Tuesday, September 23, 2014

Response to 6/28/12 Subcommittee Hearing

January 3, 2013
Lisa Lowe, Director
Heroin Action Coalition of Montgomery County

Council Member
Montgomery County Council
county.council@montgomerycountymd.gov
Dear Council Member:
On June 28th, 2012, the Public Safety and the Health and Human Services Subcommittees of the Montgomery County Council held a joint hearing on Treatment and Enforcement Efforts for Substance Abuse and Addiction.  A panel of “experts”, including Ray Crowell, Chief, DHHS Behavioral Health and Crisis Services; Hardy Bennett, Acting Senior Manager for Treatment Services; Nicki Drotleff, Manager for Children’s Services; Dr. Wilkes, Montgomery County Public Schools (MCPS); and Larry Simmons, Co-Vice Chair of the Alcohol and Other Drug Abuse Advisory Council (AODAAC), convened in order to “educate” the County Council on the “scope of the drug abuse problem” in the County.
As Director of Heroin Action Coalition of Montgomery County (HAC-MC), I would like to take this opportunity to “educate” you to some untruths, discrepancies, myths, and misperceptions regarding the information that you received in the Subcommittee Hearing, from the perspective of the recipient of the services that were discussed.
1)    Scope of the Problem:  Fallacy #1 –Using DHHS Data.  Ray Crowell reports 5.5 deaths per 100,000 County citizens as a result of intoxication.  This figure includes opiate overdose.  This translates to approximately 55 County deaths each year.  Anecdotal data, compiled by HAC-MC, shows a higher rate of death –an estimated 4 deaths per 16,000 citizens, as a result of opiate intoxication alone.  This calculates to approximately 260 County deaths per year.
The explanation for the difference in this data can be found in the distinction between how “cause of death” is defined.  Many of the deaths included in the HAC-MC data (the “Damascus count”), will not show up on DHHS charts and graphs, because the cause of death is not officially reported as intoxication.  For instance, opiate withdrawal causes severe depression.  Four young addicts who could not get treatment and subsequently committed suicide are not included in the DHHS data.  Two shot themselves and two hung themselves, rather than continue to endure the never ending roller coaster of using and withdrawing, using and withdrawing.  Opiate abuse also causes the user to “nod out” and fall asleep.  Three young adults, who used opiates prior to driving, never arrived at their destination.  Likewise, they will never appear as statistical points on the DHHS charts and graphs.  The cause of their deaths is recorded as car crashes.  The young man, who choked on his vomit after passing out as a result of opiate abuse, will not be recorded on the DHHS charts and graphs, either.  The cause of his death is suffocation while sleeping.
The fact that these deaths were an indirect result of opiate abuse or untreated addiction is an undeniable reality for the friends and family of these young victims.  The fact that families cannot get legislators to pay attention to the fatal and tragic loss of life caused by opiate addiction in this County is a travesty.  For you and other Councilmembers to deny this reality, simply because their deaths do not show up as a statistic on a DHHS graph or chart, is hurtful to the parents, friends, and other family members of those who have died of opiate related causes, stemming from untreated addiction.
On the other hand, statistics that could demonstrate wide-spread opiate abuse and addiction are no longer collected.  In fact, CESAR used to collect this data until their budget was cut in 2004.  Additionally, Montgomery County has not had enough schools participate in the Youth Risk Behavior Survey (YRBS) to extract meaningful data, even though this is a tool that most counties across the nation have used for years.  Hence, it is a proverbial Catch-22.  In order to allocate funding to solve the problem, the Council needs data to verify that a problem exists, however, the Council does not fund any of the data collection tools that could verify the data.
Councilmember Leventhal further adds salt to the wound by tasking volunteers to collect, compile, and tabulate the data without being paid for it.  At the end of the hearing, he admonishes AODAAC member, Larry Simmons, “This committee which I have chaired for 10 years does not get the full benefit of the expertise and hard work and credentials of the multiplicity of boards and commissions which as far as I know are supposed to be advising us.  …What I like to do is turn it right back on the advocates and the advisers …If we had your Advisory Council give us data that shows the problem is growing, where staff cuts are making a difference that indicates some data –grounded support for the assertion that the quality of treatment was not what it was a decade ago …your statement is compelling, but for us to make policy, it has to be substantiated.  That is not a criticism.  It is putting it back on the Advisory Council.  We have highly credentialed people on these boards and commissions.  I would challenge the Advisory Council to help us put this in context and give us recommendations as to specifically what needs to occur.”
Councilmember, I do not believe this will happen.  For the most part, AODAAC members are the same members that comprise your County’s broken treatment system.  For them to begin this work in any meaningful way, they would first have to admit that their programs are ineffective, inadequate, and unsuccessful, and that they have been unable to deal with the problem effectively, heretofore.  I have been attending AODAAC meetings for the past year, and I strongly feel that they are not likely to admit this.  Who would?  They would prefer to protect their jobs and thus their income and thus their home mortgages, car payments, and kid’s college tuitions –very valid and reasonable things to want to protect.  An AODAAC Task Force, that convened to work on these issues over the summer, was comprised mainly of non-AODAAC members, many from HAC-MC.  The AODAAC Annual Report has barely changed from one year to the next, despite the best attempts of HAC-MC members to offer personal accounts, data, and recommendations during the year prior to the latest Report.  Your constituents cannot continue to watch their children die, because you are waiting on AODAAC to provide you with data and recommendations.  This is just simply not acceptable.  We did not vote for AODAAC members to make decisions and take action, we voted for you, Councilmember, and the County Council, to make decisions and take action.
Additionally, the Council has not offered a budget to achieve these goals.  Hopefully, you would not assign the task of assessing the scope of such a serious problem to unpaid, untrained, volunteer statisticians, and expect reliable, statistically-relevant data upon which the allocations for funding new policies, programs, and projects would rely.  I cannot imagine that there would be a more serious problem on the proverbial table this legislative session than this one, resulting in at least 55 deaths per year countywide, and possibly 260 countywide deaths per year, depending on what data you choose to look at.  To assume that a volunteer committee will provide you with the tools necessary to take action, barely sounds like appropriate stewardship or good fiscal management to me.
Larry Simmons reports that, whereas in 2004, the approximate age of those attending A.A. / N.A. meetings were his same age –he is a parent of grown children, “today, as high as 70% of these meetings are kids between 18 and 25 years old”.  He urges Council members to “look into the treatment facilities” if you want realistic data, or talk to the people attending N.A. or A.A meetings, in order to understand the reality of the opiate epidemic.  “Is there a growing trend?” he asks rhetorically.  In answer to his own question, he reflects, “Most of you don’t have the opportunity to go into a treatment facility for long periods of time.  You don’t see these numbers.  There are upwards of 400 to 600 people at those [N.A. / A.A.] meetings and those people are cross-addicted between alcohol and opiates.”
2)    Scope of the Problem:  Fallacy #2 –Comparisons with Other Counties.  Ray Crowell reports that Cecil County has the highest rate of “intoxication deaths” and one of the highest rates of “heroin related treatment admissions”.  The Subcommittee concludes that Cecil County, therefore, has a bigger drug problem than Montgomery County.  This is not necessarily an accurate conclusion and there may very well be some very logical reasons for the disparities.
Community-Based Coalitions.  First, Cecil and Harford County are fortunate to have the largest, most visible, and well-funded grassroots community-based coalition in the state of Maryland –Addictions Connections Resource (ACR).  Director, Doe Ladd, and her colleagues, have worked to remove the stigma of addiction, assisted hundreds of folks in getting the treatment they need, established parent support groups, and have been very active in other related work for the past 10 years.  Certainly, the existence of a very visible, successful, and well-funded community-based coalition has eliminated many obstacles for those seeking treatment and may even have led to greater honesty and openness in acknowledging and reporting opiate intoxication as a cause of death.  In comparison, grassroots community-based coalitions in Montgomery County are not funded and have been largely ignored by treatment providers, agency administrators, and legislators.  This explanation is consistent with nationwide data that shows that prevention and treatment efforts are more prevalent and more effective in communities with a well-funded and well-supported community-based coalition.  Florida, certainly considered a state at the forefront of substance abuse prevention and treatment, boasts upwards of 250 grassroots community-based coalitions, supported and funded in varying degrees by federal, state, county, and regional money, technical assistance, training, and other support.
Recommendation #1:  Support community-based grassroots organizations, like HAC-MC, by providing technical and financial support, which enables them to work within their community to heighten awareness, identify gaps in services, link clients to appropriate treatment and wrap-around services, serve as a spokesperson for their community, and identify opportunities and venues for providing education and awareness. 

Access to Treatment:  Second, hospital Emergency Rooms in Cecil County admit patients who are suffering from opiate withdrawal or addiction much more readily than ER’s in Montgomery County.  Emergency rooms are a very logical point of entry into the treatment system in other counties, including Anne Arundel and Baltimore City, coincidentally two other jurisdictions reporting high rates for opiate related treatment admissions.  ER’s in Montgomery County will not admit patients who are suffering from withdrawal or who are “high”, unless they are unconscious or near so.  From the hospital, patients can then be referred to inpatient or outpatient treatment.  Therefore, reported “heroin related treatment admissions” are higher in counties where it is easier for opiate addicts to access treatment, as opposed to Montgomery County, where it is notoriously difficult to enter treatment and where many people do not even know where to start.  In fact, some County residents travel to Baltimore City and enter treatment there, perhaps being listed among Baltimore City treatment admissions, rather than Montgomery County admissions.
Montgomery County parents are at their wits end when they take their adolescent child to a County ER –shaking, vomiting, sweating, crying, convulsing, and begging for the needle that their parent removed from the grasp of their unconscious hand only an hour earlier –and they are turned away.   They are dumbstruck when their neighbor’s child is admitted to treatment because he or she picked up a razor blade and purposefully cut themselves.  These parents are told that one child is a “danger to themselves or others” while the other child is not.  Can you really tell me, Councilmember, which child’s life is more at risk, given this scenario?  Can you truly discern which child is the greater “danger to self”?  And are you willing to look the parent of the addict in the eye and justify this?

Recommendation #2:  Change the parameters of “harm to self or others” to include potentially fatal drug use, particularly for adolescents, similar to Florida’s Marchman Act.  This expansion would provide parents with the leverage for getting their adolescent child screened and assessed for drug dependence before they have developed a long term addiction, or worse –an early resting place at The All Soul’s Cemetery. 

Self-Pay for Private Treatment.  Third, Montgomery County, having a wealthier constituent base than some counties, may be more likely to have residents who send a child or family member to a private inpatient or outpatient treatment facility, and therefore are not counted as a DHHS statistic.
Larry Simmons explains, “We did that Forum because the people in Damascus are concerned.  Not the people here on this panel, but the people in Damascus were concerned and our job is to bring to the Council the people’s concerns.  They were speaking loud; they were speaking clear; and they were asking for help. …150 citizens concerned about their children, – their 18-year old children, –their 17-year-old children, –their 16 year old children. …In 2001, we passed No Child Left Behind.  Does that mean no child unless they are addicted to drugs and alcohol?  What does it really mean? …We are consolidating services and we are expecting the same dollars with a modest increase to complete what we need to do in recovery. …This problem is getting worse while the funding is getting less.”
At the conclusion of the Subcommittee Hearing, George Leventhal, argues that, “You have said that we have a growing problem, but we have not had that documented here this morning.  We have not been presented with information that the problem is growing.”
Councilmember, as Director of Heroin Action Coalition of Montgomery County, and a representative of some, yet unknown, portion of your constituent base, I implore you to assess this problem with all due haste, so that you can address the problem and allocate the resources that need to be allocated and implement the policy that needs to be implemented.  We, your community, who you purportedly serve, have brought you evidence that a problem exists, however anecdotal that evidence is.  Now it is incumbent upon you and the rest of the Public Safety and Health & Human Services Subcommittee to get whatever data you need to make decisions, preferably before the next mother’s son or daughter dies.  To continue to ignore this problem, because the County has failed to collect and compile data, is not an issue that your constituents should have to resolve for you.  We are calling for action during this upcoming legislative session. 
3)    Scope of the Problem:  Fallacy #3 –Using SASCA Data.  Ray Crowell informs us that adolescent data is based on kids served by SASCA.  However, this data does not accurately reflect the adolescent opiate using population for several reasons.

Access to Treatment.  First, historically, parents have not brought their kids to SASCA as a point of entry into treatment for opiate abuse or addiction.  This is due to the fact that during the data collection period, 2008 to March 2012, parents who were desperate to find treatment for their addicted kids bypassed SASCA for the following reasons:  a) when parents called SASCA, they normally got an answering machine, and it was not uncommon for a return call to take several days;  b) when they finally spoke to a SASCA rep, they were told that an assessment could not be scheduled for a week or two;  c) they may have also been told that SASCA does not refer to inpatient treatment.  When a parent discovers that his or her child has a potentially fatal addiction, usually because their child has finally reached a point where they obviously need help, parents desperately seek emergency detox services.  Opiate withdrawal is excruciatingly painful, and it is difficult for parents to watch a child endure this agony for very long.  They are just not going to wait for SASCA.  Therefore, SASCA has not been a point of entry for parents seeking opiate addiction services for a child because, in past years, they had been unable to provide addiction services in a timely manner.  Therefore, since SASCA has not provided appropriate services for opiate addicted children, they do not have statistics for opiate addiction.
4)    Scope of the Problem:  Fallacy #4 –Using Urinalysis Data.  Second, cannabis is very easy to document during urinalysis because it stays in a person’s system for approximately thirty days.  Opiates are much more difficult to detect because they remain in a person’s system for only three days or so. Therefore, if it takes a week or two to get an appointment at SASCA, and the child knows that the assessment is coming, they can easily refrain from using any drugs, knowing that the only drug that will be traceable by the time they get an assessment is cannabis.
Ray Crowell erroneously believes that “there is some validity to what the kids are telling us when they come through the door in terms of what they are testing positive for.”  The kids know they can get in trouble, they know there are consequences for using drugs, they are scared that they will receive punitive action if authorities discover their drug use, and more importantly, THEY KNOW HOW LONG EACH AND EVERY DRUG STAYS IN THEIR BLOOD SYSTEM AND IS DETECTABLE BY URINALYSIS.  This is, unfortunately, commonly discussed “street knowledge” among today’s youth.  Knowing that they cannot avoid a positive test result for cannabis, they admit to using that drug in order to be viewed as program compliant, in the hope of avoiding further consequences associated with more serious drug use –And not because they have a propensity toward honesty, particularly with SASCA drug testers.
Fudging Detection Results.  Other common “street knowledge” advice includes, taking Niacin and/or Cranberry pills, bought at a health food store, to cleanse the body of impurities, and ensure a clean urine; drinking gallons of water for three days prior to a urine test; bringing a friend’s “clean” urine to the test, in order to substitute the urine of the individual being tested.  However, the urine must be kept warm at body temperature –this can be accomplished by carrying it in a tightly sealed vial under the arm pit or testicles; purchasing a “fake penis”, that maintains another person’s “clean” urine at body temperature.  This is an alternative, albeit costly, for those who need to pass a urine test at places where the test is monitored.  Finally, as Dick Kunkle points out, many pharmaceuticals are not identified by urine tests.  Then there is always the possibility of registering a “false positive” because the client has eaten something that contains traces of naturally occurring opiates –like poppy seeds, for instance.  In conclusion, urinalysis, conducted at a place where the client may fear punitive consequences for failing to pass a clean urine, does not offer reliable data or provide an accurate assessment of the “scope of the problem”.
Urinalysis Data from Justice System Programs.  Lastly, to use urine tests of those in pre-trial and pre-release programs to attempt to gauge the opiate addiction epidemic in the County is not even remotely logical.  This data does not, by any stretch of the imagination, answer Mr. Leventhal’s question, “What is the scope of the problem”.  It does not take a rocket scientist to guess that those in treatment, particularly those who believe their freedom is at risk, are less likely to be using drugs –a whole lot less likely.
Recommendation #3:  Identify the scope of the opiate addiction epidemic in the County by fully funding and utilizing data gathering and measurement tools and resources, including administering the Youth Risk Behavior Survey (YRBS) to all middle and high school students within the County.
5)    Full Continuum of Treatment Services.  Ray Crowell informs us that we have “the full spectrum of services”.  This is simply not true.  The County does not have an adolescent detox or residential treatment facility, nor does the County contract with any providers outside the County or the State, to meet this need.  They also do not provide enough level 3.1 facilities for the adult clients who need them.  In order to compensate for this shortage of beds, providers have been known to assess clients based on available bed space.  So, if a client really meets ASAM criteria for a 3.1 level of treatment, and there are no beds, the treatment facility will ignore the client’s true need and either raise or lower their assessed level of need, in order to discharge them somewhere –anywhere, before the client’s insurance coverage for their initial period of detox runs out.  If the County suddenly had enough treatment beds at every level of care according to ASAM criteria, miraculously, patients would suddenly be found to fill those treatment spots.  The fact that clients are assessed on the availability of bed space, rather than on true ASAM criteria, is unprofessional at best, and criminal at worst.  However, to actually uncover this “butt covering” scam would require the County to monitor client treatment outcomes, which they currently do not.
Nicki Drotleff refers to Level 1 treatment for adolescents at Suburban and KHI.  She explains that they have individual, group, and family counseling.  How does she know?  Perhaps that is what they are contracted to provide by the County.  But do any of the County administrators really know what they provide?  Are the individuals and families who have participated in this treatment surveyed in order to assess whether the facility is actually providing the services that they are contracted for?  And do these services meet some standard of quality which shows they are effective for solving a problem?  Is there evidence to show exactly what type of therapy clients actually received vs. therapy that may have potentially been available to them –therapy that they may have had to request, but didn’t know was available?  Does “family counseling” involve actual conversation between an adolescent, his or her parents, and a therapist; or is the family therapy box checked off if the facility offers optional Alanon-type group meetings to parents, where the addicted patient is never present?
She refers to Level 3 programs (none of which are in the County).  The fact that she fails to mention that there are only 107 beds in the entire state is a glaring omission to any parent who has ever been unable to get a child into treatment.  She also fails to mention that Catoctin Summit, the only long term residential treatment facility, only has 23 beds (less during the year(s) when they close half the facility for months at a time due to bed-bug infestation).  Is this the capacity of need among the state’s adolescents –only 23 at any given time?  The program lasts for six months.  Does that mean there are only about 46 kids each year who need the intense level of service offered at Catoctin Summit?  Has anyone compared the number of kids who receive a referral to this program with the number of kids who actually enter into treatment?
Has Ms. Drotleff ever talked to the kids who return from some of these facilities?  Does she know the percentage of kids who are voluntary, court-ordered, transferred “stepped down” from other long-term high-security DJS facilities?  Does she know in which facilities there are frequent gang fights among the youth, which ones have complaints of sexual assaults, and which ones will discharge a youth for cursing at staff, thereby abruptly ending treatment without any further referral?  Does she know which have accredited school programs and which do not?  Does she care about the implications that these questions have on the lives of the kids who enter these programs?
What about the programs for the “children” who are commonly referred to as “transition-age”, by the mental health community (substance abuse providers make no such distinction)?  The children still in high school, still living at home, who have never had a job and never obtained a driver’s license?  –Who may still be covered under high school IEP’s and adolescent justice department oversight until age 21?  Who are viewed in the mental health treatment arena as eligible to receive youth services until age 26?  –Who are nowhere near close to achieving independent adulthood by any stretch of societal standards?  Does she know in which facilities these children can buy sex or drugs with relative ease? –And where parents are denied access to their child and are unable to even find out if their child is still at the facility because of HIPAA Laws designed to protect the rights of “adults”?
Would she voluntarily self-refer into Seven Lochs to treat her own anxiety disorder or clinical depression, her diabetes or her cancer?  Would you, Councilmember?  No?  Yet, this is what is expected of our adolescents who voluntarily seek treatment in two out of three facilities that treat adolescent substance abuse / addiction in the state.  The majority of kids in treatment may be DJS referrals, and these kids may come with a multiplicity of criminal charges and behaviors in addition to having a substance use disorder.

Recommendation #4:  Identify gaps in the continuum of care for adolescents and develop a long-term plan to fill these gaps.  Currently, there is a dearth of inpatient detox and residential care placements for adolescents.

Recommendation #5:  Establish transition-age adult SA services by recognizing that this age group (18 to 25) has different needs than older adults, and therefore requires specialized services commensurate with their developmental stage and level of maturity.  

Recommendation #6:  Require treatment providers to provide meaningful family input, particularly for adolescents and transition age adults, who will likely return home to their families following treatment. 

Recommendation #7:  Require SA treatment providers to include plans for developing co-occurring treatment protocols so that patients presenting with both substance abuse disorder and other mental health disorders are provided equal treatment commensurate with their diagnosis. 

Recommendation #8:  Adopt SAMHSA’s Comprehensive Community Mental Health Services Program for Children and Their Families for substance abuse disorder, and provide a system by which families receive a full spectrum of integrated behavioral health services seamlessly provided to meet the changing needs of the client and his or her family.

6)    Wrap-Around Services.  Ray Crowell admits that level of treatment is based to some extent on external factors; he asks “do they have family supports, do they have a place to live…do they need additional medications.”  However, treatment providers do not adequately assess these things.  How can a provider determine whether a person has family supports if they never talk to the family?  How can providers determine whether their clients are actually successful in their post-detox housing placement, if they do not follow up with the client after discharge, and ask them?  How does the client access “additional medications”, or therapy, or counseling, or alternative mental health therapies, if the provider does not refer their clients into these programs?  These practical considerations are repeatedly and consistently lacking in client discharge plans and in our treatment system’s “continuum of care” plan, in general.

Recommendation #9:  Identify gaps in the continuum of care for adults and develop a long-term plan to fill these gaps.  Currently, there is a dearth of wrap around services, including sober housing, educational and vocational training, job placement, family counseling, legal services, mental health services, family support groups, transportation services, childcare, etc. for adults in recovery from SA Disorder. 
7)    Adequate Quantity of Treatment Services to Meet Demand.  While Ray Crowell states that Montgomery County does have treatment, there is no discussion of whether the treatment is adequate or sufficient to meet the need.  For instance, there are some areas of treatment where there is a severe shortage.  As mentioned earlier, there are no adolescent detox or residential treatment services in the county, and only 107 beds in the entire state, many of which are contracted out by DJS.  This is nowhere near adequate.  Another area where there is a severe shortage of treatment is in the area of Medically Assisted Treatment (MAT).  There are only three Buprenorphine (Suboxone and Subutex) prescribers in the County who accept Medicaid clients and each provider is only allowed to accept 100 clients, per state law.  This is nowhere near sufficient.  One provider laments that she turns away three requests from potentially new patients seeking outpatient treatment services, every day.


Recommendation #10:  Expand access to buprenorphine treatment for opiate addicts to a level that equals the current demand.  Ensure that treatment is available on demand, regardless of income or insurance.  Create an updated online Buprenorphine Physician and Treatment Program Locator.

Ambulatory detox services are also insufficient to respond to potential overdoses.  By putting the opiate overdose antidote, Naloxone, into the hands of family members, trained to inject the life-saving drug into an unconscious opiate user, lives will be saved.  This is already practiced in many areas across the nation, and a medical precedent has already been set by training family members to inject bee allergy victims with epinephrine in the event that they are stung.

Recommendation #11:  Develop a Naloxone Program in the County, so that the families of opiate addicts have a readily available antidote on hand, in the event that they lose consciousness as a result of an overdose. 

8)    Lack of Treatment Outcome Data Leads to Low Quality Treatment.  Although Dick Kunkel’s question, “What level of intervention do you need to get a handle on your addiction?” is a great one in theory.  Unfortunately, the underlying premise, that treatment services are adjusted up or down based on client needs, is just not the reality.  Rather, this is nothing more than a pipe dream, perpetuated by treatment providers, who talk about best-practice treatment, but do not implement it.   In reality, if a person goes into one level of treatment and does not succeed, they often drop out or are kicked out of that treatment program –and there is absolutely no follow up.  There is no one that says –“he is obviously not doing well at this level, so let’s alter his level of treatment.”  If, on the rare occasion that someone does say that, it is usually to attempt to force the client into a higher level of treatment, regardless of whether the client is likely to participate or succeed at this higher level.  Extenuating circumstances –lack of housing, lack of transportation, conflicts with job or school, lack of medical or psychiatric care, lack of childcare, etc. are rarely factored into determining the cause of client failure.  Level of treatment is simply not negotiable.
A dangerous myth currently exists within the treatment community.  The provider knows best, and if the client does not do what they say, than the client “was not ready to get better”.  This is simply fallacious, illogical, and disrespectful thinking, perpetrated on the part of the provider to ensure that their program appears successful, while the patient shoulders all the blame for failure.  No matter how poor the treatment services are, or how low the quality of the program is, poor treatment must never appear to be the reason for poor results.  When neither the client, nor the parent, has any voice in adjusting the level of treatment, or in referring to a different level of treatment, when clients are merely kicked out of programs for non-compliance –not only are agency administrators and legislators duped, but the County tax-payer is duped, as well.  And the labels “just not ready to get better” and “has not hit rock bottom, yet” are stamped across the patient’s record, and the myth that addicts do not want treatment is perpetuated by the very people that are supposed to be helping them.  This has got to be the saddest, most despicable, most deplorable, most sinister aspect of our treatment system.  We do not tell diabetic Granny that she is “not ready to get better” or “has not hit rock bottom, yet” and kick her out of treatment when she eats a chocolate doughnut for breakfast.  We do not tell a cancer patient after three doses of chemo that they are not trying hard enough, when their tumor fails to shrink.  We do not tell a kidney dialysis patient that they are not placing a high priority on their “recovery” when they request that their treatment appointments are scheduled at a time that does not conflict with maintaining their job or completing school.
Councilman, Phil Andrews asks Ms. Drotleff, “Is there a regular evaluation done of the results or the effectiveness, the long-term effectiveness of the intervention?  –Just the programs that you are talking about?”  The answer, Councilmember, is NO!  My question is, “Shouldn’t there be?” –And who, other than the County Council, would be responsible for mandating this?
When we have treatment providers, who report that they are doing a good job, so that their funding and their jobs will continue, and the County fails to provide any meaningful oversight, or attempts to make any determination that the provider is, in fact, providing treatment that works, then we are at risk of accepting low quality treatment and poor outcomes.  This is potentially a consummate waste of taxpayers’ hard earned dollars, both in the sense that the dollars that ARE spent are wasted, plus those spent to clean up the mess of the still unresolved problem –dollars spent on enforcement, justice, health care, social services, foster care, alternative education, etc., are wasted, as well.  This fiscal drain could very well be averted by simply tying treatment outcomes to contract renewal and establishing a system whereby outcomes are monitored.
Recommendation #12:  Create a special ombudsmen position or office within the County charged with the following:  a) quantifiable assessment of treatment outcomes for discharged patients from all treatment services in the County, as well as patients discharged from any other state facility who return to the County to reside;
b) investigation of consumer complaints regarding inappropriate treatment practices;
c) assistance enforcing insurance parity; d) enforcement of provider compliance with evidence-based best-practice treatment; e) enforcement of patient abandonment laws to ensure that patients are not left without a provider in the event they relapse;
f) assurance that providers refer discharged patients to wrap-around and case management services.  This would be similar to treatment navigator services currently provided by mental health advocacy organizations. 

9)    Treatment vs. Enforcement.  According to Mr. Kunkle, “You step up the level of treatment until you eventually need incarceration.”  Well, if Mr. Kunkel’s logic is accurate, then all those incarcerated for drug charges, must have gone through lower levels of treatment.  This, of course, is simply not so.  Many who are incarcerated never went to a lower level of “treatment”, and never received any mental health treatment either, even though THEIR PARENTS MAY HAVE BEGGED COUNTY AGENCIES AND/OR INSURANCE COMPANIES FOR THESE SERVICES REPEATEDLY, YEAR AFTER YEAR AFTER YEAR, TO NO AVAIL.
Mark Elrich notes, “I cannot think of anything more expensive and possibly less effective than incarcerating someone simply for drug use.”  He adds, “That’s got to be the worst approach to dealing with drug use. …I thought it was generally recognized that locking people up for simply that was not a particularly useful way of dealing with the problem.”  Ray Crowell agrees that, “sadly, we probably lock up more people for substance abuse and mental health than we should.  It is an issue that we are always struggling with.”  Certainly, no one is “struggling with” this agreeably “sad” policy situation as much as those who are incarcerated “simply for drug use” and their families.  These are people’s lives we are talking about.  Taking away another person’s freedom, their life, their home, their family, their relationships, and their dignity and self-worth, is not just something that is “sadly” done, as we look the other way and move on to other priorities.  This “sadly done” atrocity, committed against real people, –normally young, immature, barely adults, must end.  As a county, it is imperative that we begin to shore up this very costly river of wasted tax-payer dollars.
Ray Crowell explains that “they don’t get incarcerated primarily for addiction to drugs but any number of things that might bring them to jail.”  First, many people ARE, in fact, incarcerated simply for using drugs because they are addicted.  Second, even if Mr. Crowell’s premise is true, than County residents do not want to wait until the addict commits whatever “number of things that might bring them to jail” to happen, before this individual receives the treatment they need.  This is arguably a seriously poor allocation of resources.  I think most County tax payer’s would choose to spend their tax dollars on intervention, before they have to pay for costly judicial system enforcement –not to mention the emotional costs associated with being a victim of those “things” that brought the addict to jail.
Recommendation #13:  Review progressive enforcement policies for dealing with substance abuse crimes, which already exist in other parts of the country.  Develop a referral capacity within MCPD, whereby police officers are able to refer individuals who present with SA Disorder, and other behavioral health problems, for assessment.
10)            Budgeting for Progressive Treatment:  Re-allocation and Parity Enforcement.  Federal studies have shown that for every dollar spent on prevention and treatment for substance abuse disorder, seven dollars is saved in enforcement and justice costs, and another five dollars is saved in healthcare costs.  The combined savings of twelve dollars for every one dollar spent should go a long way to pay for necessary evidence-based, best-practice treatment.
George Leventhal points out that “Parity laws have been in place for a long time. –And insurers just don’t honor them.”  Well, then, shouldn’t we do something about that in the upcoming legislative session, Councilmember?  The state of Pennsylvania sued one of the largest insurance companies, and in so doing, saved its tax payer’s millions of dollars in public treatment funding for behavioral health issues, including both mental health services and substance abuse treatment.
See Recommendation # 10
11)            Over-Prescribing of Prescription Opiates.  According to Councilmember, Roger Berliner, “some of our physicians prescribe too many pills that lie around and are available. …My belief is that this is one of the more serious problems.”  Ray Crowell agrees that this is a problem “predominantly for young people”:  1) they have access through their physicians or through parents; 2) police have done some drug reclaim / turn-in programs; 3) docs who are over-prescribing have a “tendency to prescribe fairly regularly”.  Roger Berliner asks the reps from HHS, “Do you have any suggestions for reforms at the county or state level that are appropriate in light of your concern?”  While they did not, HAC-MC does.
Recommendation #14:  Provide mandatory training to the medical community on the highly addictive nature of opiate medications.  Create a task force to analyze the problem of over-prescribing prescription pain pills and develop a reduction plan.
Recommendation #15:  Provide medication drop-off sites throughout the County, for patients to dispose of unused medications, and fund a County-wide ad campaign designed to promote the practice of proper medication disposal among all County residents. 

Recommendation # 16:  Support the growth of alternative therapies for managing chronic pain, including meditation, acupuncture, massage, yoga, etc. as an alternative to long-term opiate-based pain management.

12)            Early Intervention in County Schools.  Councilmember, Phil Andrews, “wanted to ask Doctor Wilkes, [MCPS], about how students are referred for treatment or screening.  I would think the issues often show up or are noticed in the school system by counselors or teachers.  I’m interested in how that process works.  What is the threshold for triggering some kind of action or referral by the school system of students for drug treatment?”  Additionally, Councilmember Craig Rice asks if “there is a methodology that we used in terms of identifying those children. …you could have a child who exhibits the same overlying symptoms as a person who is a drug user.  Is there training that goes into our counselors and for our teachers?  Our teachers are spending the majority of their time with the child.  I am curious as to how much we give to our teachers to help identify what some of those characteristics or behaviors might be.”
In response, Dr. Wilkes explains that “counselors meet with students and look for observable signs”; “work with parents”; “refer to school nurse”; “partner with HHS and refer kids to various facilities.”  It would be difficult for me to identify one parent of an opiate addicted child, who actually believes that this scenario is a reality or that anything the schools are currently doing makes even a small dent in the drug use epidemic within our schools.  Admittedly, Dr. Wilkes acknowledges that there is no “specific” or “formal training”.  She adds that the school psychologist and the school counselor can do more in-depth screening to determine drug use and / or addiction.  But they do not use a formal screening or assessment tool?  My first question is, How do they accomplish this assessment without these tools, when trained drug counselors cannot determine degree of drug use or addiction without formal screening tools?  My second question is, Where was my son’s school psychologist during any of the four years that he was addicted and enrolled in the County school system?  I do recall his Guidance Counselor handing me a brochure for an out-of-state program that cost $30,000 / month, after I informed her that he was addicted.  Ironically, she also knew that we qualified for the “free and reduced” lunch program.
What “observable signs” do they notice when they have no training?  How do they “work” with parents when there are no formal or written policies or procedures or guidelines?  What exactly does the school nurse do when he or she encounters a student who is obviously “high” in the classroom?  Does she even know who is appearing “high” in class?  Which facilities do they refer to, and are these facilities appropriate to deal with the problem?  How do they know?
The fact of the matter is that if Dr. Wilkes were called upon to answer these very specific questions, her answers would undoubtedly be just as vague.  Why?  Because, in reality, Montgomery County Public Schools has not yet developed a policy or protocol for dealing with the opiate epidemic, and the school nurse typically has no idea where to refer a drug dependent child.  If we are not willing to honestly admit to the fact that we have no viable screening, assessment, and referral program within County schools, than we are that much farther away from starting one.  Do working parents really need to spend their free and unpaid family time, proving to you that there is currently no consistent, visible, or effectual program in place to deal with kids who are exhibiting signs of drug dependence, addiction, overdose, or withdrawal at school?  Can’t we just all honestly admit that a viable program does not yet exist, so that we can then plan to meet at the proverbial “brainstorming table” to begin devising one?
Dr. Wilkes clearly demonstrates that she relies heavily on enforcement, rather than on intervention and treatment, if she truly believes that “possession” of anything is “more serious” than addiction.  While Dr. Wilkes offers “wrap-around services for the entire family” –many of them “free services”, she does not really know whether those services work, or whether there is a six month wait to access them, or whether the flyer that the PPW hands the family actually has a working phone number to a currently operational program, as opposed to a program that had its funding cut years ago.  She beams that MCPS personnel “provide as much information as possible so that the student is well on their way to recovery.”  I would argue that the number of personnel in the MCPS system who actually understand “recovery” and can vouch for any student being “well on their way to [it]” are less than the fingers on one of my hands.
Councilmember, Craig Rice, astutely notes, “I thought that was striking to me in terms of understanding, that the people who probably spend more time with the child than their parents, are the ones we need to work on in making sure they have the tools that are necessary …so they can help us in this –in identifying what some of those behaviors are.  I think that is something that we might want to follow-up on in terms of exploring …or something that we want to work on in the future.”  Kudos to Councilmember Rice!
Councilmember, George Leventhal asks Nicki Drotleff, “How would kids know where you [SASCA] are?”  Nicki Drotleff responds, “It is a pretty well-known program, I think they have been in
existence maybe 15 years, so I think it is well-established.  The school system refers to us.  The family crimes division refers to us as a part of their diversion program.  We get a lot of self-referrals.  The 311 as well.”
But, how does she know?  And more importantly, what if she is mistaken?  Given a survey of all high school kids and their parents (which would be easy enough to administer), I do not believe that the majority of kids or their parents would know where to refer an addicted child for treatment.  I believe that the majority would not know what SASCA is and may never have heard of it.  More importantly, it is my opinion that they probably would not know how to reach them.  In my experience, the phone calls begin with the family pediatrician, hospital ER, or insurance provider and the nightmarish maze of dead ends, inaccurate information, outdated phone numbers, and referrals to nowhere begins as the parent in crisis doggedly attempts to circumvent obstacle after obstacle on their path toward unlocking the doors into adolescent treatment.  I know –I have walked that path.
Recommendation #17:  Utilize the position of the school nurse more fully to provide screening, brief intervention, and direct referral to inpatient or outpatient treatment for students seeking or obviously needing treatment.  Develop a same-day assessment and referral plan for adolescents presenting with opiate addiction.  Provide home and hospital instruction for students who are in residential treatment until they are well enough to return to school. 
Recommendation #18:  Enhance the school curriculum so that behavioral health disorders, including substance abuse, are addressed more fully and completely from early grades through high school, similar to the way that environmental awareness has become a priority at all grade levels during the past ten years or so. 

I applaud Councilmember, Craig Rice, for taking this matter seriously.  He concludes, “I think it is important that we act quickly and address this issue. …I think all of us are committed here to providing the resources that are necessary for what I believe is a very growing nationwide trend.  There is no question that in the suburbia of our nation’s capital, we are going to experience the same things here.  As Montgomery County oftentimes is, we tend to be at the forefront.  I want to be at the forefront of addressing this issue. …Even if we only have 20 people, that is still a problem.  We need to try to make sure we can address it appropriately.  I look forward to working with your individual commission, as well as with the whole panel, in trying to make sure we address this issue.”

Recommendation #19:  Participate in and support Project Lazarus: a community-based overdose prevention and addiction treatment program, initially launched in Wilkes County, North Carolina.  This requires that various stakeholders throughout the County, including community groups, overdose survivors, patients and families, doctors and nurses, policymakers and media, law enforcement, and educators, collaborate to identify needs, develop strategies, and implement plans for combatting SA disorder. 
Recommendation #20:  Develop a media campaign designed to overcome stigma and end the myth that substance abuse disorder is a behavioral, rather than a neurological / mental health disorder, and therefore needs to be treated as a medical condition.  Addiction is not a crime; it is a treatable chronic disorder, like depression or diabetes. 
Councilmember, George Leventhal, asks, “How large is the problem in Montgomery County?  What is the shortage of beds?  Are we devoting adequate resources to the topic?”  These questions must be answered at the very beginning of this legislative session, if we are to save the lives of at least 55, and possibly 260, Montgomery County residents, this year.
I applaud Councilmember, Roger Berliner’s stance, “I come from the point of view that a progressive jurisdiction, like Montgomery County, to the extent it has authority, should use that authority to make a difference and have a conversation nationally, as well.”  HAC-MC would like to recommend that the County Council has that “conversation” during the first few weeks of the upcoming legislative session, so that whatever funding is necessary to accomplish meaningful, lasting, and quantifiable objectives and strategies for alleviating the growing opiate epidemic in Montgomery County can be allocated before it is too late.
I hope this letter has convinced you that the participation of grassroots community-based coalitions is essential in providing a key role at the policy deliberation table if any real and lasting changes are to occur.  The voice of recipients and consumers of prevention and treatment programs and services cannot be undervalued.  My colleagues and I, at Heroin Action Coalition, hope you will agree that together we can make a difference in ending the suffering of so many families within our community and curtailing the hemorrhage of public funding allocated to cleaning up the mess left by untreated addiction.
It is to this end that my colleague, Donna Evans, and I would like to meet with you prior to the beginning of the next legislative session, so that we can discuss the aforementioned recommendations for ending this fiscal, societal, and human waste.  I will call you next week to arrange a time to meet with you at your convenience so that we can ensure that this issue receives the focus that it deserves during the upcoming legislative session and beyond.
Sincerely,
Lisa A. Lowe, Director
Heroin Action Coalition of Montgomery County

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