Tx 5 smith roukie

Treatment Track: Alterna.ves to Incarcera.on and

Encouraging Care

Ron Smith, MD, PhD

Amy Roukie, BS/MBA

Moderator: Van Ingram, Execu.ve Director, Office of Drug Control Policy, Commonwealth of Kentucky

Disclosure

•  Ronald Smith has no financial rela.onships with proprietary en..es that produce health care goods and services

•  Amy Roukie has no financial rela.onships with proprietary en..es that produce health care goods and services

Learning Objec.ves

1.  Analyze alterna.ve level of care Community Triage Centers to determine if it addresses the needs of their communi.es with regards to ER diversions, dealing with the volume of the homeless, indigent and underserved mentally ill and substance abusers and treatment resistant popula.ons.

2.  Evaluate the cost-‐effec.veness of this level of care in rela.on to Emergency Responders, Emergency Rooms, jails and otherwise improper placements especially in urban areas located across the country.

3.  List three ways that medica.ons alone are not effec.ve for the treatment of substance abuse 49

4.  Outline three examples of science suppor.ng the use of Twelve Step interven.ons in promo.ng long-‐term recovery.

5.  Outline the barriers that commonly exist to u.lizing psychosocial and spiritual interven.ons in prescrip.on drug treatment and ways to overcome these barriers.

Medica.on in Recovery

Ron Smith md phd 202

3386543

Disclosure

•  Ronald Smith has no financial rela.onships with proprietary en..es that produce health care goods and services

Recovery

•  I don't know why we are here, but I'm pre]y sure that it is not in order to enjoy ourselves.

•  Ludwig Wi]genstein

Chief Complaint

•  “Anxiety

•  “Depression”

•  “Is this all there is?”

•  “I can’t sleep”

Ques.ons

•  When is Medica.on indicated?

•  What are we Medica.ng?

•  When can Medica.on be Deferred?

•  What are the Problems of Overmedica.on?

Ac.on-‐ Responsibility-‐ Medica.on

•  Educate yourself about the medica.on

•  Educa.on your Physician about Addic.on

Bias…… Prejudice…..Life Experience

•  Ambivalence

•  Big Pharma vs Great Pharma

“Wi]genstein was the only man who looked puzzled at his own lectures….for this I think very

well of him indeed.

G E Moore to Bertrand Russell

Primary Drives and Neurosis

•  “ Life, as we find it is too hard for us. It brings us too many pains, disappointments and impossible tasks. In order to bear it we cannot dispense with pallia.ve measures.

•  Work,

•  powerful diversions of interest, •  and intoxica7ng substances which make us insensi.ve to it…...something of this kind is indispensible.” – Civiliza.on and Its Discontents S Freud

»  S Freud

What am I doing here…why wasn’t I consulted?” Wi]genstein

Chief Complaint

•  “Anxiety




Big Pharma

•  “Love and Other Drugs”

•  “Side Effects”

Paradigm Shih to Meds.

•  Doctors of “Medicine” •  Origins in Koch and Lister ….An.bio.cs •  Huxley •  Freud

•  Brainwashed “The Seduc.ve Appeal of Mindless Neuroscience” Satel and Lilienfeld

Educate Yourself

• “The Power of Nothing” – Michael Specter The New Yorker

• The Truth about Drug Companies Marcia Angell NYRB

The Power of Nothing

•  “Anything that gets people away from the conveyer belts that move from the pharmaceu.cal houses to doctors to pa.ents….anything is worth considering….we need to stop pretending that it’s all about molecular biology…

•  Kaptchuk

Educate Yourself

•  Anatomy of an Epidemic Whitaker

•  Comfortably Numb Barber

•  Selling Sickness Moynihan

•  Crea.ng Mental Illness Horwitz

Educate Yourself

•  Rethinking Psychiatric Drugs Jackson

•  From Melancholia to Prozac Clark

•  Your Drug May Be Your Problem Breggin

Recovery

•  FOI •  Grow Up (Steps and Erikson) •  Learn to Play (Freud and Smith)

•  Encounter the Shadow (Jung) •  Discover the Archetype (Jung) •  Lose yourself to a cause (Shaw)

Family of Origin Issues

•  “I am acquainted with your disposi.on…you are irrita.ng and unbearable and I consider it impossible to live with you”….such a living literary journal as you would like to be is a boring and hateful thing because one cannot skip pages or fling the whole rubbishy thing behind a stove, as one can with the printed one”…

•  Johanna Schopenhauer to her son Arthur

YALOM Existen.al Psychiatry

•  You really are going to die

•  Each of us is ul.mately alone

•  Meaningless

•  Responsibility

YALOM Existen.al Psychiatry

•  You really are going to die

•  Each of us is ul.mately alone

•  Meaningless

•  Responsibility

•  Medica'on Anyone?

Kierkegaard

“What am I doing here?.......

Why wasn’t I consulted?”

Yalom

•  Momma and the Meaning of Life

•  The Schopenhauer Cure

•  Existen.al Psychiatry

Chief Complaint

•  “Anxiety




“Alexithymia”

•  A (without) lexa (words) thymia (feelings)

•  HALT

“Anxiety is the Dizziness of Freedom”

Kierkegaard

“Anxiety”

•  Alone

•  Annihila.on

•  Sleep

•  Nutri.onal

Alone

•  We all live lives of solitary confinement” •  Tennessee Williams

•  Love is not enough but it sure helps •  Kopp

Abandonment anxiety

•  Primary Fear?

•  2001

•  My Life as a Dog

“Rapprochement”

Margaret Mahler

Into Ac.on

•  Solve Rapprochement – Wri.ng

– Mee.ng(s) – Therapy – Medita.on

– Sponsor

Medica.on

•  Low dose Lithium

•  Low dose SSRI – Zoloh

•  Beta Blockers

Depression

•  Passivity

– “The passive posi.on of infancy” Klein

•  Treatment:

– Recovery (Discovery?) of Agency

“Depression”

•  Sadness •  Passivity •  Grief •  Nutri.onal •  Technology

Death

•  “We are all already dying and we will be dead for a long .me”

•  “You can run but you can’t hide”

Into Ac.on

•  Wri.ng •  Non Verbal •  Service •  Mee.ngs

•  Nutri.on •  Crea.ve Process

Medica.on

•  An.depressants – Newer – Older

Meaning

•  Is This All There Is?

Anhedonia

•  Loss of Wonder and Awe

•  Loss of Gra.tude

Meaning

•  “We are meaning seeking creatures who must deal with the inconvenience of being hurled into a universe that intrinsically has no meaning”

Meaning

•  Hero's Journey – Odyssey – Crusades

•  Spiritual Journey •  Rela.onships •  Work

•  Philosophical Materialism

responsibility

•  It is most important to run out of scapegoats

•  We must live within the ambiguity of par.al freedom, par.al knowledge, par.al power

Isak Dinesen

•  “…All sorrows can be borne……

……if you can put them in a story

……..about them…”

Recovery of Desire

•  Therapy as “Recovery of Desire”

•  “We are formed by what we desire John Irving

•  Men as desiring machines Baudrillard

•  Girls vs Sex and the City

Sleep

•  Ac.on: – Sleep Hygiene – Stay Up – Create

•  Meds – Older – Newer – Melatonin

Ted Kaptchuk “The Power of Nothing”

•  Program in Placebo Studies and the Therapeu'c Encounter

– Harvard Beth Israel Deaconess Medical Center

Kaptchuk

•  Larger the pill greater the P •  Two be]er than one •  Colored be]er than white •  Blue to sleep be]er than red •  Green best for anxiety

Kaptchuk on Morphine

•  6-‐8 mgms MS = Placebo •  Must increase to 12 Mgms to surpass placebo

Kaptchuk

•  Diazepam-‐

•  ……Has no discernible effect on anxiety unless a person knows he is taking it…….

Bible

•  Ma]hew 9:22 “Thy faith hath made thee whole.”

•  Mark 10:52 “Go thy way; thy faith hath made thee whole”

•  Luke 7:50 “Thy faith hath saved thee; go in peace.”

•  Luke17:19 “Arise, go your way: your faith has made you whole.”

Faith is a knowledge within the heart, beyond the reach of proof. Khalil Gibran

Ac.on Responsibility Medica.on

•  Educate yourself about the medica.on

•  Educa.on your Physician about Addic.on


•  Iden.fy the specific feeling

•  Ac.on


•  Reserve the right to change medica.ons/mee.ngs/sponsors/therapists/ especially psychiatrists

•  Get a second opinion •  And third

Clement Stone

•  Freedom to Decide •  Influencing Others •  Money

•  Learning Something New

“Tell them I have had a good life”

•  Wi]genstein on his death bed

Amy Roukie, BS/MBA Senior Vice President, Community Triage Center Services

WestCare Founda.on [email protected]

www.westcare.com

• To discuss realistic options to implement in any community, as an alternative to the more costly systems of emergency responders.

• To define financial resources to support these alternatives which are community-based and demonstrate buy-in from the community and connection to the law enforcement community.

• To explore options for these services from medical to social interventions, case management and success rates.

• Passed in 1986 the Emergency Treatment and Active Labor Act (EMTALA), requires all CMS-participating hospitals to provide emergency care to all individuals seeking care irrespective of ability to pay.

•  According to the Centers for Medicare and Medicaid Services (CMS), amounts to 55% of emergency care. (A.Adalja, M.D)

•  Across the nation the Mentally-ill and/or intoxicated individuals creating over-crowding, long wait times and impacting care in the Emergency Rooms.

• Adults with chronic mental-‐illness and/or intoxica.on exist in every community and are the “highest system users” cos.ng the community millions of dollars.

•  Impact the Emergency Rooms, Law Enforcement, Emergency Medical Services, Ambulance, Paramedics, Jail, Court rooms, Mental Health hospitals, etc.

•  Just to keep these individuals cycling through these systems, costs are tremendous including .me and money.

• Most .mes individuals cycle through these systems of care, several .mes a week, a month or some.mes even in a day, and there is nothing done to intervene.

• What can be done to stop the cycle and was.ng money?

•  As an alterna.ve to the Emergency Rooms, this is a mid-‐level of care for those with: –  Intoxica.on/Substance Abuse – Mental Illness

•  Assessments for inpa.ent & outpa.ent services •  Ini.al case management services •  Referrals & service linkages •  Safe & effec.ve treatment op.ons for early interven.on

•  Discharge planning •  Clients served are ohen homeless, uninsured, under-‐insured & indigent

•  The CTC’s are posi.oned to care for those who present with mental health and/or substance abuse issues as well as non-‐acute* medical condi.ons.

•  As an alterna.ve level of care, they are equipped to handle the non-‐violent behavioral health, and intoxicated clients in the community.

*Non-‐acute is defined based on medical status of the individual and the type of interven.on indicated.

•  For those being removed from a public situa.on without formal charges, the Civil Protec.ve Custody detainees, for example are taken to the CTC in lieu of the ‘drunk tank’ in jail.

•  Engagement in substance abuse or mental health treatment is also a poten.al in this environment.

•  Case Management and discharge planning are the keys to ini.a.ng change in this popula.on.

•  Of this popula.on seen in the ER, studies of the CTC popula.ons in Nevada have shown 97% have no acute medical issues, only behavioral health problems.

•  They are held in the ER for assessments, medical clearance and the lack of available psychiatric beds in the community. There are few discharge op.ons.

•  If released, there are concerns about liability, so ER’s are caught in the bind between discharging with no plan and opening-‐up beds for the medically-‐acute.

•  Staffing includes Registered Nurses, Nurse Prac..oners, Case Managers, Counselors, a Medical Director and on-‐call Psychiatrists with the ability to accept pa.ents 24-‐hours per day/ 7 days per week.

•  Medica.ons are provided for those in need of stabilizing chronic but exacerbated medical condi.ons and for any medical issues during detoxifica.on.

•  Low-‐level medical procedures can be performed, however CTC’s are not intended for that purpose.

PERSON IN

CRISIS

LAW ENFORCEMENT

EMERGENCY ROOM

EMERGENCY RESPONDERS

COMMUNITY PROVIDERS

MENTAL HEALTH

CTC

Several levels of intervention can occur with this one

person.

With the Community Triage Center approach, there is one intermediate level of care where all issues can be addressed

•  AVERAGE COST PER ENCOUNTER: •  •  Ambulance: $1,267 •  Hospital: $10,324 (billed charges) •  First Responders: $1,000 per incident

•  Per encounter es.mate: $12,591*

•  *data from Washoe County Report on Serial Inebriates 2013.

• Nevada CTC admissions: 5,770

• Average length of stay: 3.5 days • Recidivism rate: 30.6%

• Total costs: $3,806,695/ year

•  If the same 5,770 clients had one encounter each, at $12,591, there would be $72,667,380 in costs to the community versus $ 3,806,695 for the same clients at the CTC’s!

• Total savings: $68,860,685

Amy L. Roukie, MBA, Senior Vice President, WestCare Founda.on

Email: [email protected]

Website: www.westcare.com

• Universal Health Insurance Mandates, And The Emergency Care Myth

• by Amesh Adalja, M.D retrieved August 12, 2013 from: h]p://www.forbes.com/sites/realspin/2012/10/08/universal-‐health-‐insurance-‐mandates-‐and-‐the-‐emergency-‐care-‐myth/

Tx 5 smith roukie

Health & Medicine