An Inside Look at Recovery High Schools

Earlier last month I blogged about recovery high schools and how they are changing the landscape of addiction treatment among adolescents in this country. The nation's first recovery high school opened in Minnesota in 1989, and since then 20 additional schools have opened in 10 other states. The high schools provide a safe and sober environment that allows students the opportunity to get their high school diploma free from the influences of a normal, traditional high school.

Last month I took a look inside a real recovery high school in Boston. The school is called Ostiguy High School and is staffed by a wonderful principal and an amazing faculty. I spoke with several students about their experiences before coming to Ostiguy, and about their experience since coming to Ostiguy. I also spoke with the faculty about their experiences working at a recovery high school.

Here is my radio piece that I created from the interviews conducted at Ostiguy High School.

New Research Shows Effects of Drug Use on the Adolescent Brain

A recent study shows that adolescents who use drugs have greater cognitive shortfalls, including mental flexibility, later in life. Experiments on animals have suggested that adolescents are more susceptible to lower doses of cocaine and are willing to risk more for a cocaine "fix" than adults. The findings, which were presented at the Society for Neuroscience's annual meeting, suggest that the adolescent brain is only about 80 percent developed. When you consider that more than 4,300 teens try an illicit drug for the first time each day, it really puts into perspective the impact that these drugs can have on teenagers.

According to Harvard psychologist John Kelly, the associate director of the Center for Addiction Medicine at Massachusetts General Hospital, there are aspects of the adolescent brain that makes adolescents more susceptible to drug abuse. "In the adolescent brain, the nucleus accumbens, which is the brain's pleasure center, is not full developed. This means that they are more incline to see new and exciting rewards. In addition, the frontal cortex of the brain is not fully developed and this area is responsible for caution."

The image below, provided by the National Institute for Drug Addition, shows the deterioration caused by drug use in comparison to the deterioration caused by heart disease.

It is evident that they are both diseases, disrupting the normal, healthy functioning of the body's organs. While there are other factors to take into consideration, such as mental illness, genetic susceptibility, unstable family life, or exposure to physical or sexual abuse, research shows that the earlier a person begins abusing drugs and alcohol, the more likely they are to suffer further abuse and serious medical issues.

Substance Abusers at Risk for Not Receiving Preventative Medical Services

New research from Boston Medical Center and Boston University suggests that unhealthy substance use may be a risk factor for individuals lacking appropriate health services. The findings have been published in BMJ Open and carefully identify unhealthy substance abuse as a major roadblock to proper health services including mammography screening and the influenza vaccination.

Considering the fact that cancer and influenza are two of the leading causes of death for individuals in the United States, this new research presents a major concern. It is routine screening procedures that make these kinds of illnesses preventable and potentially treatable. The problem facing U.S. citizens is that even those individuals who are, in fact, eligible to receive these preventative treatment and services, are unable to do so due to low-income, lack of insurance and being foreign-born. According to Karen Lasser, a primary care physician at Boston Medical Center, it is the unhealthy substance abusers who represent the gap in citizens who receive these kinds of services.

"Basically, we compared people who had unhealthy substance use and those who did not and we found that those who had unhealthy substance use didn't get mammograms, flu shots, or basic screening tests. We took into account other things that may affect their access to proper medical screenings and we found that all signs still pointed to unhealthy substance abuse," Lasser said.

Researchers in this study analyzed data from 4,804 women who are eligible for mammograms, 4,414 women who are eligible for Pap smears, 7,008 persons who are eligible for colorectal cancer screenings, and 7,7017 persons who are eligible for the influenza vaccine. All of these patients were screened to detect substance abuse. Nearly 10 percent of the patients who were eligible for one or more of these preventative services had a positive screening for unhealthy substance abuse. More of this data can be found here.

The research collected in these findings suggests that more needs to be done to promote the importance of basic medical screenings. If substance abusers represent the gap in individuals who receive adequate medical treatment, then perhaps the promotion should begin at the treatment facilities. Lasser agrees that incorporating primary care at detox and treatment centers would be a good start. "There's patients that get treatment for methadone so I think it would be a great approach if the facilities were to also give them flu shots or proper screenings."

Unfortunately, due to lack of funding at Boston Medical Center, there is little research being done presently to utilize the results from this study. "We did have a program in place to screen patients for substance abuse, but that funding just ended so, unfortunately, we are aware of the need but are at a standstill due to the lack of resources and funding," said Lasser.

It seems ironic that there are studies being done to isolate certain issues in Mass health care; but there is little being done to utilize these findings. Let's hope that things begin to change as the nation's healthcare overhaul takes effect in 2014.

Addiction Treatment Centers in Massachusetts

Here's a look at the addiction treatment centers across Massachusetts that currently offer primary care treatment to their patients suffering from mental and behavioral health disorders. As you can see, a scarce amount of treatment centers provide medical services in coordination with substance abuse treatment. When you consider the statistic that in Massachusetts alone an estimated 196,000 people have an illicit drug addiction or drug abuse problem over one year period, as supported by the National Survey on Drug Use and Health, it is outrageous to see such neglect from the medical community.

The fact of the matter is that primary care physicians do not traditional screen for substance abuse disorders. If there is a screening test at all it is often limited to a small questionnaire intake form, which is unlikely to yield accurate results. A primary care physician plays a vital role in assisting those patients with their addiction problems while treating them for any other health care disorders they might have. The locations showed on this map are not even a quarter of the treatment facilities in Massachusetts. This emphasizes the lack of primary care integration.

View Addiction Centers in Boston in a larger map

Integrating Education with Recovery

Adults suffering from alcohol and drug abuse can go to rehab and detox centers to get clean. They might have to take weeks off from work but, in the majority of cases, they are able to take a leave of absence. But what happens when an adolescent has to go to rehab or detox? The school year doesn't stop just because someone has to go to rehab. On it goes leaving the student, who is in the midst of recovery, left behind. Sure, they can stay back a year, but what happens if relapse is a continual process? In addition to the trying period of recovery these students have to watch their friends graduate without them while they struggle to get clean.

The good news is that there is a place where adolescents can recover without interrupting their education. It's called a recovery high school and there are three in Massachusetts alone, with a fourth opening in December. These schools are just like any other high school. They are publicly funded and are taught by certified public school teachers. The students are referred to by other schools, parole offices, their parents, or rehabs or detox centers. Dr. John Kelly, the associate director of the Center for Addiction Medicine at Massachusetts General Hospital, explains the benefits recovery high schools can offer adolescent substance abusers: "The students get the peer support and the recovery norm that they would get in a rehab except it is in a school setting. The expectation is easier because they don't have to hide or feel stigmatized. The curricular is designed to deal with substance abusers and the academic curriculum is sensitive to that, allowing for the presence of the disorder."

Recovery high schools incorporate the therapeutic aspects of treatment into the academic aspects of a regular high school. According to Dr. Kelly, "For the most part it is an academic environment that is sensitive to the fact that these students are going through recovery. There are varying degrees; however." These varying degrees include urine toxicology screens, counseling support and rules that are particular to each school. Some schools are more strict than others when it comes to enforcing sobriety. Sobriety is certainly encouraged and monitored, but students are not just kicked out if they slip up or fail a drug test; the schools provide support to get the students back on track. If they need further treatment it is the schools job to make the connections necessary to support the students' recovery.

Recovery schools follow a "harm reduction" approach to treatment, meaning that they have a non-judgmental way of helping patients reduce the impact of substance abuse in their daily lives. This approach is based off of the belief that each individual has a different relationship with drugs and alcohol based off of his or her own biological, psychological and social influences. Dr. Kelly explains that most people are in favor of harm reduction strategy because it is basically claiming that any step in the right direction is positive. "The optimal outcome is abstinence because that allows for better brain functioning and better overall health; but not everyone is ready all at once to go straight to abstinence. So for these schools, I think having a harm reduction approach, if it keeps the students engaged in school and treatment while lowering their risk of harm, is a good way to go."

In one article I read it discusses how the adolescent brain is more susceptible to drug abuse because it is less matured and not as fully developed as an adult brain. This seems like an important reason for there to be more treatment options out there for teens. Ironically, Dr. Kelly informed me that there are actually less treatment options available for adults. "There is outpatient and intensive outpatient levels of care. The standard of care for adolescents is 1.5 hours of treatment 3 days a week for most of the day, or 4 or 5 hours of treatment each day of the week." There are rehabs and detoxes for adolescents and teens; however they do not provide these young brains with the educational incentive that will increase their chances of future success.

A Look at the Numbers

Take a look at these infographics displaying addiction statistics throughout Massachusetts. The findings are truly astonishing.

Data collected by the Treatment Episode Data Set (TEDS) report shows a total of 87,754 admits to drug and alcohol treatment centers in Massachusetts in 2010. The majority of the admissions were patients for heroin use.

The Centers for Disease Control and Prevention reported that the number of unintentional overdose deaths involving opioid pain relievers quadrupled during 1999-2007. They rose from 2,900 to 11,500.

The graph to the right is data collected from the 15 largest metropolitan areas in the U.S. It shows the percentages of people ages 12 or older who have used drugs over a one-month period during the years 2002-2005. The graph shows how substance abuse rates vary across the different states.

To the left is data from the Health of Boston report presented by the Boston Public Health Commission showing the deaths resulting from substance abuse in Boston neighborhoods.

When you break down statistics of this nature into graphs and maps such as these, it is much easier to comprehend the extent to which addiction has entrenched American society. When you look at the rates of substance abuse mortality in each of the Boston neighborhoods, it shows that addiction is ramped throughout the city. There is no addiction trend in relation to poorer or wealthier areas. From Charlestown to Hyde Park to North Dorchester, the addiction rates go up or down. When comparing Boston to other major U.S. cities, however, Boston's addiction rates almost double the amount of other cities. Addiction is clearly a major issue facing the city of Boston, as well as the state of Massachusetts.

High School for Addicts

Yes, it's true. There is such a thing as a high school where all of the students are recovering substance abusers. In Massachusetts alone there are three publicly funded high schools where students who are overcoming addiction can go to learn free from temptation. The concept comes from the idea that the students will be safe and more motivated in an environment that is conducive to their recovery.

The first recovery high school in the country opened in Minnesota in 1989. Since that time about 20 schools have been established across 10 states. In 2006 Massachusetts opened recovery high schools in Beverly, Boston and Springfield. The structure at these schools is very similar to that of traditional high schools. Students are referred to the schools in a number of ways: by parole officers, parents, their previous high schools, the Department of Children and Families, and even some rehab or detox centers. The tuition is paid for by their home school district and the Department of Public Health provides each school with up to $500,000 a year for substance abuse counseling and training, in addition to drug testing.

While most recovery schools in the U.S. require students to commit to full sobriety before enrolling in the school, the recovery high school in Beverly, which is one of the three publicly funded recovery schools in Massachusetts, is taking a much lighter approach. Principal Michelle Lipinksi believes that the most important thing is that the school offers a safe environment for the students who are working through their recovery process. Regardless of whether or not the students are still struggling with drug use she believes they should still be allowed to participate in the program. As she said in a bostonmagazine.com article, "Sobriety isn't how I measure success."

There is significant amount of research that shows how the adolescent brain makes teenagers more susceptible to drug use. The nucleus accumbens, which is the pleasure center of the brain, has not fully developed in adolescents so they are more likely to seek out spontaneity and excitement. Also, the frontal cortex of the adolescent brain, which senses caution, is not fully developed.

Statistics showing drug use among adolescents is astounding:

• The National Institute on Drug Abuse found that about half of the nation's 12th graders have used a drug at some point in their lives and almost a quarter of the nation's students have done so in the last month.
• Over 5 percent of 12th graders smoke pot every day and almost 8 percent of students in grades 6-11 smoke pot everyday.
• In Massachusetts alone the Department of Health reports that about 1,700 kids ages 12-17 receive state funding for substance abuse each year.

So should these recovery schools enforce a zero tolerance drug policy? By doing so will they scare away students who desperately yearn for a safe environment not offered at regular public high schools? Another thing to consider is whether a student using at these recovery schools will tempt another student to use and, in turn, cause a ripple effect throughout the entire school? There is room for debate on the topic. Next week I will be speaking with Harvard psychologist John Kelly, who is also the associate director of the Center for Addiction Medicine at Massachusetts General Hospital. Look forward to his opinions on the topic and what he thinks is the best for the students at recovery high schools.

Inside Narcotics Anonymous

“Are we that obvious?” he responded, when I asked if I was in the right place for Monday night’s NA (Narcotics Anonymous) meeting. The young man, who must have been in his early twenties, was reclining on a chair in the front entrance of the Berklee building that serves as the designated location for weekly Narcotics Anonymous meetings. He had three facial piercings and looked like he hadn't slept (or showered) in weeks. I later learned that this was his first meeting ever, and that he was less than two weeks sober.

As people began filing into the building I followed a group into the elevator to a floor that would take us to the meeting room. I took a seat in the back and observed my surroundings. It’s interesting to see who shows up for NA meetings. While some, like my acquaintance in the building entrance, seem like stereotypical characters for substance abuse users, others are your typical hard-working businessmen or women. I paid close attention to the wide assortment of individuals who filed in for the meeting. I realized that I fit in physically with the group, since there was no general typecast for the physical appearance of an NA member.

The meeting began with the introduction of newcomers and proceeded into a role call of members who were celebrating weeks or months of sobriety. One member, Andrew (name changed to protect his identity) was celebrating one full year of sobriety. The entire room clapped and cheered for him as he accepted a ribbon that represented his full year of staying clean. He spoke to the group about the meaning behind his sobriety and how NA played a primary role in encouraging him to stay clean. After he told his story about his struggle with addiction, several members congratulated him on his sobriety. After the meeting I approached Andrew and congratulated him myself. The most genuine smile I’ve ever seen appeared on his face and he said, “I’m really just happy to be alive.”

During the meeting Andrew mentioned his several failed attempts at sobriety. I asked him what finally gave him the push to follow through with staying sober, to which he responded: “When I came back from the half way house just over a year ago I started going to NA meetings around here. I met people and I just fell in love with this meeting. It just meant so much to me to have the support here. People wanted me to be around and they didn’t care what was in my pocket or what I could offer them. All they wanted was to help me. That was one of the most amazing feelings I’d ever felt. Before I’d never really had friends; I had acquaintances, but now I can honestly say that I have friends. I can honestly say that this is my new family.”

But it wasn’t only the NA group that gave Andrew the consistent motivation to stay away from drugs or any dangers that could target his substance abuse. “I never thought I’d tell another man that I loved him, and I tell me sponsor I love him on a daily basis. I call my great-grand sponsor every other day and say ‘you know, I love you. Thank you for being in my life.’ If it wasn’t for those people, I wouldn’t be standing here today.”

Andrew now runs the NA meetings in the local area and loves giving back to the community that has given him so much strength. I asked him how he felt about addiction treatment and what he felt his doctors had done for him. He responded by saying that they had done very minimal. “For the most part I avoided doctors. I felt like they didn’t want to deal with me. That I was just another screw up and that they couldn’t mend the problems that lead me to substance abuse in the first place. The half-way house was helpful but what really helped me was NA. The support and understanding of those who have been in your shoes, and may walk through your shoes again, is inspiring. We all have to help each other."

Integrating Primary Care by Using SBIRT

Very interesting video about how the Institute for Family Health is integrating primary care and substance abuse treatment. A patient speaks about her personal struggle with addiction and how she was able to change her life. A doctor also talks about using buprenorphine on patients fighting opioid addiction and dependence. The VP for Psychological Services and Community Affairs mentions SBIRT several times when talking about the Institute’s mechanism for integration. SBIRT stands for: Screening, Brief Intervention, and Referral to Treatment. Boston Medical Center was part of a grant with the Bureau of Subsidies Services that had doctors from BU train to do SBIRT. The program found several positive outcomes from the integration of primary care into addiction treatment.

Behavioral Health Care Cuts

Massachusetts' Sen. John Kerry, along with 12 other members of Congress, are currently debating a $1.2 trillion spending cut that could possibly include Medicaid. If this were to be the case, thousands of people living in Massachusetts who are currently receiving treatment for mental health or addictions disorder would be affected. Medicaid, which is responsible for paying for these services, has played an extremely important role for millions of Americans by providing critical support for people who suffer from mental illness and addiction. Medicaid allows these individuals the ability to overcome their illnesses and the potential to lead satisfying and productive lives.

The negative impacts that could result from such budget cuts include an increased demand for expensive emergency room care as well as increased strain on the criminal justice and corrections systems which are already overtaxed. In addition, cutting Medicaid just by 5% would result in tens of thousands of job losses and would cost the states $14 billion. The result of such large cuts would be a detriment to the recession we are already dealing with. The ultimate goal of outing inefficiencies that exist in our health care system needs to be done in a cost-effective and successful manner that does not threaten our network of behavioral health care services.

Congress' recommendations for controlling spending and reducing the deficit are due Nov. 23 so now is really the time to contact committee members and show support for preserving Medicaid.

A Conversation with Timothy Lepak, President and Cofounder of NAABT

It wasn't until I read a brief article on silobreaker.com that I learned about treatmentmatch.org. The article talked about how the website is leveraging their technology to help patients left without treatment after all 30 of Preventive Medicine Associates branches closed their doors. I thought it was really amazing to see the growing amount of support for these patients whose road to recovery was halted by a fraudulent act. What I really wanted to know was more about this free, online website that claims to have matched a total of 40,508 patients with 3,300 doctors nationwide as of this past Monday. I was lucky enough to have the opportunity to speak with Timothy Lepak, President and cofounder of the National Alliance of Advocates for Buprenorphine, which is responsible for treatmentmatch.org as well as two other websites

Can you tell me about what motivated you to start NAABT?

I had a friend who was addicted to heroine and opiates and no treatments worked for him; he couldn't quit. In 1999 he became involved in a study at Yale with buprenorphine and in a matter of weeks he went from talking about suicide to talking about starting classes in the fall. His cravings had subsided and he was really focusing on the positive things in his life. It wasn't until 2000 that made it even possible for doctors to prescribe buprenorphine because, since 1914, doctors were not allowed to prescribe any opiate drug to anyone who was addicted to opiates. When buprenorphine got approved, in late 2002, a lot of things started to happen. People were still dying and there were still older methods of treatment taking place there were changes taking place. At first, doctors were only allowed to treat 30 patients their first year and then 100 patients each year after that. We helped to get this rule changed by petitioning and bringing it to congress. It changed to 100 patients each year but that is still a problem. That's when we decided to start the website for people to become better educated on buprenorphine and the concept of addiction. There's a lot of stigma in the medical field in regards to addiction treatment. Many act like it's not as good of a medicine to practice. We try to educate people about addiction so we can get rid of this stigma. Once people understand it's no longer controversial. The question "how can you treat a drug addiction with a drug" slowly disappears and people realize that the medication helps these patients; they aren't just switching one addiction for another. Soon after NAABT began we saw the problem with people not being able to find doctors and we started treatmentmatch.org.

How exactly did treatmentmatch.org come about?

Well we noticed how difficult it is to find an appropriate doctor and one that is available. A good match is very hard to find because you need to consider issues like insurance and whether or not the doctor can treat your other ailments. There are still only 20,000 doctors able to prescribe buprenorphine and they are each limited to 100 patients a year. I've heard stories of doctors who've had patients die on the wait list. Another reason for the website is to encourage the patient to follow through with seeking help. When someone is finally ready to seek treatment they're usually in pretty bad shape and it's not easy to pick up the phone and call up a doctor only to hear a rejection. It's a horrible experience. So the website works like an online dating service except it connects doctors and patients. When patients register they state how far they are willing to travel for treatment. Then emails go out to doctors in those areas notifying them of the new patients seeking treatment. This way the patients are only hearing positive responses. The system works 24/7 so even at two in the morning a patient can get a response. It's like a lifeline going out to the patient.

Click here for a map of patients currently looking for treatment.

What are some problems affecting office-based addiction treatment?

Since the government started limiting and rationing the treatment of buprenorphine prices started going up. Now it's like the highest bigger gets the spot. Doctors can keep raising their prices until they are getting just enough patients. Some doctors are charging up to $400 cash only, instead of going through insurance, because of these limits. Limiting access is what's causing the diversion and the government's answer is to try and limit everything even more. Last year the DEA released a statement that they are going to show up announced to the offices of every buprenorphine doctor in the country. This lead a whole bunch of doctors who were involved in fraud to just up and leave their practices. This has resulted in a decrease in the rate of new doctors practicing and an increase in the rate of patients dropping out.

How do you get doctors to sign up with treatmentmatch.org?

Every month the District Attorney sends me a list of certified doctors. I send the doctors an email about getting on our system. Once they've filled out the paperwork they can select to be on a public locator or they can check a box that allows them to get direct emails notifying them when a patient signs up.

How do you get patients to sign up?

We do public service announcements on the radio, the subway, billboards, online advertisements, and we even display signs in pharmacies. But mostly we get patients through word of mouth. When people first reach out for help that's the time that people need to be there for them. The next time might not happen for months, or years, or it might never happen. This system is 24 hours and they can reach out whenever they want, not just between business hours. As of today we have 40,508 patients and 3,300 doctors nationwide. Just in the past 12 hours there have been 36 patients contacted. We've connected to about 80% of the patients who've signed up. Most of the ones we haven't reached out to yet are in rural areas where there are not as many doctors.

How is primary care being integrated into the addiction treatment offered by treatmentmatch.com?

We set up our system so that primary care is an integral part of treatment. The doctors we are connecting these patients to work in office-based practices. We list clinics as well but we really feel that the office-based environment is so much better. It also takes away the stigma in the sense that you are not standing in line for methadone treatment along with other methadone addicts; that can be very demoralizing. The way the government has treated the delivery system is inefficient. Whereas if you go to a doctor's office and are treated like you would be for any other condition it is much better for the patient and they have a positive experience that way. It makes more sense to go to a doctor who can also refer patients to further counseling or other treatment. Detox places have such poor success rates. It makes sense that detox would be ineffective considering what we now know about addiction; taking the drugs away doesn't help and it certainly explains why relapse rates are so high.

TreatmentMatch.org Reaches Out to Help Displaced Patients

In lieu of Dr. Punyamurtula Kishore's arrest and immediate closure of his dozens of addiction clinics across the state of Massachusetts, online service TreatmentMatch.org extends its services. The website serves as a free online resource to addicts suffering from opioid addiction. According to the website itself, 86 patients have been contacted and matched up with physicians just in the last 72 hours. The website is available 24/7 to connect people seeking treatment for addiction with treatment providers in an anonymous and confidential manner. Certified physicians can go onto the website and draw from patients in their area when they have an opening for an appointment. This eliminates the need for patients to call multiple physicians hoping to simply land one appointment. For patients who may not have access to a computer or to the internet, a counselor or advocate can sign on to the website and submit an application on the patient's behalf.

This list of certified physicians was created by the Substane Abuse and Mental Health Services Administration (SAMHSA). According to a SAMHSA employee, who prefers to remain anonymous, not all of the certified physicians choose to be put on the list; some choose not to because they already have a full load of patients to treat and this can oftentimes be an exhausting process for the patients searching for openings. Click here to view the actual list of certified treating physicians.

According to prnewswire.com, there have been over 40,000 patient-physician connections made by TreatmentMatch.org. The website is run by the National Alliance of Advocates for Buprenorphine Treatment (NAABT), which is a non-profit organization that encourages the use of buprenorphine to treat opioid addiction. The opioid medication is a drug that activates specific receptors in the brain that mimic the full opioid effect commonly associated with heroin, oxycodone, methadone, hydrocodone, and morphine. Buprenorphine also has full properties of an antagonist, which is a drug that blocks opioids by attaching to the receptors themselves without actually activating them. Antagonists block full agonist opioids and do not cause any kind of opioid effect. Acting as a partial agonist while having the full properties of both agonists and antagonists allows buprenorphine to activate the opioid receptors in the brain to a lesser degree. This allows for some of the opioid effect but also suppresses the heavy withdrawal symptoms and cravings.

To learn more about this online source visit www.naabt.org.

New Services Offered to Addicts Affected By Clnic Closings

The closure of the 30 medical branches that make up Preventative Medicine Associates has resulted in Gosnold, a treatment center on Cape Cod, offering services for the patients affected by the closings. Gosnold is the largest provider of addiction and mental health services in the Cape Cod area and offers primary care, inpatient rehabilitation, transitional care, and residential treatment. The treatment became available on October 3rd and since then a Gosnold physician and several counselors are available to see patients in Gosnold's Centerville clinic.

President and CEO of Gosnold, Raymond V. Tamasi, said that the closures have created a state of emergency for addicts in treatment. He hired Dr. Robert Friedman, medical director of the Sandwich branch of Preventative Medicine Associates to work three days a week at first to help the patients displaced by the closures. Interestingly, Friedman's Sandwich clinic was closed back in August, which was 2 whole months before the entire larger organization, Preventative Medicine Associates, collapsed a couple weeks ago. Friedman was interviewed by the Cape Cod Times back in early September on his clinic's reaction to the abrupt shut down of their clinic and how Kishore randomly layed off three employees during their lunch hour.

Tamasi expects over 100 patients from Preventative Medicine Associates to take advantage of the newly available services. Gosnold will also be expanding its services to include the use of the injection drug vivitrol that eases the withdrawal symptoms of patients by blocking opiate receptors in the brain. The drug significantly reduced the craving symptoms associated with drugs like heroin and oxycodone. Gosnold will expand these services to accommodate the new patients permanently, says Tamasi. Gosnold must now find a way to take on these new patients who need counseling and other services which are not easily covered by insurance. Tamasi released a statement to the Cape Cod Times saying, "We do what we can by going to the community (for fundraising) and applying for grants."

The website for Preventative Medicine Associates does not address the organization's current state of affairs and attempts to contact Dr. Kishore were unsuccessful. Patients displaced by the closure of PMA clinics are instructed to call Gosnold at 800-444-1554 for outpatient care.

Statewide Crisis Threatens Addiction Clinics

The last of the 30 addiction treatment centers across Massachusetts that make up Preventative Medicine Associates was shut down last week after Dr. Punyamurtula Kishore was arrested for allegedly running a Medicaid fraud "kickback" scheme. Kishore owns and manages the 30 medical branches that altogether make up a larger corporation known as Preventative Medicine Associates. According to State Attorney General Martha Coakley, Kishore carried out an intricate scheme to funnel a drug screen business in his laboratories and send the bills directly to MassHealth to cover the service fees. Drug screens billed to the MassHealth generally cost about $100 to $200. Kishore's scheme involved approximately $500,000 in taxpayer funded testing which really puts the potential damage into perspective.

The aftermath of Kishore's arrest has created a state of panic for both patients and employees. When he stopped receiving reimbursements from the state, Kishore started shutting down clinics without any notice and stopped paying employees. After his arrest last week nearly all of his clinics were shut down in addition to their supply of the anti-addiction drug Vivitrol. Since Kishore was the predominant prescriber and supplier of the drug, thousands of heroin and OxyContin addicts are now left without a prescription.

Many of his former employees and patients are making sense of a series of strange events that have occurred over the last few months. Not only were employees' checks bouncing back from their banks, but collection agencies were calling looking for payments, phone services had been shut off and the staff even had to borrow needed supplies from other doctor's offices.


Massachusetts Department of Public Health is expressing concern about the possibility of patient relapses stemming from the lack of Vivitrol. The state is currently in the process of searching for ways to provide the patients of Kishore's clinics with Vivitrol.

**Here's an interesting article on Kishore's methods of primary care and addiction treatment published before his arrest in September.

Healthcare in 2010

Implementation of the Wellstone/Domenici Mental Health Parity and Addiction Equity Act went into effect on April 5, 2010. This included several provisions that made access to important mental health and addiction treatment more readily available. It also required many health plans to cover addiction and mental health services which now included various other health conditions. For advocates of addiction treatment the implementation of parity was an enormous milestone. These laws are what require insurance agencies to provide the coverage necessary for the treatment and healthcare services of substance use and mental health patients. President Obama also signed into law the "Patient Protection and Affordable Care Act" which would help to improve coverage for access to treatment, prevention programs, and post-recovery services. The new federal healthcare law will expand coverage to millions of uninsured Americans and approximately 95 percent f the population.

Benefits from the Provision:

• Mental health and substance use disorder will both be included in basic benefits packages
• Plans within the health insurance exchange must adhere to all Wellstone/Domenici Parity Act provisions.
• Those enrolled in Medicaid will receive sufficient coverage
• SUD/MH (Substance use disorder/mental health) will be part of chronic prevention initiatives
• SUD/MH now part of health workforce development initiatives
• SUD treatment and prevention and MH service providers will be eligible to apply for community health team grants
• Americans below 133 percent of federal poverty level will have expanded Medicaid coverage

25 million Americans suffer from alcohol and drug abuse and only 4 million get the help and treatment they need. Something's wrong with the access to proper care and treatment for addiction patients if less than 16% of them are getting adequate help. Federal health care reform has now written mental health and addiction services into the federal parity law as well as into the health care law. The key push is to integrate behavioral health with primary health care. Today I spoke with Connie Peters, Vice President for Addiction Services at the Association for Behavioral Healthcare about the ongoing push for change in the realm of addiction treatment and addiction services. The lack of integration between primary health care and speciality behavioral health care is a prevalent part of the way health care systems are run in this country. The passage of the Affordable Care Act (ACA) has the potential to profoundly change this system.

ACA places an emphasis on two kinds of integrated care models. These are patient-centered medical homes and accountable care organizations (ACOs). Accountable care organizations are basically a group of coordinated health care providers who provide health care services to a group of patients. They are accountable for the quality, cost and overall care of patients assigned to them. There is plenty of evidence that link the importance of targeting integration efforts where patients will be interacting most directly with the health care system itself. Doctors need to do a better job of addressing and providing treatment for the medical needs of mental health and addiction patients. The ACA has already authorized $50 million in 2010 and additional funds all the way to 2014 for the Substance Abuse and Mental Health Services Administration (SAMHSA) to cover a type of grant called "co-location grants" to fuse services for mental illness and other medical conditions with the community-based behavioral health setting. There is also another initiative that would provide funding for the improvement of federally qualified health centers, which would mean they would provide behavioral health care in addition to the traditional means of treatment.

While the ACA continues to promise improvement in the areas of mental health, addiction and the infusion of primary health care, there are still several obstacles halting the process. One concern is that the prospect of lower numbers of uninsured people who need access to health care will tempt the government to cut direct financing. This is particularly likely considering the cuts to discretionary, or "optional", spending that the government agreed upon in the recent debt-ceiling deal. Nonetheless it remains to be seen just how health care laws will bend and reshape to improve the quality of health care though better integration methods and expanding coverage.

Disconnect between addiction and primary health care

Addiction treatment services are sometimes referred to as a "black hole" by primary care physicians. This refers to the concept that once doctors refer a patient to alcohol or addiction treatment, they are usually no informed of the patient's further progress or treatment process. Where does this disconnect between patient and primary care doctor stem from? Even in recent history, addiction treatment has been viewed as a separate entity from the typical "medical model of treatment." In addition federal and state rules regarding confidentiality have created a barrier between primary care physicians and addiction patients. After a primary care physician diagnoses a patient with alcoholism or addiction they are no longer on a "need to know" basis with that patient.

Primary care physicians also do not routinely provide screenings for substance use disorders. If there is any screening at all it is simply a couple of questions on an intake form, which does not serve as the most appropriate method for the communication of such a topic. For years doctors and primary health care providers have lacked the necessary training and knowledge to address these kinds of behavioral health problems. Research by the American Society of Addiction Medicine shows that intervention by a medical provider is extremely effective in the stages between recovery and prevention.

Boston University is offering a new education program that will help to bridge the gap between primary care physician and addiction patients. It is one of 10 inaugural programs across the country that offers specialized training in addiction. Now internal medicine residents can complete their residency as a primary care doctor with a focus on caring for addicted patients. These kinds of programs are a step in the right direction towards the integration of care for addicts, especially those who are suffering from more than just their addiction.

In an ideal world there would be no drug abuse, no alcohol abuse and no one would ruin their lives. Unfortunately the real world is far from ideal. I've chosen to cover the topic of drug and alcohol abuse from a very different angle than it is normally looked at. Like many problems in life, most of us neglect to concern ourselves unless we are directly affected by the problem itself. It's easy to ignore the drug addicts who are ruining their lives and sometimes the lives of those around them. But what about when that drug addict is your mother, your brother, your best friend or your soulmate? If it was your loved one who needed medical care and treatment for addiction wouldn't you want them to get the help they need? The good news is that attention is being drawn to the issue of substance abuse in New England. In 2014 national health care law will require that insurers begin covering addiction treatment. A growing number of addiction clinics in and around Massachusetts are putting their efforts towards better care and treatment for substance abusers. Instead of simply using methadone to treat addiction, clinics in and around Massachusetts are now including additional treatments to patients.

For years treatment clinics simply prescribed a patient methadone and sent them home. It has long been used as an anti-addictive used for patients suffering from an opioid dependency. But there seems to be something wrong with the concept of treating a drug addict with another addictive substance to ween him or her off from the original narcotic. According to the U.S. National Center for Health Statistics 3,849 deaths were linked to methadone in 2004. So clearly there is more that needs to be done than just sending the drug addict home with a new drug. The Dorchester clinic has added a primary care doctor to its staff on Friday mornings. Now patients at this clinic can be treated for high blood pressure, high cholesterol and many other common health problems. When you think about it, most of these addicts haven't seen a doctor in years. Their lives have been in a downward spiral due to their drug addiction. It's not just the addiction that they need to overcome and get a hold of, they need to regain hold of their own health and bodies.

Recovery Month

It is more than half way through Recovery Month. Now where does that leave us? Somewhere between sick and well? How many people even know that September is, indeed, Recovery Month, a time to spread awareness about substance abuse and commend those around us who have overcome their struggle with addiction. Alcohol and substance abuse affects over 400,000 men and women in Massachusetts alone. Who is helping these people recover and gain hold of their lives? According to statistics released by the US Substance Abuse and Mental Health Services Administration, the number of treatment facilities in the state of Massachusetts has decreased significantly over the last four years. In addition, the state ranks one of the highest in the country for the number of people ages 18-25 who are need of treatment but are not currently receiving any. Why do we focus so much attention on prevention programs in our schools but focus significantly less attention on those who have fallen victim to the evils we are preaching about? The question isn't what more we can do, the question is where do we start from. Some clinics in Massachusetts are focusing on such questions and are trying to enhance patient care in addiction clinics around the state. These particular clinics are doing more than their jobs require: they are recognizing what else needs to be done and are taking steps towards improvement.