64,000 and counting


The numbers are in for 2016, and they are not good. According to the National Center for Health Statistics, Centers for Disease Control and Prevention, drug-related overdoses in the United States reached their highest level. What’s more, the rate of drug overdose deaths for people under the age of 50 is occurring at a faster rate than HIV at its peak. Given the rise of fentanyluse and easy access to heroin, the number of deaths from opioids is likely to climb for this year. The New York Times published a revised breakdown of data related to the opioid epidemic. Equally as troubling with the numbers is the news that prescription opioid-related deaths have leveled off, while cocaine and methamphetamine have reared their ugly heads as contributing factors in the surge of fatalities.

So far, the recommendations made by the newly formed Commission on Combating Drug  Addiction and the Opioid Crisis appear to be unoriginal and vague. The effort to have real mental health parity in the treatment of mental health and substance abuse disorders has been echoed for decades to no avail. While the commission encourages easier access to opioid replacements (“MAT”) such as subutex  , there is a greater need to understand and analyze the reason drug use is on the rise across various socio-economic, cultural and racial groups. The epidemic has not and is not affecting just white suburbanites, inner city minorities and Appalachia. In fact, the three states that saw the highest increase in opioid-related deaths were Delaware, Florida and Maryland.

State legislators have begun to implement prescription drug monitoring programs to detect the rate patients have been prescribed pain medication. However, this system regulates the patient, not the doctor. It is widely known that doctors (see pill mill crisis of 2011) routinely overprescribe, but 300 million prescriptions for pain medication were written in 2015. The commission does discuss the need for more screening tools to assess addiction and pain, but tools already exist.

One place to look for a new solution is the state of Ohio, where new rules for prescribing opioids caps doctors at dispensing a maximum of 7-day prescriptions for adults in chronic pain. Additionally, the state will require diagnostic codes on all prescriptions for pain medications beginning in December.

As I have written about in the past, practioners on all levels who work in medicine, psychology, addiction and the like, must look at the rise of addiction from a multi-disciplinarinary approach. The guidelines and suggestions handed out by the commission focus primarily on reactive measures. Those on the front line of treating the epidemic must return to analyzing family structure, mental health pathology, performance in school and other societal factors that are being sidelined as explanations for the explosion in opioid-related disorders and subsequent fatalities.


Dismissing Freud 2.0


It happens every few years: historians, psychologists, journalists and investigators find “new” material to dismiss and discredit the work of Sigmund Freud. Since his passing in 1939, the man, who is often mythologized, has undergone numerous character assassinations. Many have said his work is both unscientific and offensive, while others have labeled him a racist and a sexist. Most recently, his work and its lack of empirical research, has been cause (somewhat fairly) for concern about the effectiveness of psychoanalysis. In his new book, the British author and critic Frederick Crews continues his take down of the late Freud. The book, “The Making of an Illusion,”  focuses on Freud’s shortcomings as a man and a professional, and rails against a form of treatment that created a “cult of personality” in the late 19th and early 20th centuries.

Freud’s most notable dissenters have spent years rejecting his theories on penis envy, the Oedipus Complex and the core concept of the sexual drive inherent in all humans. His experimentation with cocaine has poured into mainstream culture. But the main problem with dismissing Freud outright is the lack of understanding of the value of psychoanalysis. At its core, psychoanalysis is a talking cure (coined by Josef Breur in 1895). Patients are able to therapeutically process emotion, content, disturbances and conflicts. The contemporary relational psychoanalyst Susie Orbach said “Psychoanalysis is the study of human subjectivity. It is a clinical practice. It theorises the vicissitudes of human attachment, of the psychological development of mind and body that occur within a relational, cultural field.” She is correct. Furthermore, psychoanalysis proper is rarely practiced today because of the “need” for brief, concrete and managed mental health treatment.

Swept up in the Freudian revisionism is a more common problem, which is the dismissal of the magnitude his ideas have had on the field of psychology for 100 years. Freud’s groundbreaking understanding of transference and countertransference, along with his working model of the mind, are still understood and used today. Psychiatric assessments refer to “attitude toward writer,” which can be linked to a patient’s transferential projection onto the therapist. Because of Freud, we now understand the omnipotence of defense mechanisms and the unconscious motives of our drives.

Freud normalized sexuality for men and women. The ability to relate sexuality to early childhood experiences is a sensitive issue, but one that needs exploration in the therapeutic setting. Today, we have a greater appreciation for attachment theory, psychosocial development and the ego because of Sigmund Freud. The problem with the argument that Freud’s work was not empirical rests on the idea that therapy is strictly a science. Cognitive behavioral approaches, along with other standardized modalities are ubiquitous, but their long-term efficacy remains unknown. Behavioral interventions negate defense mechanisms, unconscious conflicts, inhibition, drive and attachment.

The mind is still a largely unknown construct. Psychoanalysis has allowed therapists, physicians and lay people to inch closer to understanding its processes. Replacing this with psychopharmacology and shallow methodologies of treatment that rely on labels and symptoms fails to grasp the rewards of the subjective therapeutic experience.


Complacency in an age of apathy


As we all know by now, Baltimore has been the epicenter of cultural, political, economic, social and psychological conflict over the past few weeks. With the death of Freddie Gray, light has begun to shine on some of the underlying problems we face in our cultural and social DNA. In addition to this event, which has left many heartbroken, angry, confused and saddened, another tragedy took place in New York City, with the brutal murder of a social service shelter manager. Her murderer, a former resident of the shelter she managed, stalked her, followed her to her car, attempted to rape her and as she was able to bravely escape, he gunned her down in the middle of the street.

As more horrific events like these become common, I wonder if we have become numb or complacent to the breakdown in our social contract. We have learned to accept and disregard the effects of unemployment, low wages, income inequality and mental illness. Collectively, we have failed to seriously address the pressing issues of our time that have led to the manifestation of racial tensions, mistrust between authority and citizen and above all else, a sense of apathy for action…real action.

Light has been shined on the broken neighborhoods of Baltimore, where drug dealing and gang violence have replaced work and education. Several politicians, many of them at the state level, have cited the amount of money that has been poured into poor neighborhoods for community centers and parks. While this is nice, it is a misappropriation of funds. As someone who works with the homeless, the addicted, the poor and the disenfranchised, I will be the first to tell you that the real issue lies in the disincentives to work. We have created more barriers, such as back-to-work programs, that do virtually nothing. We assume that the disparaged cannot work and must receive government assistance. This is wrong.

We need to increase the minimum wage and get people working so that drug-dealing and other activities no longer need to be the top viable option for income. I, too, would turn down a $7.50/hour job, if I knew I could make $2,000 a week in heroin sales. In essence, we are subsidizing drug dealers!

Pour money into education, after school programs and implement structure for young adults. The PC police will need to sit back on this one, but we must thoroughly address the problems as they are, not as we think they are. The murder of the social service worker in New York City is another stigma for the mental health field. Let’s stop accepting the occurrence of such events. We need more mental health facilities, more long-term treatments for the chronically ill and a more comprehensive understanding of the ills that plague many people in society. Until we accept that many individuals with severe mental illness need long-term, intensive treatment in a safe environment, more tragedies will continue to occur.

I use the word complacency, because as a society, we have yet to take the necessary measures to address these concerns. The poverty rate today is the same as it was in the 1960s. Money alone is not the issue. We need to come together to form comprehensive legislation that focuses on treatment, education and employment.

Critiquing the AA/12 Step model

Let me begin this post by disclosing that I am not affiliated with AA, have never been in AA nor participated in any outpatient treatment center or program for alcohol use or abuse.  Prior to reading about the faulty and scarce research about the efficacy of 12 Step Programs, I formulated my own opinions about the AA-model from my work in an outpatient substance abuse clinic in New York City.

Many of the men in treatment are homeless and have extensive histories with battling addiction. What came across in group sessions was a division between those individuals who subscribe to the 12 Step Program and those who cringe when they hear the language of “powerlessness” and “shortcomings.”  I was first turned off from the ways of 12-Step because of the rigidity of the steps. They came across as finite and restrictive. Relapse was a black or white concept. No middle ground.

I began to think about the term addiction and place it into the overall context of mental health.  Despite the evidence that addicts have fewer dopamine receptors in the brain’s reward pathways than non-addicts, it is hard to label someone’s choices as a disease that one cannot control. What is striking about the AA model is that there is little separation or distinction between someone who has been clean for 2 months or 20 years, a relapse is a relapse and that individual has to restart the steps from the beginning. This rigidity seems to assert that if an individual “slips up,” his disease has gotten the better of him.

AA’s rate of success is also relatively low. A Cochrane Collaboration study that ranged almost 40 years (1966-2005) found “no experimental studies unequivocally demonstrated the effectiveness of AA.” The success rate is somewhere between 5-10%. A 1991 New England Journal of Medicine study found addicts treated in hospitals fared better than those treated in an AA setting.  This lack of success only prolongs an addict’s recovery, as most outpatient treatment programs in the country integrate a 12-step model.

In recent years, AA meetings have made room for atheist and agnostic members who are uncomfortable with step 2: “Came to believe that a Power greater than ourselves could restore us to sanity.” This inclusion is a sign of progress.

Much of AA’s evidence for success is anecdotal and thus, is prone to criticism. Although I am critical of the model as a treatment, I do believe AA offers a support system that does not discriminate based on any race, gender, income bracket or sexual identity.  While an insight-oriented approach that helps the client/patient identify underlying thoughts and feelings is preferred, it is a timely and costly modality that might not yield a positive result.

Evaluating crime and mental illness

In a May 27th opinion piece in The New York Times, Dr. Richard A.  Friedman of Weill Cornell Medical College asked the million dollar question:  Why can’t doctors identify killers? His article was in response to Elliot Rodger’s shooting spree in Santa Barbara, CA on May 23rd . After a tragedy of that magnitude, where Rodgers killed six people, politicians, pundits and “mental health experts” all called for the country’s mental health system to be examined. However, even if mental health care is radically changed in the United States, it will be difficult to prevent these tragedies. As Dr. Friedman points out, “…mass killings are very rare events. In 2012, they accounted for only about 0.15 percent of all homicides in the United States. Because of their horrific nature, however, they receive lurid media attention that distorts the public’s perception about the real risk posed by the mentally ill.” What is it about the United States and mass murder that seems to be the exception rather than the rule? After all, mental illness is not limited to the United States.

While many call for stricter gun laws (me included), there are other changes that need to occur. Barriers to involuntary psychiatric treatment need to be eased. Short of threatening harm to oneself or others, it is almost impossible to be hospitalized against one’s own will. This needs to change. Second, the perception of who commits crimes needs to change. Most people with severe mental illness are not harmful. The latest statistics show that roughly 4% of  overall violence in the United States is from the mentally ill. Individuals who are under the influence of drugs and alcohol are far more likely to commit a crime. Lastly, it is about guns. Access to guns is too easy. Individuals with extensive psychiatric histories should never (yes, never) be allowed to purchase a gun. Public safety takes precedent over the second amendment.

Finally, the larger question that these tragedies pose is: What are mental health professionals and law enforcement agencies currently doing to evaluate and assess for such crimes? The simplest answer appears to be very little.  Prior to Mr. Rodger’s shooting spree, police officers met with him in April and determined there was nothing they could do. According to a May 25th New York Times article, “The officers reported that Mr. Rodger was shy and had told them that he was having difficulties in his social life.” Later on, Mr. Rodgers, writing in his soon-to-be released manifesto, wrote “If they had demanded to search my room that would have ended everything. For a few horrible seconds I thought it was all over.” There needs to be greater collaboration between psychiatrists, social workers and law enforcement agencies. Interventions for potential criminals needs to be more extensive than a brief house visit. Family members and clinicians  should have greater resources at their disposal to involuntarily commit an emotionally disturbed individual.