tag:blogger.com,1999:blog-71608968327351740902024-02-07T20:36:17.553-05:00Redesigning Mental IllnessOrdinary people help each other cope with tough issues like depression, addiction, trauma, anxiety disorder, PTSD, and schizophrenia every single day in every culture on earth.Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.comBlogger131125tag:blogger.com,1999:blog-7160896832735174090.post-35084988064059807662024-01-19T11:03:00.000-05:002024-01-19T11:03:36.422-05:00New research, new thoughts, new platformAfter several years of brand new field work focused on the day-to-day needs of people who use food pantries and other basic community service systems, I am moving forward with new publishing projects. I am consolidating all of this material on a new web platform.<div><br /></div><div>The new site is called Human Intervention - a key theme is finding out what it actually takes to connect a person with effective services. These days, care is most often a system, and the systems exist in nearly every community -- but they are just beyond the grasp of ordinary people. And if the system's mission involves outreach, the people that most need the service aren't able to be helped during office hours.</div><div><br /></div><div>What I have been exploring is the power of <i>connectors</i>, the friends, community members, church communities, and volunteers who help people connect with the help they need. Connectors supply the follow-through and support that makes system workers effective. The result I often see is that people move forward in their lives .. in the best way possible.<br /><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjM6Vr2mns0-TZFBlb8eY8TKbGMmqdVoSDdozMU9900viJTuAbqjNKKjrSxAw0-5JiPcpMUJ-SW1NrWMpXf2XDmIbp7R07RqHgvt7rFqu8t3RphBGHkqPw8GWq4Pqf36ppEaILQqz3XETGi8MtrMXZEcrxVWWhwm29_ne5tycttp2uzr8OyVPsiDi2Vn9W6/s642/HUMAN%20INTERVENTION%20LOGO%202023.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="602" data-original-width="642" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjM6Vr2mns0-TZFBlb8eY8TKbGMmqdVoSDdozMU9900viJTuAbqjNKKjrSxAw0-5JiPcpMUJ-SW1NrWMpXf2XDmIbp7R07RqHgvt7rFqu8t3RphBGHkqPw8GWq4Pqf36ppEaILQqz3XETGi8MtrMXZEcrxVWWhwm29_ne5tycttp2uzr8OyVPsiDi2Vn9W6/s320/HUMAN%20INTERVENTION%20LOGO%202023.png" width="320" /></a></div><br /></div><div>We'll be open for business soon at <a href="https://humanintervention.substack.com" target="_blank">https://humanintervention.substack.com </a></div><div><br /></div><div>Scheduled opening date: February 1, 2024.<br /></div></div><div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-7160896832735174090.post-27292970152050873642019-05-12T15:07:00.001-04:002019-05-12T15:07:57.325-04:00Welcome to the ArchiveRedesigning Mental Illness was my main "work in process" website from 2012 to 2015, as I developed my approach to personal recovery (<i><a href="https://www.amazon.com/Defying-Mental-Illness-2014-Community/dp/1494786443" target="_blank">Defying Mental Illness</a></i>) and community treatment systems (<a href="https://www.amazon.com/gp/product/1501003496/" target="_blank"><i>SHARP Stop Heroin and Rescue People</i></a>).<br />
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I hope you find this material useful.<br />
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--pk---<div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.com0tag:blogger.com,1999:blog-7160896832735174090.post-44271507731656473972017-03-04T11:19:00.000-05:002017-03-05T10:20:34.572-05:00Stuck Systems Slow Reforms<div class="separator" style="clear: both; text-align: left;">
Over the past five years, advocates and organization leaders throughout the country have focused on the overdose epidemic. Have we made sufficient progress? What obstacles get in way of reform? <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjxXV5nrkKQ7NzgrKBgXXVmXLSZARB2XVQyMPDz76X7QkTlpCIKLenVOkMD83VJnlXgGG_KYA-G29Q2zprGHR2RJuqxhrOfXaCev1dGgARRfjkHcYMhlt0h2C1J4YEwOCnm3I3fvUG-RgY/s1600/enhanced-6233-1421069339-5.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="212" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjxXV5nrkKQ7NzgrKBgXXVmXLSZARB2XVQyMPDz76X7QkTlpCIKLenVOkMD83VJnlXgGG_KYA-G29Q2zprGHR2RJuqxhrOfXaCev1dGgARRfjkHcYMhlt0h2C1J4YEwOCnm3I3fvUG-RgY/s320/enhanced-6233-1421069339-5.jpg" width="320" /></a></div>
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Nebraska’s former Director of Behavioral Health, Scot Adams, says healthcare organizations are just like people with addictions, in that they are stuck in denial. People in trouble must confront and overcome denial in order to change for the better. The systems that serve the public must also confront and overcome issues of denial if they are to fundamentally improve how they operate. Adams enumerates several aspects of denial embedded in healthcare systems. He writes:<br />
<blockquote class="tr_bq">
Twenty-five percent of general hospital beds are filled with persons being treated for effects of substance abuse, like overdose, but not the core issue – addiction. And that goes further to include physical health care, with the standard practice at many emergency departments to “fix what’s in front of me” and ignore the rest. Or at best, refer it somewhere else. Value-based health care is helping this – however that is more the payer’s hot ticket right now and less the provider organizations that are still working as they were trained. They are paid to fix the broken arm, but not to drill down about the cause – a drunken fall.</blockquote>
Adams also blasts systems for tolerating “good ole denial.” He notes that this takes several forms. One creates a culture in which addictive behaviors appear normal because they are so prevalent. Another involves clinicians who avoid unpleasant or resistant clients. A third leaves medical professionals reluctant to identify dangerous behaviors because they don’t want to wrongfully accuse someone of being an addict or mentally ill. A fourth form of denial involves “old schoolers” in the addictions field who deny the value of medication-assisted treatment (MAT). Adams writes:<br />
<blockquote class="tr_bq">
Some of these professionals have never been trained in the specifics of addiction and think it’s just another mental health malady to add to the treatment plan. </blockquote>
Public health and addiction experts have been calling out examples of embedded systemic denial and explaining how this produces barriers to effective care. When Dr. Jennifer Mooney of the Cincinnati Health Department recently testified about overdose trends before Cincinnati City Council, she said first responders face issues of inadequate training and a system that’s “really not congealed” in trying to help addicts. She said police “run into dead-ends a lot of times.” She said even though Hamilton County is “resource rich” with treatment options, including intensive outpatient care, 28-day programs and long-term residential programs, there’s not enough capacity for all the people who need help right now.<br />
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The terms “really not congealed” and “not enough capacity” are well taken, because few local treatment programs are specifically designed for opiates. The reason for the lag in evidence-based care for opiate addiction? Dr. Mooney cited “the comfort level of prescribing clinicians.”<br />
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Here is another example. In mid-2016, Dr. Christine Wilder, director of the UC Healthcare system’s addiction practice delivered a keynote address to an audience of over 200 advocates, clinicians, and funders at the Hamilton County Recovery Service Board’s annual meeting. In her remarks, she urged her audience to start delivering more medication assisted treatment. She told the audience she heard a colleague say he “just doesn’t like buprenorphine.” “Not like?” Dr. Wilder said. “Practicing medicine should not be like Facebook.” <br />
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Systemic denial pervades every element of community systems, hindering not only what happens in clinical offices, but also the level of effort and pace of reform. Resistance to change affects healthcare organizations, treatment funders, housing providers, residential care facilities, courts, prosecutor’s offices, and jails. It produces odd combinations of wishful thinking and weak action. Leaders might advocate publicly for solutions, but delay required approvals. Resistance to change is keeping systems weak, disconnected, underpowered, and fragmented. It is producing horrific results for clients despite the best efforts and intentions of clinicians and public servants.<br />
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Terry DeMio of the Cincinnati Enquirer recently reported on the efforts of some three dozen experts working in treatment systems and the criminal justice system in Kentucky and Ohio (along with dozens of ordinary community members) to help a young woman move past prostitution and addiction – unsuccessfully – over the course of four months. The article relates how, time after time, the young woman and her expert helpers encountered systemic barriers including limits on treatment, lack of secure housing, and medication treatment delivered without psychosocial support. The situation DeMio describes is not uncommon. Municipal Court judges see people with this set of problems every day. <br />
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What is left unsaid in DeMio’s article is the slate of treatment approaches and care models that are known to be powerful enough to address situations like these, but are not being deployed in our communities. Assertive community treatment (ACT) teams, trauma-informed care approaches, and integrated care models are well-documented and evidence-based. When solutions are implemented, delay is typical. Ohio declared an overdose emergency in 2011, but took six years to adopt American Society for Addiction Medicine’s evidence-based treatment protocols.<br />
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Those who know about evidence-based protocols and practices recognize the technical failures and stuck systems. They also know that the bodies of overdose victims are literally piling up. The Dayton, Ohio, Coroner’s office has run out of space to store bodies, and must rent cadaver storage space from funeral homes.<br />
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References <br />
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del Valle, L. (2017). Ohio coroner’s office running out of room because of overdose deaths. Retrieved February 10, 2017, from <a href="http://www.cnn.com/2017/02/01/health/ohio-coroner-overdose-deaths-trnd/index.html">http://www.cnn.com/2017/02/01/health/ohio-coroner-overdose-deaths-trnd/index.html</a><br />
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DeMio, T. (2017) In hell: The fight to save one addict. Retrieved February 10, 2017, from <a href="http://www.cincinnati.com/story/news/2017/02/03/saving-dominique-the-fight-to-save-one-addict/91550636/">http://www.cincinnati.com/story/news/2017/02/03/saving-dominique-the-fight-to-save-one-addict/91550636/</a><br />
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Ohio Psychiatric Physicians Association (2017) Ohio MHAS promotes ASAM guidelines for treatment of opioid use disorder. Retrieved February 10, 2017, from <a href="https://www.ooanet.org/aws/OPPA/pt/sd/news_article/133664/">https://www.ooanet.org/aws/OPPA/pt/sd/news_article/133664/</a><br />
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Oss, M. (2017). Addiction & Hospital Utilization – The Endless Loop? Retrieved February 10, 2017, from <a href="https://www.openminds.com/market-intelligence/executive-briefings/addiction-hospital-utilization-endless-loop/">https://www.openminds.com/market-intelligence/executive-briefings/addiction-hospital-utilization-endless-loop/</a><br />
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Rosemeyer, J. (2017). Cincinnati saw fewer heroin overdose deaths in 2016 than the year before. Retrieved February 7, 2017, from <a href="http://www.wcpo.com/news/cincinnati-saw-fewer-heroin-overdose-deaths-in-2016-than-2015">http://www.wcpo.com/news/cincinnati-saw-fewer-heroin-overdose-deaths-in-2016-than-2015</a><br />
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Image from Getty Images/iStockphoto Studio-Annika <div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.com0tag:blogger.com,1999:blog-7160896832735174090.post-48784854307069048022016-09-11T17:12:00.000-04:002016-09-11T17:13:34.905-04:00Fighting heroin in Cincinnati with money we already have and volunteers who are ready to start<i>A huge crisis. A new treatment paradigm. Now what do we do?</i><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgKYHfyksnJd83hw346OxRg3Moopxkl4Dogmjb4MfaSg8hxolX_hC9rvIxBBxU7ig4OpyKYHFtGfkebHnxXnQ7dAy0L76PRsV5qA2grk2FxXRO09zxyieMv-QmuvroJj9RhFrrAPryTbew/s1600/9023269525_353ddc1682_o.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="306" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgKYHfyksnJd83hw346OxRg3Moopxkl4Dogmjb4MfaSg8hxolX_hC9rvIxBBxU7ig4OpyKYHFtGfkebHnxXnQ7dAy0L76PRsV5qA2grk2FxXRO09zxyieMv-QmuvroJj9RhFrrAPryTbew/s400/9023269525_353ddc1682_o.jpg" width="400" /></a></div>
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I live in Cincinnati, where over 300 people have overdosed this past week. People have been calling this a “bad batch” of heroin, but overdoses have also ramped up across southern Ohio, West Virginia, Kentucky, and in Ohio’s other big cities. This is not a “bad batch.” It’s a product evolution, and it is coming to your town soon.<br />
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Fortunately, our community response systems have reached a tipping point on policy. Police here are offering immunity to people who turn in their drugs and ask for treatment. Medication assisted treatment is supported as the norm. Earlier this week, I spoke at a Cincinnati City Council committee meeting to offer my take on what might help. I used to be an outlier on policy, advocating for harm reduction and medication treatment in a community that favored nonmedical 12-step approaches and abstinence based care. This week, people were nodding their heads as I spoke, and I was nodding in agreement as treatment program leaders spoke. <br />
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To put it bluntly, we have reached a Kumbaya moment on addiction policy. Naloxone, medication assisted treatment, and community support programs are mainstream concepts now. People agree that we need a system that provides these things. What we need now is action. This creates new issues — implementation issues. How fast can we implement a new systems paradigm? Where will the money come from? Where will workers come from?<br />
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Fortunately, in Ohio, the money and protocols are already in the system. Certain reforms that have already been worked out must be implemented several months sooner than planned. Ohio has been in the midst of a behavioral health finance redesign for several years. These reforms are scheduled to kick off in mid-2017. The redesign process will move the state’s behavioral health system much closer to a “pay-for-performance” finance model. It also adds coverage for some new services, including peer support. Given the overdose emergency we are facing today, it should be possible to pilot the new payment system immediately in the places where overdoses are raging. In practice, this means training up existing staff, and upgrading payment systems to use new billing codes. It won’t cost more to implement reforms early. Because every dollar invested in medication assisted treatment saves around $5 in other healthcare system costs, the question is not “how much more we need to spend.” The real questions are “how much do we want to save?” and “how fast can we start?”<br />
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Who is going to do the work? Cincinnati already has the human resources to implement reforms at scale. We have about 1250 primary care physicians in Hamilton County, where the City of Cincinnati is located. If just ten percent of them took on 30 medication assisted treatment patients each, they could stabilize 3,750 people this year. Next year, federal regulations will allow each of these doctors to expand their caseloads, and serve 100 patients each, for a total of 12,500 people. That is the entire population that needs treatment in Hamilton County today, stabilized in just two years. <br />
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Our region is fortunate to have sufficient healthcare infrastructure to implement the new paradigm. We have four large hospital systems, a dozen or more Federally Qualified Health Centers, and several networks of behavioral health providers. These provider systems already negotiate rates and treatment protocols with public and private insurance systems. If provider systems step up their game, they can work together to create what are called Accountable Care Organizations (ACOs) and Special Needs Plans (SNPs). These are legal structures and insurance arrangements that support collaboration and help finance the work. It takes leadership and some technical skill to put this together, but the models to accomplish this exist. <br />
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Like other communities in America, Cincinnati has no shortage of willing volunteers. Church groups and community organizations are looking for ways to address the social needs of people in recovery. Our hospital systems at the center of the new treatment paradigm already manage volunteers. The missing ingredient is action. <div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.com0tag:blogger.com,1999:blog-7160896832735174090.post-20984427205741139802016-02-25T12:18:00.000-05:002016-02-25T12:18:48.449-05:00Mercy for AddictsPope Francis has recently declared a Jubilee Year of Mercy If we care to give mercy a try, we can start with our brothers, sisters, and neighbors who are suffering and dying from addiction. <br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhIIWp9BRfc9XjoTShIjyeYlEahoetD0KsjSSIsMtLGUnurG1PjsSxvYNObQUxmJEXYYCGhl2gSya9GsCrM2R2zrYvdppCtj5vL_oOOrj5iuxEZRAkCD5vHZCFy1yg9R4vzb8cwfosmI5w/s1600/NURSE.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhIIWp9BRfc9XjoTShIjyeYlEahoetD0KsjSSIsMtLGUnurG1PjsSxvYNObQUxmJEXYYCGhl2gSya9GsCrM2R2zrYvdppCtj5vL_oOOrj5iuxEZRAkCD5vHZCFy1yg9R4vzb8cwfosmI5w/s320/NURSE.png" width="247" /></a>In the last few years we have learned that people who use heroin and other opiates are risky, traumatized, disordered, and distressed. They have pain, addiction, immaturity, and mental illness all mixed together. They are in deep trouble. They need rescue. They need treatment, safety, and support, not lectures, punishment, and scorn. They need mercy.<br />
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We can heal the sick, and offer treatment to everyone who needs it. Northern Kentucky treatment agencies receive 40 calls a day from people seeking admission to care. We can say yes to everyone who calls, and if half show up, that’s 20 people every day, 100 every week, 5000 in a year. That is everyone at risk of overdose death in Northern Kentucky, brought to treatment in one year. It is not that costly to fund that surge of treatment. <br />
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Most people who use opiates stabilize quickly with medication and day treatment, but they require support to recover long term. We can show these people mercy, and support them as they make progress in their lives. We can house the homeless, feed the hungry, and offer comfort to the afflicted. Treatment groups can team up with churches and volunteers to help people stay in treatment. Ordinary human trouble disrupts treatment. Guest rooms, church dinners, safe recreation, and basic friendship help people overcome loneliness, rejection, transportation issues, and relationship trouble, the top barriers to retention in treatment.<br />
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Don’t forget jobs. When people emerge from drug use they tend to be poor and unemployed. We can give alms to the poor by combining jobs with support. This is another way for volunteers and co-workers to pitch in. <br />
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A minority of people have great trouble stabilizing, even with treatment. They may be too immature, too traumatized, or just too far out of control. Many of the people in this last group become prisoners for their own safety. Some are in jail, others are in secure facilities. We can show these people mercy too, by offering them treatment and connecting them with community support as soon as they are ready. <br />
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Mercy is good public policy. It aligns with effective medical care for addiction. Why are we so stuck in suffering? Perhaps mercy is our greatest challenge.<br />
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This post previously appeared in the <a href="http://www.cincinnati.com/story/opinion/contributors/2016/01/12/opinion-mercy-cost-blocks-us-helping-addicts/78699208/" target="_blank">Cincinnati Enquirer</a> and <a href="https://communityvoicescincy.wordpress.com/2016/01/27/mercy-for-addicts/" target="_blank">Cincinnati Community Voices</a> <div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.com0tag:blogger.com,1999:blog-7160896832735174090.post-16914286668401381272015-06-01T10:38:00.003-04:002015-06-01T10:38:41.195-04:00Church groups challenge social service systems<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQDqSbr9NFisYMFhZ5G2aTqhiFFcMgPDuWq9szB4RIP6GrrULqKq-sf18g03ch6URppZGAzjABvP6lKvRmgOTtkHj4_8dWdU_OOqAgBqDANZjdHpCCUPTBbOxJm8JGczMc8dBLa-GqWLs/s1600/80.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="272" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQDqSbr9NFisYMFhZ5G2aTqhiFFcMgPDuWq9szB4RIP6GrrULqKq-sf18g03ch6URppZGAzjABvP6lKvRmgOTtkHj4_8dWdU_OOqAgBqDANZjdHpCCUPTBbOxJm8JGczMc8dBLa-GqWLs/s320/80.jpg" width="320" /></a></div>
I’ve been approached by a former student to connect her church group with resources to help congregation members improve their daily lives. I visited the church and met the pastor and other church leaders. It’s a small African American congregation here in Cincinnati. The issues of interest to the members are familiar to anyone who works with poor and working class families:<br />
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<ul>
<li>Education</li>
<li>Childcare</li>
<li>Jobs</li>
<li>Personal health</li>
<li>Chronic illness</li>
<li>Diet</li>
<li>Healthy families</li>
</ul>
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A congregation choosing to improve the health of its members is no rare thing. People have always found ways to support each other in church organizations. Those in the so-called “helping professions” consider church groups a key “natural support.”<br />
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Unfortunately, we seem to know little about leveraging natural support relationships to improve health. The science plainly demonstrates our society’s failure to deliver success to the populations at the heart of social service mission. Service systems have directed countless dollars and resources at church groups in poor communities over the course of decades. Poverty, poor health, and trouble persist.<br />
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My hypothesis is that the American approach to health promotion and health improvement within church groups in high-poverty areas has been fundamentally incorrect. We treat natural supports as targets for professionals to manipulate. Congregations become the “primary target” of health interventions designed to reach intended “secondary targets,” meaning people with diseases or risk factors. Again and again, we measure the initial state of the target group, catalogue their troubles, and enumerate their risk factors and ailments. Later, we measure them again. At the end of our program, we announce that there has been some marginal statistical improvement. But that improvement never spreads to the population as a whole, and it’s hard to find actual living people who embody whatever improvement is announced.<br />
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What might we accomplish if we reversed the process? What might happen if we started with the desires and intentions of people in church congregations? What are their dreams? What are their strengths? What skills do they want to improve? What is the kind of life they envision for their children?<br />
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A population-centered starting point changes the direction of social service work. It turns the logic model inside out. What was once the “target population” is now the “action population.” The local service system becomes the “primary target.” Changing the service system changes the health of the action population, and impacts the broader population. The “secondary target” becomes the overall social and economic environment.<br />
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And here’s what’s most important. Delivering good results on personal goals actually improves a person’s life. Not some straw man, or statistical sort of person. A real person, with a real life, with blood in the veins. A person who has relationships, and perhaps even children, who influences other people every minute they draw breath.<br />
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Picture: WPA Church drawing<br />
http://lva.omeka.net/items/show/139<br />
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<div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.com0tag:blogger.com,1999:blog-7160896832735174090.post-21214000923766683032015-05-20T22:43:00.003-04:002015-06-15T17:34:47.568-04:00Redesigning Case Management Training<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi3kIN8hg7hBPCdrw1zihiabzkjVhYgKUTNSmG82t4Zoktx1tIHYOQRjwTFfrEBVXcDLIvZn7CIn_XxkfMwrJIIcMWvyvJcARBpkYfd9TRCSsu6FGBmFF7so1j7JzEqfy9bRRkz0BZswE0/s1600/The+Pyramid+of+Personal+Support.png" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="274" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi3kIN8hg7hBPCdrw1zihiabzkjVhYgKUTNSmG82t4Zoktx1tIHYOQRjwTFfrEBVXcDLIvZn7CIn_XxkfMwrJIIcMWvyvJcARBpkYfd9TRCSsu6FGBmFF7so1j7JzEqfy9bRRkz0BZswE0/s320/The+Pyramid+of+Personal+Support.png" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><b><i>Supporting Success</i></b><br />
<b>The Pyramid of Personal Support</b></td></tr>
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What might happen if case managers delivered person-centered, strength-based, and trauma-informed service to people enrolled in service systems?<br />
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People find themselves enrolled in service systems because they have experienced some sort of trouble or difficulty in life. The stress of that trouble carries some traumatic impact. If bad behavior was involved, the person may have experienced additional penalties with additional impact, and the person’s family circumstances may be disrupted. From a human development perspective, the effect of all this is to knock a person off their developmental path or at least slow the velocity of a person’s progress. People who find themselves enrolled in service systems need a boost to get back on course. <br />
<br />
Unfortunately, most service systems have organized themselves around problem-solving, not person-boosting. This is a historical social remnant, a consequence of history. Less than one hundred years ago, it was common for people with behavioral health issues to be treated as less than fully human. The various service professions were complicit in this. Members of the so-called “helping professions” facilitated atrocities, delivered inhumane care, enforced social control measures, and heaped on social consequences. Enlightened problem-solving fixes some of this, but much more progress is possible. Even today, much of the literature of care is still written in dehumanizing terms.<br />
<br />
Kentucky Certified Peer Specialist Chad Ponchot and I have redesigned case
management training in an attempt to rid the system of "one size fits
all" service. <a href="http://casemanager1.eventbrite.com/" target="_blank">Learn more, and sign up here. </a>Twelve hours of training are spread across two days. The
first day is experiential. Participants model relationship-building,
communication strategies, strength-finding, and resource development.
The second day applies that experience to issues encountered by the
service population. Kentucky has approved our work -- we are rolling out our model this summer.<br />
<br />
<a href="http://www.yourmindyourbody.org/badge/APA-BlogDayBadge-2015.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="http://www.yourmindyourbody.org/badge/APA-BlogDayBadge-2015.jpg" /></a><i><b>Supporting Success </b></i>delivers person-boosting from start to finish, with rigor – but this is not some ditzy New Age approach. We see the case manager’s job as technical assistance that supports healthy self-determination. <br />
<br />
Case managers can be among the best person-boosters within service systems. They operate closest to a person’s home. They serve as observers for systems and coaches for their clients. The strengths, aspirations, talents, and capacities of the person receiving the assistance are paramount, but subject to the ordinary constraints of life on Earth. Some choices are healthier than others. Some courses of action have more risk than others. Relationships have benefits, but are not without conflict and drama – including professional relationships. And within service systems, professionals may have more technical knowledge, but the client is still the boss.<br />
<br />
If you are interested in <i>Supporting Success</i>, visit <a href="http://www.humanintervention.net/">www.humanintervention.net</a><br />
<br />
Sign up for the training at this link. <a href="http://casemanager1.eventbrite.com/">http://casemanager1.eventbrite.com</a> <div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.com0tag:blogger.com,1999:blog-7160896832735174090.post-77273079168704643882015-05-11T11:17:00.002-04:002015-05-11T11:18:47.817-04:00My interview on "An American Epidemic"<iframe width="560" height="315" src="https://www.youtube.com/embed/M7fkR_abR08" frameborder="0" allowfullscreen></iframe><div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.com0tag:blogger.com,1999:blog-7160896832735174090.post-48535450426912931912015-03-08T21:29:00.001-04:002015-03-08T21:29:20.422-04:00An invitation for people in recovery<p dir="ltr">Someone from the local syringe exchange program sent me the following request. Looks worthwhile. Participate if you can.</p>
<p dir="ltr">---</p>
<p dir="ltr">Hello everyone, I am trying to get the word out about an upcoming project that I will be helping out with for the Cincinnati Exchange Project. Please feel free to forward the following info...</p>
<p dir="ltr">This Is Recovery – We Are So Much More Than Our Addiction.</p>
<p dir="ltr">Cincinnati Exchange Project is excited to launch our public/social media campaign, “This Is Recovery.” Our mission is to provide a platform for addicts to share the stories of their lives beyond their addictions. </p>
<p dir="ltr">We are looking for recovering addicts who are willing to participate in our photo campaign. You will be photographed but the photo does not need to show your face, it can be your hands, your feet, whatever you would like. You may chose to give us your name but that is not necessary either. </p>
<p dir="ltr">You are perfect for our project if you identify as an addict/former addict/recovering addict. We don't care what your addiction is/was and your recovery is self-defined. Your participation may help inspire other addicts to seek help and show the community at large that there is a life beyond addiction and that our lives matter. </p>
<p dir="ltr">We would like to begin photographing in March and hope to begin the campaign in April. For more questions or info please email <a href="mailto:cep.thisisrecovery@gmail.com">cep.thisisrecovery@gmail.com</a>. </p>
<div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.com0tag:blogger.com,1999:blog-7160896832735174090.post-23722988225083335832015-03-02T09:38:00.000-05:002015-03-02T09:56:39.423-05:00Out for Justice -- for Addicts<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi9IldUrzvMZFDX90c0fBlq1ThUBbK3DgXMgwQzg3oEkGHDQuNyDVLzY-SD0zLyoue5Sm0Vy_IKfXTeKhzuTeXK0jNnPnPxdqaE2zvD3TflKg62zCUjZqlDd778OalVT9TYWMhZDemp5oY/s1600/pk+ourt+for+justice.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi9IldUrzvMZFDX90c0fBlq1ThUBbK3DgXMgwQzg3oEkGHDQuNyDVLzY-SD0zLyoue5Sm0Vy_IKfXTeKhzuTeXK0jNnPnPxdqaE2zvD3TflKg62zCUjZqlDd778OalVT9TYWMhZDemp5oY/s1600/pk+ourt+for+justice.png" height="320" width="281" /></a></div>
Last week, the Cincinnati Enquirer published an opinion piece I wrote: <a href="http://www.cincinnati.com/story/opinion/contributors/2015/02/25/drug-courts-addicted-ignorance/24004037/" target="_blank">Drug Courts Addicted to Ignorance. </a>It has generated well over 500 Facebook shares and 30 comments. I know it is controversial. It was meant to generate discussion. Here are some of the comments.<br />
<blockquote class="tr_bq">
I am an opiate addict of 16+ yrs . I've been to detox centers and rehab, and I've quit cold turkey more than a dozen times, only until I got into a medical treatment program coupled with meetings and 1 on 1 therapy , on March 11th I celebrate my first year in 16 year without taking 1 opiate, I also am a dual-diagnosis case , not only do I suffer from addiction I suffer from ptsd, bipolar, and anxiety disorder this medication based treatment as helped me regain myself, my children, I'm a productive member of society. I support this type of treatment 100 %</blockquote>
That is what I hear from people who have not been able to succeed on 12-step alone. Another commentator saw things differently:<br />
<blockquote class="tr_bq">
"When people switch to medicine instead of street drugs, criminal behavior stops." Anyone who knows anyone on methadone knows this just ain't the case. Why would the author make such a statement? <br />
"...medication-assisted treatment is the only way to successfully keep people from relapsing on illegal drugs." Again, we all know numerous folks who have done it differently, and successfully. Again, why would the author make such a statement? Mr. Komarek himself acknowledges that at least "one out of 10 find recovery through an abstinence-based program." <br />
"We've even learned that 12-step programs like AA and NA do not work for the population using heroin today." But we all know people for whom these programs have worked. More often than not the "heroin population" is not working the programs, not the other way around. So again , why would the author make such a negative blanket statement?</blockquote>
In my experience, people who have achieved recovery through 12-step methods see their own experience as typical. When someone fails, they say the person fails because they are not "working the program." What the research says, and what I have seen, is that working a program is not enough for most people. People try, and try, and some succeed, but too many lose their tolerance to the drug, relapse, and die --- after being shamed and blamed repeatedly for "failing to work their program."<br />
<br />
Someone who works with local drug courts wrote an extensive criticism. It started with this.<br />
<blockquote class="tr_bq">
"Has the author ever even spoken with a drug court Judge or attended a drug court session. Has he asked the Judge's opinions about MAT. I know he hasn't in NKY." </blockquote>
I have not visited any of those drug courts, but I know of many people who have suffered because of them. I asked my advisory group to give me a reality check about this comment. They referred me to the recent <a href="http://projects.huffingtonpost.com/dying-to-be-free-heroin-treatment" target="_blank">Huffington Post expose on lack of access to evidence-based care.</a> One sent me a copy of this sign found hanging in a northern Kentucky courtroom -- published in the same article.<br />
<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixuGwjqu7bLPepzOFpIC3Wm4rHVkqXH7bksUkP_aTV6itGLQjlvMJpCPi3Fau8m_ndw1VyAakLiDXMjGXHIbgFsFE3LEh03XfWuyZcnod5q0MkGrHDMdO0N-xOtbjEnqDkASedWaDF6Ws/s1600/court-b58412ba9218bf2de97e6828246146e8.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixuGwjqu7bLPepzOFpIC3Wm4rHVkqXH7bksUkP_aTV6itGLQjlvMJpCPi3Fau8m_ndw1VyAakLiDXMjGXHIbgFsFE3LEh03XfWuyZcnod5q0MkGrHDMdO0N-xOtbjEnqDkASedWaDF6Ws/s1600/court-b58412ba9218bf2de97e6828246146e8.jpg" height="266" width="320" /></a></div>
<br />
<br />
This is serious stuff. In many parts of the addiction treatment industry, medication assisted treatment is seen as a threat. One of my advisors told me someone lost their job at a local treatment agency after speaking with reporters about the need to include medicine as part of treatment.<br />
<br />
This is an important concern -- truly life and death for many people in our communities. Let's keep working on it.<div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.com0tag:blogger.com,1999:blog-7160896832735174090.post-57172389955602252162015-02-26T01:59:00.003-05:002015-02-26T02:01:23.857-05:00The choice is heroin or hope<iframe allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/FhYZ_AnOMnw" width="560"></iframe><div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.com0tag:blogger.com,1999:blog-7160896832735174090.post-55877079840465330922014-12-19T12:43:00.000-05:002014-12-19T12:47:47.845-05:00Christmas Snapshot, Heroin in SW Ohio 2014<div class="separator" style="clear: both; text-align: center;">
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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.<br />
<br />
Here's the lowdown, in snapshot format, following the milestone and infrastructure model in my book <a href="http://www.sharpstopheroin.com/" target="_blank">Sharp Stop Heroin and Rescue People.</a><br />
<br />
<b>Date: December 19, 2014</b><br />
Community: Southwestern Ohio<br />
Author: Paul Komarek<br />
<b><br />
Extent of problem</b><br />
Severe.<br />
<br />
<b>Enrolled in System</b><br />
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.<br />
<br />
Hamilton County has a designated “front door” for recovery services, but no one mentioned it in the course of a three hour public meeting.<br />
<br />
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. <br />
<br />
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. <br />
<br />
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. <br />
<br />
Primary care systems are not connecting with treatment systems. <br />
<br />
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.<br />
<br />
Ohio’s Medicaid plan needs updating, and will not be effective until it accommodates all levels of care.<br />
<br />
Apart from the VA, Ohio treatment organizations are not systematically integrating behavioral health electronic health records with commercial systems. <br />
<br />
<b>First Aid Available</b><br />
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.<br />
<br />
<b>Safe from Infection</b><br />
Syringe exchange is available during restricted hours in two Cincinnati neighborhoods. It is not available in the suburbs.<br />
<br />
<b>Medicine, Not Street Drugs</b><br />
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.<br />
<br />
<b>Social Support</b><br />
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.<br />
<br />
<b>Rehab</b><br />
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.<br />
<br />
<b>Sober Living</b><br />
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.<br />
<br />
<b>Long-Term Recovery</b><br />
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. <div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.com0tag:blogger.com,1999:blog-7160896832735174090.post-30730465642408200912014-12-07T17:20:00.002-05:002014-12-07T17:40:45.888-05:00Heroin W.M.D.<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgIML8KQhyoWwvpQhWkocyDBmELafE5WXDHlfOBwnyYtIxrQ3lHF7QFat8Ax4UFTroHq8Bua4Z0XJsmdNN3UqVOsMDnZmpuEvfTUh9sAuW2UPg0L_86ZsakKoJ7M_SQ56FNDAZfhQcaZNM/s1600/its-da-bomb.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgIML8KQhyoWwvpQhWkocyDBmELafE5WXDHlfOBwnyYtIxrQ3lHF7QFat8Ax4UFTroHq8Bua4Z0XJsmdNN3UqVOsMDnZmpuEvfTUh9sAuW2UPg0L_86ZsakKoJ7M_SQ56FNDAZfhQcaZNM/s1600/its-da-bomb.jpg" height="400" width="318" /></a>Heroin is not that complicated. It’s a weapon of war, part of an invasion that delivers a plague.<br />
<br />
Our mission is relatively simple: Repel the invader. Save the people.<br />
<br />
Anything else plays into the enemy’s hands. <br />
<br />
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. <br />
<br />
“Friend or foe?” and “What can I do to help you?” are key questions. They help us stop the damage.<br />
<br />
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. <br />
<br />
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.<br />
<br />
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.<br />
<br />
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.<br />
<br />
---<br />
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.<br />
<br />
Learn more at <a href="http://www.sharpstopheroin.com/">http://www.SharpStopHeroin.com</a><br />
<br />
or RSVP at <a href="http://www.meetup.com/SHARP-Stop-Heroin-Study-Group/events/218807100/" target="_blank">http://www.meetup.com/SHARP-Stop-Heroin-Study-Group/events/218807100/ </a><br />
<br />
<br />
<div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.com0tag:blogger.com,1999:blog-7160896832735174090.post-26517493808974344752014-10-25T13:37:00.000-04:002014-10-25T13:39:32.555-04:00Separated Orphan Twins<div class="separator" style="clear: both; text-align: center;">
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In 2014 my work focused on addiction, specifically on the heroin epidemic claiming so many lives across the U.S. My new book<a href="http://www.amazon.com/SHARP-Stop-Heroin-Rescue-People/dp/1501003496/" target="_blank"> SHARP Stop Heroin and Rescue People</a> reflects that work. <br />
<br />
That work helped me to focus more on the question of integrated care. Poor social choices and bad public policy have caused mental health and addiction care to develop like separated orphan twins.<br />
<br />
Mental health and addiction are both biopsychosocial, with biological, psychological, and social aspects that continuously reinforce each other and cannot be easily separated, but the treatment systems are separated. Over the course of decades, each system figured out how to emphasize and advocate for its particular service delivery style, treatment philosophy, and culture of care.<br />
<br />
This has caused clinicians to develop blind spots. People come away with a different diagnosis and different treatment depending on the system they walk into. <br />
<br />
The separation has affected the overall health of the population using mental health and addiction services. We see this in the resistance of addiction treatment systems to medicine-assisted addiction treatment. We also see this in the tendency to overmedicate people in the mental health system.<br />
<br />
The separation from mainstream healthcare also allows for a certain amount of medical shunning. People with mental health and addiction problems can be self-destructive, edgy, difficult, noncompliant, willful or just plain strange. Separated systems make it easy for medical doctors to minimize their own accountability, and kick responsibility over to someone else.<br />
<br />
The mainstream medical system is not some add-on or accessory to psychiatric care or addiction treatment. It’s the other way around.<div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.com1tag:blogger.com,1999:blog-7160896832735174090.post-13584804892674848692014-10-01T16:17:00.000-04:002014-10-01T16:21:29.699-04:00The Smell of Heroin and Snake Oil<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEifmLJNfm3ghHL2Avv5mQG98JlJ6XNOprk4jFS1wwEyKYqz785dwVsqppEXTL7cMojS03gNEYJaxIUXEz-B4BtQZ5S_yfOPDAEcw1VZA4NaW0FhjsRZ2NC8k5F4OMy-6Z3zE8fDLczw-8k/s1600/Snake+oil.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEifmLJNfm3ghHL2Avv5mQG98JlJ6XNOprk4jFS1wwEyKYqz785dwVsqppEXTL7cMojS03gNEYJaxIUXEz-B4BtQZ5S_yfOPDAEcw1VZA4NaW0FhjsRZ2NC8k5F4OMy-6Z3zE8fDLczw-8k/s1600/Snake+oil.jpg" height="320" width="280" /></a>There's a quaint old-fashioned smell of snake-oil around addiction treatment in Kentucky. Kentucky is the center of the heroin epidemic, but its top investment in addiction care isn't, formally speaking, addiction treatment. It is a housing program with peer support, group meetings, and workbooks. <br />
<br />
Recovery Kentucky, the program that builds recovery centers across the state, uses a non-medical model from the Healing Place in Louisville, a model that is used in other states to side-step the formalities of science-based addiction care. The program is not physician-supervised, and does not follow a medical model. People with chronic pain or medication needs cannot be served in the program. <br />
<br />
For heroin, the National Institute of Drug Abuse recommends Medication Assisted Treatment and cognitive behavioral therapy. Recovery Kentucky uses neither. It relies on peer group meetings, and "trudging."<br />
<blockquote class="tr_bq">
“Trudging is an important part of the Recovery Kentucky Program. When an addict is in the midst of their addiction, they will go to any extreme to get their drug of choice. Once they have entered into the program, they are asked to have that same dedication to achieving their recovery. All recovery centers have their MT classes in off-site locations that the clients walk to and from. Clients generally walk two-to-four round-trip miles a day, based on location. The only time participants do not trudge is if the weather or conditions pose a danger to them—not an inconvenience but a danger, such as an ice storm or tornado. Recovery Kentucky participants can be seen walking in the heat of summer, the leaves of fall, the snow of winter, or the rain of spring. “ </blockquote>
Now don't get me wrong. There are people who respond well to this sort of program. I have met many people who have rebuilt their lives after their experience in Recovery Kentucky.<br />
<br />
But only about one in three or four individuals who enter these facilities make it through the program The rest wash out in the first few weeks of the program. They do not make it to the point of entry to "Phase One" (which is actually the fourth step of Recovery Kentucky's five-phase program). All of Recovery Kentucky's success statistics are based on people who have made it to this fourth step in their process.<br />
<br />
Kentucky needs programs that help the other 70 to 75 percent of people who are stuck on heroin, the ones who cannot trudge through the Recovery Kentucky process. And fast. When people fail programs like these, they always relapse --- and relapse is when heroin is most fatal.<br />
<br />
<b>Sources</b><br />
<br />
Designed <i>not</i> to be treatment<br />
<a href="http://www.treatmentmagazine.com/newswires/481-the-healing-place-looking-to-expand-model-to-west-virginia-.html" target="_blank">http://www.treatmentmagazine.com/newswires/481-the-healing-place-looking-to-expand-model-to-west-virginia-.html</a><br />
<blockquote class="tr_bq">
The Healing Place Huntington is far from the first center to try a
"regulatory arbitrage" approach to get around expensive licensure
requirements by employing a non-medical model, thus asserting in fact
not to be a treatment center as defined by state regulatory codes.</blockquote>
Trudging<br />
<a href="http://www.ncsha.org/system/files/Kentucky_Combating_Homelessness.pdf">http://www.ncsha.org/system/files/Kentucky_Combating_Homelessness.pdf</a><br />
<br />
<br />
Recovery Kentucky Guidelines <br />
<a href="http://kyhousing.org/Specialized-Housing/Documents/RecKYGuidebook.pdf">http://kyhousing.org/Specialized-Housing/Documents/RecKYGuidebook.pdf</a><div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.com0tag:blogger.com,1999:blog-7160896832735174090.post-16437493738226617042014-09-17T09:40:00.000-04:002014-09-17T09:40:02.310-04:00I Am a Fugitive from an Ohio Drug Court<div dir="ltr">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh6wHwAA-sXghyMIEVMo8uEr8GIQRxzFo0n_Pf28LYuIbdtb4Hce2Q3zDizyTtfQiX0cv-gPp_O0wLJ61sz0EbDAUvXV7b1yRlDKNxZj_ZLTQ0J2ttuxntcU4QAwFLYBMP5FTzNPBp0pdE/s1600/i-am-a-fugitive-from-a-chain-gang-trailer-title.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh6wHwAA-sXghyMIEVMo8uEr8GIQRxzFo0n_Pf28LYuIbdtb4Hce2Q3zDizyTtfQiX0cv-gPp_O0wLJ61sz0EbDAUvXV7b1yRlDKNxZj_ZLTQ0J2ttuxntcU4QAwFLYBMP5FTzNPBp0pdE/s1600/i-am-a-fugitive-from-a-chain-gang-trailer-title.jpg" height="240" width="320" /></a>It is time to reform some of our "reforms." As I visit elements of our mental health and addiction service systems, I am finding out that certain reform efforts are having trouble delivering on their promises. For the people hit by these failures, people with mental health and addiction and their families, this is a scandal that causes as much suffering and death as old-style chain gangs. </div>
<div dir="ltr">
<br /></div>
<div dir="ltr">
<b>I. DRUG COURT DEBACLE</b> </div>
<div dir="ltr">
<br /></div>
<div dir="ltr">
I spent a day in drug court recently. </div>
<div dir="ltr">
<br /></div>
<div dir="ltr">
What a disappointment. It was an exercise in piling probation violations on top of felony convictions for being an addict. </div>
<div dir="ltr">
<br /></div>
<div dir="ltr">
The court does not offer medication assisted treatment, so it is to be expected that nearly everyone relapses -- which then becomes a new conviction. </div>
<div dir="ltr">
<br /></div>
<div dir="ltr">
I was there with a man who had a 5th degree felony possession conviction for less than a gram of heroin (something actually against the prosecutor’s indictment policy) from two years ago. He’s still on and off the docket, and getting intermittently incarcerated. </div>
<div dir="ltr">
<br /></div>
<div dir="ltr">
What a waste of time and resources – and a profound extended life disruption for this man, who has extensive trauma, anxiety and mood problems, and needs stability, not this. </div>
<div dir="ltr">
<br /></div>
<div dir="ltr">
Everyone else on the docket seemed to be living out the same story. </div>
<div dir="ltr">
<br /></div>
<div dir="ltr">
I hope this was not a typical day for Drug Court. If so it is a system failure. Everyone doing the work seemed appropriately committed to delivering a good result. They just had a tool that was broken, one that doesn't fit heroin.</div>
<div dir="ltr">
<br /></div>
<div dir="ltr">
<b>II. MENTAL HEALTH COURT MADNESS</b> </div>
<div dir="ltr">
<br /></div>
<div dir="ltr">
I met a woman in a peer recovery center last month who is in trouble with her </div>
Mental Health Court because she isn't taking her medication. She has a therapist she visits regularly, and a doctor who is happy with her not using medication, but the court keeps threatening to sanction her unless she starts taking medication.<br />
<div dir="ltr">
<br /></div>
<div dir="ltr">
Even though she is pregnant. </div>
<div dir="ltr">
<br /></div>
<div dir="ltr">
<b>III. THE LIE THAT KILLS </b></div>
<div dir="ltr">
<br /></div>
<div dir="ltr">
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Methadone is the most widely used medication to manage
cravings for heroin and other opiate drugs. It has been used for close to 50
years to stabilize people, especially those who have the most trouble moving
past heroin use. The “market rate” cost of methadone treatment is about $15 per
day. Most people who need methadone can’t afford it unless Medicaid covers this
expense.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
In Northern Kentucky, the local methadone clinic wants to
bill Medicaid for its methadone dispensing service, but it can’t. The state has
not set up a way for the clinic to enroll as a Medicaid provider. There is no
code to use for billing, and no fee structure. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The State Medicaid Plan mandates methadone service, but state
officials won’t act. This violates the federal benefit rights of vulnerable
people and puts people’s lives at risk. When the people who have the most
difficulty making progress without medical help are left without options, they
relapse and die. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
This part of the Medicaid plan is just a lie that kills.</div>
<div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.com0tag:blogger.com,1999:blog-7160896832735174090.post-68803440807304424652014-09-08T08:21:00.001-04:002014-09-10T23:16:24.575-04:00The first coherent strategy for the heroin epidemic<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj8V-MzirZOvfUDXiFXn1cOqGkgE5y__RKa3uzreOIyyfDm2bvqBZYyt3YkT2BFCCeflL2jcHuI5uPrqxszoUlwJ5dLdRt6Bl82LPvkD9_hXFFsHND9NAb_jOd4KY0OlnOKVlwu95j1fps/s1600/SHARP+COVER.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj8V-MzirZOvfUDXiFXn1cOqGkgE5y__RKa3uzreOIyyfDm2bvqBZYyt3YkT2BFCCeflL2jcHuI5uPrqxszoUlwJ5dLdRt6Bl82LPvkD9_hXFFsHND9NAb_jOd4KY0OlnOKVlwu95j1fps/s1600/SHARP+COVER.jpg" height="320" width="200" /></a><br />
My focus this past year has been the heroin epidemic. The result is a book that delivers three things.<br />
<ul>
<li>A coherent strategy to manage heroin overdose risk for the population.</li>
<li>A strong narrative of recovery that supports harm reduction.</li>
<li>A public policy framework that aligns service systems and creates the necessary infrastructure.</li>
</ul>
From the Introduction<br />
<blockquote class="tr_bq">
Heroin is an epidemic, a health threat. What has kept us from attacking it effectively is a social stance we have taken towards the people who suffer. We face a decision point. We can attack it with all we've got. Our health system and legal system can align their efforts, work together, and solve this. Or we watch more people die.</blockquote>
This is a book for personal recovery, for advocacy, and for system building work. From the chapter "Social Infection"<br />
<blockquote class="tr_bq">
Alignment and continuity matter. The fatal risk around heroin is frighteningly high, and people who use heroin are fragile. When people disconnect from service systems, relapse turns fatal fast.</blockquote>
<blockquote class="tr_bq">
Heroin is proving to be a kind of signaling system. It shows us how shunning, exclusion, violence, neglect, and system failure infect our safe world. This population is tough to serve, but so what. People in service systems have the capacity to adapt, and a duty to respond to the people at the heart of their missions.</blockquote>
Purchase<a href="http://www.amazon.com/SHARP-Stop-Heroin-Rescue-People/dp/1501003496/" target="_blank"> SHARP Stop Heroin and Rescue People at Amazon</a><br />
<br />
I have also started a meetup group to pursue development of systematic rescue in communities. Learn more at <a href="http://www.sharpstopheroin.com/" target="_blank">http://www.sharpstopheroin.com</a> The website also features downloadable worksheets for community planning work.<br />
<br />
The book addresses several audiences: community workers, people pursuing recovery and family members, and all the rest of us. The real alternative to heroin is a positive, safe world. It is our efforts, how we treat each other as well as the opportunities we create, that build and sustain that world.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjxEdbIWdehF_PiUjucB6NxlZcbZ9mACJfbbIzO5gdveR_Hn7Hait13lGizLub8d4ZGaBPpMnAAxiiNKRKF0W3yuU32V3-HCYz4nGKmUqprG2y_XS7UWoaKEZSqTipVtuTDblaBGzU6f4/s1600/Path+to+positive+and+safe+complete+picture+rev+082214.gif" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjxEdbIWdehF_PiUjucB6NxlZcbZ9mACJfbbIzO5gdveR_Hn7Hait13lGizLub8d4ZGaBPpMnAAxiiNKRKF0W3yuU32V3-HCYz4nGKmUqprG2y_XS7UWoaKEZSqTipVtuTDblaBGzU6f4/s1600/Path+to+positive+and+safe+complete+picture+rev+082214.gif" height="398" width="640" /></a></div>
<br /><div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.com2tag:blogger.com,1999:blog-7160896832735174090.post-6588270137099969962014-07-22T13:43:00.003-04:002014-07-22T14:34:57.192-04:00Kentucky Medicaid Plans Restrict Addiction Care<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg0RK_ng4knn_0-gNwE9HfbeaXTm1QnVz91nbEiCjrwDt7-XuNnp0UDR7YpSIzNuZgJWgyCCwKoQg3HtuuV11ZMtR_F6xqKVkFhubWXpbcXz7m3icaELiGhtVAPgNPFNdPMvfTI1Q6aosA/s1600/4741451457_6344b99835.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg0RK_ng4knn_0-gNwE9HfbeaXTm1QnVz91nbEiCjrwDt7-XuNnp0UDR7YpSIzNuZgJWgyCCwKoQg3HtuuV11ZMtR_F6xqKVkFhubWXpbcXz7m3icaELiGhtVAPgNPFNdPMvfTI1Q6aosA/s1600/4741451457_6344b99835.jpg" height="266" width="400" /></a>In Kentucky, efforts to combat widespread opiate addiction and heroin poisoning deaths are hitting limits built into Kentucky's newly-expanded Medicaid system. A big part of the <a href="http://www.redesigningmentalillness.net/2014/04/mobilizing-medical-warriors-to-stop.html" target="_blank">answer to this epidemic</a> is access to medication that helps stabilize patients while they receive treatment or wait for further care. Unfortunately, Kentucky's new Medicaid system is built on a health insurance infrastructure that can be fairly unfriendly to families with chronic care needs.<br />
<br />
American healthcare has evolved into a gatekeeper-driven system. Insurers save money by rationing care and by putting barriers in the way of care. All of this is calculated. Companies know that when service becomes inconvenient, a certain number of people will simply give up, and the company will never have to pay. The extent to which a company puts self-interest ahead of patient interest is embodied in its published plan documents, regulatory filings, and customer service practices.<br />
<br />
The preferred drug list or formulary is a list of medications a plan intends to pay for. The plan might eventually approve or pay for others on a case-by-case basis, but customers who need medicines that are not on these lists should expect to encounter obstacles. This is intentional. Companies know that drug formularies are interpreted as a reflection of company attitudes towards patients with various specific healthcare needs. Insurers manipulate formulary listings to discourage certain patients from enrolling in their plans. In public benefit situations like Medicaid or Medicare, insurers are paid for managing a certain population’s health risk – and the higher the risk of the patients they enroll, the lower the company's bottom line.<br />
<br />
Here’s how these factors impact patient care for addiction in Kentucky. The three medications which are FDA approved for Medication Assisted Treatment for opiate and heroin addiction are Methadone, Suboxone, and Vivitrol.<br />
<br />
Kentucky has five Medicaid Managed Care Organizations. I tracked down each company's online drug formularies/preferred drug lists, and discovered the following.<br />
<blockquote class="tr_bq">
- One provider lists only Methadone.<br />
<br />
- Another lists only Suboxone.<br />
<br />
- Two providers list two of the three medications: Methadone and Suboxone.<br />
<br />
- Only one lists all three: Methadone, Suboxone, and Vivitrol.</blockquote>
What I read from this is that only one of the companies seems willing to support all the available medication options. You can draw your own conclusions.<br />
<br />
<b>If you or your family's health depends on Kentucky Medicaid</b><br />
<br />
You can start your own research journey at <a href="http://www.chfs.ky.gov/dms/mcolinks.htm" rel="nofollow" target="_blank">this link</a>.<br />
<br />
Companies update formularies periodically, so perhaps the situation will change. Kentucky requires managed care organizations to post their plan documents online, but as of today it does not offer plan-by-plan comparison tools. Medicaid representatives say customers who are denied services under any of the plans have appeal rights, but to me that's just another built-in obstacle. Folks at high risk need prompt care.<br />
<br />
People who find out that they are stuck on the wrong managed care plan can switch from one plan to another, even after the open enrollment period ends, using a process described <a href="http://www.chfs.ky.gov/NR/rdonlyres/32A68460-3EBE-4AEC-9FB2-94E94A90E472/0/HowtochangeyourManagedCareOrganization.pdf" rel="nofollow" target="_blank">here</a>.<br />
<br />
More information about Kentucky Medicaid managed care enrollment is found <a href="http://www.chfs.ky.gov/dms/member+information.htm" rel="nofollow" target="_blank">here</a>.<br />
<br />
---<br />
Meet me August 6th to talk about what it will take to stop heroin deaths, at the Cincinnati SHARP Stop Heroin Meetup. <a href="http://www.sharpstopheroin.com/" target="_blank">Learn more.</a> <div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.com0tag:blogger.com,1999:blog-7160896832735174090.post-15154684115927623852014-07-12T12:14:00.000-04:002014-07-12T12:15:43.117-04:00My System Reform Wishlist<div class="separator" style="clear: both; text-align: center;">
<a href="http://upload.wikimedia.org/wikipedia/commons/c/c0/Ausf%C3%BCllen_des_BDA-Fragebogens.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="http://upload.wikimedia.org/wikipedia/commons/c/c0/Ausf%C3%BCllen_des_BDA-Fragebogens.JPG" height="240" width="320" /></a></div>
What might really improve behavioral health? The Ohio Mental Health and Addiction Service Department has a <a href="https://www.surveymonkey.com/s/SJHP875" rel="nofollow" target="_blank">survey</a> out, looking for input.<br />
<br />
Here are the key survey questions, and what I wrote.<br />
<br />
<b><i>1. Briefly describe the top 5 issues (in rank order) that, if addressed, would have a significant impact on the lives of persons with substance abuse challenges in your community?</i> </b><br />
<b><br />
</b>1 Establish a clear path to safety and good health, and align system resources to support that path<br />
2 Eliminate system-created barriers, delays and disincentives <br />
3 Foster population-level nonclinical social support and volunteer-delivered service networks <br />
4 De-emphasize pathology thinking (e.g. AA), emphasize personal strengths, learning, improved cognition, improved relationships, and safe environments <br />
5 Align justice system practices with the path to safety and good health <br />
<br />
<b><i>2. Briefly describe the top 5 issues (in rank order) that, if addressed, would have a significant impact on the lives of persons with mental health challenges in your community?</i></b><br />
<br />
1 Establish a clear path to safety and good health, and align system resources to support that path <br />
2 Eliminate system-created barriers, delays, and disincentives <br />
3 Establish population-level nonclinical social support and volunteer-delivered service networks <br />
4 De-emphasize pathology thinking (e.g. personal identity connected to clinical diagnosis), emphasize personal strengths, learning, improved cognition, improved relationships, and safe environments <br />
5 Align justice system practices with the path to safety and good health <br />
<br />
<i><b>3. Do you have specific ideas about how to address the issues you mentioned in questions 1 & 2? Please explain:</b></i><br />
For a variety of reasons, our systems pay lip service to the notion that behavioral health is biopsychosocial. We only invest in biological methods. We underfund the psychological, and ignore social support completely. This imbalance creates failure, because we are trying to solve population level problems with the most expensive techniques imaginable. Our system has developed a siege mentality. It is plain from reading community plans that system leaders mostly look inward, fretting over the little resources they have. The system must start facing outward, and figure out ways to serve the whole population effectively. This means that, instead of acting like 88 service fortresses in 88 service deserts, the system needs to act more like a network of service hubs. If the system can’t support funding a particular technique (e.g. medication assisted treatment for addiction), it should remove the service from the behavioral health carve-out, and find ways to collaborate with systems that can support the technique. There should always be a path to the least expensive, most accessible way to deliver what is needed when it is needed. People should feel safe and connected if they must wait for a more intensive service.<br />
<br />
The relevant techniques for redesigning effective service systems are community organizing, appreciative inquiry, civic engagement, asset based community development, and the IDEO Human Design toolkit.<br />
<br />
I developed NAMI Ohio’s court and jail training, worked on the Hamilton County SAMI team. I have developed crisis de-escalation training, and worked on tough issues in multiple service systems. I have been working and learning from Peter Block and other civic engagement experts about how to generate positive solutions to seemingly intractable problems. I do licensing and accreditation work for service delivery agencies. For the past several years I have focused on what ordinary people can do to support each other, and writing about how to change the experience of having mental illness. I have written a well-regarded book that embodies what I have learned. For the past year, I have also worked with anti-drug advocacy groups in Northern Kentucky about heroin poisoning issues. I have learned that it is possible to articulate a path to safety and good health that is practical, understandable, consensus based, and effective. <br />
<br />
<i><b>4. Who would you need to partner with in your community in order to effectively address the issues you mentioned in questions 1 & 2? </b></i><br />
Behavioral health is a population-level issue. The whole community has a stake in it. Effective system reform will come from engaging business leaders, neighborhood groups, church groups, parent groups, service system users and political leaders. Today’s reforms are mostly about responsiveness and clarity, not about delivering a smidgen more of what the current system cannot deliver. <br />
<b><br />
</b> <b><i>5. Briefly describe what the impact would be to your community if these issues were addressed?</i></b><br />
People with substance abuse issues – particularly heroin – would move from having a life that is unsafe, at risk of harming others, and is essentially criminal, to a life of a person who is enrolled in a system, who has first aid available, who is safe from infection, whose life is managed, not criminal, less risky, positive, supported and safe. People with mental illness would retain economic and social capacity, move from social isolation and control by others to a life that is safe, socially supported, with access to care as needed, delivered in an ethical, collaborative fashion, and oriented to achieving the ordinary milestones of human development.<br />
<br />
---<br />
Photo By Carin fuerst (Own work) [CC-BY-SA-3.0-at (http://creativecommons.org/licenses/by-sa/3.0/at/deed.en)], via Wikimedia Commons<div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.com0tag:blogger.com,1999:blog-7160896832735174090.post-19096935052597968142014-05-25T16:47:00.002-04:002014-05-25T16:49:33.631-04:00Social services, and pots of money<div class="separator" style="clear: both; text-align: center;">
<a href="http://upload.wikimedia.org/wikipedia/commons/c/ca/Serried_ranks_of_flower_pots_in_the_potting_shed_-_geograph.org.uk_-_1400983.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="http://upload.wikimedia.org/wikipedia/commons/c/ca/Serried_ranks_of_flower_pots_in_the_potting_shed_-_geograph.org.uk_-_1400983.jpg" height="300" width="400" /></a></div>
I learned about pots of money in grant proposal writing class.<br />
<br />
The instructor showed us four flowerpots, four empty cups, and a watering can. Each cup had a label. Each flowerpot had a label. She poured water from the watering can into each of the cups. Then she matched each cup to each flowerpot, then she poured from each cup into its matching flowerpot. <br />
<br />
The instructor said funding social services meant thinking in terms of pots of money. These turned into pots of client service. Enough pots, and the agency could sustain its work. <br />
<br />
This lesson was absolutely true. My boss at Catholic Social Services often talked in terms of pots of money. A pot of money meant a pot of agency resources to put staff people in jobs. Each pot let our agency address a certain kind of trouble. One problem, one service, one flowerpot. Our agency was a tray of flowerpots, funded with matching pots of money. <br />
<br />
People in service agencies have adapted to pot-of-money thinking. We analyze each person looking for service who walks through our doors, identify each person’s list of problems, match the problems to pots of money, and deliver whatever services might match. And only those services. What we deliver is always hit-or-miss. <br />
<br />
The truth is that our pot-of-money system is perfectly designed to deliver hit-or-miss services. It does that every day, even though the process started with all the resources in a single watering can.<br />
<br />
Is there a way to ditch the cups and flowerpots, give up on matchy-matchy pot-of-money thinking, and start a real garden instead? <br />
<br />
---<br />
Photo Rod Allday [CC-BY-SA-2.0 (http://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons<div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.com0tag:blogger.com,1999:blog-7160896832735174090.post-13148758448533554952014-05-01T09:51:00.000-04:002014-05-01T10:10:07.490-04:00The Service Fortress in the Service Desert<div class="separator" style="clear: both; text-align: center;">
<a href="http://upload.wikimedia.org/wikipedia/commons/3/3f/Forteresse_frontali%C3%A8re.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="http://upload.wikimedia.org/wikipedia/commons/3/3f/Forteresse_frontali%C3%A8re.JPG" height="400" width="278" /></a></div>
I have been reading through a collection of community mental health plans, shocked and disappointed by the number of people that Ohio’s state and county governments have written off.<br />
<br />
Our mental health service system has become a fortress in a desert. Sentries guard the doors. Leaders signal for help and unload supply wagons, but hesitate to let people inside.<br />
<br />
This makes no sense in modern times. There is no special magic in a walled-up system. People who need mental health services are dispersed throughout our society. They need help where they are. <br />
<br />
Ohio has a system of county mental health boards, whose mission is to look out for what the population needs. Read enough community health plans, and you’ll see the siege mentality that has taken hold. Planners count survivors and fret about what's left inside the fortress walls. <br />
<br />
In Hamilton County, where I live, the poverty rate has climbed from 10.8 percent to 18.5 percent from 2002 to 2011. This factor alone drives increased rates of depression and dysfunction, but our county public system does not address this. The county planners write. <br />
<blockquote class="tr_bq">
Due to limited resources, there is limited capacity for outpatient counseling for those clients who do not have a severe and persistent mental illness.</blockquote>
In practice, “limited capacity” means “no service.”<br />
<br />
The implications of “no service” are predictable. People suffer. Families suffer. There’s economic damage, career disruption, more poverty, more drug abuse, more crime, more violence, more failure.<br />
<br />
What our planners write about the downside of “no service” is this.<br />
<blockquote class="tr_bq">
The limited capacity for outpatient counseling for clients who do not have a severe and persistent mental illness could result in the use of more costly Medicaid and non-Medicaid services.</blockquote>
And <br />
<blockquote class="tr_bq">
Untimely access to pharmacological services for children and families due to the shortages in child psychiatry services may result in more rapid decompensation in children’s functioning which could lead to more utilization of inpatient services, out of home placements, and other costly interventions.</blockquote>
And<br />
<blockquote class="tr_bq">
Gaps in access for low income populations, lack of resources for housing, medication and long term residential services, ultimately impacts the AOD [Alcohol Or Drug] client either using jail bed days, hospital days or death. This is a high cost for the community. </blockquote>
Ohio’s mental health system is self-focused, inward looking, not community focused. It chooses not to adapt. It chooses to live under siege, when it might focus on collaboration, and on creating seamless networks of service that permeate communities.<br />
<br />
There’s a lot of noise and self-congratulation this Mental Health Month. Pay no attention. The people in the service fortress are whistling in the wind. The service system needs a good wallop of retargeting and reform Read the service plan before you buy the ticket to the gala.<br />
<br />
<br />
<br />
<br />
---<br />
Ohio’s community mental health service plans can be found at this link.<br />
<a href="http://mha.ohio.gov/Default.aspx?tabid=153" target="_blank">http://mha.ohio.gov/Default.aspx?tabid=153</a><br />
<br />
<br />
---<br />
photo © Dr Michel Royon / Wikimedia Commons<div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.com0tag:blogger.com,1999:blog-7160896832735174090.post-1548308475983668092014-04-30T13:44:00.001-04:002014-04-30T13:44:32.298-04:00SHARP Stop Heroin And Rescue People<div class="separator" style="clear: both; text-align: center;">
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<br />
Heroin is today's plague of dead children. As David Pepper <a href="http://davidpepper.com/the-heroin-epidemic/" target="_blank">points out in this post on his website,</a> Town Hall meetings will not solve the heroin crisis. We must act <i>urgently </i>to defeat this epidemic. The solution involves reducing demand through prevention and treatment, while law enforcement targets trafficking and violence.<br />
<br />
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.<br />
<br />
David has the plan. Let me offer an acronym. SHARP Stop Heroin And Rescue People. <br />
<br />
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--- <br />
<br />
My prior posts on the heroin crisis<br />
<blockquote class="tr_bq">
<ul>
<li><a href="http://www.redesigningmentalillness.net/2014/04/mobilizing-medical-warriors-to-stop.html" target="_blank">Mobilizing medical warriors to stop heroin</a> </li>
<li><a href="http://www.redesigningmentalillness.net/2014/04/mainstreaming-addiction-services-how.html">Mainstreaming addiction services: How pharmacy clinics can help put an end to the heroin epidemic</a></li>
<li><a href="http://www.redesigningmentalillness.net/2013/11/changing-whole-cultures-to-stop.html">Changing whole cultures to stop addiction and achieve better health</a></li>
</ul>
</blockquote>
<div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.com0tag:blogger.com,1999:blog-7160896832735174090.post-44047028648916161802014-04-28T12:34:00.001-04:002014-04-28T12:37:32.175-04:00Local paper prints old news about me<div class="separator" style="clear: both; text-align: center;">
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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.<br />
<br />
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.<br />
<blockquote class="tr_bq">
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.</blockquote>
<blockquote>
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.<br />
<br />
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.</blockquote>
<blockquote>
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.<br />
<br />
Best wishes.<br />
Bob Laufman</blockquote>
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.<br />
<br />
Here is the message I sent back to Bob Laufman.<br />
<blockquote class="tr_bq">
Bob<br />
<br />
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.<br />
<br />
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.<br />
<br />
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. <br />
<br />
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.<br />
<br />
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.<br />
<br />
Please call me any time. My home number is .... </blockquote>
<br />
<br />
If anyone wants to have a chat about all this, call my campaign phone number. (513) <span class="phoneNumber">494-6280.</span> <div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.com2tag:blogger.com,1999:blog-7160896832735174090.post-11033207603421394952014-04-27T17:42:00.004-04:002014-04-27T18:33:02.747-04:00Mobilizing medical warriors to stop heroin<br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg81sKgRK__rpFYwYbVTSE4M-nSt06aPJYj_03ofTQ0G3olJ9G5XnDbjSUyaaAfE7ZLwXCUe0OsV-w4fUyF6Wn3S_u6MXaH4c4fitN7Qisa-CvRwgTuVXjU7EhYq5vz0zt8pySnPWsarOQ/s1600/Path+to+positive+and+safe.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="Pathway to safe and positive" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg81sKgRK__rpFYwYbVTSE4M-nSt06aPJYj_03ofTQ0G3olJ9G5XnDbjSUyaaAfE7ZLwXCUe0OsV-w4fUyF6Wn3S_u6MXaH4c4fitN7Qisa-CvRwgTuVXjU7EhYq5vz0zt8pySnPWsarOQ/s1600/Path+to+positive+and+safe.png" height="270" title="" width="400" /></a><br />
<a href="https://drive.google.com/file/d/0B3izqe-7gw9-S3hDaTM5NzVYMU0/edit?usp=sharing" target="_blank">Heroin Plan In A Nutshell</a><br />
<br />
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.<br />
<br />
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.<br />
<br />
I learned that:<br />
<br />
We need to recruit dozens of physicians who are each willing to care for 30 addiction medication patients annually.<br />
<br />
We need to recruit hospital systems to house and support these physicians.<br />
<br />
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.<br />
<br />
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.<br />
<br />
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.<br />
<br />
Read my earlier post:<br />
<div class="post-title entry-title" itemprop="name">
<a href="http://www.redesigningmentalillness.net/2014/04/mainstreaming-addiction-services-how.html" target="_blank">Mainstreaming addiction services: How pharmacy clinics can help put an end to the heroin epidemic</a><br />
<br />
Download <a href="https://drive.google.com/file/d/0B3izqe-7gw9-S3hDaTM5NzVYMU0/edit?usp=sharing" target="_blank">Heroin Plan In A Nutshell</a></div>
<!-- Blogger automated replacement: "https://images-blogger-opensocial.googleusercontent.com/gadgets/proxy?url=http%3A%2F%2F1.bp.blogspot.com%2F-wdHaWDdIRtI%2FU113WFPUmAI%2FAAAAAAAABvM%2FyhraHuEBcQA%2Fs1600%2FPath%2Bto%2Bpositive%2Band%2Bsafe.png&container=blogger&gadget=a&rewriteMime=image%2F*" with "https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg81sKgRK__rpFYwYbVTSE4M-nSt06aPJYj_03ofTQ0G3olJ9G5XnDbjSUyaaAfE7ZLwXCUe0OsV-w4fUyF6Wn3S_u6MXaH4c4fitN7Qisa-CvRwgTuVXjU7EhYq5vz0zt8pySnPWsarOQ/s1600/Path+to+positive+and+safe.png" --><div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.com0tag:blogger.com,1999:blog-7160896832735174090.post-46796630408251517692014-04-25T16:29:00.000-04:002014-04-25T16:42:45.176-04:00Chatter from young psychiatrists<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgTfbLGu3SjJr7E7rq6r3WoEPWvkxnivZxqRgPcKHNg3os5zyUQYtYw2VHpY-yPCHaKEcIP1e7jj7Gw7omt07yMNcWRVkEJesWmO4ECCe50QH8wunfV9R7Sku8Tus97jcqcfPr0AqxBLgo/s1600/NURSE.BMP" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgTfbLGu3SjJr7E7rq6r3WoEPWvkxnivZxqRgPcKHNg3os5zyUQYtYw2VHpY-yPCHaKEcIP1e7jj7Gw7omt07yMNcWRVkEJesWmO4ECCe50QH8wunfV9R7Sku8Tus97jcqcfPr0AqxBLgo/s1600/NURSE.BMP" height="320" width="247" /></a></div>
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.<br />
<br />
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.<br />
<br />
---<br />
<blockquote class="tr_bq">
With what I see the psychs are seeing more patients an hour. My guess is that there are a couple reasons for this:<br />
<br />
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)<br />
<br />
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. </blockquote>
---<br />
<blockquote class="tr_bq">
I can't solve all the mental health problems.<br />
But I can help the people who want my help and appreciate it. </blockquote>
---<br />
<blockquote class="tr_bq">
I think people in medicine come from pretty sheltered (and generally affluent) backgrounds, which can limit our work with our patients. </blockquote>
---<br />
<blockquote class="tr_bq">
The nurse practitioner question<br />
<br />
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"<br />
<br />
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. </blockquote>
---<br />
<blockquote class="tr_bq">
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.<br />
<br />
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.<br />
<br />
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. </blockquote>
---<br />
<blockquote class="tr_bq">
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.<br />
<br />
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... </blockquote>
---<br />
<br />
<blockquote class="tr_bq">
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.</blockquote>
<blockquote class="tr_bq">
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.</blockquote>
<blockquote class="tr_bq">
3) Dispo arrangements should have already been done by social work. </blockquote>
---<br />
<blockquote class="tr_bq">
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). </blockquote>
---<br />
<blockquote class="tr_bq">
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.</blockquote>
---<br />
<blockquote class="tr_bq">
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.</blockquote>
<blockquote class="tr_bq">
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.</blockquote>
---<br />
<blockquote class="tr_bq">
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...</blockquote>
<blockquote class="tr_bq">
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.</blockquote>
<blockquote class="tr_bq">
Deliver better standard of care and show superior results compared to the NPs.</blockquote>
<blockquote class="tr_bq">
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. </blockquote>
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Source: <br />
http://forums.studentdoctor.net/threads/current-practice-environment.1057875<div class="blogger-post-footer"><em>Paul Komarek is the author of <a href="http://www.defyingmentalillness.net">Defying Mental Illness</a>. Follow <a href="http://twitter.com/pkomarek">Paul Komarek on Twitter</a></em> </div>Paul Komarekhttp://www.blogger.com/profile/02293455617305598680noreply@blogger.com0