VIII – Concluding Considerations:
North Country Forums: Answers to the questions I’ve posed above will come from the bottom-up, from friends and family and neighbors, not from government bureaucrats or politicians or treatment providers stuck with commonplace solutions that don’t work.
The third page on my website,www.paddlingupstream.org, which is currently being re-fashioned, is entitled North Country Forum. It’s where I post my blogs, my opinions on the issues of the day, and where I invite readers to post their reactions to what I write so a discussion can ensue between us. I harbor the ambition to establish a “live” Forum in Long Lake sometime in the Fall; and, if that does get up and running, I’d like to see folks from nearby communities pay us a visit and bring the idea of a forum, a venue to discuss problems like the opioid epidemic, back to their own towns. It strikes me as ironic and shortsighted that the folks who live the problems are rarely, if ever, asked by politicians and government officials what their take is on those problems, and equally infrequently, have the opportunity to debate and discuss possible solutions. It’s the only way out of the box.
In the interim, three key issues likely to spark a spirited debate at a North Country community forum are outlined below. Their presentation will serve to conclude my primer on and summary description of the opioid epidemic afflicting the North Country and the nation.
1st – Overcoming barriers to treatment: Outreach is the ultimate answer. It remains to be seen if the State will fund it to connect addicted persons to treatment. The original NY State outreach program in mental health was Intensive Case Management (ICM), whose objective was to assist individuals presumed to have serious mental illnesses and discharged from State and acute care psychiatric hospitals to re-settle in their home communities. I directed a large ICM program preceding my retirement in 2010, since which time all ICM programs throughout the State have been replaced by computer-driven Mental Health Homes, whose case managers monitor their clients’ treatment compliance via internet software and intervene with them personally only when they fail scheduled appointments with their treatment providers. The direct antithesis of Intensive Case Management.
The one State-sponsored program that has continued is Assertive Community Treatment (ACT), whose presumed mentally ill clients within a specified catchment area are served by an ACT Team , the latter comprised of several mental health professionals, each with her/his own area of expertise – psychiatry, nursing, social work, etc. It is regarded as a “Best Practice” program, i.e., approved by third-party insurance payers, primarily Medicaid, as providing a re-imbursable service. While used extensively in New York City, ACT was originally developed in Wisconsin to serve rural areas of the state that lacked necessary community-based resources, particularly those related to medication maintenance, social and financial support and drug and rehab counseling.
Needless to say, an ACT Team would appear to have the capacity to reach those persons in the State’s many rural areas, including the North Country, who are abusing opioids and other addictive drugs or have become addicted to them, who, until some calamity befalls them, rarely seek treatment at their own initiative. It’s my guess that these are the individuals at greatest risk of overdose. The ACT Team’s job would be to visit various small communities within a given area, its visits advertised well in advance, and render the assistance needed and make necessary referrals. Although again a guess or speculation on my part, the Team could be comprised of a nurse practitioner (NP), a nurse case manager and a drug treatment specialist, perhaps a social worker, at least one of whom would be CASAC–certified (Credential in Alcoholism and Substance Abuse Counseling), and all of whom would have familiarity with opioid abuse and related treatment medication. The NP would have chief responsibility in this area and would be licensed to prescribe needed medications.
Most importantly, and key to any outreach operation, the Team would provide a needle exchange for those who are using drugs intravenously, usually a great attractant that will serve to facilitate a connection between the IV drug users and the team and have the added benefit of reducing the risk of HIV or Hepatitis C infection. (For additional information on needle exchanges, readers are directed to the Injection Drug Users Health Alliance (IDUHA), www.iduha.org, and to St. Ann’s Corner of Harm Reduction (SACHR), www.iduha.org/st-anns-corner-of-reduction, a Bronx-based drug treatment program and IDUHA affiliate.)
Since the foregoing would involve the use of ACT in a novel – or out-of-the-box – enterprise, i.e., outreach to persons abusing drugs, the State and OASAS will resist mightily. The biggest obstacles will be how to pay for it and will it be worth the cost, answers to which can only be provided via a pilot program, i.e., placing ACT teams in two or three locations for 1-2 years and tracking their effectiveness or success in attracting and helping their prospective clients; determining the ideal staff composition; identifying unforeseen barriers; and obtaining an on-the –ground estimate its cost. In short, a pilot program will cost money; and a determined advocacy campaign will have to be organized and political support mustered from fellow Adirondackers, our State representatives and experts. A very tall order but an illustration of the enormity of the task in effecting necessary change.
2nd – De-criminalization & ending the War on Drugs: This is where the money will have to come from, an even taller order of business.
Frankly, I can’t wait until the phony War on Drugs is ended – too little gained at too high a cost for black men, for men and women of all ethnic backgrounds, for all the people of the Americas, North and South. It’s time to surrender our international title as prison capital of the world. Yet, while de-criminalization of all drugs considered illicit is many years off, the legalization of recreational marijuana seems right around the corner. California was among the first states to legalize the medical use of marijuana, in 1996. My sister who, together with her wife, cultivates a small crop of medical marijuana in Mendocino county, reports a recent upsurge in the number of medical marijuana purveyors, accompanied by tighter government regulation, both setting the stage for California’s ballot initiative this November to legalize recreational marijuana. It’s seen as likely to pass. Six other states have the same initiative on their ballots, but California holds the key to opening Pandora’s box of legalization, which, if the ballot initiative carries, is expected to set off a wave of legalizations by other states and pressure the Federal Government to do likewise.
Fortunately, legalization and its correlative de-criminalization won’t catch the State and Federal governments unaware and unprepared. Colorado, which approved recreational marijuana use in 2012, appears to have very quickly established a thriving and well-regulated recreational marijuana industry in the State. My niece, who lives in Aurora just outside of Denver, tells me that marijuana retail stores have the appearance of well-appointed boutiques, with the many varieties of cannabis and their dosages clearly labeled and each’s finer points highlighted. It will offer a business model and regulatory guidelines for other states to follow. My niece reports that the State’s coffers are filling with marijuana tax monies, and large quantities of cash from retail sales are accumulating but can’t be deposited and safeguarded in local banks due to the Federal government’s anti-drug laws. With California leading the charge, it’s inevitable that the growing number of states that have approved the use of recreational marijuana by their residents will begin lobbying the Feds and the Congress to repeal the laws that legislate criminal penalties for use. It’s equally certain that Big Pharma, with its very large pocketbook, will join and take a leadership role in the lobbying effort. It’s only a matter of time, perhaps 10 years, maybe longer.
I confess to some ambivalence about legalization – probably more than half of all Americans are walking around with their brains altered by pharmaceuticals and intoxicants at a time when clear-headedness would seem to be a valuable national commodity. I guess that beats reality, and it’s either that or Pokemon-go. The one consolation is that fewer people will get incarcerated for marijuana possession and selling. I’m also curious about where all those marijuana-generated tax dollars, surely the carrot for most states, are going to go. A recent article in “Marijuana Politics” (February, 2016) informs that, in Colorado in 2015, nearly $1 billion in sales generated $135 million in tax revenue, $35 million of which will be invested in capital improvements to local schools. And what about the other $100 million – where will that go? Will any money go to drug treatment or to providing the employment, training, housing and related resources required to re-integrate persons recovering from addiction back into the social fabric? I’m too well versed in the reigning philosophy of denigrating the “other” and throwing her/him away to have any confidence that government will invest money in “junkies”, even if they happen to be white.
De-criminalization of cocaine, the opioids and methamphetamine is an entirely different matter. Still associated with the “other” these days, despite the realities of the opioid epidemic – I’m referring to black Americans and poor Americans, who continue to be stereotyped as those more likely to become “junkies” – de-criminalization of drugs that carry higher risk is an entirely different matter. It would represent the de facto end of the War on Drugs and, as a consequence, the Drug Enforcement Agency (DEA), which, together with its law enforcement, Congressional and corporate allies, can be expected to protest the loudest. The DEA just reiterated its opposition to the Federal legalization of medical marijuana, citing the FDA’s contention that marijuana has no scientifically validated medical use (National Public Radio [NPR], August, 2016). Which is like throwing a rock into a rising torrent. The DEA was also on the verge of conducting forays into local pharmacies that were filling large numbers of opioid scrips until President Obama ordered it to stand down. I can just picture SWAT-suited DEA agents storming into my Rite Aid pharmacy in nearby Tupper Lake and scaring everyone to death. In any event, the DEA budget will be $30 billion for FY 2017 and promises to continue to grow annually, as it has since the DEA was legislated into existence in 1973. That’s a lot of money and it represents enormous power and political influence.
In short, de-criminalization of the more dangerous drugs is a very long shot, and, should it happen, will occur gradually over a long period of time. By way of endorsement, Johann Hari cites the Portuguese experience, where, over the course of 15 years, Portugal went from having 1% of its 8 million residents addicted to heroin in 2000 to a 50% reduction in IV drug use by 2015. The government de-criminalized the use of heroin, stopped its fruitless war on drugs and transferred its entire drug enforcement budget to treatment and social remedies, i.e., subsidized jobs and housing. A British Journal of Crimology study of the Portuguese initiative reported a dramatic reduction in overall addiction rates. Portugal, of course is not the United States, and the use of controlled substances has never been as politicized as it is in the U.S.
It’s important to clarify that de-criminalization need not necessarily equal legalization, It might best be employed, given the opposition it is certain to stir, as a gradual or transitional strategy that would lead, one far off day, to legalization. Specifically, it could involve the reduction of criminal penalties, as has been done in several large U.S. cities, notably New York, with the possession of small amounts of marijuana reduced from a low level felony to a misdemeanor. Such an approach readily complements the objectives of advocates of criminal justice reform and their political allies here in New York, who are working to secure the early release from prison of persons sentenced for drug possession under the harsh penalties of the Rockefeller laws, and to restore sentencing discretion to criminal court judges.
The Law Enforcement Assisted Diversion (LEAD) pilot project initiated by Seattle in 2011 represents a promising example of a gradualist approach, and was prompted by the large number of young, homeless IV heroin users and addicts who were flooding Seattle’s downtown business district and committing a slew of petty crimes, often victimizing the area’s workers or tourists. The HBO documentary program, VICE, featured LEAD in its April, 15, 2105, program, which is how I learned of its existence. Law enforcement before LEAD was largely a revolving door operation — the Seattle P.D. would dutifully stop and arrest those openly using or selling illicit drugs, usually heroin, or those committing petty crimes and found with drugs in their possession ; would bring them in for arraignment, where those arrested were given the option of serving jail time or entering a methadone detox program and having their sentences reduced. Members of both cohorts eventually returned to Seattle’s streets and continued their pre-arrest behavior, repeating the process.
LEAD was designed to interrupt the revolving door. It is described by those who originated it as a harm reduction program that is rooted in client choice and the close cooperation between the Seattle police, the Seattle municipal court and LEAD case managers. Accordingly, it attracts those individuals who are ready to make the changes that will take them off the streets and lead to their social re-integration. In essence, LEAD’s clients self-select, but they can also be referred by the cops on the beat who have gotten to know them. The only conditions they have to agree to comply with are to accept the services of a case manager and to not commit any petty crimes or person-on-person crimes, i.e., steal from or assault or mug anyone. Violation of the latter will automatically revoke the agreement they made with the municipal court judge and result in their immediate remand to jail or prison to complete their sentences. Once they’re in the program, their case managers can help them to develop a plan to pursue a purposeful life: link them to housing and employment, help them re-connect to estranged families and friends, and assist them to enter treatment and drug rehab programs. The choice to enter treatment or not is solely theirs to make, increasing the likelihood that they will take responsibility for and follow through on their decisions.
The VICE report characterized LEAD as largely successful, with much satisfaction expressed by its clients and by the case managers and police officers working with them. Seattle has decided to continue the program, which is funded, at least in part, from savings accrued from reduced municipal jail and court costs.
Whatever the eventual outcome of de-criminalization and legalization v. the War on Drugs and business as usual, there is sufficient money at hand, in the form of Federal tax dollars, to secure effective treatment for those who want it and provide the social reintegration resources that are the key to drug-free lives for those who are addicted to opioids and other substances. Yet it appears the Congress cannot be trusted to do that. In May, the grandiose-sounding Comprehensive Opioid Abuse Reduction Act, aimed at bolstering law enforcement programs, was enacted but funded at only $103 million annually over 2017-2021. A relatively paltry sum, given the need, but one that raises the question as to why almost nothing for treatment and over $400 million for a system that does not need the funding. War on Drugs knee-jerk response, I suppose. Then in July, the House passed a bill designed to redress that grave oversight and fund new addiction treatment and prevention programs. However, as The New York Times noted in a July 12, 2016 editorial, no funding was appropriated. In response to a dispute with the President over money – Obama wanted a $1 billion treatment appropriation, the House leadership one-half that amount – the House tabled that discussion until September. So much for the urgency of the opioid epidemic.
The putative criminal justice reforms that social justice advocates and sympathetic politicians are beginning to push will complicate matters further. If enacted, increasing numbers of inmates, most convicted of low-level drug offenses and many of whom former addicted persons, will be released back home. What resources will be provided for them to effect successful community re-integration? Will they just be allowed to revert to old habits and over-learned criminal and addicting behaviors? Just to refresh readers’ memories, we do have a tried but not so true template for sending long-term institutional inmates back to their communities without the necessary resources. Remember “de-institutionalization”, the social experiment initiated over 50 years ago when long-term patients of State mental hospitals, the largest single contingent of which, approximately 250,000 persons, was here in New York State, were abruptly discharged from the hospitals and sent home to families and to communities ill-equipped to help them. That’s why my ICM program and the ACT teams came into being, over twenty-five years too late. The presumed mentally ill persons sent home are to be considered the first institutional throw-aways. Those prison inmates released early will likely constitute the second wave. Will addicted persons, regardless of ethnic identity, be treated any differently? The mother lode of tax dollars is be found in the $30 billion DEA budget, and the struggle to re-order its expenditures from interdiction and law enforcement to the type of effective treatment and social re-integration programs that actually work will be long and fierce and will entail dismantling the DEA and its long-failed War on Drugs.
The keystone goal of the North Country Forums will be the reclamation of the throwaways – of those presumed to be mentally ill and abandoned; of those presumed to be dangerous drug addicts and abandoned to unconscionably long prison sentences; of those persons addicted to opioids and other drugs and running the risk of being abandoned to disability, social isolation and the comfort of addicting drugs. Self-education on the relevant issues as well as unrelenting advocacy directed at those with the power of the purse or access to it will be the tools used by Forum members. Their primary task will be to join the advocates that are beginning to coalesce to confront the DEA and its political and corporate supporters. Family involvement will be essential.
3rd – Families & Social Connectedness: Family members are crucial to their loved ones’ treatment, and will help them make the social connections necessary to break their social isolation. Who will most addicted persons turn to when they return home from their treatment programs? Who are most likely to love them and validate their efforts at recovery? Treatment staff will object to family involvement in the addicted person’s treatment, mired as they are in antiquated notions of confidentiality that serve to isolate rather than protect their clients. Sharp and determined advocacy will be needed to overcome this barrier to effective treatment.
Family members will learn how to be advocates. They will not learn the needed skills at Nar-anon groups – loosely affiliated with Narcotics Anonymous and modeled on Al-anon – designed to be attended by friends and family members of the addicted persons so they can monitor their recovery and provide support. These groups have as their focus the addicted person and can tend to be punitive and traumatizing for those who attend them, emphasizing, as they do, the errors the family has committed that have contributed to their loved one’s addiction. As such, they tend to look backwards rather than hold out hope for a future where neither they nor their loved family member will be held prisoner by the past and by their shame and can escape their isolation and re-join their extended family and the larger community.
Family advocacy organizations have yet to be organized – at least Google doesn’t list any. Treatment professionals are much more comfortable with quiet, compliant families, those who will do as they are asked and no more, fearful they will cause their loved one’s relapse. Rather, the focus needs to be on unsettling complacent and patronizing professionals and obliging them to listen to families’ analyses of problems afflicting the treatment system and interfering with their loved one’s recovery. Ditto patronizing politicians, who don’t want to be exposed to families’ anger and pain.
In short, families must do the unexpected and say to those who hold the power in the treatment system exactly what’s on their minds, decorum be damned. It’s your family’s and your love one’s lives that hang in the balance and you must be heard if no else is to die. I would hope that the North Country Forums could serve as the venues for families to practice and hone these new skills, and receive the support and validation of their fellow Forum members that they are on the right track.
In conclusion, I’ve used the opioid epidemic to illustrate how such a process might unfold in a future forum in Long Lake or other North Country communities; outlined the questions that might well be asked; and suggested possible responses and the actions Long Lakers and others might undertake to bring their ideas to the public. I welcome meeting with my fellow Adirondackers sometime soon, debating and devising solutions to the problems besetting us.
I’ll close by offering the advice, perhaps apocryphal, put forward by the murdered I.W.W. labor organizer, Joe Hill, one hundred years ago but still pertinent today – When the going gets hard, “Don’t mourn, organize.”
Hari, Johann, Chasing the Scream: The First and Last Days of the War on Drugs, 2015
Hinton, Elizabeth, From the War on Poverty to the War on Crime: The Making of Mass Incarceration in America, 2016
Junger, Sebastian, Tribes: On Homecoming and Belonging, 2016
Szalavitz, Maia, Unbroken Brain: A Revolutionary New Way of Understanding Addiction, 2016
Written By Dr. Jack Carney
Originally published at: http://www.paddlingupstream.org/america-addiction-a-primer-from-the-war-on-drugs-to-the-opioid-epidemic/
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