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."