Steven Kassels, M.D.


I hope you have enjoyed the first four articles in this five part series on who and what to blame for the heroin epidemic in America. More importantly, I hope that by better understanding how and why the opioid epidemic came to be, the solutions presented will be considered and assist in developing greater insight and activism to address this scourge to society. If you have missed any prior articles in the October – January editions of The Sober World Magazine, you can easily review them by going to www. thesoberworld.com and go under past issues.

Mental Health Treatment or actually the lack thereof has contributed to the overall increase in illicit drug and alcohol use.

It is well documented that patients with mental illness are still greatly underserved, and despite some positive movement to increase treatment funding and access, the drastic cuts from the distant and recent past have not been eliminated. NAMI, the National Alliance on Mental Illness, released the report “State Mental Health Cuts: A National Crisis” which documents the drastic cuts implemented by states between 2009 and 2011 for spending for children and adults living with serious mental illness. These cuts led to significant reductions in community and hospital based mental health services, with a direct effect also on access to psychiatric medications and crisis services. The Medicaid funding issue is a complex analysis, but there is no question that too many patients are left without viable treatment options.

Also, in an article by the Pew Charitable Trusts, “Some States Retreat on Mental Health Funding”, Medicaid expansion “may also have persuaded some states to pull back funding for community mental health centers and other mental health initiatives, including school and substance abuse programs.”

The lack of access is not limited to the Medicaid insured population, as many commercial insurers also do not cover mental health services in parity with medical and surgical illnesses. In addition to private insurance companies not abiding by parity laws, the federal and state governments, who are responsible for overseeing compliance, apparently are not doing a good job. Despite laws, mental health coverage often falls short. It was also reported that “NAMI found that patients seeking mental health services from private insurers were denied coverage at a rate double than those seeking medical services … [and] patients encountered more barriers in getting psychiatric and substance use medications.”

Enough with the statistics! How does this lead to the heroin epidemic? Simply stated, patients with mental illness are no different than patients with a wide variety of complaints – they all want to feel better. However, when there are roadblocks related to funding and access to treatment and medication for psychiatric illnesses, patients look elsewhere to feel better. It is a well-known phenomenon that patients who cannot access care are more likely to self-medicate. So it should not surprise us that patients with depression, anxiety, bipolar illness and other psychiatric health issues reach for drugs that make them feel better: alcohol, stimulants such as cocaine, and opioids such as OxyContin or heroin are commonly used.

So we have now exposed another cause leading to the heroin/opioid crisis; but let’s focus on another solution. Federal and State Governments must enforce parity laws and we must increase access and funding for mental illness. As they say in the Midas commercial, “You can pay now or you can pay later, but you are going to pay.” Inadequate mental health treatment leads to substance use, crime, dysfunctional family dynamics and an overall increase in financial costs to society.

This now brings us to the final reason for the heroin/opioid epidemic – and what a way to end – by blaming our politicians and other public officials. Why? – Because if all our public officials showed the leadership and courage of Vermont Governor Shumlin, we would be further along in implementing solutions to curb the heroin epidemic. Governor Shumlin spent his entire State of the State address on the heroin/opioid crisis in bucolic Vermont and in doing so, risked his political career on exposing the issue for what it is – with no sugar coating, no minimizing, and no blaming – just good old fashioned straight talk! ! Here is a brief excerpt from Governor Shumlin’s 2014 State of the State Address:

The crisis I am talking about is the rising tide of drug addiction and drug-related crime spreading across Vermont. In every corner of our state, heroin and opiate drug addiction threatens us. It threatens the safety that has always blessed our state. It is a crisis bubbling just beneath the surface that may be invisible to many, but is already highly visible to law enforcement, medical personnel, social service and addiction treatment providers, and too many Vermont families. It requires all of us to take action before the quality of life that we cherish so much is compromised.

We must cut back on the demand to stand a chance of limiting the damage. Lives and dollars are at stake and it is time to lead the charge to educate through scientific fact and not out of fear. I commend Governor Shumlin for his call to attack the epidemic on the demand side (treatment); recognizing that putting more people in jail may make us feel safe on the short term, but does not solve the problem. Although Governor LePage of Maine has also addressed the issue of drug addiction as an economic issue, he unfortunately does not advocate for increased funding for treatment and access to care, but instead only for expanded law enforcement and judicial response.

As the death of the likes of Philip Seymour Hoffman reinforces, drug addiction, including heroin dependency, is an equal opportunity disease affecting all socioeconomic strata; and knows no boundaries. This is not a problem of the welfare state or the poor or less fortunate. The disease is present in our impoverished neighborhoods as well as our wealthy suburban communities and in our resort towns and backwoods. Establishing treatment centers for addiction in one’s own locale should be worn as a badge of honor, no different than establishing a cancer treatment center or cardiac center; both of which are illnesses that may be related to the disease of addiction. NIMBY (Not in My Back Yard) no longer works!

As I stated in an Op-Ed in the Boston Globe, “The Scourge of Heroin Addiction”

There should be just as many public service announcements about addiction as there are Viagra and Cialis commercials. In addition, expansion of addiction treatment services in jails would help to mitigate much of the revolving door phenomenon. Furthermore, we should demand that our medical schools and hospitals improve addiction training of our physicians. While there is plenty of blame to go around, let’s focus on the solutions. The scourge of addiction is in all of our yards. The solution is to decrease the demand with bold public initiatives and a change in attitude. It is both the humanitarian and fiscally responsible thing to do.

We can make great strides to solve the scourge of heroin addiction, but we need to stop blaming and put words into action. As I have discussed in this five part series, there is plenty of blame to go around! Unfortunately, as illustrated in my book, Addiction on Trial, Police Chief Bergeron’s reflections are reflective of the unfortunate attitudes of many.

Although Chief Bergeron had witnessed first-hand the increasing influx of drugs into not only his community but into all of Downeast Maine, Annette’s death and the likelihood it was drug connected posed challenges never before encountered.

There had been a prolonged battle within the ranks of city government and among the citizens who irrationally opposed the siting of the treatment center, delaying its opening for years. Eventually, there was some acknowledgment that Downeast Maine, no different than innumerable regions and communities up and down the east coast, had a heroin and Oxycontin problem, but it was greatly minimized. The clinic was finally approved after much rancor, but treatment was initially limited to one hundred patients. Since no one ever wants to believe its municipality has a significant drug problem, it was decided that opening up one hundred outpatient slots would more than satisfy the need and help to quell the escalating controversy. The clinic filled all its patient slots within a month and droves of needy patients were placed on waiting lists.

This struggle to establish treatment centers was not unique. There were similar controversial and heated discussions in many cities and towns … Lawsuits
between municipalities against well-intentioned medical providers were not unusual. Paradoxically, at about the same time, a New England Governor’s Council Forum had convened … Presentations by illustrious speakers demonstrated the extent of the epidemic …What Bergeron remembers most from the conference was the statement by a prominent elected official that “these are telling times when elementary and middle school children are offered a bag of
70-80 percent pure heroin for the price of a double scoop ice cream cone.” The forum’s mantra was interdiction, education, and treatment. This battle cry was good in theory, but in practice it was a different story at the local level. NIMBY—“Not in My Back Yard”—was the rallying cry of most municipalities. No town would admit to having a significant drug issue; it was always the next town over that had the problem. The rationale was based on the fear that if a drug addiction center was established in one’s own town, which of course did not have a problem to begin with; all the addicts from the neighboring townships would spread the scourge as they migrated for treatment, thereby creating a drug problem that never before existed. Despite the documented epidemic of drug abuse across the nation, hardly any individual town, if you spoke to the locals, had much of a problem. Chief Bergeron understood the apprehension of the townsfolk, that a drug treatment center in West Haven Harbor would label the town as a drug haven. The tourists would be frightened and stay away, the local economy would falter, and everyone would suffer. As a result, many in need of treatment never got it.

It is time for attitudes to change!

Dr. Kassels has been Board Certified in both Addiction Medicine and Emergency Medicine. He serves as the Medical Director of Community Substance Abuse Centers. He is the author of “Addiction on Trial”, written as a murder mystery/legal thriller to reach and educate a wide range of readers. The book has recently been entered into medical school curriculum to help decrease physician bias. The book is available at: Amazon (http://www.amazon.com/Addiction-Trial-Tragedy-Downeast-Maine/dp/1491825316) and free author book club presentations and educational meetings (in person or using Skype) can be arranged at: http://addictionontrial.com/author-events/