Tagged Mental Health

Newsom: To Fix Homelessness, California Must Fix Mental Health

SACRAMENTO, Calif. — Gov. Gavin Newsom made a bold move Wednesday. In his second State of the State address, an annual speech that usually focuses on political wins or the state’s booming economy, Newsom dedicated 35 of 42 minutes to the urgent but unsexy issue of homelessness.

By proclaiming homelessness the most “pernicious crisis in our midst,” the first-term Democratic governor staked his political reputation on his ability to solve it.

That means his reputation also rides on his ability to fix mental health care in California.

“Health care and housing can no longer be divorced,” Newsom declared in the ornate, mint-chip-ice-cream-hued state Assembly chambers. In attendance were the state’s other executive officers, legislators from both houses, and their families and guests.

During the speech, Newsom outlined several mental health proposals he plans to push this year.

He touted his ambitious “once-in-a-generation reform” plan for Medi-Cal, California’s public insurance program for low-income people. Newsom wants to invest $695 million to help the state’s most vulnerable residents, including homeless people and those with mental health problems, in unconventional ways, such as housing aid.

He also raised the controversial issue of involuntary treatment for people with behavioral health problems.

While he criticized the historic practice of confining patients with mental illness to asylums, he said the state needs to make it easier for law enforcement, health care providers and families to get people into treatment. ”All within the bounds of deep respect for civil liberties and personal freedoms,” he added.

One of the impassioned parts of Newsom’s speech was his call to reform the Mental Health Services Act, or Proposition 63. Adopted by voters in 2004, the law imposes a 1% tax on personal income over $1 million to help counties expand mental health care.

Newsom said the problem is that counties aren’t held accountable for how the money is spent.

“The money is used in 58 counties in 58 different ways,” said Tom Insel, chair of the board of the Steinberg Institute, a nonprofit that focuses on mental health and homelessness, whom Newsom calls his “mental health czar.”

That’s not going to work for Newsom, who said in his speech that he wants the money to be spent primarily on three populations: children, homeless people and formerly incarcerated people.

And, he demanded, the money has to be spent.

Newsom said counties are hoarding $160 million in funding that could be used to get people off the streets and into treatment.

“My message is this: Spend your mental health dollars by June 30th, or we’ll make sure they get spent for you,” Newsom said.

State Sen. Scott Wiener, a Democrat from San Francisco, has made mental health and housing reform signature issues. He said Newsom’s speech has created “political space” to accomplish some controversial housing reform that has stalled in the legislature.

“Impactful housing bills are controversial, impactful homelessness bills are controversial, and impactful mental health and addiction bills are controversial,” Wiener said.

It’s not the first time Newsom has taken responsibility for an intractable issue. A month before the State of the State address, he promised $105 million in new spending to fix the wildfire crisis, saying he would dedicate “emphasis, energy and sense of urgency” to the issue.

Now, he’ll also be judged on how he tackles homelessness, a problem that worries 85% of Californians.

“The governor has a very full plate,” said Mike Gatto, a former Democratic state Assembly member from Los Angeles who is trying to put a November ballot measure before voters that would increase involuntary treatment.

“We saw him take ownership of the wildfire issue and now he has boldly taken ownership of this issue, too. The state has to be ready to help him with these tremendous endeavors.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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No Quick Fix: Missouri Finds Managing Pain Without Opioids Isn’t Fast Or Easy

ST. LOUIS — Missouri began offering chiropractic care, acupuncture, physical therapy and cognitive-behavioral therapy for Medicaid patients in April, the latest state to try an alternative to opioids for those battling chronic pain.

Yet only about 500 of the state’s roughly 330,000 adult Medicaid users accessed the program through December, at a cost of $190,000, according to Josh Moore, the Missouri Medicaid pharmacy director. While the numbers may reflect an undercount because of lags in submitting claims, the jointly funded federal-state program known in the state as MO HealthNet is hitting just a fraction of possible patients so far.

Meanwhile, according to the state, opioids were still being doled out: 109,610 Missouri Medicaid patients of all age groups received opioid prescriptions last year.

The going has been slow, health experts said, because of a slew of barriers. Such treatments are more time-consuming and involved than simply getting a prescription. A limited number of providers offer alternative treatment options, especially to Medicaid patients. And perhaps the biggest problem? These therapies don’t seem to work for everyone.

The slow rollout highlights the overall challenges in implementing programs aimed at righting the ship on opioid abuse in Missouri — and nationwide. To be sure, from 2012 to 2019, the number of Missouri Medicaid patients prescribed opioid drugs fell by more than a third — and the quantity of opioids dispensed by Medicaid dropped by more than half.

Still, opioid overdoses killed an estimated 1,132 Missourians in 2018 and 46,802 Americans nationally, according to the latest data available. Progress to change that can be frustratingly slow.

“The opioids crisis we got into wasn’t born in a year,” Moore said. “To expect we’d get perfect results after a year would be incredibly optimistic.”

Despite limited data on the efficacy of alternative pain management plans, such efforts have become more accepted, especially following a summer report of pain management best practices from the U.S. Department of Health and Human Services. States such as Ohio and Oregon see them as one part of a menu of options aimed at curbing the opioid crisis.

St. Louis chiropractor Ross Mattox, an assistant professor at chiropractic school Logan University, sees both uninsured patients and those on Medicaid at the CareSTL clinic. He cheered Missouri’s decision to expand access, despite how long it took to get here.

“One of the most common things I heard from providers,” he said, “is ‘I want to send my patient to a chiropractor, but they don’t have the insurance. I don’t want to prescribe an opioid — I’d rather go a more conservative route — but that’s the only option I have.’”

And that can lead to the same tragic story: Someone gets addicted to opioids, runs out of a prescription and turns to the street before becoming another sad statistic.

“It all starts quite simply with back pain,” Mattox said.

Practical Barriers

While Missouri health care providers now have another tool besides prescribing opioids to patients with Medicaid, the multistep approaches required by alternative treatments create many more hoops than a pharmacy visit.

The physicians who recommend such treatments must support the option, and patients must agree. Then the patient must be able to find a provider who accepts Medicaid, get to the provider’s office even if far away and then undergo multiple, time-consuming therapies.

“After you see the chiropractor’s for one visit, it’s not like you’re cured from using opioids forever — it would take months and months and months,” Moore said.

The effort and cost that go into coordinating a care plan with multiple alternative pain therapies is another barrier.

“Covering a course of cheap opioid pills is different than trying to create a multidisciplinary individualized plan that may or may not work,” said Leo Beletsky, a professor of law and health sciences at Northeastern University in Boston, noting that the scientific evidence of the efficacy of such treatments is mixed.

And then there’s the reimbursement issue for the providers. Corry Meyers, an acupuncturist in suburban St. Louis, does not accept insurance in his practice. But he said other acupuncturists in Missouri debate whether to take advantage of the new Medicaid program, concerned the payment rates to providers will be too low to be worthwhile.

“It runs the gamut, as everyone agrees that these patients need it,” Meyers stressed. But he said many acupuncturists wonder: “Am I going to be able to stay open if I take Medicaid?”

Structural Issues 

While helpful, plans like Missouri’s don’t address the structural problems at the root of the opioid crisis, Beletsky said.

“Opioid overutilization or overprescribing is not just a crisis in and of itself; it’s a symptom of broader structural problems in the U.S. health care system,” he said. “Prescribers reached for opioids in larger and larger numbers not just because they were being fooled into doing so by these pharmaceutical companies, but because they work really well for a broad variety of ailments for which we’re not doing enough in terms of prevention and treatment.”

Fixing some of the core problems leading to opioid dependence — rural health care “deserts” and the impact of manual labor and obesity on chronic pain — requires much more than a treatment alternative, Beletsky said.

And no matter how many alternatives are offered, he said, opioids will remain a crucial medicine for some patients.

Furthermore, while alternative pain management therapies may lessen opioid prescriptions, they do not address exploding methamphetamine addiction or other addiction crises leading to overdoses nationwide — even as a flood of funds pours in from the national and state level to fight these crises.

The Show-Me State’s refusal to expand Medicaid coverage to more people under the Affordable Care Act also hampers overall progress, said Dr. Fred Rottnek, a family and addiction doctor who sits on the St. Louis Regional Health Commission as chair of the Provider Services Advisory Board.

“The problem is we relatively cover so few people in Missouri with Medicaid,” he said. “The denominator is so small that it doesn’t affect the numbers a whole lot.”

But providers like Mattox are happy that such alternative treatments are now an option, even if they’re available only for a limited audience.

He just wishes it had been done sooner.

“A lot of it has to do with politics and the slow gears of government,” he said. “Unfortunately, it’s taken people dying — it’s taken enough of a crisis for people to open their eyes and say, ‘Maybe there’s a better way to do this.’”

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Conservative Indiana Adopted Needle Exchanges But Still Faces Local Resistance

Back when Cody Gabbard was shooting heroin, his only significant human contact was with others in the throes of addiction, who only cared to see him when he had drugs.

Then he walked into the basement of Fayette County’s courthouse in the eastern Indiana city of Connersville, where two women — a public health nurse and a recovery coach — ran a syringe exchange program.

“There were days I went in there, to be honest with you, I just felt like killing myself. That would usually change by their spirits,” said the now-27-year-old Gabbard, who contracted hepatitis C during his drug use. “As people say, a smile can do a lot for a person, and it certainly does, especially when you’re in a dark spot in life.”

Cody Gabbard poses for a portrait at Fayette County Community Corrections in Connersville, Indiana, on Jan. 23, 2020, when he was participating in a work-release program. Now in recovery, Gabbard previously used a syringe exchange in Connersville. He recalls that the women who operated the exchange were not only the first people in a long time who treated him like a human being, but they also put a new idea in his head: You don’t have to live like this.(Meg Vogel for KHN)

Besides hope and connection, the program he visited in 2017 offered free, clean needles and a place to dispose of dirty ones. People could also get HIV and hepatitis C testing, the overdose-reversal drug naloxone, fentanyl test strips, immunizations and wound care, plus referrals to drug treatment and other community resources.

Such programs were illegal in Indiana until 2015. That’s when an HIV outbreak among injection drug users in southern Indiana’s Scott County caused lawmakers to reconsider their objections to syringe exchanges, making the state ground zero for conservatives’ growing acceptance of giving clean needles to people struggling with addiction.

But five years later, syringe exchanges are operating in only nine of Indiana’s 92 counties, including Fayette, even though federal health officials warn that eight more are vulnerable to an HIV outbreak similar to Scott County’s. Some public health experts say this reflects a continuing reluctance to treat addiction as a health issue and the political and logistical difficulties of starting exchanges and keeping them open.

“We’ve definitely made a lot of progress since the Scott County outbreak,” said Don Des Jarlais, a professor in the School of Global Public Health at New York University, noting that the number of syringe exchanges nationwide has roughly doubled since 2015. “But we still have a very, very long way to go.”

Darci Moore and Charmin Gabbard collect safe injection equipment and syringes for a participant at the Fayette County Harm Reduction Alliance syringe exchange in Connersville, Indiana, on Jan. 23, 2020.(Meg Vogel for KHN)

Charmin Gabbard, who runs the Fayette County Harm Reduction Alliance syringe exchange, talks with a participant on Jan. 23, 2020. The syringe exchange is open twice a week at the offices of Meridian Health in Connersville, Indiana. Gabbard says she hopes to increase its hours of operation and extend services to perform street outreach.(Meg Vogel for KHN)

In Indiana and West Virginia, he said, syringe exchanges have shut down or had restrictions placed on them because of backlash in the communities. This has happened despite decades of research showing that syringe programs prevent the spread of disease and reduce health care costs without increasing illegal drug use or crime.

Other conservative states that lifted restrictions on syringe exchanges in the wake of Indiana’s HIV outbreak have fared better. For instance, Kentucky and North Carolina, which eased regulations in 2015 and 2016, respectively, both have exchanges available in about half their counties.

Darci Moore, an intern at the Fayette County Harm Reduction Alliance, collects safe injection equipment for a participant at the syringe exchange in Connersville, Indiana, on Jan. 23, 2020.(Meg Vogel for KHN)

Indiana state Rep. Ed Clere, a Republican who authored the original needle exchange legislation in 2015, would like to see greater acceptance of the programs in his state.

“Syringe service programs have saved countless lives and prevented countless cases of HIV and hepatitis C,” he said. “I see how well it’s working in the counties that have a program, and I hate it that syringe programs aren’t available for all Hoosiers.”

Indiana’s law requires syringe exchanges to be authorized by either a county’s executive body or a municipality’s legislative body, and then be renewed at least every two years. Alternatively, Indiana’s health commissioner can declare a local state of emergency. The statewide law, once set to expire in 2019, was amended to end on July 1, 2021. A bill in the Indiana Senate to repeal the expiration date was defeated in early February.

Since April 2015, when the first legal syringe exchange opened in Scott County, nine more have launched across the state. Three have closed, with two of them eventually reopening.

The bigger issue is “we have a lot of communities that want to get one started, but they can’t,” said Indiana University researcher Carrie Lawrence.

Enabling Drug Use Or Saving Lives?

Instead, some local health departments in Indiana have resorted to distributing so-called harm reduction kits that include everything but syringes, such as sterile supplies to cook, snort and smoke narcotics. Still, these, too, have drawn the ire of some politicians and law enforcement.

“We’re handing people equipment we know [is] going to be used for injection or ingestion of narcotics. We’re not getting anywhere,” said Lt. John Watson, a police officer in Seymour, Indiana, who has spoken out against his county health department’s harm reduction program.

Charmin Gabbard, who runs the Fayette County Harm Reduction Alliance in Connersville, Indiana, shows a syringe exchange participant the intramuscular Narcan on Jan. 23, 2020.(Meg Vogel for KHN)

The syringe exchange run by the Fayette County Harm Reduction Alliance provides access to and disposal of syringes and injection equipment. (Meg Vogel for KHN)

But public health officials argue that the supplies are critical to stopping the spread of infection, and that people will get high regardless of whether they have clean equipment.

“They’re going to use a spoon. But they’re going to use their mother’s kitchen spoon instead,” noted Khala Hochstedler, administrator of the Tippecanoe County Health Department, which has operated an exchange since 2017. “That could have hepatitis C on it, and another family member could pick it up.”

One of the most vocal opponents of the syringe service programs has been Indiana Attorney General Curtis Hill, who argues for strict one-on-one exchanges of used needles for clean ones.

“Distributing needles without any reasonable degree of accountability … simply leads to wider abuse of illegal drugs and increased likelihood of death by overdose,” he said in a statement, citing anecdotal testimony from public safety officials he had visited throughout the state. He also pointed to a media report from Richmond, Indiana, saying the county prosecutor had documented a fatal overdose involving a needle from the local syringe exchange.

The Centers for Disease Control and Prevention cites research showing that syringe exchanges reduce the amount of needle waste in a community, by providing avenues for safe disposal; in the past, Hill has publicly quarreled with the agency over its research. According to the Indiana State Department of Health, 82% of syringes distributed by the programs have been returned.

Indiana has seen a drop in new HIV diagnoses linked to injection drug use — from 175 in 2015, the year of the outbreak, to 17 three years later. During that period, new hepatitis C cases rose from 7,144 to 7,837, though some syringe exchange officials said they expected those numbers to initially increase as more people got tested.

A participant gives Charmin Gabbard used syringes that she had been collecting in a disposal box for used needles for months at the syringe exchange run by the Fayette County Harm Reduction Alliance in Connersville, Indiana, on Jan. 23, 2020. The participant said she would reuse the needles until they “felt like a fishing hook and hurt.”(Meg Vogel for KHN)

Politics Has Closed Exchanges

Stephenie Grimes, administrator for the Madison County Health Department, said she finds one-for-one exchanges problematic because staffers are forced to ask confrontational questions that might turn people away. Users bring their soiled needles back in disposal containers that are not transparent, so you can’t tell how many syringes are inside.

“There is no good way to ensure you’re getting one for one,” she said.

In 2016, a year after an exchange started in her central Indiana community, her agency went to the one-for-one model to address public concerns. Opponents weren’t assuaged.

The Fayette County Courthouse is a historic courthouse located in Connersville, Indiana, on Central Avenue. Back when Cody Gabbard was shooting heroin, he would go to a syringe exchange program in the basement of the courthouse.(Meg Vogel for KHN)

The following year, even though the Madison County commissioners — the county’s executive body — had renewed the exchange, the county council — the fiscal body — voted to pull funding for the health department if it continued the program.

The initiative shut down for 12 months until a local nonprofit health system, Aspire Indiana, agreed to operate it.

About 120 miles away, in southern Indiana, Lawrence County abandoned its syringe exchange in 2017, after only a year, when county commissioners expressed concerns about abetting illegal drug use. Commissioner Rodney Fish elicited national attention when he cited a verse from the Old Testament that commands people to pray and “turn from their wicked ways.”

Reached in December, Fish said his opinion on the matter hasn’t changed and added: “Our community is dealing with the issue in other, compassionate ways.” He declined to comment further.

The syringe exchange in Connersville, where Gabbard used to go, shut down last May after the local hospital where it had moved, Fayette Regional, went bankrupt and closed.

But the exchange reopened Jan. 22 at Meridian Health’s Connersville clinic. The program aims to serve the same number of people it did before, about 100 a month.

Gabbard recalled that the women who operated the exchange not only were the first people in a long time who treated him like a human being, they also put a new idea in his head: You don’t have to live like this.

So after his last narcotics-related arrest, in June 2018, he opted for drug court, which allows defendants to get treatment in lieu of jail time.

Research has found that IV drug users who go to a syringe exchange are significantly more likely to enter treatment and stop or cut back on shooting narcotics than those who don’t.

“Really, the needle exchange was the reason why I even started to think about getting clean,” Gabbard said.

Now in recovery, he hopes to be a better role model for his 7-year-old son. He has dreams of starting a landscaping business. And he no longer needs a syringe exchange.

Charmin Gabbard, who runs a syringe exchange through the Fayette County Harm Reduction Alliance in Connersville, Indiana, embraces a participant on Jan. 23, 2020. Gabbard used drugs for almost 30 years and served about 10 years in prison, but she has been in recovery for six years.(Meg Vogel for KHN)

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Finding Connections And Comfort At The Local Cafe

For Alzheimer’s patients and their caregivers, social and emotional isolation is a threat. But hundreds of “Memory Cafes” around the country offer them a chance to be with others who understand, and to receive social and cognitive stimulation in the process. (Heidi de Marco/KHN)

LOS ANGELES — Doug and Connie Moore met at seminary. He was a student and pastor of an inner-city congregation, and she was a student and a public health nurse.

“She’s the one who drew me to the needs of the poor,” Doug says.

The pair wed in 1974, and Doug became a pastor at the First Evangelical Free Church of Los Angeles in 1983. They became deeply involved in their community and dedicated much of their free time to teaching English as a second language, creating tutoring programs and mentoring students in poor communities here and abroad.

But these days, the retired couple spends most of their time inside their modest two-bedroom apartment in Los Angeles. “There are a lot of hours spent alone,” says Doug, 69. “I can’t have a conversation with Connie.”

Connie, now 73, was diagnosed with Alzheimer’s, the most common form of dementia, in 2015. About 10% of Americans age 65 or older have the disease, according to the Alzheimer’s Association, including an estimated 670,000 people in California.

Doug, Connie’s primary caregiver, knows his wife needs as much stimulation as possible. So, twice a month, the Moores visit a program often referred to as a “Memory Cafe,” which offers social activities for people living with Alzheimer’s and dementia — and their caregivers. Activities include art, music, poetry, presentations and social interaction.

There are more than 800 regular gatherings around the country listed in the Memory Cafe directory, including more than 20 in California. Some meetings go by different names such as “Memory Mornings” and aren’t listed in the directory. The gatherings take place in coffee shops, hospitals, libraries, schools, senior centers and faith-based organizations. Free of charge to participants, the cafes are usually funded by grants, individuals, corporate sponsorships or faith-based organizations.

“Participating in social activities does not just provide social and cognitive stimulation for both the caregiver and the loved one, but they give each the opportunity to create new social groups for themselves with people who understand their situation,” said Susan Howland, programs director for the Alzheimer’s Association California Southland Chapter.

Doug and Connie Moore have been married for 45 years and have two children and one grandchild. Doug says he never dreamed his wife would get Alzheimer’s. After hearing the diagnosis, he says, “we both wept.” (Heidi de Marco/KHN)

Every morning, Doug reads Connie Scriptures from the Bible while she eats breakfast. Doug says his faith has remained solid through the process of caring for his wife. “Not to say that there are not moments when I come to tears,” he says. “But I can see her faith is still there.” (Heidi de Marco/KHN)

Before she retired, Connie was the director of nursing services for the Los Angeles Unified School District, in charge of seven-figure budgets and a large staff. When her ability to do math started to fail, Doug knew something was wrong. Connie needs help bathing and dressing, but still remembers Doug, her children and the names of her two Siamese cats — Frodo and Emi.(Heidi de Marco/KHN)

Connie’s Alzheimer’s was diagnosed early but advanced rapidly. As the disease progressed, the couple faced inevitable sadness and occasional questions of “Why me, Lord?” Doug says. “She always verbalized she feared she would be abandoned because of the disease.”(Heidi de Marco/KHN)

Doug helps Connie get dressed for their Memory Mornings meeting. Picking out his wife’s clothes has been a challenge because, Doug says, he’s not entirely sure how to put together an outfit. A parishioner from his church helps a few hours a week, choosing outfits for the coming days. (Heidi de Marco/KHN)

As Connie’s dementia progresses, dressing and grooming become harder for her. For now, she is still able to comb her hair and brush her teeth.

Doug and Connie head to the local Alzheimer’s Los Angeles office, about five minutes from their apartment, for their bimonthly Memory Mornings gathering. The activities include pet therapy, arts, music, dance and storytelling. (Heidi de Marco/KHN)

Licensed clinical social worker Sarah Jacobus leads a group of 19 caregivers and patients in an exercise called TimeSlips, which is an improvisational storytelling technique that stimulates the imagination of people with Alzheimer’s. “People may not remember that I’ve been there a week ago, but they remember the pictures and the storytelling,” she says. (Heidi de Marco/KHN)

As part of the TimeSlips exercise, all participants are given the same photograph and asked to answer questions about what’s happening in the scene. “Every person in the group responded in their own way, with a range of verbal capacity and lucidity. But they responded!” Jacobus says.(Heidi de Marco/KHN)

Linda Goldfinger, the facilitator of Memory Mornings, writes down the group’s descriptions of what is happening in the photograph. At the end of the exercise, she compiles the responses into a story, types it up and gives a copy to each participant.(Heidi de Marco/KHN)

Karen Pearson and her partner, Ilene Barg, work on formulating a description of the photograph. Karen is Ilene’s caregiver and a regular participant in the program. “The connections being made are so valuable,” Pearson says. “No matter what the content, we always walk away with a good feeling.” (Heidi de Marco/KHN)

The meetings allow Connie to interact with others with the same disease, Doug says, and they help him learn new ways to engage and entertain Connie at home. But the gatherings also serve as a reality check on Connie’s cognitive abilities. “Today, she could not verbalize or answer the questions,” Doug says. “In my mind, I would put her at the bottom of the group.” (Heidi de Marco/KHN)

Doug and Connie head home after spending two hours at the Memory Mornings meeting. The meetings are not meant to serve as respite for the caregiver, but as a safe place where the couple can socialize with others in the same situation.(Heidi de Marco/KHN)

Doug prepares lunch for Connie after returning from the meeting. Connie says she’s hungry, but she doesn’t say much else. “I try to talk to her,” Doug says. “But you can’t have a dialogue with her.”(Heidi de Marco/KHN)

Connie keeps herself busy for hours fiddling with random objects, such as Frodo’s felt cat toy. Even though Doug tries to keep a busy calendar for himself and Connie, he still feels a sense of loneliness. “There are a lot of hours spent alone, no matter what we do,” he says. (Heidi de Marco/KHN)

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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