Non-medication remedies for ADHD

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.


A few must-reads about incarceration in America

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.”


A Mother Shares Her Pain

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.


Big Pot Problems in Colorado

I was not surprised to see this headline in the New York Times yesterday:

After 5 Months Of Sales, Colorado See the Downside of the Legal High

A few quick quotes and points from the article:

(1) “I think, by any measure, the experience of Colorado has not been a good one unless you’re in the marijuana business,” said Kevin A. Sabet, executive director of Smart Approaches to Marijuana, which opposes legalization. I’ve written about Kevin Sabet and his amazing book Reefer Sanity before. You’ll see his name in more and more articles over the next few years.

(2) The industry has generated $12.6 million in taxes and fees so far, though the revenues have not matched some early projections. I wrote about this before. Click here.

(3) “Every major institution said this would be horrible and lead to violence and blood in the streets,” said Brian Vicente, one of the authors of Amendment 64, which legalized marijuana in Colorado. “None of that’s happened. The sky did not fall.” This is both hyperbole and a lie. No one, as far as I’m aware of, predicted “blood in the streets.” What we did predict was that more kids would try marijuana, more people would get addicted to marijuana and that the revenues would not be what was projected.

(4) Many of Colorado’s starkest problems with legal marijuana stem from pot-infused cookies, chocolates and other surprisingly potent edible treats that are especially popular with tourists and casual marijuana users.

On Colorado’s northern plains, for example, a fourth grader showed up on the playground one day in April and sold some of his grandmother’s marijuana to three classmates. The next day, one of those students returned the favor by bringing in a marijuana edible he had swiped from his own grandmother.

“This was kind of an unintended consequence of Colorado’s new law,” said John Gates, the district’s director of school safety and security. “For crying out loud, secure your weed. If you can legally possess it, that’s fine. But it has no place in an elementary school.”

So far this year, nine children have ended up at Children’s Hospital Colorado in Aurora after consuming marijuana, six of whom got critically sick. In all of 2013, the hospital treated only eight such cases. I wrote about this before too. Click here.

(5) Even supporters of legalization such as Mr. Vicente say Colorado needs to pass stricter rules about edible marijuana. He said the state was racing up a sharp learning curve.

“Marijuana was illegal for 80 years,” Mr. Vicente said. “Now it’s legal, and everyone’s just trying to figure out how to approach these new issues.” Exactly. Let Colorado and Washington be the petri dishes. Let them see what works and doesn’t work. There is no need to pass any other marijuana laws in other states for the next three years.


Addendum (6/3/2014): More unintended consequences and policy implications: Legalized marijuana and workplace testing


Addendum #2 (6/5/2014): The New York Time’s Maureen Dowd’s bad edible marijuana experience in Colorado was detailed here.


Addendum #3 (6/6/2014): Marijuana coffee. That makes no sense. It will be sold in Washington.


Addendum #4 (6/7/2014): Marijuana for your dog. Here is a story that describes how marijuana helped a dog stop having seizures. Dogs are popular (almost as popular as babies and veterans), and so if you go against marijuana in this instance, you are also going against dogs. It’s an animal interest story planted to swing people off the fence towards the marijuana industry.


Addendum #5 (6/9/2014): Marijuana is leading to more car crashes and 12% of fatal accidents now involve pot. Colorado has seen a huge increase since 2009 (when the first medical marijuana dispensary opened in that state). We can’t really call this unintended consequences of medicalization & legalization, because a number of us have called it for years.


Addendum #6 (6/25/2014): More data about the increased number of people arrested while driving under the influence of marijuana can be found here. I have to say it again: I told you so.



Locking up the mentally ill

There was an article two weeks ago in the New York Times about the rising number of mentally ill inmate attacks on prison staff at Rikers Island. It is not a particularly good article, as it addresses the wrong problem, but you can read it here.

What is particularly interesting is the reactions to the article.

A letter to the editor from the May 30th New York Times:

As a former Rikers Island mental health worker, I found that although your article spotlights the challenges in providing mental health treatment behind bars, the larger question is why the mentally ill — specifically, those with schizophrenia, bipolar disorder and dementia — are being treated in a jail setting to begin with.

When the big state psychiatric hospitals were shuttered decades ago, it was with the promise that they would be replaced with smaller, community-based supervised housing — something that never materialized.

Most of the psychiatrically impaired have been arrested on minor offenses, like trespassing, as in the case of the homeless vet who recently “baked to death” in his cell.

Making good on the long-awaited promise of outside support and supervision would likely reduce the number of low-level transgressions that lead to arrest, would mean humane care for our most fragile citizens, and would go a long way in reducing jailhouse chaos.

Brooklyn, May 22, 2014

The writer, a psychiatric social worker, was an assistant mental health chief at Rikers in the Giuliani administration.

And these from June 1:

To the Editor:

Re “End Mass Incarceration Now” (editorial, May 25):

For nearly five decades, I have worked with formerly incarcerated men and women. Two things guided me to reach the conclusion that our prison system is an exercise in institutional futility.

First, the system almost never allows the inmate to consider the factors that led him or her to addiction and/or crime. In fact, to survive in that dehumanized subculture, you have to continue the behavior and thinking that lead to imprisonment.

Second, virtually nothing in jail or prison prepares a person for re-entry to society. One man described it best, saying: “I had to put on coats of armor to survive in prison. Someone has to teach me to remove those cloaks of protection so I can function in society.”

The bottom line, reflected in the country’s high recidivist rate, is that the prison system is contributing to antisocial behavior. We have to be more creative in how and why we incarcerate, and whom.

New York, May 25, 2014

The writer is the founder of the Fortune Society.

To the Editor:

One salient fact was not mentioned in your editorial: the percentage of those incarcerated who suffer significant mental illness. This fact was revealed in your coverage of Rikers Island (front page, May 22), which reported that nearly 40 percent of those prisoners were mentally disabled.

Have we emptied our mental health facilities only to have former patients end up in jails and prisons? Is that where they belong?

Is it better to have the mentally ill controlled by prison guards rather than by psychotherapists, and by fire hoses rather than by therapy and drugs?

Is their incarceration not a national disgrace?

Washington, May 25, 2014

The writer, a former reporter for The New York Times, is a trustee of the Bazelon Center for Mental Health Law.

To the Editor:

As a professor of criminal justice and a researcher who has spent 40 years examining the long-term effects of mass incarceration on prisoners and society, I believe that the concept of redemption must play a much larger role.

Redemption — the ability finally to forgive — is consistent with a positive notion of the human condition. The alternative is to continue to lock people up for extended sentences with little regard for how this is crushing American society financially and spiritually.

Countless inmates (arrested for both nonviolent and violent crimes) pose no discipline problems within the prison system. After years of being incarcerated, many have redeemed themselves. Their behaviors have changed, and yet they are not released. At some point, keeping such a person locked up becomes simply cruel.

If given the opportunity, incarcerated people can change and show transformation and growth through such means as earning a high school equivalency diploma, staying off drugs, getting back with their families, connecting with their children, and connecting with the families of victims.

But can the public forgive such people and offer them a second chance to become productive citizens, instead of their remaining costly, endless drains on our resources?

Milwaukee, May 28, 2014

The writer is dean and a professor at the Helen Bader School of Social Welfare, University of Wisconsin-Milwaukee.

To the Editor:

The problem with prison overcrowding is that prison operation is becoming a new major moneymaker, at the expense of the most vulnerable.

The Corrections Corporation of America was formed in 1983, during a Reagan privatization moment, and since then, the business of running our federal, state and local prisons has been slowly passed on to private companies whose goal is to have all their jail beds filled to keep the wheels of commerce churning profits.

Many of these companies hire out the inmates to provide essentially slave labor for manufacturers, paying the inmates little or nothing — slave wages.

It’s hard to stop a moneymaking operation once the shareholders are happy. Sounds like another great financial successful story.

Peterborough, N.H., May 25, 2014


Two recent articles on prisoners in Baltimore and how marijuana causes brain damage

This was supposed to be posted back on April 16, but it got lost in the shuffle. I’m releasing it now without edits.


I’ve posted a lot in the last two days, so I’ll just link to these articles with minimal comments.

Jeffrey Tobin posted this about prisoners at a Baltimore McDonalds on The New Yorker’s website today. He discusses how prison is a ubiquitous experience in certain parts of America.

This article from NBC news reports that even casual use of marijuana causes brain damage. The news is more grim for heavy users (those that use 3x a week or more).


America Fails Its Veterans

In the spring of 1932, 43,000 people (including 17,000 veterans) marched on Washington DC to demand WWI bonus money that had not been paid out. It was known as the Bonus March. Most of the veterans had been out of work for a long time and were really struggling during the first few years of the Great Depression. President Hoover sent in the Army (led by General Douglas MacArthur) and had them forcibly removed. A smaller group marched on Washington the next year and FDR avoided the mistake of his predecessor, sending his wife to talk to them instead of using armed force. However, the veterans did not get their money until Congress passed the Bonus Act in 1936, four years after the march and 18 years since the end of WWI. It would be neither the first nor the last time that America had not honored its debt to her veterans.

File:Bonus marchers 05510 2004 001 a.gif

As America celebrates Memorial Day with baseball, barbeque and the beach, the Veterans Administration has been in the news because its delays, inefficiency, incompetence and corruption has caused the deaths of many veterans. This is just the latest tragedy that has befallen our Soldiers, Sailors, Marines and Airmen.

During the Pacific Nuclear testing in the 1950’s, thousands of sailors were exposed to dangerous radiation (in the picture below, they just shield their eyes from the blast). At first, they were told that they weren’t in any danger. As time passed and more and more sailors got sick, the evidence became overwhelming that they got sick from radiation exposure. They were eventually compensated, but it was much too late and not nearly adequate.

The military experimented on its personnel with amphetamines and LSD in the 1950’s as well (members of the Armed Forces have historically made great guinea pigs, as they are legally bound to follow the orders of their superiors and also disproportionately made up from poor and/or minority groups).

Earlier this year,

U.S. District Judge Claudia Wilken ruled the Army must notify veterans of possible health concerns related to the experiments. In November, the Army requested a delay in the process, claiming the notification process would cost nearly $9 million. This request was denied after Wilken ruled the cost borne by the Army paled in comparison to the health of veterans.

During Vietnam, members of the Armed Forces were exposed to Agent Orange. This selection from Wikipedia sums it up nicely:

While in Vietnam, the veterans were told not to worry, and were persuaded the chemical was harmless. After returning home, Vietnam veterans began to suspect their ill health or the instances of their wives having miscarriages or children born with birth defects might be related to Agent Orange and the other toxic herbicides to which they were exposed in Vietnam. Veterans began to file claims in 1977 to the Department of Veterans Affairs for disability payments for health care for conditions they believed were associated with exposure to Agent Orange, or more specifically, dioxin, but their claims were denied unless they could prove the condition began when they were in the service or within one year of their discharge.

By April 1993, the Department of Veterans Affairs had only compensated 486 victims, although it had received disability claims from 39,419 soldiers who had been exposed to Agent Orange while serving in Vietnam.

In the 1990’s, servicemen were instructed to take the Anthrax Vaccine. Early on, there was some suspicion that there were a number of problems with it and that it may have caused the Gulf War syndrome. Those that refused to take it were threatened with a court martial and/or a dishonorable discharge (I declined to take it in the late 1990’s while in the NJ Army National Guard).

Five years ago, CNN reporter Jack Cafferty asked the question “Why don’t we take better care of our veterans?” (click on it and read in horror how little has changed in five years). The article cites delays at the VA, inadequate care, skyrocketing rates of PTSD, addiction and suicides. Little was done then and little is being done now.

A few years ago, I began hearing about how therapists were asked to diagnose soldiers and veterans with borderline personality disorder instead of PTSD (if a soldier has PTSD, then the military must pay for that soldier’s treatment; borderline personality disorder is a diagnosis that is considered lifelong (so not the military’s fault) and the treatment of it is not paid for by the government or by insurance). The New York Times published the story about a female therapist (a Captain) who was discharged because she had borderline personality disorder. She didn’t have borderline personality disorder; instead, she had PTSD from serving in a war zone. The military has a long history of diagnosing personnel with disorders they don’t have in order to get rid of them.

Despite all of this, many veterans would like to get treated by the VA. But a number of them are ineligible because they did not get an honorable discharge. Thousands and thousands of warriors from Vietnam to the present have been given an other than honorable discharge for reasons such as PTSD or substance abuse. They end up in our emergency rooms, institutions, jails or in the streets. It is a fate that is both unfair and economically disastrous for everyone involved. (The Daily Show had a great segment on this issue last winter: to see it, click here)

Many of those aforementioned substance abuse problems began in the military when doctors prescribed the servicemen painkillers. One of my current students at Rutgers was a Marine in Afghanistan. While over there, he was wounded. He experienced PTSD and had trouble sleeping. There were many Marines in his unit with similar issues. The unit doctor prescribed them all with Xanax and Oxycotin. They were able to sleep better and return to the field, for a time. Eventually, they became addicted and were discharged under other than honorable conditions. My student returned to NJ and quickly moved on from pills to heroin. He ended up on the streets of Paterson. His story is the rare case in that it has a happy ending – he got sober, learned a trade, went to community college and then transferred to Rutgers. He is a good, honorable man and an excellent student. And he is ineligible for VA services.

Two weeks ago, the New York Times ran a front page story about veterans and painkillers. It’s fantastic and I urge you to read it here.

In the May 25, 2014 NJ Star Ledger, State Senate President (and probable 2017 Gubernatorial candidate) Steve Sweeney wrote an op-ed piece about the sacrifice of veterans and all the things that NJ is doing for them. There is only the briefest mention about mental health treatment and nothing about addiction treatment:

…we must do whatever we can to help veterans, those who remain in service and those who become civilians. The wounded should be cared for and treated with the best medical and rehabilitative services we have. This includes physical, mental and psychological wounds. These are all casualties of war.

And yet my student and thousands of other veterans like him in NJ can’t get federal or state funded treatment. Republicans and Democrats like to wear flag pins and talk about the sacrifice of veterans yet they continually fail them when it comes time to provide and fund treatment. And many citizens are not much better – they repost memes and pictures on Facebook and engage in hashtag activism, but that doesn’t solve this problem. Call your local and state officials. Let them know you are outraged. Tell them you want funding (real funding) for the mental health and addiction treatment of all veterans, including those with other than honorable discharges.


The great exception to all of this has been the G.I. Bill, which has paid for millions of veterans to go to college since the end of World War II. The G.I. Bill was partly responsible for the post-war economic boom of the 1950’s and 60’s and largely responsible for the success of that generation. The G.I. Bill is both a reward and an investment in our veterans. We need to build on it.



Addendum (5/26 12:07 pm): Steve Fulop, the current mayor of Jersey City and another 2017 Gubernatorial hopeful, penned his own op-ed for Memorial Day as well (you can see Sweeney and Fulop lining each other up in their sights). While it is better than Sweeney’s and follows up on my own summation, it misses on a few of my aforementioned points.



What Are Prescription Drug Monitoring Programs and Why Do They Make Sense?

NJ Spotlight’s description of Prescription Drug Monitoring Programs (PMP’s) is the best I can find anywhere on the internet. You should click on that link before continuing with this post.

I have a friend who was clean and sober for 13 years. He had a problem with alcohol and heroin. He got clean in his early 20’s, earned a professional degree, got married, bought a townhouse and had a respectable job. He had a back injury and was prescribed prescription painkillers. He found that he really liked them and quickly began to take more than was prescribed. Pills that were supposed to last 30 days would last 10…so he began to see other doctors and have them prescribe him more painkillers (this is called doctor shopping). He would get Oxy 30’s from the the North Brunswick Rite-Aid, Vicodin from Flemington Eckerd and more Oxy 30’s from the New Brunswick Walgreens.

This was before NJ had a PMP, so none of the doctors that he saw could check to see if he had gotten other drugs from other doctors. They could only see what he got at their own facility. The same was true for pharmacists – they could not see what he was getting from other pharmacies. As a result, he got terrible medical care and was able to game the system (and abuse his mind and body). His life spun out of control, and his job, marriage and life were in danger.

New Jersey’s PMP was instituted in January of 2012 (my Task Force colleague Tom Calcagni was the driving force behind it). In March of 2012, my friend went to two different doctors and got two separate prescriptions for painkillers. He filled one at a pharmacy in Somerville. He tried to fill the other prescription at a pharmacy in Edison, but the pharmacist checked the PMP and saw that he had just gotten the other prescription filled. My friend left (it was a good job by a diligent pharmacist…except that pharmacist should have alerted the authorities so that my friend could have been dealt with).

The NJ PMP has been up and running for 2 1/2 years, but only 15 (15!) doctors and advanced nurse practitioners use it. Pharmacists are much better, but less than 20% of them check it. A PMP can be very effective at preventing prescription drug abuse,  catching abusers, and cutting the supply of drug dealers (some people doctor shop to stock up on pills to sell) if it has full participation by prescribers and dispensers. 16 states currently have mandated PMP’s; sadly, NJ is not one of them.

My friend continued to abuse prescription drugs throughout the summer and fall of 2012. He bounced in and out of treatment centers. At one in-patient rehab, he learned from other patients which pharmacies and doctors use the PMP and which ones don’t. This kind of news is valuable in the drug using community and travels fast. After he left that treatment center and relapsed, he sought out the doctors and pharmacies that didn’t use the PMP.

Last summer, the NJ State Commission of Investigation released a report that urged the governor and the legislature to make the PMP mandatory. This March, the State Task Force on Heroin and Other Opiates made the same recommendation. Despite the fact that more people in NJ die every year from opiate overdoses, mandated PMP bills continue to meet resistance from some doctors and legislators. A few of the doctors that have spoken out against it (including Burlington Democratic Assemblyman Herb Conway) say that it will unduly burden their profession. More accomplished doctors like Dr. Louis Baxter think it is necessary and non burdensome. There may be no one that knows more about drug policy in America than Dr. Thomas McLellan; not surprisingly, he also supports mandating PMP’s.

The infra-structure of the PMP is already in place in NJ. Mandating it will cost very little and the benefits will be large (it will save money and lives). It will add a few minutes a day to the workload of a doctor (actually, it won’t – the bill we support allows for an office staff member to enter and check the PMP).

My friend’s wife went to Al-Anon, set firm boundaries and forced him to get honest and go to treatment. He’s clean and sober for over a year now and doing much better. He is very lucky. He could have overdosed, gotten arrested, been fired from his job or lost his marriage. If NJ had a mandated PMP, he would have been caught much earlier. If he had died, his friends and family would have been left to wonder what might have been. It didn’t happen to him, but it happens so many other times.

This is a no-brainer. Governor Christie knows it, but he won’t push for it. If we can’t pass it in NJ, I’m cynical about our ability to make changes in more difficult areas to address this epidemic.



Medication for Alcoholics and What Most Doctors Don’t Know

There was a nice article in the health section of the New York Times on 5/13/2014. I’ve linked to it here.

The gist of it is that there are medications, naltrexone and acamprosate, that can help reduce cravings for alcohol and increase abstinence rates.

Very few doctors are aware of these types of medications and even fewer are trained on them. If you or someone you love has an alcohol problem, they should see a professional, licensed substance abuse counselor (in NJ, the license is a LCADC: to find a provider in your state, click here). Additionally, they should get a physical exam and see an ASAM doctor. They understand addiction and will prescribe the best medication, if applicable (and more importantly, are less likely to mis-diagnose and falsely medicate some other perceived psychological issue).

Medications should not be taken in a vacuum. They should accompany some type of therapy (individual or group), regularly monitoring, and patients should be encouraged to check out AA meetings and/or Smart Recovery.

There are a number of people in AA who disapprove of medication assistance for alcoholics (or addicts). Those people are wrong and are acting, at best, irresponsibly and at worst, criminally, by telling someone not to take medication if they want to be sober. The only opinion AA has on this is that outside professional help is often needed and that members should not act as doctors.