Tagged Mental Health

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California’s New Attack On Opioid Addiction Hits Old Roadblocks

Jennifer Stilwell, a 30-year-old mother of two young children, kicked heroin cold turkey five years ago, but she got hooked again last fall.

Stilwell, an accountant in Placerville, California, tried to quit a second time, but she couldn’t tolerate the sickening withdrawal symptoms. She resisted going to the emergency room because “I thought they’d treat me like a drug addict and not a patient in pain,” she said.

Instead, she kept smoking heroin to keep the agony at bay. Then, in February, a county mental health worker told her about a new program that promised stigma-free treatment for her addiction.

She went to the ER at Marshall Medical Center in Placerville, where a doctor put her on buprenorphine, one of three drugs approved by the Food and Drug Administration for medication-assisted treatment (MAT) of people with opioid dependency.

Her ongoing treatment includes intensive counseling and social support, providing what is known in the recovery field as “whole person” therapy.

“It’s still early in my battle,” Stilwell said. “But my withdrawals are gone. Now I can concentrate on being a mother.”

Marshall is one of a growing number of health care institutions across California that offer medication-assisted treatment with funding and support from the state’s MAT Expansion Project, which started in 2018 and is financed by $265 million in federal grants.

Numerous studies have shown that relapse and overdose rates are lower among opioid users who get MAT than those who don’t. From 2016 to 2018, for example, the overdose death rate in Humboldt County — one of California’s highest ― dropped by about half, which officials attributed in large part to the MAT Expansion Project.

In February, California’s Department of Health Care Services, which administers the project, touted its success, reporting that it has provided care for 22,000 previously untreated Californians with opioid addictions and created 650 new locations where patients can receive MAT.

But the number of new people brought into treatment is only a small fraction of those who need it. In 2019, more than half a million Californians with an opioid use disorder lacked access to treatment, according to a study by the Urban Institute.

The state effort faces many of the same obstacles that have hindered wider acceptance of MAT for years: the stigma of addiction, federal regulations that depress the number of MAT providers, and hostility in some corners of the treatment community to the very notion of using drugs to combat drug addiction.

Moreover, the addiction treatment industry has become a magnet in recent years for unscrupulous operators who aggressively recruit clients, eyes fixed on the dollar signs rather than on evidence-based treatments such as MAT.

Now there’s another, hopefully temporary, challenge. The COVID-19 crisis and related social-distancing measures are forcing MAT practitioners to scramble for new ways to accommodate patients, said Eric Hill, a “substance navigator” at Marshall Medical Center who helps guide patients through their MAT treatment.

Hill said MAT patients entering the program through emergency rooms are now given prescriptions for up to a month, rather than a week. He said he is following up with clients by phone rather than in person, and he and others are trying to arrange video calls between doctors and patients for prescription renewals.

The state program seeks to broaden access to MAT by launching or enhancing treatment programs at ERs, hospitals, primary care clinics, residential treatment programs, county mental health centers, jails and drug courts. Training more doctors to provide MAT is also a pillar of the campaign.

But patients who take anti-addiction drugs can have difficulty finding housing and recovery therapy, which are integral to their treatment. They are often shunned by groups adhering to traditional 12-step theories of sobriety that require participants to be free of drugs — including MAT drugs.

“MAT patients will say that the treatment was working. They were just starting to feel better, going to support groups, back at their jobs, but they had a hard time finding a place to live,” said Hill.

Many patients who stop taking their MAT drugs in order to get a roof over their heads have relapsed, Hill said.

Marlies Perez, a division chief at the state health care department, said the agency “is taking a strong stand against such stigma that prevents patients from their continued recovery.” Through its media campaign, Choose Change California, it seeks to alter perceptions within the recovery community and persuade more doctors and patients to embrace MAT.

The state expansion project puts a strong emphasis on building MAT capacity in emergency rooms, where opioid users often face suspicion.

Of the 320 acute care hospitals with emergency rooms statewide, 52 currently offer MAT. In those hospitals, staff members like Hill help patients get the care they need, including the psychological and social dimensions. Health care department officials say they plan to quadruple the number of participating hospitals to more than 200 over the next few years.

(Photo Courtesy of Jennifer Stilwell)

Opioid misuse is not nearly as deadly in California as in the rest of the U.S., even though the rise of fentanyl has begun to cause bigger problems in the Golden State.

In 2018, the rate of opioid overdose deaths in California stood at 5.8 per 100,000 residents, far below the national average of 14.6 per 100,000. In some rural counties of California, however, opioid death rates exceed the national average. The two states with the highest rates were West Virginia, at 42.4 per 100,000, and Delaware at 39.3.

Another obstacle to MAT expansion, one squarely in the sights of California health authorities, is that many doctors are hesitant to participate because they must undergo federally mandated training for a waiver that allows them to prescribe buprenorphine.

“Doctors can prescribe OxyContin with abandon but not buprenorphine, which has been shown to be helpful to opioid addicts,” said Dr. Aimee Moulin, a director at the California Bridge Program, which helps administer the state’s MAT program.

Buprenorphine is less powerful and less likely to cause fatal overdoses than methadone, another drug commonly used to fight opioid addiction. And doctors who get the waiver for buprenorphine can prescribe it in their offices, while methadone must be administered in federally certified treatment programs.

The state’s health care department said the expansion project has thus far trained 395 new MAT prescribers. But as of July 2019, just 3.2% of prescribers in the state were authorized to prescribe buprenorphine, according to the Urban Institute study.

Dr. Peter Liepmann, a Pasadena-based family physician with an interest in addiction medicine, said it can be difficult to find a buprenorphine prescriber. Not long ago, when he was thinking about opening a practice in Glendale, California, he consulted the Substance Abuse and Mental Health Services Administration’s (SAMHSA) listings of physicians who offer MAT.

“If you were looking for somebody to dispense buprenorphine and you called people on that list, you would have come up with one doctor who ran a cash-only, no-insurance practice, and he was very expensive,” Liepmann said.

The state’s Perez said some doctors may not fully understand the benefits of MAT because medical schools devote little time to addiction training. Another element of the MAT project, she said, is to fund a substance-use-disorder curriculum at training hospitals.

Perez counseled patience: “We didn’t get into this opioid dependency situation overnight, and we’re not going to find a total solution overnight either.”

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

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Although Some Cities Have Banned Evictions, Advocates See Need For More Extreme Measures

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Addiction Is ‘A Disease Of Isolation’ — So Pandemic Puts Recovery At Risk

Before the coronavirus became a pandemic, Emma went to an Alcoholics Anonymous meeting every week in the Boston area and to another support group at her methadone clinic. She said she felt safe, secure and never judged.

“No one is thinking, ‘Oh, my God. She did that?’” said Emma, “’cause they’ve been there.”

Now, with AA and other 12-step groups moving online, and the methadone clinic shifting to phone meetings and appointments, Emma said she is feeling more isolated. (KHN is not using her last name because she still uses illegal drugs sometimes.) Emma said the coronavirus may make it harder to stay in recovery.

“Maybe I’m old fashioned,” said Emma, “but the whole point of going to a meeting is to be around people and be social and feel connected, and I’d be totally missing that if I did it online.”

While it’s safer to stay home to avoid getting and spreading COVID-19, addiction specialists acknowledge Emma’s concern: Doing so may increase feelings of depression and anxiety among people in recovery — and those are underlying causes of drug and alcohol use and addiction.

“We consider addiction a disease of isolation,” said Dr. Marvin Seppala, chief medical officer at the Hazelden Betty Ford Foundation. “Now we’re isolating all these people and expecting them to pick up the phone, get online, that sort of thing — and it may not work out as well.”

Emma has another frustration: If the methadone clinic isn’t allowing gatherings, why is she still required to show up daily and wait in line for her dose of the pink liquid medication?

The answer is in tangled rules for methadone dispensing. The federal government has loosened them during the pandemic — so that patients don’t all have to make a daily trip to the methadone clinic, even if they are sick. But patients say clinics have been slow to adopt the new rules.

Mark Parrino, president of the American Association for the Treatment of Opioid Dependence, said he issued guidelines to members late last week about how to operate during pandemics. He recommended that clinics stop collecting urine samples to test for drug use. Many patients can now get a 14- to 28-day supply of their addiction treatment medication so they can make fewer trips to methadone or buprenorphine clinics.

“But there has to be caution about giving significant take-home medication to patients who are clinically unstable or actively still using other drugs,” Parrino said, “because that could lead to more problems.”

The new rules have a downside for clinics: Programs will lose money during the pandemic as fewer patients make daily visits, although Medicare and some other providers are adjusting reimbursements based on the new stay-at-home guidelines.

And for active drug users, being alone when taking high levels of opioids increases the risk of a fatal overdose.

These are just some of the challenges that emerge as the public health crisis of addiction collides with the global pandemic of COVID-19. Doctors worry deaths will escalate unless people struggling with excessive drug and alcohol use and those in recovery — as well as addiction treatment programs — quickly change the way they do business.

But treatment options are becoming even scarcer during the pandemic.

“It’s shutting down everything,” said John, a homeless man who’s wandering the streets of Boston while he waits for a detox bed. (KHN is not including his last name because he still buys illegal drugs.) “Detoxes are closing their doors and halfway houses,” he said. “It’s really affecting people getting help.”

Adding to the scarcity of treatment options: Some inpatient and outpatient programs are not accepting new patients because they aren’t yet prepared to operate under the physical distancing rules. In many residential treatment facilities, bedrooms and bathrooms for patients are shared, and most daily activities happen in groups — those are all settings that would increase the risk of transmitting the novel coronavirus.

“If somebody were to become symptomatic or were to spread within a unit, it would have a significant impact,” said Lisa Blanchard, vice president of clinical services at Spectrum Health Systems. Spectrum runs two detox and residential treatment programs in Massachusetts. Its facilities and programs are all still accepting patients.

Seppala said inpatient programs at Hazelden Betty Ford are open, but with new precautions. All patients, staff and visitors have their temperature checked daily and are monitored for other COVID-19 symptoms. Intensive outpatient programs will run on virtual platforms online for the immediate future. Some insurers cover online and telehealth addiction treatment, but not all do.

Seppala worried that all the disruptions — canceled meetings, the search for new support networks and fear of the coronavirus — will be dangerous for people in recovery.

“That can really drive people to an elevated level of anxiety,” he said, “and anxiety certainly can result in relapse.”

Doctors say some people with a history of drug and alcohol use may be more susceptible to COVID-19 because they are more likely to have weak immune systems and have existing infections such as hepatitis C or HIV.

“They also have very high rates of nicotine addiction and smoking, and high rates of chronic lung disease,” said Dr. Peter Friedmann, president of the Massachusetts Society of Addiction Medicine. “Those [are] things we’ve seen in the outbreak in China [that] put folks at higher risk for more severe respiratory complications of this virus.”

Counselors and street outreach workers are redoubling their efforts to explain the pandemic and all the related dangers to people living on the streets. Kristin Doneski, who runs One Stop, a needle exchange and outreach program in Gloucester, Massachusetts, worried it won’t be clear when some drug users have COVID-19.

“When folks are in withdrawal, a lot of those symptoms can kind of mask some of the COVID-19 stuff,” said Doneski. “So people might not be taking some of their [symptoms seriously], because they think it’s just withdrawal and they’ve experienced it before.”

Doneski is concerned that doctors and nurses evaluating drug users will also mistake a case of COVID-19 for withdrawal.

During the coronavirus pandemic, needle exchange programs are changing their procedures; some have stopped allowing people to gather inside for services, safety supplies, food and support.

There’s also a lot of fear about how quickly the coronavirus could spread through communities of drug users who’ve lost their homes.

“It’s scary to see how this will pan out,” said Meredith Cunniff, a nurse from Quincy, Massachusetts, who is in recovery for an opioid use disorder. “How do you wash your hands and practice social distancing if you’re living in a tent?”

This story is part of a partnership that includes WBUR, NPR and Kaiser Health News.

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Coronavirus Has Upended Our World. It’s OK To Grieve.

On weekday evenings, sisters Lesley Laine and Lisa Ingle stage online happy hours from the Southern California home they share. It’s something they’ve been enjoying with local and faraway friends during this period of social distancing and self-isolation. And on a recent evening, I shared a toast with them.

We laughed and had fun during our half-hour FaceTime meetup. But unlike our pre-pandemic visits, we now worried out loud about a lot of things — like our millennial-aged kids: their health and jobs. And what about the fragile elders, the economy? Will life ever return to ‘normal’?

“It feels like a free fall,” said Francis Weller, a Santa Rosa, California, psychotherapist. “What we once held as solid is no longer something we can rely upon.”

The coronavirus pandemic sweeping the globe has not only left many anxious about life-and-death issues, but it also has left people struggling with a host of less obvious, existential losses as they heed stay-home warnings and wonder how bad all this will get.

To weather these uncertain times, it’s important to acknowledge and grieve lost routines, social connections, family structures and our sense of security — and then create new ways to move forward — said interfaith chaplain and trauma counselor Terri Daniel.

“We need to recognize that mixed in with all the feelings we’re having of anger, disappointment, perhaps rage, blame and powerlessness is grief,” said Daniel, who works with the dying and bereaved.

Left unrecognized and unattended, grief can negatively affect “every aspect of our being — physically, cognitively, emotionally, spiritually,” said Sonya Lott, a Philadelphia psychologist specializing in grief counseling.

Yet with our national focus on the daily turn of events as the new coronavirus spreads and with the chaos it has brought, these underlying or secondary losses may escape us. People who are physically well may not feel entitled to their emotional upset over the disruption of normal life. Yet, Lott argued, it’s important to honor our own losses even if those losses seem small compared with others.

“We can’t heal what we don’t have an awareness of,” said Lott.

Recognize Our Losses

Whether we’ve named them or not, these are some of the communitywide losses many of us are grieving. Consider how you feel when you think of these.

Social connections. Perhaps the most impactful of the immediate losses as we hunker down at home is the separation from close friends and family. “Children aren’t able to play together. There’s no in-person social engagement, no hugging, no touching — which is disruptive to our emotional well-being,” said Daniel.

Separation from our colleagues and office mates also creates a significant loss. Said Lott: “Our work environment is like a second family. Even if we don’t love all the people we work with, we still depend on each other.”

Habits and habitat. With the world outside our homes no longer safe to inhabit the way we once did, Daniel said, we’ve lost our “habits and habitats.” We can no longer engage in our usual routines and rituals. And no matter how mundane they may have seemed — whether grabbing a morning coffee at the local cafe, driving to work or picking up the kids from school — routines help define your sense of self in the world. Losing them, Daniel said, “shocks your system.”

Assumptions and security. We go to sleep assuming that we’ll wake up the next morning, “that the sun will be there and your friends will all be alive and you’ll be healthy,” Weller said. But the spread of the coronavirus has shaken nearly every assumption we once counted on. “And so we’re losing our sense of safety in the world and our assumptions about ourselves,” he said.

Trust in our systems. When government leaders, government agencies, medical systems, religious bodies, the stock market and corporations fail to meet public expectations, citizens can feel betrayed and emotionally unmoored. “We are all grieving this loss,” Daniel said.

Sympathy for others’ losses. Even if you’re not directly affected by a particular loss, you may feel the grief of others, including that of displaced workers, of health care workers on the front lines, of people barred from visiting older relatives in nursing homes, of those who have already lost friends and family to the virus, and of those who will.

4 Ways To Honor Your Grief

Once you identify the losses you’re feeling, look for ways to honor the grief surrounding you, grief experts urge.

Bear witness and communicate. Sharing our stories is an essential step, Daniel said. “If you can’t talk about what’s happened to you and you can’t share it, you can’t really start working on it,” Daniel said. “So communicate with your friends and family about your experience.”

It can be as simple as picking up the phone and calling a friend or family member, said Weller. He suggests simply asking for and offering a space in which to share your feelings without either of you offering advice or trying to fix anything for the other.

“Grief is not a problem to be solved,” he said. “It’s a presence in the psyche awaiting, witnessing.”

For those with robust social networks, Daniel suggests gathering a group of friends virtually to share these losses together. Using apps like Zoom, Skype, FaceTime or Facebook Live, virtual meetups are easy to set up daily or weekly.

Write, create, express. Whether you’re an extrovert or introvert, keeping a written or recorded journal of these days offers another way to express, to identify and to acknowledge loss and grief.

And then there’s art therapy, which can be especially helpful for children unable to express themselves well with words, and also for teens and even many adults. “Make a sculpture, draw a picture or create a ceremonial object,” said Daniel, who often incorporates shamanic ceremonies into grief workshops she conducts.

Another exercise she often uses in grief workshops is a simple one in which participants use their breath to blow their sadness, fear and anger into a rock they then throw away.

“What this does is takes all that intense, painful energy out of your body and into an inanimate object that they symbolically throw far away from themselves,” Daniel said.

Meditate. Regular meditation or just taking time to slow down and take several deep, calming breaths throughout the day also works to lower stress — and is available to everyone, Lott said. For beginners who want guidance, she suggests downloading a meditation app onto your smartphone or computer.

Be open to joy. And finally, Lott urges, make sure to let joy and gratitude into your life during these challenging times. Whether it’s a virtual happy hour, teatime or dance party, reach out to others, she said.

“If we can find gratitude in the creative ways that we connect with each other and help somebody,” she said, “then we can hold our grief better and move through it with less difficulty and more grace.”

This story was produced in partnership with NPR and Kaiser Health News.

Stephanie O’Neill is the recipient of a journalism fellowship at the Natural Hazards Center at the University of Colorado-Boulder, supported by Direct Relief.

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