Category Archives: addiction

Serious Brain Illness: We Can Tear Down This Wall


Today, on the birthday of Dr. King, what will you do to honor his memory?  I took some time to think about the particular essence of the work he took up, the work that never gets completed and is always necessary.  I’d like to suggest there are two basic elements of that work.  First, we must always bear witness to our shared wrongdoing, by naming and calling out the human-made class, habit and stereotype driven barriers to human potential; and second, we must just as vigorously speak of our capacity for something better, offering each other enlivening glimpses of the possible future, through the yet-to-be torn down walls.

The barrier I want to call out to you today is the one we’ve created for those with serious brain illnesses like schizophrenia and other psychotic disorders.  We didn’t cause these brain illnesses, as best we can tell— they present their own barrier, for sure, but that’s not the one I’m naming. 

The barrier I mean is our special singling out of humans with life-threatening brain illnesses to be left largely without treatment, ignored and even criminalized.   If you watch this video of a man with schizophrenia, homeless due to his illness, being beaten to death by police instead of given desperately needed treatment, and you then learn his killing was not found criminal by a jury, you can see what our created barrier has done.

I had a hard time watching that.  I had to do it in pieces.  I said I wasn’t going to watch, because my imagination was painful enough, and because nothing about this event is actually new or unusual, and because I am a caregiver for a young adult with this same illness, and because I didn’t need another reason to cry about what is happening to sick people.  Lots of excuses, but bearing witness means we have to watch the hard parts.

Now you can take a breath, and I’d like to offer the second half, a glimpse of a future where we tear down the barriers to treatment we have built.  We made them:  we can take them down. 

We haven’t seen substantial national legislative effort to do anything until recently, with the Helping Families in Mental Health Crisis Act.  Representative Tim Murphy, a psychologist, has put forth a game-changing bill that would go a long way towards allowing people with serious brain illnesses to live safely and with dignity in their communities, instead of being consigned to homelessness, jail, and early death.  I have read and thought about the bill in entirety (there are links in the site above).  I endorse it strongly. I am contacting my legislators to request their support.  I believe it will do some work that seriously needs doing.  That’s my short version.  If you’d like to know a few more specifics, please read on and also see discussion of the bill here.  If there are questions not addressed, please let me know and I’ll try to get an answer for you.

Quick Summary of HR3717: Helping Families in Mental Health Crisis Act

This bill would restructure administration of planning and funding at the federal level in a shift towards known to be effective policy and an evidence-based approach to evaluating programs.  Focus would be put on services allowing persons with serious brain illness to stay in their communities while being effectively treated.  Specific parts of HIPAA (health information privacy law) would be modified to allow caregivers to know information necessary to health and safety. 

I have seen criticism of the bill from advocates with milder brain illnesses who fear mandatory treatment would be forced upon them or that choice would be removed from those who have done, as is typically said “nothing wrong besides being mentally ill and homeless.”  I can certainly understand why someone with a mild illness would extrapolate the same ability to think and reason clearly to someone more severely affected and be concerned about the ill person’s freedom.  Indeed, we all might do well to have the level of concern necessary to monitor treatment programs and legal action from misuse.  There will always be a gray zone where assessment of competency to make decisions is uncertain.  On the other hand, we don’t quit giving antibiotics to patients with meningitis just because they are used wrongly for viral illnesses. We don’t shut down hospitals that are needed but are not functioning well, because we still need somewhere to go when we have heart attacks—we fix them. Wait, we DID do that…but only for brain illnesses.

Reading this bill, I would say that if an error has been made, it appears more likely in the direction of slightly undertreating, due to long-standing fears of overcalling brain illness.  The gray zone has been largely excluded. Only those with the most severe psychotic illnesses are addressed by the bill, and some will still be left out in the effort to preserve rights.  Breaking down a barrier takes time and sometimes has to be done stepwise.

As I’ve discussed in prior blogs, those with severe brain illness often present with anosognosia—inability to recognize their illness.  Rational thought is lost due to the illness itself, which renders the choice of treatment or not meaningless to the person.  Paradoxically, mandatory treatment can sometimes restore thinking ability to the point of competency.  Even when that doesn’t happen, treatment increases the chance substantially that the person will be able to live in the community and enjoy the normal rights and potentials the rest of us enjoy.  A person having a stroke will be treated, even though he can’t ask for help.  A person with severe brain illness, whose illness steals his ability to understand why help is needed, is not treated because he doesn’t ask.  Both must be treated in order to access their ordinary civil rights.

Funds Currently Misdirected

SAMHSA, the Substance Abuse and Mental Health Services Administration, would come under direction of a new office, the Assistant Secretary for Mental Health and Substance Use Disorders, as part of the Department of Health and Human Services.  This person would have to be an actual psychiatrist or psychologist with research and clinical experience.  A National Mental Health Policy Laboratory would consult with the National Institute of Mental Health to identify evidence-based policy, implement it, and monitor outcomes.  An interagency coordinating committee would work to integrate all federal work on mental illness and would include representatives affected by brain illness under treatment, family members, and advocates.  Professional peer review would be required for all grants and proposals.

At present, SAMHSA is not administering available funds in a targeted, evidence-based manner.  Priority is not being given to those with the most severe though treatable illnesses and is being distributed to various fluff grants instead.  Sometimes redesigning administrative functions is just window dressing.  And sometimes, that is the only way to shake things up enough to change them.

A few years ago, I was offered a chance to attend a SAMHSA funded training session for healthcare providers on substance abuse screening.  Because I was in the process of helping a group of pediatricians in my state select a screening tool for teens, I registered, hoping I would learn more about how to use the tool.  I had a paid trip to Miami, where I stayed in a fancier hotel than I would ever manage on my own, for a 2 day session targeted primarily at screening and motivational interviewing for basically well people.  Instead of focusing on how we could work with patients ill with serious addiction, the thrust was on how anything more than 1 drink a night for women or 2 for men could be a health risk and how we could help people quit doing that.  Addiction was normalized and thus forgotten.  How many people could have undergone actual treatment for the funds taken to do that conference?  If the restructuring frees up funds to be used well, we can afford to do so much more.  Throwing money at a problem definitely doesn’t solve it when so much goes in the storm drain or gets blown away—aiming and directing money at a solution works much better.

Redirecting Funds: What is AOT?

There would be 50 grants available to establish new Assisted Outpatient Treatment programs (AOT).  AOT is an evidence based therapy to provide monitored treatment of brain illness in an outpatient, community setting.  The requirements are stringent—only those who are not able to provide for their own basic needs due to brain illness, who are likely to substantially deteriorate without treatment, who lack the capacity to make decisions, who have a history of violence, incarceration due to illness or repeated hospitalizations due to non-adherence with treatment, or who present a danger to self or others would be included.  AOT has been determined constitutional in court.  Typically outpatient commitment is ordered for a one year period and can be renewed, but only if the same conditions are still met.  At the court hearings for commitment to AOT, the patient would have legal representation and could give testimony.  No permanent or longstanding sentence is imposed.   If a year seems long, remember illnesses this severe and chronic are not likely to be going away.  And prison sentences for untreated persons are often far longer.

This does not mean the eccentric guy who puts out funky lawn ornaments is going to be held down and given a shot.  It does not mean every person who hears voices, or mumbles to herself in the grocery store, or is disheveled, or preaches on the street corner is going to be picked up by police.  Forget what you’ve heard about mental illness being so common and ordinary—it is not, not the kind covered by this bill.  We don’t have the money to do that kind of thing anyway.

The bill would increase funding for the most serious forms of brain illness and specifically devote a portion to illnesses associated with violent acts, in effort to find more effective treatments.  It would provide for education in schools on signs of brain illness and how to respond.  It would extend meaningful use funding for electronic health records to psychiatric facilities.  Liability protection would be extended to qualified volunteer physicians at outpatient psychiatric clinics.  Funding would be put into suicide prevention programs.

The bill would give grants to establish telepsychiatry programs and train primary care doctors to work in collaboration with psychiatrists.  It would give planning grants to 10 states to establish Federally Qualified Behavioral Health Clinics, which would be required to include child and adolescent trained psychiatrists and staff, training in dual diagnosis (addiction plus another brain illness), rehabilitation services, peer support, and supported education/ employment.   It would fund training for first responders to recognize brain illness and act appropriately to avoid killing the person they need to help or being killed themselves.  It would strengthen funding for mental health courts and veterans’ treatment courts.  It would protect medications from exclusion from state Medicaid formularies.  It would fund inpatient and residential treatment for those on public insurance between age 21 and 65.

Eliminating Obstacles to Sharing Vital Information with Caregivers

For patients being supported by a caregiver, usually a family member, at present HIPAA creates a dangerous barrier to good care.  In order to provide home care that is actually a form of residential, medical care, the parent or other family member must be able to know what medications are to be given, what side effects to look for, what symptoms of relapse are, and how to respond appropriately.  The caregiver must also be able to locate a hospitalized family member and be able to give crucial information to the treatment team.  We ran into a problem with this a few years ago, when we were not contacted upon hospitalization of our family member until he gave consent the next day.  He had been started on a medication that had given him dangerous side effects in the past, and we could have prevented that had we been notified.

The bill would allow only such pertinent information to be shared with caregivers, the same as it would be shared with nursing home staff.  If a person is not ill enough to need a caregiver, this section is irrelevant.  So it does not mean that your therapist is going to tell your mother about your session and what you said about her.

Flaws in the Bill

So, what are the flaws in this bill?  Every bill has them, of course.  These are the ones I see:  non-brain-based language is used throughout—“behavioral” is a particular annoyance.  People with heart attacks are having a “behavior” when they grab their chests, I guess.  The same-old same-old “quality” monitoring measures and incentives are proposed, which are not really measurements of quality care but of less sick patients.  Effective quality improvement can be done, and not like that.  The HIPAA improvements do not, for some reason, include 14 to 18 year olds.  A friend suggested to me this was because state laws regarding minors are so different.  However, at least it would be wise to include caretakers for emancipated minors in the safety-motivated release of information.  There is no provision to require medical information to be given to primary care doctors by psychiatrists, which turns out to be harder to get done than you’d think.  Many states have restrictions on sharing such information, despite it being crucial to safe patient care.  I see a lot of grants and funding which appear temporary, so I do have concerns that states may establish services that will then lose funding.   This is not a reason to avoid beginning, just a caveat that we will need effort to maintain what we start.  I do not see any of these flaws as critical to change before passing the bill.

Today, I have made my very small act in honor and appreciation of Dr. King and his life’s work.   I have called out a harmful, human-made barrier to the lives and dignity of those affected by serious brain illness.  And I have shown you a view of the possible, a better path forward.  Small acts can add up, when we all do them.  What do you see, in place of the barrier?  What will you do to help take it down?

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Filed under addiction, evidence based medicine, Healthcare reform, mental health

Your Epidural is Against the Law: What Alabama Women and Doctors Need to Know


We have one more day of Alabama’s 2013 legislative session, when it is still possible to ward off the ghastly specter of Foreign Law from being forced upon us.  Colorado, that means you—stand back, with your Rocky Mountain High and your happy newly-weds.  Meanwhile, our beloved state Supreme Court has brought pregnancy and childbirth back to what they think God meant it to be—drug free.  No epidurals.  That can work well, especially if you have a midwife or a doctor skilled in normal unmedicated birth, but do women want to give up that option?  How about no spinal blocks for c-sections?  Girlfriends, better practice your breathing!  Obstetricians, addiction specialists and anesthesiologists, do I have your attention?

 

Our story begins back in 2006, when Alabama passed a Chemical Endangerment statute meant to protect children from harm in meth houses.  Although it said nothing whatsoever about pregnant women and was never intended to apply to women who become pregnant while addicted or who use a drug during pregnancy, that didn’t stop prosecutors from jumping right in.

 

I first learned of the problem when National Advocates for Pregnant Women (NAPW) contacted me about efforts to challenge the prosecutions of two Alabama women jailed under such misuse of the law. I decided to add my name to amici curiae briefs that explained to the court how dangerous these prosecutions are for maternal, fetal, and child health.  I’m proud to be listed right there with the 47 groups and individuals who co-signed, including ACOG (The American College of Obstetricians and Gynecologists), the American Medical Women’s Association, the National Perinatal Association, and NOW-Alabama.  Y’all know I’m a good progressive, but ACOG has never been accused of such.  What gives?

 

I know my obstetrician friends are truly concerned about the well-being of pregnant women and babies, and I’m sure that’s part of ACOG’s reason to sign on.  They must know the law puts these women in an impossible position—abort, or deliver and go to jail.  Stopping drug use before delivery is often not a safe option.  ACOG also had to be aware of risks to their professional membership.  The law as it was originally enacted and intended by the legislature says a prescription of a controlled substance is only legally given to a child if directly prescribed for the child.   If revised to include prosecution of pregnant women who take a drug, there is no exception within the statute for the many situations when physicians prescribe controlled substances to pregnant women.  A controlled substance given partly to protect a fetus (such as methadone, if a woman with addiction wants to safely continue pregnancy) is not prescribed to the fetus.  An epidural used during labor or a spinal block for a c-section contains opiates as a way to reduce the need for toxic anesthetics, but it is prescribed to the woman.  General anesthetic protocols include several types of controlled substances, again dosed for the woman.  What’s left, supposing you need your appendix out while pregnant?  Bite hard on that stick and it’ll be over soon.

 

Despite a well-done court challenge, Alabama’s Supreme Court couldn’t resist the chance to get back-door personhood.  In January, they decided the word “child” included fetuses and went a giant step further by adding non-viable fetuses, embryos, and fertilized eggs.  Talk about judicial activism!  We are informed that “outside the right to abortion created in Roe and upheld in Planned Parenthood, the viability distinction has no place in the laws of this State.”

 

You really ought to read the ruling to get the full contortionist flavor.   I’ll wait while you go wash your mouth out.  If you didn’t make it to the end, here it is:  “We conclude that Court of Criminal Appeals correctly held that the plain meaning of the word “child” in the chemical-endangerment statute includes an unborn child or fetus.  However, we expressly reject the Court of Criminal Appeals’ reasoning insofar as it limits the application of the chemical-endangerment statute to a viable unborn child.”

 

Applause came quickly on the anti-choice sites, such as this one quoting Liberty Council founder Mathew Staver: “The U.S. Supreme Court’s abortion cases are an aberration to law and stand on an island by themselves, and that island will one day disappear.”  We know that is the underlying intention of these prosecutions and of the Alabama Court’s decision.   What a nice bonus for them that women also get to experience pain of Biblical quality while undergoing surgery without medication!

A Senate Resolution is in the works which would affirm the Court’s interpretation of the statute as correct.  If passed, will Governor Bentley sign it?  Does he understand the consequences to his physician friends?

 

Here’s an interesting scenario:  let’s suppose a pregnant woman is pressured or forced to undergo c-section against her wishes and is given spinal anesthesia.  She is royally outraged, as she should be, and requests charges pressed against the obstetrician and hospital for chemically endangering the fetus.  Can the prosecutor refuse to do so?

 

There are two paths I can see for prosecutors to travel.  They could comply with their duty to enforce the law as interpreted, in which case physicians who care for pregnant women ought to look a mite more nervous—if not sweating and trembling or packing their bags—when I pass them in the hallway.  Or we could continue to see this law used selectively, for low-income women who are addicted.  I can tell you that at least where I practice, no one is arresting well-off mothers taking prescribed opiates during pregnancy.  Much as I’d like to, I sure haven’t seen a slow-down in c-sections either.  The law is broken many times a day, without so much as a raised eyebrow.  Huntsville, Alabama, living on the edge. . .

 

Without even a token effort to apply the law equitably, it seems to me the law is unconstitutional as applied.  The state must be aware it is violating Equal Protection by not defending all fetuses, only poor ones.  If so, we ought to expect at least a few arrests of women taking prescribed pain medications or methadone, and perhaps their physicians.  Who will that be? Are you quite certain it won’t be you?

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Filed under addiction, Alabama Legislative Session 2013, women's healthcare

The Dismantling of Justice and Rise of the Medical-Police State


As Alabama continues its slide into financial ruin, many of you may be unaware how severely curtailed some of our necessary state functions already are.  We continue to pile on the tax incentives to corporations without demanding proof of economic effectiveness, and at the same time we add new crimes at a fast clip.  Increased demands on law enforcement and prisons are oddly excused from state requirements to locate funding for the effects of legislation.

 

Drug possession is arrested heavily in Alabama, without regard to whether the possession results from addiction and/or other illnesses, like chronic pain with inadequate treatment or mental illness.  The great majority of arrests have nothing to do with sales—less than 10% in our state.  It is illegal to have the active illness of addiction, and extra illegal to be addicted and black.  If you are a woman and happen to become pregnant while addicted, you can be additionally prosecuted for the “chemical endangerment” of a child.  This is a gender-specific crime—there’s no penalty to the man who contributed to initiating pregnancy within the body of an addicted woman. The only sure-fire way for a woman to avoid those additional charges is to abort.

 

Who will pay the cost of our medical police state?  Just as with sales tax, the burden of funding will fall increasingly on the shoulders of those least able to pay.  We already have multiple “pre-trial diversion” programs in Alabama that allow arrested persons to enter various treatment programs, at their cost, instead of going through the court system, at our cost.  I’ve talked with attorneys who are glad to have these options for their clients, but they admit the programs are mismanaged in many cases and that addicts are placed in them often without regard to likelihood of ability to complete such a program.  Upon failure, they enter prison according to their pre-signed guilty admission and still owe the costs of the diversion program.

 

One lawyer told me he has clients do a dry run of treatment, not supervised by the court, in the time leading up to a decision on diversion.  Because our system has such a backlog, he may have as long as a year to see if his client can succeed.  He will only advise his client to enter formal diversion if the person has done well on the practice effort.  But with low pay for court appointed attorneys, there are unfortunately those with far too heavy a caseload who don’t even meet their clients ahead of time.

 

The quality of the programs is borderline in many areas of the state.  I have a friend whose significant other, a man with bipolar illness and addiction, was sent to one of the “faith-based” programs locally.  When he told the supervisors about his mental illness diagnosis, did they do the correct thing and request psychiatric treatment?  No.  They called in a couple of preachers to pray away the demon of bipolar.

 

Arrest and exorcism as a treatment tool in the war against drugs makes about as much sense as arresting tobacco addicts in the war against cancer.

 

Twelve step groups can be critical for recovery of the whole person, more than just treatment of the addiction itself, and I’ve spoken to many addicts in recovery who say the groups saved their lives.  They tell me there is a tremendous difference between being sober as a “dry drunk” and being in meaningful recovery as part of a community.  But “intention to treat” success rates in twelve step recovery are not substantially better than other methods, meaning that when you take a random group of addicts and send them to walk the twelve steps, it “works if you work it.”  Many addicts will benefit from such groups as an adjunct to additional medical and professional psychological treatment but will fail without ongoing professional help.  There are evidence-based treatments available, including for dual diagnosis of addiction and mental illness, but they cost money—Alabama has none left after the corporate vig.

 

SB 285 is up (again) this year.  This bill would expand the use of pre-trial diversion at the unregulated discretion of the local DA, without need for local legislation or approval.  It specifically allows the use of “certified” faith-based programs.  The administrative fees paid by arrestees would go into the DA’s funds, instead of being used to fund good treatment programs or legitimate fair trial in drug courts.  Although there are provisions to waive the fees for indigent clients, there is no provision against causing a minimally self-supporting person in recovery to become indigent as a consequence of the fees.  I am told by treatment providers this creates a significantly higher risk of relapse during early recovery.  Advocates for those with addiction and mental illness need to vigorously oppose “pay to play” programs that financially burden sick people without giving them a fair trial.

 

We need to reform our entire approach to drugs and addiction.  I’d like to suggest Alabama enter a state-wide Twelve Step program, which can be done in a non-religious way.  Our first step as co-dependents is to admit that all our efforts against drugs that treat addiction as criminal have failed, and the second is to look elsewhere for help.  Testing potential Medicaid and foodstamp recipients for drug use and then cutting off benefits or throwing sick people into prison makes as much sense as emptying an addict’s stash into the toilet or tying a drunk man to the bedposts and hitting him with a skillet.

 

We need to move to the making amends part pretty quickly.  A good start would be to accept the Medicaid Expansion post-haste as well as fully funding addiction and mental health treatment services—good ones, not those involving exorcism. Then we need to seriously consider the benefits of Medicare for All, with full parity for addiction and mental health medical treatment.  Treatment should ideally be provided through evidence-based public programs instead of through faith-based or private programs that rely heavily on funds from high relapse rates.

 

Please contact your legislators and tell them why you are opposed to these bills.  Speaking as an individual citizen and not in representation of any advocacy group, I am dismayed at the public silence of the Alabama Department of Mental Health.  On behalf of their clients, they ought to be all over the news, calling for a moratorium on criminal prosecution of illness.  Their vision statement reads “lifting life’s possibilities through a system of care and support that is consumer driven, evidence-based, recovery focused, outcome oriented and easily accessible, with a life in the community for everyone.” DMH, where are you? Will you not speak up?

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Filed under addiction, Alabama Legislative Session 2013, evidence based medicine

The Courage to Raise a Ruckus


Whenever I turn on the news lately, there is Charlie Sheen, disintegrating in front of the world.  I am far more appalled at the media and their audience, however, than I am at him.  They have put his suffering on display as if he were a circus animal, and their viewers respond with snide comments on Facebook.  For shame, for shame.

Addiction is a brain disease.  It is not any of these things: a spiritual failure, a character defect, a lack of willpower, or a lack of self-respect.  Yes, it usually leads to all those problems, but it is primarily a disease of the brain, just like mental illnesses, Alzheimer’s, or autism.  We have substantial scientific evidence to prove it.  Treating patients with therapy and support groups helps (although these don’t cure the disease), but effective treatment doesn’t imply a cause—broken bones are not a splint deficiency, cancer is not a chemotherapy deficiency, and strep throat is not a penicillin deficiency.  We understand that with most other diseases but somehow fall into stupid thinking when it comes to addiction.

Imagine this scenario—we declare a War on Cancer.  To this end, we throw cancer patients in jail if we catch them being sick. We allow insurers to refuse payment for their treatment. Insurers that do pay for a cancer diagnosis cover two weeks of chemotherapy, just until the patients feel a little better, but are allowed to deny payment for the full three month treatment research has shown to be more effective.  If cancer patients do go into remission and then relapse, we put them on national television and make fun of their distress.  And just to make it clear that the cancer is their fault (after all, they are the ones who ate the fast food or got sunburned), we tell them to call themselves cancerists, not people stricken with the disease of cancer.

When family members of cancerists try to help but don’t know how to do it effectively, we call them codependent and encourage them to take care of themselves instead, detaching from the sick people.  Sometimes we do tell them to have cancer interventions, where they show the cancerists the effects of their disease, convince the cancerist to get treatment, and then don’t pay for it.  We would never suggest families wear pink ribbons and hold fund-raising marathons or publicly advocate for insurance coverage—that would be codependent too.  Cancerists and their families should be discrete and not speak publicly about the illness anyway.  Instead of funding enough research to find a real cure, we embrace a chronic disease model for cancer.  Cancerists must accept that they will be cancerists forever.

Sounds ridiculous, right?  But that is just what we have done.  We have declared a War on Addicts and called it a War on Drugs. 

In Twelve Step Programs, addicts and their families learn a simple prayer to help them cope, the Serenity Prayer.  It goes like this:  God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.  It’s a beautiful prayer and has been helpful to many, but it is not the prayer families of patients with addiction need right now.  Let me propose an alternative.  God grant me the courage to raise a ruckus!

Here’s a challenge to you all.  Before passing judgment on sick people, educate yourself about the illness of addiction. Whenever you turn on the television and see any person being mocked because of mental illness, addiction or otherwise, turn it off and call, write or picket the station and network.  Boycott companies who fund these networks with advertising.  If you advertise on TV, pull your commercials in protest.  “Dislike” the catty Facebook comments of your friends.  Declare War on Addiction—advocate for increased NIH research and insist on full insurance coverage for evidence-based treatment.  Do these things noisily enough to be heard—it’s going to take a real ruckus to make any difference.  Quit being so serene and get a little wiser. Our attitude toward the disease of addiction is something we can change.

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Filed under addiction, Healthcare reform