Apr 30, 2014

SHARP Stop Heroin And Rescue People

Heroin is today's plague of dead children. As David Pepper points out in this post on his website, Town Hall meetings will not solve the heroin crisis. We must act urgently to defeat this epidemic. The solution involves reducing demand through prevention and treatment, while law enforcement targets trafficking and violence.

By the way, David has been working on connecting health care with justice for a long time. Many of the practices starting to be implemented in jails across the US connect with David's initiatives in Hamilton County when he served as County Commissioner. Our county was one of the first to suspend, not terminate, Medicaid benefits for prisoners in jail. This helped us connect released prisoners to treatment for mental health and addiction care. This was a bipartisan effort. Everyone benefits from a safer, healthier community.

David has the plan. Let me offer an acronym. SHARP Stop Heroin And Rescue People.


My prior posts on the heroin crisis

Apr 28, 2014

Local paper prints old news about me

I am one of the first people in the mental health recovery community to run for a substantial public office, so it's not surprising that the local paper would find this interesting.  Today, the Cincinnati Enquirer published a story about me, headlining my law license suspension 16 years ago.

The real story about my life is not about my falling down. It is about my recovery, and the work I have done since then to improve people's lives. The man who prosecuted my law license discipline case agrees. Last year, when the Enquirer published a suicide prevention article I wrote, this gentleman sent me a note.
I have often thought of you and wondered what had happened to you after your suspension. I observed your transformation from the time of your deposition throughout your diagnosis and argument in the Ohio Supreme Court. I was amazed at how well you argued. You established that while mental illness is not a complete defense it can be use in mitigation. It is still the landmark case on the subject.
I am sorry you could not return to law but you can do more good and help more people in need that you ever could as an attorney. I hope you and your family are happier now as a result of your change. I am proud that you dug yourself out of what I feared was an insurmountable hole. I am delighted that you are doing so well. Congratulations.

Kathy was a psychiatric social worker and for many years has been co-chair of GLSEN working with schools to prevent bullying which often lead to suicides She also has a younger sister who is bipolar so we have a special interest in the work your are doing.
I am now retired and living in a condo. We would welcome hearing from you but understand if you never want to hear from me again.

Best wishes.
Bob Laufman
My story has not been hiding. It is part of my Amazon profile, and my Blogger profile. The court decision is on the Ohio Supreme Court website. The local Bar Association and the Ohio Supreme Court have funded my work.  The recovery process I describe in my book and on this blog is what helped me. The local Bar Association knows I have spoken with other lawyers who have been dealing with mental health issues. And these days, I do campaign finance work for judges.

Here is the message I sent back to Bob Laufman.

Thank you so much for your kind note. I just read it aloud for my wife. It made my day. I always understood you had a role to play. I've been at peace with it all for many years.

For years I have considered myself the poster child for the do-gooder kicked out lawyer. I attribute my recovery to the unwavering support of my family, the right diagnosis and treatment, and the willingness of people to send me opportunities. I've considered ways to normalize my status, perhaps transitioning from ‘suspended’ to ‘retired’ or some sort of restricted practice where I could do some public policy work or teach, but I never thought it worth the effort. I should probably go after it, just to complete the story.

I have always done justice-connected work, starting in the late 1990s when I designed the website for the Collaborative Law group and the Center for Mediation of Disputes. I was on the SAMI initiative, one of the early mental health jail diversion initiatives, from 1998-2003. In 2000--2001 I wrote the NAMI Ohio mental health training curriculum for courts and jails. I took that training across the state and to Kentucky, where it became mandatory for deputy jailers across the state, part of a jail suicide prevention initiative. I wrote a NAMI policy paper on the Olmstead decision, and authored a guardianship support program. I've been Nadine Allen's campaign treasurer for the past two campaigns. Now I am doing that with Ted Berry Jr.

Would you be interested in doing some sort of programming around mental health and recovery in the profession? I have no idea where the law has gone since my case came up, but I’m interested in having a real dialogue about it. It’s time for me to tell my story.

Finally, what I remember most about the Supreme Court hearing was the number of people who talked about being inspired by the character Atticus Finch. I have always considered him a false hero. My hero is Boo Radley, the outsider guy who really saved the lawyers kids.

Please call me any time. My home number is ....

If anyone wants to have a chat about all this, call my campaign phone number. (513) 494-6280.

Apr 27, 2014

Mobilizing medical warriors to stop heroin

Pathway to safe and positive
Heroin Plan In A Nutshell

In the Greater Cincinnati region, we have most of the infrastructure needed to create a pipeline that enrolls addicts while they are still using drugs, makes their lives safer, and conducts them along a path to safety and rescue from addiction. The next step is to enroll doctors and healthcare institutions, and form a coalition of the willing to wage war on the heroin epidemic that steals lives daily throughout our region.

In the past week, I have spoken with health educators at Cincinnati Children’s Hospital and the Cincinnati Health Department, an administrator at the local Recovery Services Board, the head of a local treatment provider agency, community members concerned about a proposed needle exchange program, anti-drug educators, and dozens of street outreach workers and health communicators participating in our region’s largest and most significant annual urban health outreach event.

I learned that:

We need to recruit dozens of physicians who are each willing to care for 30 addiction medication patients annually.

We need to recruit hospital systems to house and support these physicians.

We need to connect the public drug treatment system (which is funded to supply medication for addiction treatment) with physicians who are funded to provide medical supervision in neighborhood primary care clinics (FQHCs) and other healthcare settings.

We need to connect paramedics and health educators with sources of the first aid drug for overdoses, so this resource becomes available throughout the community the same way automatic defibrillators are available to stop heart attacks.

We need high level leadership – those who are willing to talk outside of their “funding gutters”  and connect up their systems – to meet each other and declare their commitment to stop this epidemic by every means within their power.

Read my earlier post:
Mainstreaming addiction services: How pharmacy clinics can help put an end to the heroin epidemic

Download Heroin Plan In A Nutshell

Apr 25, 2014

Chatter from young psychiatrists

I stumbled on a message board for young doctors, offering a treasure trove of anecdotes about the current state of psychiatric practice. The issue at the start of the March 2014 conversation was a doctor who felt threatened by an influx of nurse practitioners (NPs). Medical doctors have significantly more training than NPs, but the economics of psychiatric practice may not reflect that differential. The conversation veers off into a discussion of the standard of care that patients demand, or are entitled to.

This is a mere bundle of anecdotes, to be sure, but a fascinating bundle. I've clipped bits and pieces from the discussion thread. It's pretty raw for doctor talk.

With what I see the psychs are seeing more patients an hour. My guess is that there are a couple reasons for this:

1) the pt is likely to get even more upset if a nurse rushes them in an out in med check style in less than 5 minutes. If someone who is an md does it, they may just assume that is what md's get to do or whatever. But if a nurse treats them that way....(again not saying it's right, but that may be the perception)

2) the psych(competent ones at least) is more likely able to practice whack and stack psychiatry because they usually can identify obvious pharmaco no-no's quicker almost as a reflex, whereas the psych np may have to think about those things for a second. So in a way the greater fund of knowledge of the psych allows them to practice relative safe whack and stack psychiatry easier.
I can't solve all the mental health problems.
But I can help the people who want my help and appreciate it.
I think people in medicine come from pretty sheltered (and generally affluent) backgrounds, which can limit our work with our patients.
The nurse practitioner question

Replying to "As far as the public goes, they can suck it. They benefit from residents keeping the lights on in Americas hospitals then then they can pay for it. It and the years of effort and sacrafice it takes to make a doc. They want to replace us. F@ck them"

Unfortunately, doctors being entitled and telling the public they treat to just suck it is one of the reasons we're fighting the things we're fighting.
This post makes me think about crossing psychiatry off the list of potential specialties. Only 1% from my school choose psychiatry in the last match, and I can't see how anecdotes of NP's replacing psychiatrists will do anything except scare off more med students and make psych even more unpopular.

The argument that psychiatrists don't have to worry about their jobs because they add more value than an NP would be laughable to a hospital MBA, owner of a practice group, or insurance exec. Adding value means adding money to the bottom line. NP's add more value than a psych if they cost less but generate the same amount of revenue and have the same malpractice risk.

Seems like the only people who care about "quality" are the very small subset of patients who can do cash pay. Otherwise, the general public has no say on the quality and value of their psych because their 3rd party payer dictates what is "value". The public only cares that someone in a white coat accepts their insurance, can see them in a timely manner, and won't kill them. It's a low standard that NP's can fulfill, just like the masses of IMG's and assorted folks who couldn't match into anything else are doing now.
I haven't followed this whole thread so I apologize if I'm repeating anything. But I just wanted to jump in, because the issue about NPs interests me. I started a job last summer after finishing residency. It's mostly outpatient with some inpatient coverage. Overall it's going pretty well. Certainly it's an improvement upon the horrors of residency. But my fellow psychiatrists here each supervise one if not more NPs, and their NPs cover the inpatient unit too. Sometimes I come on call after them, and am then asked to discharge patients the NPs have admitted and followed. The thing is, they make some astonishingly poor medication choices and their notes are the worst notes I've ever seen. At times it's impossible even to understand why they are in the hospital and what has been done. So when I have to discharge these patients I am pretty nervous. They no longer meet commitment criteria and I end up having no choice. I try to document that I recommend they stay in the hospital and recommend they try medication X or whatever instead of whatever they're on, but I imagine this documentation only will protect me so far. Last week I had a patient bounce back after such a discharge. The guy was taking 20mg q4h PRN of zyprexa for anxiety. Yes, that was one of his meds. And risperdal BID. There was no good reason mentioned as to why. Obviously I did not continue the PRN zyprexa when he left. But I don't know if the antipsychotic effect was actually helping? There sure were no notes to guide me. The diagnosis wasn't consistent or justified by his presentation.

I do think the NPs have a good rapport with patients and I'm not trying to discredit them, but I worry about my own liability coming on after them. There's no way I'll bring this up with my colleagues - I'd quit before I'd confront them because I suspect they'll be defensive, not to mention they'll have illogical justifications rationalizing how they are "working with" the NPs, and I don't want to hear it. Plus I'm in a different part of the country than where I did residency, and the medication philosophies seem to be different here. Not that it was perfect where I was for residency, of course. But even from local psychiatrists I'm seeing these gigantic doses of layered on antipsychotics, and a lot of polypharmacy. Benzos and adderall are big. Psychotherapy is done by social workers largely and from what I hear, most patients aren't big fans. Can you blame them? Maybe it's because I'm not in an academic environment, maybe that's the problem. But academia has its problems too...

1) Psychiatrists don't come up with differential diagnoses. Internists do. In psychiatry we have about 10 or so conditions we routinely use, and almost invariably the patient gets fit into one of those 10 or so, rather than a genuine process of "differential diagnosis" occurring. If you disagree then tell me the last time you made a serious list in your "assessment" section of what the problem could be, and what specific diagnostic tests, procedures, or observations you were going to do to "rule out" some of the possibilities and "rule in" others.
2) Risk assessments in real life are boilerplate. They are written with the intention of justifying whatever decision was made. They are not written and then used to make decisions.
3) Dispo arrangements should have already been done by social work.
I disagree with the differential comment. I think working through a DDx both in your head and in your notes is a useful exercise, and can help keep your mind open to different (and maybe less likely) possibilities. Probably most useful with a new patient with no known psych history. Also useful on consults, and with patients who may or may not have a personality disorder clouding their picture. I think dismissing the entire approach of using a differential (at least for difficult or complex cases) is throwing away a useful tool and strikes me as pretty sloppy. You could miss some important stuff (i.e. that "easy" case was actually complicated by heavy substance use that nobody knew about, or that simple delirium consult had focal neuro findings from a brain met that nobody really checked for).
For those of us with more experience, the differential is usually fairly simple - when I admit a psychotic patient (psychosis nos) I know that I will probably need to start an antipsychotic and if the precise dx is not known, start the work up (or suggest the workup if it is a weekend and there aren't SW's around to help)- get collateral history/check labs/get old records. Usually the diff involves primary vs drug-induced, with the rare neurologic/medical etiology. When I admit a pt, I usually spend much more time thinking about their comorbid medical problems (HTN, DM, etc) than the differential. You got to get the patient stabilized and then fine tune the diagnosis during the hospitalization. I am of course talking about psychiatry in an inpatient environment.
Now not every inpatient falls in the category where it doesn't matter if you work really efficiently and finish it up quickly vs taking a thorough and slow approach, but many do. For every 100 inpatients you see, think about how many are patients where the outcome and/or care isn't going to vary whether you spend x minutes or 4x minutes. A *lot*. At least at the different inpatient places I've worked. Yes, it does take a good bit of time to go over pt education with a low functioning family whose 19yo son is in the hospital for the first time with psychosis. But for every 1 case like that, there are 5-6 that don't have issues where time is required like that.
Now for the most part I don't think inpatient is where patients really get better or where much of anything positive happens....and that's why I'm not going to do it. But if I did do it, I think I would be pretty darn efficient at it.
Ummm what?? Are you serious about not having a differential diagnoses. I view psychiatric disorders as diagnosis of exclusion. Everyone gets a medical workup and drug screen. Anything less and you are providing substandard care and essentially not using what you should have learned in medical school. Can't say how many times I have pressed this point to medical students and insurance companies that initially deny tests only to approve it after I contact them. I have found tumors on MRIs, (+) syphillis tests, obviously numerous sub induced disorders including bath salts, etc...
People are talking about psych NPs encouragement on psychiatrists and us needing to shorten our training. What needs to happen is that within our own speciality there needs to be a better standard of care. I may poke fun at some NP med management skills, but I am appalled at some of the diagnosis and polypharmacy that is rampant in our speciality and it is quite embarrassing.
Deliver better standard of care and show superior results compared to the NPs.
As far as jobs go, everyone in my program landed a solid job. One has the same setup as ---. 60 min intake, 30 min follow up. 215K.

Apr 17, 2014

Mainstreaming addiction services: How pharmacy clinics can help put an end to the heroin epidemic

I am tired of hearing tragic stories about heroin deaths. It’s time for action. I’ve spent nearly a year working with Dr. Jeremy Engel and advocacy groups from Northern Kentucky working on this problem. I have done my homework. Here’s my approach.

1. Treat heroin as an epidemic, a health threat, with social side effects. 
Throughout history, addiction was treated as a social problem, not a health care issue. Now we must adjust the War on Drugs to make it less of a War on Addicts. We want to save our sons and daughters. We have learned we cannot make much progress if all we do is shun and imprison people. Nowadays, we have medical approaches.  Here’s what’s in the arsenal.
  • Naloxone. Heroin kills by suppressing respiration. Naloxone neutralizes heroin, and restores breathing. It costs $65 for a rescue kit.
  • Methadone, Suboxone, and Vivitrol. These three drugs do not stop addiction, but reduce cravings, and help people progress towards recovery. They have good social side effects. They may not stop addiction, but they do stop burglaries and thefts.
  • Needle exchanges remove sources of deadly infection from the streets, and provide a pathway to treatment. The risks around needle exchanges can be managed.
  • Community support and education. Many anti-drug and health care groups are already on board.
2. Use the strengths of existing systems to attack the threat. 
Healthcare has an open door in every community, with protocols, privacy regulations, security set-ups, connections to regulators, connections to law enforcement, and connections to the broader economy. What might we accomplish if the healthcare system treated addiction and heroin death prevention like every other health concern? We might start with needle exchange in every place that sells flu shots. Every visit is a way to distribute Naloxone. Every visit can connect people who want to stop using drugs with treatment.

3. Work with the willing.
Not everyone is comfortable working with addicted populations, but many of us are. We must ask more groups to sign on. For example, is Kroger willing to sign on, and put Naloxone and needle exchange in its retail clinics?

4. Attend to risk.
Healthcare groups have risk management procedures in place. We see them whenever we stand in line at a grocery store pharmacy. People with drug problems are with us everywhere in our community. They bring with them real risks, but we can address them. If we do, we can make progress on this epidemic of death.

Photo by Unknown photographer [Public domain], via Wikimedia Commons

Apr 3, 2014

Mental illness, suicide, and violence

I have been written a surprising number of pieces about mental health, suicide, and violence over the course of the past two years. Here’s a list of thirty of these bog posts, arranged (for the most part) in reverse chronological order. My approach is to look at the suicide first, and then the homicide. Fewer than two percent of suicides also involve a homicide.

Adam Lanza’s suicide ignored by state report

Christian Stenographer’s Rant offers clues to mass violence

Aaron Alexis and the demon delusion

What crisis de-escalation really sounds like

Is it Kendra’s law, or better care, that helps people get better?

Preventing the next bomb plot

Did violent videogames cause the Newtown massacre?

Mentalizing, mental health and the restoration of community

Notes on the PBS After Newtown coverage

Teach suicide prevention wherever people buy guns

How to smoke out a suicidal spree killer before anyone gets hurt

The Five Step Way to think about Security, Suicide and Guns

Best comment by a police officer on the ramifications of armed teachers in schools

Suicide and gun risk are worth checking out

World's biggest task force, but nobody says anything new

Dear Vice-President Biden, Here’s what it takes to fix mental health

Vice-President Biden, a few new items for your mental health plan

What I am doing to respond to Sandy Hook

Frightened moms at the instant before the trigger

Political correctness in the mental health community is killing people

Coping with a violent child

Mass murder is the new flavor of American suicide

Defending Recovery

Don’t Blame Deinstitutionalization

Your hate group, and all our safety

Campus security failures in two mass killings

What it takes to prevent mass killings

What’s a risk management person expected to do?

Mental Illness and Crime Prevention

Claiming some violent territory for mental illness