guard), Conover learns the folly of going by the book; the best officers recognize “the inevitability of a kind of relationship” with inmates. Whether working the gallery, the mess hall or transportation detail, the job is both a personal and moral challenge: at the isolation unit (“the Box”), Conover begins to write up his first “use of force” incident when a fellow officer waves him away. He steps back to offer a history of the prison, the “hopelessly compromised” work of prison staff and the unspoken idealism he senses in fellow guards. Stressed by his double life and the demands of the job, caught between the warring impulses of anthropological inquiry and “the incuriosity that made the job easier,” Conover struggles but nevertheless captures scenes of horror and grace. With its nuanced portraits of officers and inmates, the book never preaches, yet it conveys that we ignore our prisons–an explosive (and expensive) microcosm of race and class tensions–at our collective peril.

Michelle Alexander published The New Jim Crow in 2010. This blurb from her website does an excellent job describing her masterpiece:

…today an extraordinary percentage of the African American community is warehoused in prisons or trapped in a parallel social universe, denied basic civil and human rights—including the right to vote; the right to serve on juries; and the right to be free of legal discrimination in employment, housing, access to education and public benefits. Today, it is no longer socially permissible to use race explicitly as a justification for discrimination, exclusion, and social contempt. Yet as civil-rights-lawyer-turned-legal-scholar Michelle Alexander demonstrates, it is perfectly legal to discriminate against convicted criminals in nearly all the ways in which it was once legal to discriminate against African Americans. Once labeled a felon, even for a minor drug crime, the old forms of discrimination are suddenly legal again. In her words, “we have not ended racial caste in America; we have merely redesigned it.”

This is a moving story about a woman whose son was killed by a drunk driver in 1998. On June 2, she spoke at North Hunterdon High School.

I think that these kind of prevention programs are helpful – one never knows how they will resonate with attendees. I do think that schools should hold follow up discussions over the next few weeks after programs like these. The North Hunterdon-Voorhees Regional High School district has a pair of excellent student assistance counselors (SAC’s) that organize quality programs. More schools should follow their lead.

You can read the article here.