Friday, March 28, 2014

How one-size-fits-all drug treatment leaves minorities in a lurch

An abridged version of this article appeared in The Philadelphia Tribune on March 2, 2014.

If you're looking for the nucleus of the drug and alcohol recovery community in Philadelphia, a good place to start would be the roughly one-mile stretch between York Street and Allegheny Avenue under the El in North Philadelphia.

Cloistered among the mom-and-pop businesses and vacant buildings that line Kensington Avenue, a string of informal missions, drop-in centers and “dry” boarding houses – many of them unlicensed, and almost all run by recovering addicts – wraps itself around one of the city's poorest residential zip codes, acting as a de facto triage center for those seeking refuge from the drug-infested “Badlands” just a few steps to the west.

For hundreds of mostly Black and Latino addicts, this is the first stop on the long road to recovery; and it serves as a stark reminder of the unique hurdles low-income communities face in accessing behavioral health care in America.

Public welfare cuts enacted by Governor Tom Corbett in 2012 have strained county resources. But experts say a lack of funding is just one of the many obstacles facing minority drug abusers in the pursuit of effective treatment. Even when that treatment is free or mandated by the courts – a common avenue for many African American and Latino users – data shows that ethnic minorities in general, and Blacks in particular, are significantly less likely to succeed than similarly situated whites.

A survey of national treatment data published last year in the journal “Health Affairs” shows that African Americans are disproportionately represented among the nearly 700,000 people who either drop out of publicly funded drug treatment each year or are asked to leave. The number is highest among Black males between the ages of 17 and 20 years – the nexus of a growing population of disconnected urban youth at increased risk for drug-related incarceration.

Brendan Saloner, a health policy researcher at University of Pennsylvania and a co-author of the report, blames the disparities largely on socioeconomic factors. He says, in general, Blacks are more likely to receive county-funded treatment in areas of high social stress and low social support.

“Treatment is about getting you into a position where you are no longer using a substance, but that's only part of the process,” said Saloner, adding that minorities often require a host of ancillary services as part of their recovery. “If part of the challenge is that you're using drugs because your personal life is challenging, you lack adequate housing or are struggling to find a job...a lot of addiction treatment providers just don't have the resources to help at that level.”

In Philadelphia, the official tasked with overseeing county funded treatment programs, Arthur C. Evans, has made addressing these resource gaps a priority. Since taking over as Commissioner of the Department of Behavioral Health and Intellectual disAbility Services in 2004, Evans has worked to create a more collaborative system that treats addiction as a chronic disorder rather than an acute medical condition.

“When I came in, [each agency] was coming at the issue from their own way, so one of the first things we needed to do was to come up with a unifying treatment philosophy to get everyone on the same page,” Evans explained. “Our goal when someone comes through the door is to get them everything they need for long-term success, not just to treat the symptoms.”

Among other things, Evans says he worked with providers to expand access to comprehensive street-level services in the communities that needed them the most. Thanks to his efforts, he says Philadelphia is one of the few cities in the country where a drug addict without insurance can walk off the street today and be in a residential treatment facility tonight. But he admits there is still work to be done to make sure everyone, regardless of race or ethnicity, has the same chances of success once they get there.

“Are there still disparities in Philadelphia? The answer is yes. But we have worked very hard to reduce them and have been very intentional in addressing them,” he said.

Variable encounters produce variable results

What a person can expect to experience when they enter drug treatment in the U.S. has a lot to do with where they live. Everything from the talent of the clinicians, to the physical setting, to the admissions protocol itself is highly variable and can range from robustly therapeutic to one step above jail depending upon who's paying the majority of the bills.

For instance, at one inner-city Philadelphia detox center where nearly every patient is paid for by the county, addicts report being required to strip, shower and exchange their clothes for a paper jumpsuit before entering – a demeaning process that's strikingly different from the typical reception at a more patient-centric facility in the suburbs. Even something as basic as the quality of food served can have an impact on the treatment experience and how long a patient is likely to stick around.

According to a study published in the “Journal of Substance Abuse Treatment,” a treatment setting that is comfortable, convenient and safe with reasonable privacy is “vital if clients are to be retained in treatment and if treatment goals are to be met.”

Devin Reaves, a recovering addict and certified addiction counselor who directs programs for the Brotherly Love House in Philadelphia, says he has seen strikingly different levels of quality in treatment facilities depending on the ratio of patients on public assistance compared to those with private insurance.

“In terms of under-insured or uninsured populations, a lot of time the facilities they are going to are not on par with those primarily funded by private insurance,” he said. “You need structure, accountability, quality programming, peer-to-peer recovery support systems, and if you don't have money, you're less likely to access this kind of treatment.”

Culture matters

The barriers to successful drug and alcohol treatment for minorities closely parallel those commonly encountered throughout the U.S. mental health system. In 2001, Dr. David Satcher – who served as Surgeon General under Presidents Clinton and Bush and made reducing ethnic health-care disparities one of the primary missions of his four-year tenure – released a groundbreaking study that found minorities are less likely to receive mental health services, often receive a poorer quality of mental health care, and are underrepresented in mental health research.

Satcher identified cultural factors as playing a pivotal role in how both patients and therapists respond to behavioral health issues.

Roland Williams – author of the book “Relapse Prevention Counseling for African Americans,” and a consultant who advises treatment facilities on cultural competency – says that by adopting a “one-size-fits-all” model of recovery, treatment programs are often blind to the unique cultural experience of African Americans. Even the sharing-based 12-Step approach – which remains the primary vehicle for addiction recovery in America – was developed, according to Williams, “by and for white, middle-aged men” and lacks sensitivity for the discomfort many Black clients feel about “putting [their] business out on the street.”

Williams also cites the absence of a distinction between substance “abuse” and “addiction” in most formal treatment settings. Since African Americans are more likely than whites to come to treatment through compulsory means – such as drug court or child services – Williams says many do not meet the diagnostic criteria for true substance dependence.

Nevertheless, he writes: “Clients are forced to identify themselves as addicts and alcoholics in the program and the 12-Step meetings they are mandated to attend.” Clients who resist this labeling are deemed unwilling and unmotivated, while others become “institutionally compliant” in order to graduate but never talk candidly about how they got where they are.

Saloner, of the University of Pennsylvania, says the best way to resolve this disconnect is for facilities to strive for a “high degree of concordance” between treatment staff and the clients they serve. But for young, Black men in particular, winding up in treatment with counselors who share their cultural framework is not a common enough occurrence.

Social workers, therapists and peer specialists are overwhelmingly white and female, according to federal workforce data from 2013. Blacks of both genders are notably underrepresented across all mental health professions, as are young treatment professionals under the age of 35. While Blacks account for roughly 30 percent of the U.S. population, fewer than six percent of American psychologists are African American. Minority peer specialists more closely mirror the general population, but still fall below the national average.

Dr. Stephan Arndt – a researcher at the University of Iowa, who published a paper last year that closely mirrors Saloner's findings on ethnic treatment disparities – says the solution is about more than simply training counselors to be culturally sensitive. It also means tailoring treatment protocols that address the different ways culturally distinct groups respond to recovery. As an example, he cites research he is currently undertaking that suggests employment may be a more powerful stimulus for African Americans’ successful completion of drug treatment than criminal justice sanction, while the reverse is true for whites.

“My guess is that different cultural groups react differently to different structures, motivators, incentives and approaches,” he said.

While there may be no single solution to eliminating ethnic treatment disparities, there is widespread agreement that opening the door to recovery for more addicts is an important place to start. Ironically, implementation of the Affordable Care Act – which is designed to give millions of uninsured Americans access to treatment while promoting mental health parity – has the potential to exacerbate the disparities without additional efforts from health care professionals.

According to Saloner, states like Pennsylvania that have chosen not to expand Medicaid under the ACA could begin to funnel public money away from residential treatment and into more cost-efficient outpatient settings – which have poorer overall completion rates. Meanwhile, even in those states that do expand Medicaid, current law excludes Medicaid funding for so-called “Institutions for Mental Disease” (IMDs) – which includes most residential drug and alcohol treatment facilities. This is a holdover from the days when state and local psychiatric hospitals housed large numbers of patients at their own expense, and one that policy groups like the National Alliance on Mental Illness are fighting to change.

Still, if there is a single lesson in the data on ethnic disparities in drug and alcohol treatment, it's that getting people through the door to treatment is just the first step in a long and often complex process; and keeping them there long enough to get a grip on recovery means rejecting the notion that all addicts are created equally and treating each patient on his or her own unique terms. 

Friday, March 21, 2014

Monday, March 3, 2014

Friday, January 24, 2014

Move over NSA, here comes the DEA

With America united in collective outrage over revelations of widespread domestic surveillance by the National Security Agency, another federal branch – the Drug Enforcement Agency – has quietly set about dismantling the Fourth Amendment when it comes to accessing our private medical data.

Last week, the American Civil Liberties Union joined the State of Oregon in federal court in Portland to challenge the DEA's attempt to use warrantless “administrative subpoenas” to obtain information on patients from the state's prescription drug monitoring database.

It's unlikely the plaintiffs will prevail; while Oregon law prohibits state police from digging into patient prescription data without a search warrant, thanks to the gradual erosion of civil liberties under the “war on drugs,” the DEA does not require a court order to request such information in the course of an open investigation.

But at least Oregon is fighting for the privacy rights of its citizens. Pennsylvania, on the other hand, seems intent on giving them away.
Since September, three bills have been introduced in Harrisburg designed to expand the commonwealth’s own prescription monitoring system by establishing a database listing all prescriptions of controlled medications and the identities of the citizens who receive them.

The latest proposal  was introduced in November by Sen. Pat Vance, R-Cumberland, and, unlike Oregon, would give state and federal law enforcement officials virtually unimpeded access to the prescription records of millions of Pennsylvanians who take Schedule II drugs.

These include not only narcotic painkillers like hydrocodone, oxycodone and morphine, but drugs like Ritalin and Adderall that are used to treat childhood ADHD.

Reggie Shuford, executive director of the American Civil Liberties Union of Pennsylvania, put it best when he said: “The privacy of the child who breaks his arm on his bike or who takes attention deficit medication is being sacrificed because someone across town is abusing these substances.”

If that seems reasonable to you, imagine for a moment a law requiring the registration and monitoring of any other class of law-abiding consumer on the grounds that the product they purchase has the potential to be misused.

Well, you don't have to imagine; some of the very same lawmakers who support a prescription database have been working diligently to dismantle the state's firearms-transfer registry  on the grounds that it unfairly targets law-abiding citizens.

That despite the fact that guns – many of them illegally diverted from legitimate sources – kill and maim more people each year than all legal and illicit drugs combined. If that seems hypocritical, it's probably because it is.

There are, of course, legitimate concerns legislation like Sen. Vance's seeks to address. Pharmaceutical overdoses are responsible for hundreds of thousands of emergency room visits a year; and, according to data from the Centers for Disease Control, prescription drugs led to the deaths of more than 20,000 people in 2010 – the last year for which data is available. Trouble is, there is little hard evidence that strict prescription monitoring systems are helping.

Even data from Trust for America’s Healthwhich strongly supports monitoring programs – calls the benefits of such initiatives into question.
For instance, New Mexico, which maintains one of the most restrictive prescription monitoring laws in the nation, has more overdose deaths per capita than Missouri – the only state in the U.S. without a database.

Patients in South Dakota and Nebraska don’t even need a physical exam before getting a painkiller prescription, but the rise in prescription drug-related deaths in those states over the past decade is on par with Vermont, whose monitoring program has been held up as a model for other states to follow.

Such data confirms what experts already know: addiction is a complex disease, the causes and treatment of which go far beyond simple access. Just ask any alcoholic, whose drug of choice is no further away than the corner bar.

There are, fortunately, better ways to address the legitimate problem of prescription-drug abuse. These include increasing penalties for diversion, educating patients on the need to properly secure and dispose of medication, passing laws requiring the reporting of lost and stolen meds and, above all, tackling the problem of addiction by alleviating barriers to treatment.

Unfortunately, the Corbett administration has slashed funding for the very behavioral health programs designed to transition people into recovery. And the governor's refusal to expand Medicaid under the provisions of the Affordable Care Act will cut off some 800,000 Pennsylvanians from guaranteed drug and alcohol treatment.

Viewed through this lens, legislation that trades off patient privacy as an alternative to tried-and-true remedies to drug addiction and abuse is a political red herring that places far too much power in the hands of investigatory agencies at a cost to consumers.

If the potential of having the federal government nose around in your private medical data isn't worrisome enough, consider that in 2009, hackers stole the records of more than 8 million patients from Virginia's prescription database and threatened to sell them on the black market if a $10 million ransom wasn't paid.

But perhaps the most dangerous side effect of unwarranted restrictions on access to therapeutic medication is the chilling effect they have on doctors and pharmacists. Research shows that burdensome restrictions on pain management have a ripple effect that leads doctors to withhold medication from people who need it out of fear of prosecution or censure, even when that fear is unfounded.

This, at a time when medical experts are warning of “a global pandemic” of untreated pain.
Sick Americans, particularly the roughly 115 million that suffer from chronic pain, already face enough burdens to treatment without having their medical information used as leverage in the war on drugs.

If registries are an invasion of privacy for citizens who voluntarily choose to buy a gun, surely they are for those who have no choice but to be sick.

Tuesday, December 17, 2013

Monday, December 9, 2013

Tuesday, December 3, 2013