Dr. Martin Luther King Jr. was assassinated on April 4, 1968 in Memphis, Tennessee. He had traveled down there to fight for better conditions and wages for sanitation workers (people who work on garbage trucks) in that city. He was mourned and lionized after his death, becoming more and more popular in the years that followed. President Reagan signed a bill that made Dr. King’s birthday a national holiday in 1983 (it would not be celebrated by all 50 states until 2000*).  What many people don’t know is that he was quite unpopular for the last year of his life. This piece is about that final year and how his teachings are incredibly relevant today (his words appear in black bold throughout this article).

A nation that continues year after year to spend more money on military defense than on program’s of social uplift is approaching spiritual death.

These are the most well known lines from his April 4, 1967 speech at Riverside Church in NYC where he came out very strongly against the war in Vietnam. With this speech, he alienated President Johnson, turned off much of the black middle class, lost a number of his civil rights allies and was lambasted by the media. This did not surprise him – his advisers told him it would happen. Dr. King wrestled with whether or not he should speak out – he had won a Nobel Prize, had worked with the President on major civil rights legislation and had the respect and goodwill of a large number of Americans. After an internal debate, Dr. King decided to give the speech because he felt obligated to lead people in a direction that he felt was morally right, even if it came at great personal and professional cost.

When one sits down and comprehends Dr. King’s work and travel schedule, it is only then that one can see how authentic, passionate and tireless he was. Make no mistake, for the last several years of his life (and especially his last year), the man was exhausted. He would visit with regular people, meet with officials and speak in front of groups all in the same day, and he traveled to several different cities and states most weeks (but he tried to be in Atlanta for his Sunday sermon as much as he could). Dr. King did all of this without keeping any donated money (Coretta unsuccessfully lobbied him to set aside some to help with the bills and provide for the children’s education).

Dr. King traveled to cities like Chicago and Newark, where he spoke and marched and organized for improved housing conditions for the underprivileged, equal education, and better employment conditions while fighting against and raising the awareness about racial profiling and police brutality. This was in the 1960’s. It’s mindnumbing to reflect on those issues in Chicago and Newark in 2016.

There is a very dangerous development in the nation now to equate dissent with disloyalty.

Dr. King uttered these words about Muhammad Ali. In late April of 1967, Ali rejected induction into the US Army saying that “ain’t no Vietcong every called me nigger.” He was stripped of his titles, banned from boxing and sentenced to prison. Ali was able to avoid prison but he was held out of the ring for 3 1/2 prime years of his career. Some people called Ali a traitor. This deeply disturbed Dr. King. Criticism and dissent are quintessential American traits and rights. When people label their opponents as disloyal, they seek to silence other citizens, limit opinion, and lower the quality of public discourse. This has continued (and possibly gotten worse in the last 50 years), and it is behavior that both Republicans and Democrats currently engage in.

…less than 1 percent of the Negroes of our country have engaged in riots. More than 99 percent of the Negroes have remained nonviolent tactically.

He spoke these words on Meet the Press in response to the question about whether civil disobedience inevitably leads to civil disorder. Today, these words can be applied to Americans that are currently being unfairly demonized for the actions of an ultra-tiny percentage: latinos, latinas and Muslims.

Don, you’ll never know how easy you and Jackie and Campy made it for me to do my job by what you did on the baseball field.

Dr. King said this to Don Newcombe, a pitcher for the Dodgers and one of the first black players to play in the majors. Mr. Newcombe was stunned by those words and told Dr. King that he just played baseball and wasn’t the one that had dogs sicced on him, was beaten or thrown in jail. Dr. King responded by telling him that the baseball players led and he followed. This is particularly inspirational for me, because no matter the heights Dr. King attained, he acknowledged the legacy of others that came before him and paid them great homage.

Tell them not to mention that I have a Nobel Peace Prize – that isn’t important. Tell them not to mention that I have three or four hundred other awards – that’s not important. Tell them not to mention where I went to school. I’d like somebody to mention that Martin Luther King Jr. tried to give his life serving others. I want you to be able to say that I tried to be right on the war question…say that I did try to feed the hungry. I won’t have any money to leave behind. I won’t have the fine and luxurious things of life to leave behind. But I just want to leave a committed life behind.

This was part of Dr. King’s sermon to his Atlanta congregation on February 4, 1968. He was speaking about his eventual death and how he wanted to be remembered.Two months later, he would be killed at the age of 39. Today, I am a few months older than Dr. King was at the time of his murder. He has been, is and will continue to be one of the great role models of my life. I believe it to be a very worthy goal “to leave a committed life behind.”

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* Arizona and South Carolina were among the last states to acknowledge it as a holiday. To this day,  Alabama, Arkansas and Mississippi call the day Dr. Martin Luther King/Robert E. Lee Day.

One additional note: I’ve read a number of books and articles on Dr. King, but this piece owes a heavy debt to Tavis Smiley’s Death of a King, which is about the last year of Dr. King’s life and was published in 2014.

As his favorability numbers continue to plummet in NJ and his polling numbers hover in the single digits in New Hampshire, Governor Christie gave a State of the State address in Trenton today that was full of his typical bluster and bravado and soaring rhetoric and devoid of specifics. I am only going to respond to his statements about addiction and mental health policies in this piece, as I’ll let other experts react to what he said about the economy and education in their respective forums. I’ve been a critic of this Governor for a long time, and I went public with those criticisms after he delayed the release of the NJ Heroin and Opiate Task Force Report. I’m going to look at this piece by piece. The Governor’s words will appear in bold black.

Today, I’m asking you to join me in doubling down on our state’s fight against drug addiction. There are few things that I’ve worked on harder as Governor or that I believe in as strongly as this.

I can’t speak to whether he believes super strongly in the fight against drug addiction, but I fervently disagree that he has worked hard on this. The following list is damning:

1) In 2012, he vetoed the Good Samaritan Law. It would take lots of ground work by community activists like Paul Ressler, Patty DiRenzo and Linda Surks, dozens of editorials and the near overdose of Bon Jovi’s daughter in NY state to convince the Governor to change his mind and sign the Overdose Protection Act in May of 2013. In between his veto and signing, several hundred people died from overdoses.

2) His office did not provide any help when a group I was a part of (from 2010 – 2012) tried to open a Recovery Charter High School in Newark. Despite getting $500,000 from the federal government, his office was unresponsive to our requests for help. When the department of education denied us for a 2nd year in a row in 2012, we reached out to his office again and received no response.

3) He has neither visited nor acknowledged nor helped raise money for the NJ Recovery High School in Union, NJ. I can only guess this is because it is championed (and named after) by a nemesis, Democratic State Senator Ray Lesniak.

4) In fact, the Governor recently vetoed an overwhelmingly popular bill that would have established 3 state-sponsored recovery schools.

5) The Star Ledger’s Tom Moran wrote that “the number of addicts admitted to treatment has dropped on his watch, according to the “daily tracker” run by his own Division of Mental Health and Addiction Services. State spending on addiction has dipped as well.”

In 2013 we brought in the drug court program to provide mandatory treatment to first-time, non-violent, non-dealing drug offenders.

There is some lying, some exaggerating and an omission here. Drug Courts have existed in NJ for over a decade. Governor Christie did sign off on a bill that expanded the eligibility to more offenders, but he also did not provide additional funding (read that last sentence again).

Narcan has now been administered more than 7,500 times through this program – and we’ve achieved the first decline in overdose deaths in our state in four years.

I’m a huge fan of Naloxone (the drug that is in Narcan) and I’m glad it is getting distributed more and more. Again, this distribution was made possible by local activists and forward thinking law enforcement leaders. The Governor dragged his feet on this. And opiate-overdose deaths increased from 741 in 2013 to 781 in 2014, so there hasn’t been a decline. Unless the Governor already has the data from 2015 handy (if so, that begs the questions (a) why hasn’t it been released and (b) how come he was able to get this data so easily when he claims everything else takes so much time), it’s obvious that Christie lied.

And last July, we instituted a single point of entry for people to gain access to treatment, and more than 30,000 calls have already been made by people looking to connect with drug treatment programs. Not dozens of calls to try to find help; just one call, to one place. Now that’s the way government should work for those in need.

That’s true. This was proposed in our Task Force Report that was delivered to the Governor in the fall of 2013. The vice-chair, Eric Arauz, wrote that recommendation and it was carried out by the NJMHA. The report was published in 2014. It took the Governor 16 months to implement a phone line – is that “the way government should work for those in need?”

Today I’m announcing an expansion of one of our most promising anti-addiction efforts, the Recovery Coach Program. This month, the Department of Human Services is launching a treatment intervention pilot program in hard-hit counties for people recovering from drug overdoses. The specialists leading these interventions are often in recovery themselves, and they’re deployed to emergency rooms so they can provide guidance, support and referrals for treatment. With the benefit of their own experiences on the path to recovery, these recovery coaches can step in at the moment when victims of drug use are often at their most vulnerable and when support is most needed.

Stephen Stirling of the Star Ledger reported that “this program was spearheaded by the Ocean County Prosecutor, and began last year.” So he’s taking a lot of credit here that shouldn’t go to him. Also, I’m a bit wary of Recovery Coaches. Their current prescribed role of helping people that have been hospitalized after a Naloxone reversal find treatment is perfect. However, Recovery Coaches are a cheaper, less educated, less professionalized, and less experienced group than the Licensed Alcohol and Drug Counselors (LCADCs). Recovery Coaches require little training and no supervision – it is imperative that they be used for very specific purposes with clear guidance. There is a shortage of LCADCs in the state and it has an effect on the quality of treatment.

Today, I’m very proud to announce a historic financial commitment of more than $100 million to increase access to care for mental health and substance use.

This is the most significant point. He should have led with this. The big question is if it is $100 million additional dollars per year (this would be .2% of the state budget, a pittance, but totally acceptable to me), or is it $100 million over 3 years, or 5 years or 10 years (over several years is more likely). He didn’t get specific. Specifics are the Governor’s Kryptonite.

We’re going to provide more competitive reimbursement rates for services and providers. Nearly two years ago I commissioned Rutgers University to analyze the characteristics of our most expensive Medicaid patients. What they found was totally clear. Within the top 1 percent of the most-expensive Medicaid patients, more than 86 percent have a mental illness, substance abuse issue, or both. If we can help people get access to coordinated care for their physical conditions, mental health and addiction issues, we can deliver more effective treatment and lower the long-term cost to the state.

Good. My friend Glenn Duncan wrote an amazing piece about the problems of Medicaid reimbursements and how programs can’t provide treatment to a huge number of people who need it. Increasing the amount of money that Medicaid pays for inpatient and outpatient treatment will help thousands of people in NJ who have mental health and/or addiction problems. The “coordinated care” for all of those issues is straight out of Obamacare. Straight out of it (I took a health care policy class in the fall of 2014, and we spent half of the semester on the Affordable Care Act). Christie likes this aspect of Obamacare. Too bad he’s too much of a coward to tell the GOP primary voters that.

I propose today that we re-open Mid-State as a fully dedicated, certified drug abuse treatment facility for New Jersey prison inmates. The victims of addiction deserve treatment, whether they’re in the community or incarcerated. If we can break the cycle of addiction anywhere, we should break it.

Awesome. We can’t look at drug policy issues without looking at criminal justice issues. The GOP is going to be more effective on criminal justice reform than Democrats (who have always feared appearing soft on crime). I just don’t want to see the Governor turn the running of it over to a for-profit company. The half-way houses that Governor Christie’s friends own are rife with problems. Let a non-profit or the state run it. It can be modeled after the program Governor Jim McGreevey runs up in Jersey City. Governor Christie and Governor McGreevey are buddies.

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Last summer, I wrote about Governor Christie’s failures and how Romney’s campaign in 2012 was horrified with how Mr. Christie acted like he was Tony Soprano. Several political experts have written about how Christie has no shot at the Presidency, and I agree with them. That said, he will continue to be our Governor for another 2 years, and here are some specific tasks and programs that can actually address the addiction scourge and mental health problems that plague our state (I wrote about some of these in that aforementioned late summer piece as well):

(1) Expand the drug courts and fund them.

(2) Develop and implement a prescription drug education program to be taught to students throughout NJ, starting at age 10.

(3) Decriminalize marijuana.

(4) Mandate the prescription drug monitoring program (recently, he signed a bill that requires providers to check it every 3rd time, which is actually real progress).

(5) Consider early release of non-violent drug offenders who were given harsh sentences for possession of drugs (the Vera Institute of Justice estimates that it costs NJ between 50 and 60 thousand dollars to incarcerate someone here).

(6) Incentivize the creation of supportive housing for people with mental health and/or addiction disorders. Those houses need to be licensed or regulated though, as otherwise they’ll be full of abuse and neglect and will just add to the current problems.

(7) Speak out on behalf of the NJ Recovery High School in Union County. It bears Senator Ray Lesniak’s name (they hate each other), and by doing so it would show that the Governor can rise above petty feuds. It will also help get the word out about the school, which is suffering from low enrollment, despite the obvious need for it to exist.

At first glance, Governor Christie talks a good game. But a closer examination reveals that Mr. Christie appears to have issues with the truth, a poor memory, questionable follow through and a predilection for hurling personal insults at people. His speech today was more for the people of New Hampshire than New Jersey. In February, they’ll show him that they believe him as little as Garden Staters do. We all deserve better.

Ever since I was named to the Governor’s Council in 2011, I have increasingly thought about how politicians and the media influence and impact public perception (and thus, public policy) on addiction. I initially had high hopes for Governor Christie, as he was a former prosecutor who had talked about expanding the Drug Courts and the importance of treatment. As time went by, I saw that he talked a good game but neither provided additional funding to prevention/treatment/recovery services nor signed off on forward thinking bills. After his office delayed the NJ Heroin and Opiate Task Force report for over a year, I became a vocal public critic of the Governor. Last July, I wrote about how Mr. Christie has no shot at becoming President (and I listed his scandals and failures with lots of references) and offered advice about how he can be more effective in his remaining two years in office, with a particular focus on addressing substance addiction and recovery.

Last November, a speech by Mr. Christie in New Hampshire about his mother’s tobacco use and his law classmate’s addiction went viral and sent the political media into a tizzy (even liberal pundits said they were impressed). Mr. Christie talked about how it was a public health issue and that people with addictions should get treatment, rather than be arrested. I appeared on NPR with Brian Lehrer to discuss Mr. Christie’s speech and whether his policies match his rhetoric (spoiler alert: they don’t). That said, empty rhetoric is better than no rhetoric. From 2011 to 2015, I attended the Rutgers Edward J. Bloustein School of Public Policy and I spoke with multiple professors about my problems with Governor Christie and his empty rhetoric. Their responses can be summed up easily:

1) No one wins or loses elections talking about mental health or addiction policy

2) Even if a politician doesn’t actually do anything about it, the fact that he or she is talking about these issues brings it to the fore and allows for greater public awareness

In mid-December, I interviewed Sam Quinones, the author of Dreamland, which provides the best account of the history of heroin and the American opiate epidemic that I’ve come across. We talked for 80 minutes, and parts of that interview will be released on other professional sites. Mr. Quinones and I discussed Governor Christie and the rhetoric of politicians, and he echoed my policy professors’ views:

Frank Greenagel: It is election season, and I’ve been very critical of my own state governor, Governor Christie. He got a lot of press a month ago by giving an impassioned speech about his mother’s tobacco use and his law school buddy’s drug problem. Conservatives liked it and Democrats liked it and he was praised on MSNBC. I’ve heard the speech before, but when push comes to shove, he doesn’t fund anything. He still criminalizes marijuana; I’m for the decriminalization of it. He criminalizes marijuana, he hasn’t funded treatment bills, he resisted naloxone expansion, he resisted the Good Samaritan law. There’s point after point after point, so his rhetoric soars high above his actual policies. What happened after his speech is that politicians on both sides of the aisle have been tripping over themselves in announcing that they have a friend who is an addict. Or my family member is an alcoholic. I’d like you to speak to that. I know you like what Governor Kasich did in Ohio. Is there anyone else or anyone that has any kind of policies that said anything that seems to get it or is it all just a kind of campaign bravado, like I’ve seen from Governor Christie?

Sam Quinones: Regardless of what follow-throughs he did or did not do, the mere fact that people are beginning to talk about it is really important and remarkable. I don’t know his record in New Jersey in funding programs or passing laws. I did think it was interesting to listen to him to say that because those words spoken 15 years before would have disqualified him from the Republican nomination. His campaign would have halted right then. Now, you can see these Republicans now are, again, as you say, tripping over themselves trying to tell the most gripping story of addiction in their family, which I think is a huge step forward. I really do. I think it’s very important. I don’t know that I see anyone who has understood the issue well enough. Nor do I even think Barack Obama does. I watched him at the Charleston, West Virginia town hall meeting that he held and it seemed to me that it was an issue that was far off for him. He did not feel comfortable with it, didn’t know how to pronounce naloxone and this kind of thing. That’s understandable. He’s got ISIS. He’s got a million other things that are important, but it seems to me that it’s still in the phase where people are approaching this, or not entirely comfortable with this topic yet.

About a week after Governor Christie’s New Hampshire talk, Ben Carson responded to a question about addiction by not answering and instead chose to talk about political correctness. I pilloried him for it in an article, and took that as an opportunity to write about past Presidential families and their problems with addictions (Adams, Roosevelt, Ford). Unlike Mr. Christie, Dr. Carson said all the wrong things.

Yesterday, Carly Fiorina penned a piece for Time magazine. She wrote about her step-daughter, who died from addiction at the age of 34. She also wrote about what the government should do for those with mental health problems and addiction disorders, and how we need to reform the criminal justice system:

We must invest more in mental health and in the treatment of drug addiction. We shouldn’t be criminalizing addiction. If you’re criminalizing drug abuse, you’re not treating it. In New Hampshire alone, 85% of state prisoners have a substance abuse problem. These men and women need help. We need to reform the criminal justice system and make sure we’re putting the right people in prison. The federal prison population has nearly doubled in the last 20 years—and nearly half of the inmates in federal prison are in there for non-violent drug offenses.It’s important to keep violent criminals out of our communities—but it’s also true that prison is not always the right answer. Drug offenders who go into treatment—rather than through the normal criminal justice system—are about 25% less likely to be re-arrested in the two years after leaving the program.

I’m thrilled that she made these points. This is an astonishing change from 30 years ago and the disastrous policies of President Reagan, when prevention programs were based on “Just Say No” and funding for treatment programs were cut and the prison populations exploded due to draconian sentences for drug possessions. Now multiple Republican candidates are talking about the importance of drug treatment and sensible criminal justice reform, including the son of Ronald Reagan’s VP.

Today on The Medium, Jeb Bush wrote about his daughter’s addiction and recovery:

As a father, I have felt the heartbreak of drug abuse. My daughter Noelle suffered from addiction, and like many parents facing similar situations, her mom and I struggled to help. I have so many friends and know so many families who have faced this terrible challenge. Addiction crosses all barriers, all lines, all races and all incomes. It creates real hardship and heartbreak in families. And, it places substantial demands on government at every level. I never expected to see my precious daughter in jail. It wasn’t easy, and it became very public when I was Governor of Florida, making things even more difficult for Noelle. She went through hell, so did her mom, and so did I.

It’s very debilitating when you have a loved one who is struggling, and you can’t control it. You have to love them, but you also have to make it clear you cannot enable the behavior that gets them in trouble. Showing a lot of courage, Noelle graduated from drug court. Drug courts use a restorative solution model involving multi-disciplinary coordination, including the judiciary, the prosecution, mental health specialists, social services and treatment professionals. I was the proud dad that saw Noelle finish that. She’s drug-free now.

The New York Times reported on his post today and also wrote that Governor Bush would be appearing at a drug policy forum in New Hampshire later this afternoon and would talk about his plans to address mental health and addiction problems:

Mr. Bush’s plan to deal with the issue has four main components: preventing drug abuse and addiction, strengthening the criminal justice system, securing the southern border with Mexico to stop the flow of illegal drugs, and improving treatment and recovery programs.

Neither Mr. Bush, Ms. Fiorina, nor Mr. Christie have released detailed policy plans yet, but the fact that they are all talking about these issues is substantial forward progress.

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

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

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“The Poppy”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Are businesses being supportive of veterans?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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