Treatment: Alternatives to Incarceration and Encouraging Care -

1. 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

2. 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

3. 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.

4. Medica.on
in
Recovery
Ron
Smith
md
phd
202
3386543

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

6. 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

7. Chief
Complaint
• “Anxiety
• “Depression”
• “Is
this
all
there
is?”
• “I
can’t
sleep”

8. 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?

9. Ac.on-­‐
Responsibility-­‐
Medica.on
• Educate
yourself
about
the
medica.on
• Educa.on
your
Physician
about
Addic.on

10. Bias……
Prejudice…..Life
Experience
• Ambivalence
• Big
Pharma
vs
Great
Pharma

11. “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

12. 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

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

14. Chief
Complaint
• “Anxiety
• “Depression”
• “Is
this
all
there
is?”
• “I
can’t
sleep”

15. Big
Pharma
• “Love
and
Other
Drugs”
• “Side
Effects”

16. 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

17. Educate
Yourself
• “The
Power
of
Nothing”
– Michael
Specter
The
New
Yorker
• The
Truth
about
Drug
Companies
Marcia
Angell
NYRB

18. 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

19. Educate
Yourself
• Anatomy
of
an
Epidemic
Whitaker
• Comfortably
Numb
Barber
• Selling
Sickness
Moynihan
• Crea.ng
Mental
Illness
Horwitz

20. Educate
Yourself
• Rethinking
Psychiatric
Drugs
Jackson
• From
Melancholia
to
Prozac
Clark
• Your
Drug
May
Be
Your
Problem
Breggin

21. 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)

22. 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

23. YALOM
Existen.al
Psychiatry
• You
really
are
going
to
die
• Each
of
us
is
ul.mately
alone
• Meaningless
• Responsibility

24. YALOM
Existen.al
Psychiatry
• You
really
are
going
to
die
• Each
of
us
is
ul.mately
alone
• Meaningless
• Responsibility
• Medica'on
Anyone?

25. Kierkegaard
“What
am
I
doing
here?.......
Why
wasn’t
I
consulted?”

26. Yalom
• Momma
and
the
Meaning
of
Life
• The
Schopenhauer
Cure
• Existen.al
Psychiatry

27. Chief
Complaint
• “Anxiety
• “Depression”
• “Is
this
all
there
is?”
• “I
can’t
sleep”

28. “Alexithymia”
• A
(without)
lexa
(words)
thymia
(feelings)
• HALT

29. “Anxiety
is
the
Dizziness
of
Freedom”
Kierkegaard

30. “Anxiety”
• Alone
• Annihila.on
• Sleep
• Nutri.onal

31. Alone
• We
all
live
lives
of
solitary
confinement”
• Tennessee
Williams
• Love
is
not
enough
but
it
sure
helps
• Kopp

32. Abandonment
anxiety
• Primary
Fear?
• 2001
• My
Life
as
a
Dog

33. “Rapprochement”
Margaret
Mahler

34. Into
Ac.on
• Solve
Rapprochement
– Wri.ng
– Mee.ng(s)
– Therapy
– Medita.on
– Sponsor

35. Medica.on
• Low
dose
Lithium
• Low
dose
SSRI
– Zoloh
• Beta
Blockers

36. Depression
• Passivity
– “The
passive
posi.on
of
infancy”
Klein
• Treatment:
– Recovery
(Discovery?)
of
Agency

37. “Depression”
• Sadness
• Passivity
• Grief
• Nutri.onal
• Technology

38. Death
• “We
are
all
already
dying
and
we
will
be
dead
for
a
long
.me”
• “You
can
run
but
you
can’t
hide”

39. Into
Ac.on
• Wri.ng
• Non
Verbal
• Service
• Mee.ngs
• Nutri.on
• Crea.ve
Process

40. Medica.on
• An.depressants
– Newer
– Older

41. Meaning
• Is
This
All
There
Is?

42. Anhedonia
• Loss
of
Wonder
and
Awe
• Loss
of
Gra.tude

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

44. Meaning
• Hero's
Journey
– Odyssey
– Crusades
• Spiritual
Journey
• Rela.onships
• Work
• Philosophical
Materialism

45. 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

46. Isak
Dinesen
• “…All
sorrows
can
be
borne……
……if
you
can
put
them
in
a
story
……..about
them…”

47. 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

48. Sleep
• Ac.on:
– Sleep
Hygiene
– Stay
Up
– Create
• Meds
– Older
– Newer
– Melatonin

49. Ted
Kaptchuk
“The
Power
of
Nothing”
• Program
in
Placebo
Studies
and
the
Therapeu'c
Encounter
– Harvard
Beth
Israel
Deaconess
Medical
Center

50. 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

51. Kaptchuk
on
Morphine
• 6-­‐8
mgms
MS
=
Placebo
• Must
increase
to
12
Mgms
to
surpass
placebo

52. Kaptchuk
• Diazepam-­‐
• ……Has
no
discernible
effect
on
anxiety
unless
a
person
knows
he
is
taking
it…….

53. 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.”

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

55. Ac.on
Responsibility
Medica.on
• Educate
yourself
about
the
medica.on
• Educa.on
your
Physician
about
Addic.on

56. Ac.on
Responsibility
Medica.on
• Iden.fy
the
specific
feeling
• Ac.on

57. Ac.on
Responsibility
Medica.on
• Reserve
the
right
to
change
medica.ons/
mee.ngs/sponsors/therapists/
especially
psychiatrists
• Get
a
second
opinion
• And
third

58. Clement
Stone
• Freedom
to
Decide
• Influencing
Others
• Money
• Learning
Something
New

59. “Tell
them
I
have
had
a
good
life”
• Wi]genstein
on
his
death
bed

63. Amy
Roukie,
BS/MBA
Senior
Vice
President,
Community
Triage
Center
Services
WestCare
Founda.on
amy.roukie@westcare.com
www.westcare.com

64. • 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.

65. • 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.

66. • 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.

67. • 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?

68. • 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

69. • 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.

70. • 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.

71. • 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.

72. • 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.

73. 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

74. • 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.

75. • Nevada
CTC
admissions:
5,770
• Average
length
of
stay:
3.5
days
• Recidivism
rate:
30.6%
• Total
costs:
$3,806,695/
year

76. • 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

77. Amy
L.
Roukie,
MBA,
Senior
Vice
President,
WestCare
Founda.on
Email:
amy.roukie@westcare.com
Website:
www.westcare.com

78. • 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/