Dec 19, 2014

Christmas Snapshot, Heroin in SW Ohio 2014

I spent three hours yesterday attending a meeting of PAR Ohio,  learning about the brokenness of systems meant to respond to heroin. The best I can say is that things here are at the starting point.

Here's the lowdown, in snapshot format, following the milestone and infrastructure model in my book Sharp Stop Heroin and Rescue People.

Date: December 19, 2014
Community: Southwestern Ohio
Author: Paul Komarek

Extent of problem


Enrolled in System
The “system” in place is largely irrelevant to public service needs. The public’s experience is chaotic and disorganized. Very few people know how to access basic system resources.

Hamilton County has a designated “front door” for recovery services, but no one mentioned it in the course of a three hour public meeting.

There was some knowledge of Medicaid, but no generally known single point of contact for enrollment, and no readily available resource. Ohio’s Medicaid system is in peril, in any event.

Emergency treatment systems are poorly understood. Ohio has multiple overlapping mandatory treatment statutes, and each county has a different process. Some courts have forms, others don’t. None of them are organized in such a way as to solve the entire problem of someone who needs immediate care because they pose a danger to self or others.

Criminal justice service systems are not connecting with treatment resources. Jails are the de facto detox resource for the community, but the largest jail provides no detox medication support.

Primary care systems are not connecting with treatment systems.

The treatment landscape is entirely different in each of four SW Ohio counties. Each county has opiate task forces working on local approaches to problems, but they are lunging after one solution or another, not working regionally, and doing whatever they prefer. They actually compete against each other for scarce grant funding resources. Ohio’s Medicaid behavioral health carveout makes this worse, and slows the development of effective regional systems and access to new resources.

Ohio’s Medicaid plan needs updating, and will not be effective until it accommodates all levels of care.

Apart from the VA, Ohio treatment organizations are not systematically integrating behavioral health electronic health records with commercial systems.

First Aid Available
Naloxone prescriptions are available, but there is uncertainty around obtaining the actual kits. Opiate prescribers are not routinely prescribing Naloxone. The proper legislation is in place.

Safe from Infection
Syringe exchange is available during restricted hours in two Cincinnati neighborhoods. It is not available in the suburbs.

Medicine, Not Street Drugs
Methadone is available, but the general public objects to it. Some dispensaries are reportedly not moving people towards dose reduction. Suboxone is available, but Ohio Suboxone prescribers are requiring Medicaid patients to pay hefty fees for clinical services. Vivitrol is available, but mostly at the jail door, dispensed to released prisoners, and paid for by grant funding. There is poor public understanding of the role of medication in opiate treatment, especially around the notion of appropriate medication use for years or even for a life time. Local jails do not support medication assisted treatment.

Social Support
Cincinnati has an active AA/NA community, with several hundred meetings each week. There is very limited access to secular support (Women for Sobriety, SMART, LifeRing). The AA/NA community is positioned as anti-medication, especially methadone. The public is advocating for detox, not medication assisted treatment, despite the research on effectiveness of MAT. People who use MAT are shamed in AA/NA groups. Local faith-based groups are not stepping forward to support people in recovery.

Rehab resources exist, but are not accessible without sponsorship or substantial external funding. Ohio Medicaid does not pay for inpatient rehab. There is insufficient variety and personalization with respect to treatment approach. No one is managing or balancing available system resources. There may nominally be “plans” but they are not focused on what it takes to actually solve the problems.

Sober Living
There is a severe shortage of recovery housing. What exists is explicitly 12-step based, which presents difficulties for people who use medication assisted treatment.

Long-Term Recovery
Relatively few people experience true recovery under the existing Ohio “system.” Evidence-based resources for people with complicated sets of problems are essentially nonexistent. The mental health system is overtly oriented towards managing the lives of dependent, non-addicted populations with high levels of disability burden, not those dying in high numbers today.

Dec 7, 2014

Heroin W.M.D.

Heroin is not that complicated. It’s a weapon of war, part of an invasion that delivers a plague.

Our mission is relatively simple: Repel the invader. Save the people.

Anything else plays into the enemy’s hands.

The drug cartels are clever and heartless. They exploit our vulnerabilities, and make us complicit in our own destruction. They use people with economic vulnerabilities to sell drugs to people with health vulnerabilities. When we jail our own children, it produces more business for our enemies.

“Friend or foe?” and “What can I do to help you?” are key questions. They help us stop the damage.

The neighbor kid with the needle in his arm passed out on the floor is not the enemy. The kid on the street corner with packets of drugs in his pocket is not the enemy. Both are pawns, people who've been hijacked by the invader. It's better to protect them. They both need a path from drugs, a way to return to us. One needs treatment The other needs a real job.

Sure, both are technically criminals. Big deal. People can change under the right conditions. We know how to help, and we know prisons and jails waste people. With heroin, we are facing an invasion. The larger goal is more important. We can’t afford to overlook opportunities to save vulnerable people.

Smart legislation, smart court rules, smart diversion programming, smart discretion at time of arrest, smart bail policies, smart probation services all save people. They are investments that lower the body count. And they limit collateral damage -- the families and communities who suffer too. Besides, people who overcome challenges become more resilient. When people reach their ultimate potential, our society wins.

If we become become smart about criminal justice, recovery becomes our counterattack. Given what we are facing, smart justice may well be the key to victory.

Join me 9 am - noon on Saturday December 13 at the PIER in Newport KY for "A Course About Solutions." It's a 3-hour class about heroin and public policy.

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