September 2007 Newsletter
The Newsletter of the National Association of County Behavioral Health and Developmental Disability Directors
In this Issue...
Board Discusses Medicaid Rehabilitation Option; Elects New Officers
The NACBHDD Board has met twice in the past few months – once on July 13 in Richmond, Virginia at the same time as the National Association of Counties (NACo) 27th Annual Conference and Exposition, and again on September 6 and 7 in Napa, California. The three primary issues addressed were the proposed Centers for Medicare & Medicaid Services (CMS) rules related to the Medicaid Rehabilitation Option, the election of new Board officers, and the review and approval of a new committee structure for the organization.
The Rehabilitation Option
NACBHDD has been discussing the CMS regulations with the Board, state association members, other advocacy organizations, including the Campaign for Mental Health Reform (www.mhreform.org), and with NACBHDD committees through conference calls. The September Board meeting in California afforded NACBHDD the opportunity to have members of the California state association's Board join a discussion about the Rehab Option. NACBHDD is preparing comments to send to CMS by the October 12 deadline. NACo will be sending a letter to CMS in support of NACBHDD's comments. A copy of the comments will be sent to the membership.
If members have questions or information on how the regulations would affect programs in their counties, NACBHDD would appreciate hearing them. NACBHDD encourages members to send their own comments and feedback to CMS as well. The proposed CMS regulations can be viewed in the Federal Register at:
http://a257.g.akamaitech.net/7/257/2422/01jan20071800/edocket.access.gpo.gov/2007/pdf/07-3925.pdf.
New Board Officers
New NACBHDD Board officers were elected at the July meeting and assumed office at the September Board meeting. ; they will serve for two years. NACBHDD's new Board is as follows:
Leon Evans, Chair. As Chair of NACBHDD's Board, Evans acts as a spokesperson for the organization (in conjunction with Executive Director Ellen Witman). In addition, he is responsible for overseeing all Board of Directors and Executive Committee meetings, and he works in partnership with the Executive Director to insure that all Board resolutions, as well as the organization's Strategic Plan and Work Plans, are carried out.
Evans is President/Chief Executive Officer of the Center for Health Care Services in San Antonio, Texas, where he oversees a staff of over 650 employees and administers services for the mentally ill, the mentally disabled, and individuals with substance abuse disorders. He is the immediate past Vice-chair of NACBHDD, and he serves on the National Association of Counties' (NACo) Justice and Public Safety Steering Committee, as well as the NACo Board of Directors. Evans is also a member of NACo's Youth Aging Out of Foster Care Task Force, which is part of NACo President Eric Coleman's Children Aging Out of Foster Care Initiative. For more information about this initiative, click here.
In March, Evans testified before the House Judiciary Committee's Subcommittee on Crime, Terrorism, and Homeland Security at a hearing on "Criminal Justice Responses to Offenders with Mental Illness." He spoke about Bexar County's local collaboration on the award-winning Bexar County Jail Diversion Program, which was nationally recognized in 2006 with the American Psychiatric Association's Gold Award and the National Council for Community Behavioral Healthcare's Excellence in Service Delivery Award. The program also was highlighted in the SAMHSA journal for innovation and creativity.
Dan Ohler, Vice Chair. As NACBHDD’s Vice Chair, Ohler will become Chair of the Board in 2009. He serves on NACBHDD’s Executive Committee, Policy Committee, and the State Associations Committee.
Ohler is Executive Director of the Ohio Association of County Boards of MR/DD (OACBMRDD), which serves 70,000 individuals and their families in Ohio’s county boards of mental retardation and developmental disabilities. He is a member of the Ohio legislative MRDD Futures Committee, the MRDD Strategic Planning Group, the ARC of Ohio and the Ohio League for MR.
As a registered legislative lobbyist, he endeavors to give Ohio legislators a comprehensive understanding of the issues faced by the state’s 88 county boards. Prior to joining OACBMRDD, Ohler worked with the Ohio Department of Mental Retardation and Developmental Disabilities and the Ohio Bureau of Workers’ Compensation.
Pat Fleming, Secretary. As Secretary, Fleming is responsible for maintaining the accuracy of all Board records, including the Bylaws, and is responsible for performing any other duties assigned him by the Chair or Vice Chair. He serves on the NACBHDD Executive Committee.
Fleming is Director of the Salt Lake County, Utah, Division of Substance Abuse Services. Fleming has worked in various capacities in human services for more than 24 years, including direct services, program management, business management, and policy development, and he has worked at the federal, state, and county level, as well as for private nonprofit agencies. For the last 19 years, he has worked almost exclusively in substance abuse prevention and treatment. He serves on the National Association of Counties' Methamphetamine Task Force, and has testified before Congress about the methamphetamine crisis. He also has served at the national level as Treasurer and Board member of the National Association of State Alcohol and Drug Abuse Directors.
Cindy Sill, Treasurer. As NACBHDD's Treasurer, Sill works closely with the Executive Director on an ongoing basis and provides a monthly financial report at each Board or Executive Committee meeting.
Sill is Executive Director of Tri-County MH/MR Services in Conroe, Texas, where she oversees the Center's comprehensive treatment of individuals with mental illness, mental retardation, and dual diagnosis of mental illness and chemical dependency. The Center, which serves 6,000 consumers in three counties in rural and suburban east Texas, has an annual budget of over $19.8 million. Prior to her current position, Sill was Executive Director of the Denton County, Texas, MHMR Center, where she oversaw the growth of the Center's annual budget from $2.8 million to $8.4 million, coordinated all aspects of a 28,000 square foot building renovation, and managed a staff that grew from 75 to 270 employees.
Sill serves on the Advisory Board of the Texas Correctional Office on Offenders with Medical and Mental Impairments, chairs the Contract ork group of the Texas Correctional Office of Offenders with Medical and Mental Impairments, and is the founder and first president of the Texas Mental Health Counselors Association.
Margaret Hanna, Chair Emeritus. As the immediate past chair of the Board, Hanna remains an officer of the organization, and she serves on the Executive Committee. Hanna is Executive Director of the Bucks County Drug & Alcohol Commission in Pennsylvania. She has been working for more than 37 years in behavioral health management in the public and private sector, has years of experience working as a consultant and trainer in the field, and has served on local and national boards. She serves on the Executive Management Team for the Bucks County Behavioral Health System, which is the lead entity for the Medicaid managed care program. In addition, she serves on the Board of Directors of the Pennsylvania Behavioral Health and Aging Coalition.
Debbie Donaldson, Director, Human Services, Sedgwick County, Kansas, has completed four years as the NACBHDD representative to the NACo Board, and she is now serving as Vice Chair of the National Association of Counties (NACo) Behavioral Health Subcommittee. Donaldson served as Chair of the NACBHDD Board prior to Hanna's tenure.
David Wiebe, Executive Director, Johnson County Mental Health Center, Kansas, is Chair of NACo's Behavioral Health Subcommittee and chairs the NACBHDD Medicaid Committee.
NACBHDD Has New Committee Structure
For a number of years, NACBHDD has had eight standing committees: Executive Committee, State Association Directors, Medicaid, Developmental Disabilities, Substance Abuse, Corrections, Conferences and Programs, and Membership. At the July Board of Directors meeting it was suggested that an Ad Hoc Committee on Committees take a look at the committee structure and discuss ways to improve the effectiveness of NACBHDD committees and increase the interaction and integration of their deliberations. The Ad Hoc Committee was chaired by Dan Ohler (OH) and included Patrick Fleming (UT), Mary Ann Bergeron (VA) and Mike Chambers (PA). The Ad Hoc Committee recommended restructuring the standing committees, and the recommendation was adopted by the Board at the September Board meeting in Napa, California.
Three overarching principles guided the restructuring:
Based on these principles, the Ad Hoc Committee recommended, and the full Board adopted, the following new committee structure:
The Executive Committee will be led by the Board Chair (as it is now) and consists of the five NACBHDD officers, the Chairs of the Membership & Marketing Committee (see description below) and the Conferences & Programs Committee, and two additional members to be determined by the Chair. Depending on whom the officers and committee chairs are in any given year, the two additional Board members would be chosen based on region of the country or area of expertise (mh, sa, dd, or state association) to ensure full representation of NACBHDD's membership on the Executive Committee.
The Executive Committee will have the full power of the Board in those months that the Board does not meet. It will be responsible for the overall direction of the agency and supervision of the Executive Director as well as oversight of fiduciary activities and two subcommittees.
Most of these activities are already the responsibility of the Executive Committee. Two changes were adopted, however, to ensure that the Executive Committee has all the information it needs to meet its responsibilities and remain up-to-date on important organizational actions. First, the free-standing Finance Committee (which is currently only the Treasurer) is eliminated. The Treasurer, who is a member of the Executive Committee, will work closely with the Executive Director on an ongoing basis and provide a monthly financial report at each Board or Executive Committee meeting.
One new subcommittee will be created: a Trilogy Subcommittee to provide advice, marketing assistance and troubleshooting related to Trilogy's Network of Care and e-learning components. The subcommittee members will be from counties that use Network of Care and can promote it and/or respond to questions or concerns from local authorities considering purchasing a Trilogy product.
Because so many of the public policy issues NACBHDD follows impact more than one segment of our membership (even if one is more directly affected than others), the Ad Hoc Committee felt it is important to have a diversified, representative Public Policy Committee in which all areas of our membership and all geographic regions engage in discussion together. Medicaid laws and rules, for example, cut across all areas of behavioral health and many disabilities services. Housing availability, job training, case management issues and other policy areas are cross-cutting and should not be discussed only in the mental health silo or the disabilities silo.
The Public Policy Committee will be headed by the Board's Vice Chair and co-chaired by another Board member. The committee will consist of representatives from all areas of the membership – mental health, substance abuse, and developmental disabilities – and will also include State Association representatives.
The current substantive issues committees will become subcommittees of the Public Policy Committee and continue to exchange information via conference calls or the new message boards that will be part of NACBHDD's redesigned Website which will debut shortly. When policy issues arise, the subcommittees will make policy recommendations to the Public Policy Committee, which will discuss each issue and recommend a position on behalf of the full membership. The recommended position will be sent to the NACBHDD Board or Executive Committee for adoption.
This committee expands both the scope and size of our current Membership Committee. Our strategic plan includes growing our membership, reaching out to the disabilities and substance abuse authorities, potentially adding some local authorities in states that are not county-based services, and other areas where growth in size and growth in influence are possible. To meet these goals NACBHDD needs better marketing materials, new designs, and personal interaction with peers around the country. A reinvigorated committee is essential to meeting these goals.
The committee will be responsible for assessing the variety of materials NACBHDD will need in order to educate county behavioral health and disabilities directors about the value of our organization and promote membership. Other tools, such as a DVD or PowerPoint presentation about NACBHDD that could run continuously at a conference or in an exhibit hall, would also help get our message out. Another necessity is a brochure about NACBHDD that can be left in Congressional offices or handed out to coalition partners and others who have common interests with our members.
Our current Conferences and Program Committee will remain, but its responsibilities will expand to include helping with the planning of future programs, recruitment of speakers, and logistical decisions. In addition, the committee is charged with thinking through the value of connecting two of our three conferences with NACo meetings and the third with a state association meeting. The committee will look at the calendar for the next three years and determine if Board meetings and conferences are too close together or too far apart, if regional conferences might attract more members, and if the Legislative Conference is timed appropriately to maximize our influence in the legislative process. The Program Committee will recommend to the Board of Directors any proposed changes in NACBHDD's meeting schedule.
The Ad Hoc Committee recommended keeping the State Association Committee as a stand alone committee because there is significant value in having a forum in which the State Association Directors can discuss not only public policy issues but also recruitment of counties in their states, marketing issues, Network of Care, best practices, research and many other issues.
New, Improved, Interactive Website Coming in November
Starting in November, the NACBHDD website will have a new, improved look, and members will have the opportunity to communicate with each other through online message boards and to advocate for their local interests in Congress through the Advocator, an online advocacy tool. The message boards and the Advocator will be available through the member-only pages, and the Legislative Updates, newsletters and conference information will be available to anyone visiting the website. The membership will be notified by email when the newly designed site is launched. The new website has been designed and will be maintained by Trilogy Integrated Resources, Inc., the same company that produces the Network of Care website cited by the President's New Freedom Commission on Mental Health as a model program. For more information on Trilogy, or to access the Network of Care, see www.trilogyir.com.
Legislative Conference Scheduled for February 28 and 29
NACBHDD's annual Legislative Conference is scheduled for February 28 and 29 in Washington, DC. (The National Association of Counties will hold its annual Legislative Conference in Washington, DC, March 1-5, 2008.) NACBHDD's Legislative Conference is an opportunity to hear first-hand from federal representatives and national advocacy partners about current and upcoming legislative priorities. It also affords NACBHDD members and potential members a venue in which to network, exchange information about programs and issues, and become part of a national effort to improve care and services in the fields of behavioral health and developmental disabilities. Conference registration forms, hotel information, and conference materials will soon be available on the website.
SCHIP Update: Congress Trying to Resolve Differences in Bills
Both the Senate and the House have been addressing the need to extend the State Children's Health Insurance Program (SCHIP). As of the writing of this newsletter, an agreement has been reached and passed by the two houses of Congress and the bill has been sent to President Bush. Unfortunately, a veto is anticipated. NACBHDD will continue to keep the membership updated on the most recent activity related to SCHIP via the DC Updates sent to the membership on Friday afternoons.
To view Maeghan Gilmore's September 25 and September 21 DC Updates on activity related to SCHIP, click here.
Parity Passes the Senate; House Committees Still Considering Legislation
On September 18, the Senate passed the mental health and substance abuse parity bill for private insurance. In the House, , The Paul Wellstone Mental Health and Addiction Equity Act (H.R. 1424) has been reported out of two of the three committees with jurisdiction. Both the Education and Labor Committee and the Ways and Means Committee held hearings, marked-up the bill and reported it favorably to the full House. Only the House Energy and Commerce Committee still needs to mark-up and report the legislation. It is expected that they will do so in early October; a hearing was held earlier in the year. By mid-October it is anticipated that the full House of Representatives will vote to pass the bill.
NACBHDD Executive Director Ellen Witman sent an announcement regarding the recently passed Senate parity bill to the membership on September 19. Portions of her announcement are below followed by a Congressional Quarterly article about the Senate's action.
Last night the U.S. Senate passed the mental health parity bill. The version that passed by voice vote was the latest Manager's Amendment which eliminates, in most cases, preemption of state laws stronger or more inclusive than the federal bill. This was a tremendous victory for parity advocates and for the bill's sponsors -- Senator Edward Kennedy (D-MA) and Senator Pete Domenici (R-NM) -- who have spent more than a decade trying to achieve parity for mental health care.
Kudos to all of our members who weighed in on this top priority issue and especially to NACBHDD's Public Policy and Government Relations Director, Maeghan Gilmore, who has represented us so well in coalitions and on Capitol Hill.
Below this message is a brief article from Congressional Quarterly about the Senate's action.
The House of Representatives still has a way to go before final passage of its version of a parity bill (HR 1424). … The Energy and Commerce Committee remains key to moving parity legislation to passage in the House. To date, the Committee's Health Subcommittee has held a hearing on the bill, but has not yet moved to mark-up and full Committee consideration. We remain hopeful that all three committees will complete their work and send the parity legislation to the full House for a vote and passage before the end of the year.
Maeghan and I will continue to work with our coalition partners to encourage the House Committees to move this legislation forward. We will keep you posted. You should continue to make sure your Members of Congress understand the critical need for national parity legislation. Parity needs to remain a front burner issue until a new law is enacted.
From CQ TODAY – HEALTH, September 18, 2007
Senate Passes Legislation Aimed at Parity in Coverage for Mental Health
By Kathleen Hunter and Drew Armstrong, CQ Staff
The Senate on Tuesday passed legislation that would require mental health benefits to be equal in amount and scope to other benefits in insurance plans.
Senators passed the bill (S 558) by voice vote after amending it so it would not pre-empt tougher state mental health parity laws.
"For states that do a really good job, there's no ceiling put on them," said an aide to Edward M. Kennedy, D-Mass., a chief architect of the measure.
The underlying bill, which has wide support from insurers and businesses, would protect mental health benefits for 113 million people, its backers say.
"This bill represents a major breakthrough for those with mental health needs, ensuring their access to fair and equitable health insurance," Kennedy said in a statement.
The bill had appeared set for passage just before the August recess, only to be stalled by an objection from Jim DeMint, R-S.C., who wanted floor time to debate the measure.
"The Senate attempted to hotline over 150 bills with over $60 billion in new spending before August recess," said DeMint spokesman Wesley Denton, referring to a process by which Senate leaders agree to speed the passage of bills. "Sen. DeMint objected to a number of these bills from being secretly passed at the last minute without debate or a vote."
After discussing his objections with Kennedy and bill sponsor Pete V. Domenici, R-N.M., DeMint "is no longer objecting to this bill," Denton said.
The House Ways and Means Health Subcommittee is scheduled to mark up companion legislation (HR 1424) on Wednesday, but a GOP aide said Kennedy had "made it clear to other senators that the Senate bill will be the final version of the legislation."
The House measure is sponsored by Kennedy's son, Patrick J. Kennedy, D-R.I.
Housing for the Aging Developmental Disabilities Population: NACBHDD Member Urges Careful Examination and Planning
NACBHDD's Developmental Disabilities Committee has identified housing as one of its major policy issues – specifically the current and future housing needs of the aging developmental disabilities population. These individuals, their families, and county behavioral health officials face some complex challenges in determining the best possible housing situation for them as they age. Many age forty and fifty-year-old individuals with developmental disabilities have parents who are in their sixties and seventies, so that examining and addressing this challenge is a looming priority.
In addition, to the population aging and facing the loss of parents with whom they may have lived with in the community their entire lives, these individuals may be facing many critical physical care needs. But, county officials know that traditional group homes do not meet the needs of this aging population; they do not provide the range of services they are starting to need or are likely to need in the near future. As George Braunstein, Executive Director, Chesterfield Community Services Board, in Chesterfield, Virginia, and a member of the Developmental Disabilities Committee, says, "There will be significant challenges to providing housing to people we've made a commitment to serve for life."
Braunstein estimates that in Chesterfield County there are over fifty individuals with developmental disabilities who will need housing supports in the next five years. These fifty individuals are currently on a Medicaid waiver, but will need some nursing home level of care within the next five years. While he does not know the statistics beyond his county, it is widely acknowledged in the field that housing is a looming and critical priority, and Braunstein hopes that the Developmental Disabilities Committee will explore the numbers and carefully examine the issues related to housing for this population. He has been actively involved in planning and implementing housing in Chesterfield County, and outlines some of the challenges and some of the housing solutions.
The physical care needs of the aging DD population are complex, vary among individuals, and drive what type of housing best suits an individual's needs. Some individuals with developmental disabilities were born with serious medical conditions that become more critical with age, and others may suffer from dementia, deterioration of joints, difficulty ambulating, cardiac issues (such as hypertension and strokes), and respiratory issues. As Braunstein explains, this range of physical care needs means that people with serious medical needs may be best served by living in more medically-driven buildings, while others may be able to reside in houses that have been made accessible. For example, a ranch-style house might be renovated to include adaptive hallways and accessible showers and toilets so that it accommodates wheelchairs.
ICFs/MR offer the level of services and mix of services needed. Braunstein argues that because of the level of medical care needed for much of this aging population, ICFsMR (Intermediate Care Facilities for the Mentally Retarded) may be the logical choice because they provide for a much higher level of medical services, including a skilled level of medical care. Adequate housing means the right mix of services, not simply a place to live, and a lot of these services are available in a traditional nursing home. The funding sources in some states are "very parsimonious," says Braunstein, and if the ICF/MR is not used, there will be no reimbursement.
Families and advocacy groups are concerned that some of these homes may resemble nursing homes and do not want their loved ones in a nursing home environment. As deinstitutionalization has progressed over the years, families and advocacy groups have advocated and continue to advocate for the housing standard in the field to move away from nursing homes. As a result, the name and type of licensure will raise "red flags" with advocates.
Braunstein worries that the move away from deinstitutionalization, coupled with the terminology "ICF/MR" and "nursing home," has created a philosophical hurdle to productively addressing the unique housing needs of this population as they age. And, this challenge carries over into the agencies that fund and underwrite their care. He believes that ICFs/MR should be viewed simply as terminology, rather than an absolute definition and description of a residence.
Chesterfield County is involved in constructing nursing homes based on the Greenhouse model (available for the general population). For information on the Greenhouse model, click here. This type of home allows people to operate on a more adaptive model of care in the environment, and Braunstein describes them as looking like "a big old house with medical devices in the bedrooms." For example, a lift might be placed in a bedroom as unobtrusively as possible. However, he emphasizes, this can only be accomplished with licensure that allows for cost-based reimbursement to pay for the level of care needed.
Braunstein estimates that the fifty people in his county who need housing in the next five years will reside in ten houses with four to five to a house or in five houses with ten to twelve people in a house. To date, Chesterfield County has developed the following solutions for housing aging individuals with developmental disabilities.
Policy issues for NACBHDD. Braunstein believes that different levels of support are needed for different people, and the following issues need to be carefully discussed with a "common vernacular" at the state and federal level:
Members may contact George Braunstein at BraunsteinG@chesterfield.gov.
NACo Survey Shows More Teens, Women, Minorities Abusing Methamphetamine
The National Association of Counties (NACo) recent survey of 500 law enforcement officials in 44 states found that 47 percent of counties consider methamphetamine their "number one illegal drug problem." The survey found that the demographic on methamphetamine is changing, and includes the following:
The survey, "The Methamphetamine Epidemic: The Changing Demographics of Methamphetamine," was conducted to determine the effectiveness of precursor laws and examine whether increased public awareness of methamphetamine have changed patterns of manufacture, acquisition, and usage. To view a complete description of the survey's findings, NACo's advocacy and legislative plans, and to access the survey, click here.
NIMH To Study Benzodiazepine Exclusion In Medicare Part D
From the June 22 NIMH Science Update:
New Study Will Examine Effects of Excluding Anti-anxiety Medications in Medicare Part D Coverage
A new research grant funded by NIMH will examine the costs and benefits of excluding a commonly prescribed class of anti-anxiety medications—benzodiazepines—from coverage in the new Medicare Part D program. Medicare Part D, the prescription drug coverage plan for people insured by Medicare, went into effect in January 2006. The two-year grant will examine how this large public health initiative is affecting treatment of anxiety disorders in older adults.
The decision to exclude benzodiazepines from Medicare Part D coverage was based in part on clinical studies indicating that even though the medications are an effective treatment for anxiety disorders, older people who take them are at an increased risk for falls and hip fractures, and they may worsen conditions such as emphysema, urinary incontinence and depression. Susan Ettner, PhD, of the University of California, Los Angeles, and colleagues will examine how the exclusion is affecting patient care and the use and costs of health care services, including mental health services.
The researchers will use prescription drug, behavioral and medical claims of Medicare participants enrolled since 2004 to analyze their rates of hospital stays, emergency department visits, doctor's visits, and overall behavioral and medical costs. To assess the short-term effects of the exclusion, the researchers will examine participants who had been taking a benzodiazepine before Medicare Part D went into effect. To assess long-term implications of the exclusion, they will examine participants newly diagnosed with an anxiety-related disorder. These data will be compared with data on individuals whose benzodiazepine coverage was unaffected by the Medicare Part D program.
The researchers seek to understand not only how the change in coverage affects the health of patients, but also whether the change will result in health care savings or additional costs for the Part D program. The results will help to inform the ongoing policy debate about whether Medicare Part D needs to be amended to include coverage for benzodiazepines.
Advocate and Treatment Professional in Long-Term Recovery "Puts a Face and a Voice" on What Works
This September marked the18th Annual National Alcohol and Drug Addiction Recovery Month, sponsored by SAMHSA's Center for Substance Abuse Treatment (CSAT). The goal of this year's theme, "Join the Voices for Recovery: Saving Lives, Saving Dollars," was "to raise awareness about the financial and human costs of substance use disorders and [to highlight] the benefits that investing in treatment can have on those who enter recovery, their families and the larger community." (For more information see www.recoverymonth.org.) In addition to Recovery Month's focus on the financial and human costs of substance abuse, the NACo survey outlined above highlights some of the high costs of methamphetamine to women and teens and to counties. This month NACBHDD spoke with an advocate and treatment professional who has been in recovery from methamphetamine for 17 years.
Tonya Wheeler, Director of the Miracles Program for the Council of Substance Abuse and Mental Health in Denver, Colorado, made a point of first relaying her enthusiasm about being interviewed for the NACBHDD newsletter before she even started talking about methamphetamine addiction and long-term recovery. She was eager to talk because, as she said, methamphetamine use is often represented in the media as an addiction from which there is little or no hope for recovery, and she emphasized, "That's absolutely not true." Wheeler is in a position to know the critical impact of methamphetamine use on an individual and their family, as well as what it takes to sustain a long-term recovery. She has been in long-term recovery from methamphetamine and other drug use for 17 years, is the mother of two grown daughters, and is not only a certified addictions counselor, but also a leading advocate in her role as President of Advocates for Recovery in Colorado.
The impact on the individual
Wheeler's drug use started with smoking marijuana in her teens, and she used methamphetamine from the ages of 18 to 22. During this period, her two children were born; she had her first daughter when she was 16, and her second daughter was born when Wheeler was 19. She described that time as "four years of a daily drug habit." And, within that four-year period, there was a period of daily methamphetamine use. Wheeler pointed out, "You can pick up where you left off with an addiction," and her worst meth period was October 1988 through March 1989. Much of that time is a blur, said Wheeler. She was, for the most part, unemployable and could not even work in her parents' business. In addition, even though her daughters were safe with her parents, she was unaware of where they were most of the time.
The impact on the children; custody issues are common
Wheeler's parents were awarded custody of her first daughter when she was two years old. Wheeler explained that it is common for many mothers using methamphetamine to be dealing with custody issues. "The addiction is so strong with meth that all else loses importance." As Director of the Miracles Program, an intensive six-month outpatient substance abuse program for women, Wheeler is involved directly with women who have children and who also may be involved in the criminal justice system; the majority of her referrals come from the state child welfare system or the probation system. As a result, she does a lot of presentations for child welfare workers, and she always emphasizes that the addiction is "not about the mothers not caring about the kids." As she said in an article on the impact of methamphetamine use on children, "For a person addicted to the drug who has children, it's not about not loving your kids; it's about the disease of addiction. I loved my children every single day that I was addicted to meth. But the main truth of it is, the disease takes over everything." To view this article and for an in-depth look at efforts in Colorado to address and support recovery, child welfare, and families through coordination between law enforcement and social services, click here. For more information on the National Alliance for Drug Endangered Children, which supports multidisciplinary coordination between "prevention, law enforcement, courts, probation, social services, treatment, mental health, medical, child welfare, education, public health, federal agencies, tribal nations, non-profit organizations, and the community," see http://www.nationaldec.org.
Treatment: a personal perspective on what works
Wheeler's experience with inpatient treatment was brief and not positive. Her parents took her to a treatment center in Dallas, Texas, in 1986, and told her when she agreed to sign herself in that if there was no meth evident in her drug tests that they would take her home. The tests came back negative, which Wheeler said she knew they would when she was admitted because she had not used in a few days. In addition, she was allowed no outside contact for 72 hours, which was difficult. When her drug test came back clean, she phoned her parents after the 72 hours were up, and they said that they would discuss her leaving the treatment center when they arrived. Instead, she called her boyfriend to pick her up from the treatment center and she left with him. When she returned to Paris, Texas, her parents had taken custody of her daughter.
By March 1989, Wheeler was "nearly starved to death," weighed 103 pounds, and she said, "I knew I was going to die if I didn't get treatment." She and a man she was dating had been arrested for methamphetamine, and she was on probation. However, she was not subjected to any drug testing while on probation. Wheeler's managed to get herself to a treatment center in March 1989. Two days into treatment she was told her care would not be covered by insurance, and she had to leave.
After she left that treatment center, she moved in with her parents, who had moved 120 miles from their original home. Wheeler emphasized that this move was truly a significant turn of events, as she was now no longer near the people with whom she had been using methamphetamine. Although she stopped using methamphetamine at this point, she continued her marijuana and alcohol use from March 1989 to May 1990. She then began outpatient treatment, and had extensive support around her, including a twelve-step program. She was not completely clean and sober until May 23, 1990.
The social supports are an absolute necessity for ongoing recovery as far as Wheeler is concerned. Although she has daily professional exposure to the world of addiction and recovery as a drug and alcohol counselor, and she has been clean and sober for 17 years, she still goes to all her meetings because she says, "it works. People who relapse – the first thing they do, is that they get away from their support networks."
In terms of what type of treatment works, Wheeler says her program has implemented the evidence-based matrix model developed in California (see www.matrixinstitute.org), which she describes as "very cognitive-based; it encourages people to think things through." Unfortunately, she said that is not what she experienced in treatment, and that for her, the biggest key to her continued success in recovery has been finding and maintaining "ongoing positive social support." She cited everyday examples of this ongoing positive social support. For example, in the early years of her recovery, she was raising two little girls on her own, and she needed other single mothers to help her model how to parent and to help her model common life tasks and skills, such as paying bills. She feels that the matrix model has this emphasis on positive social support built into it.
While she believes the matrix model incorporates the social supports, she describes the importance of having a system of positive support and behavior "all around me." She emphasized that her friends and social supports are also people in long-term recovery, and she knows that if she "picked up drugs and alcohol again, I would lose all this." She has "heightened what I have to lose," including solid family relationships with her parents and with her daughters, who are now 19 and 23. As Wheeler says, the positive social support has to be there or an individual in recovery will relapse. "If you want to see how you're doing, look at who you're hanging out with. It is scary to reach out your hand for help, but the data shows it is impossible to do it alone. Jail will not make addiction better."
The Miracles Program employs the matrix model and the Seeking Safety curriculum, which relates trauma and substance abuse. Wheeler underscored the need for the supportive nature of treatment, "In working in counties, the best thing is to provide support without enabling addiction."
Advocacy: putting a face with a voice
Wheeler described the significance behind being so open about her addiction and recovery, "It is so important for us to put a face with a voice. For many years, so much has been anonymous in the twelve- step programs. The public needs to see hope."
In 2000, Wheeler became involved in Advocates for Recovery in Colorado. (www.advocatesforrecovery.org) "When we started, there were probably ten of us, and we talked about all the things we wanted to do." They especially wanted to emphasize how treatment works and how recovery does happen. They barely had money to mail their first newsletter, but they managed to mail it through personal collections from the group; and a year later, they had their first Rally for Recovery. The group has continued to have rallies to represent the success of recovery in Colorado, and they try schedule their rally on the same date as the national rally. Last year, Dr. Westley Clark, Director of SAMHSA's Center for Substance Abuse Treatment, spoke at their rally. And, Wheeler has helped "put a face on recovery" on the national front. In September, 2006, she spoke at a SAMHSA press conference to announce the release of SAMHSA's National Survey on Drug Use and Health as part of National Alcohol and Drug Addiction Recovery Month. The organization often supports the legislative efforts of the national organization, Faces & Voice of Recovery, including the Paul Wellstone Mental Health and Addiction Equity Act of 2007 (H.R. 1424).
Wheeler lends her personal experience and professional expertise to addressing substance abuse at the state and local level. The methamphetamine problem is very prevalent in Colorado, says Wheeler. Much of Colorado is very rural, and rural areas have long been known as places where it is easier for methamphetamine to be made and be unnoticed or hidden. The product also enters Colorado easily from meth "super labs" in California and Mexico. And, Wheeler described funding for drug treatment in Colorado as "horrible," as it is in many states. Despite the prevalence of methamphetamine and the dearth of funding, she is optimistic about support for treatment and recovery in Colorado. Andrew Romanoff, speaker of Colorado's House of Representatives, is "their greatest supporter," and Wheeler has spoken several times in front of the Colorado House. (Romanoff won the Advocates for Recovery's Advocate of the Year in 2005.) In addition, Colorado's governor Bill Ritter is supportive of treatment instead of criminalization. Denver's mayor John Hickenlooper is interested in addressing the drug problem in Denver, and Wheeler has been appointed to the Denver Drug Strategy Commission, whose task is to formulate a plan for how to address the drug problem in the city and county of Denver. The committee is composed of treatment professionals, physicians, and other people in recovery, in addition to Wheeler. The commission will research how to involve schools and employers, and Wheeler has been asked to give insight into what works in the recovery process.
Wheeler summed up her feelings about treatment and recovery. "Treatment works but we don't create the exposure for people to access treatment." Wheeler is busy creating that exposure. She can be contacted at tonaywheeler@advocatesforrecovery.org.
Increase in Teen Suicide Corresponds with Reduced Antidepressant Use
Two recent studies, one conducted by the Centers for Disease Control and Prevention (CDC) and one lead by a University of Chicago researcher, found that a significant increase in teen suicide corresponded with a decrease in the use of anti-depressants by adolescents. After clinical trials found an increased in suicidal ideation among children and adolescents taking SSRIs the Food and Drug Administration issued a "black box" warning for antidepressant use in children and teenagers in 2004, and expanded the warning to include young adults last December.
The CDC study found that from 2003 to 2004, for children and teens between the ages 10 and 24, the suicide rate rose 8 percent, which is the largest increase in 15 years. The largest increase in the suicide rate was among 10 to 14 year old girls, with a 67 percent increase. Among girls age 15-19, the suicide rate increased 32 percent; rates for males in that age group rose 9 percent. The rate is still less than one per 100,000. (Greg Bluestein, "American Girls' Suicide Rates Spike," washingtonpost.com, September 7, 2007)
The University of Chicago study lead by Robert Gibbons, a professor of biostatistics and psychiatry, is published in the September issue of the American Journal of Psychiatry. The study found that from 2003 to 2004, the suicide rate rose 14 percent among Americans younger than 19; this was the most significant rise in the suicide rate since the government starting collecting statistics on suicide in 1979. In the Netherlands, which was also included in the study, antidepressant use decreased 22 percent in children between 2003 and 2005, and the suicide rate for children increased 49 percent. Gibbons found that "The data suggest that for every 20 percent decline in antidepressant use among patients of all ages in the United States, an additional 3,040 suicides per year would occur." About 32,000 Americans commit suicide each year. The director of the National Institute of Mental Health, Thomas Insel, commented on the study, "We may have inadvertently created a problem by putting a 'black box' warning on medications that were useful." He added, "If the drugs were doing more harm than good, then the reduction in prescription rates should mean the risk of suicide should go way down, and it hasn't gone down at all -- it has gone up.'" (Shankhar Vendantam, "Youth Suicides Increased As Antidepressant Use Fell," washingtonpost.com, September 6, 2007)
The National Alliance of Mental Illness's (NAMI) Medical Director Ken Duckworth issued the following statement on the studies (see www.nami.org):
Teen suicide is an often preventable tragedy. It is an appropriate focus of research and inquiry. Two new studies focused on the issue raise both important clinical and policy questions.
In the September 2007 issue of the American Journal of Psychiatry, researchers looked at children and teen suicide rates in the United States and the Netherlands, two countries which have put major warnings on the medications to treat depression, with a resulting substantial drop in medication prescriptions for children and teens. They observed a large increase in suicide in children and teens following controversy about advisory warnings—one that correlates to the drop in prescriptions for antidepressants. Suicide has many dimensions, and medication treatment is an important one. This study is an opportunity to begin to put key pieces together relating regulatory demands, warnings and the tragedy that is suicide.
One possibility is that the FDA "black box warning" on the use of antidepressants with children and adolescents has reduced access to a useful (but risky on rare occasions) treatment—with bad outcomes as a result. It will take more study and time to fully assess how central this element of the rate increase is. NAMI will support and follow that research.
NAMI favors fully informed consent about the risks and benefits of all treatments and the often overlooked risk of no treatment of all—along with careful monitoring of individuals who have suicidal concerns and a comprehensive treatment plan that looks at all aspects of a child's or teenager's life in order to maximize their chances of a safe recovery from depression or other psychiatric illnesses.
Also this week, the Center for Disease Control released a report documenting that the rate of suicide in teenage girls is increasing. Again, this could have many causes but it will be important to follow in terms of whether it is a clear and persistent trend or an anomaly.
Programs like Columbia University's Teen Screen have been shown to be safe and are an important way to reach out to at-risk children and teens. With parental consent, NAMI endorses the program.
Risperdal Approved for Use in Children and Adolescents
The following is reprinted from the August 22 issue of FDA news:
The U.S. Food and Drug Administration today approved Risperdal (risperidone) for the treatment of schizophrenia in adolescents, ages 13 to 17, and for the short-term treatment of manic or mixed episodes of bipolar I disorder in children and adolescents ages 10 to 17. This is the first FDA approval of an atypical antipsychotic drug to treat either disorder in these age groups.
Until now, there has been no FDA-approved drug for the treatment of schizophrenia for pediatric use and only lithium is approved for the treatment of bipolar disorder in adolescents ages 12 and up.
"The pediatric studies of Risperdal provided an opportunity to assess the effectiveness, proper dose, and safety of using this product in the pediatric population," said Dianne Murphy, M.D., director of FDA's Office of Pediatric Therapeutics. "These data have permitted the identification of the effective pediatric dose ranges and have provided an evidence-based approach for treating these disorders in pediatric patients."
The FDA first approved Risperdal in 1993 for the treatment of schizophrenia in adults. The drug later was approved for the short-term treatment of acute manic or mixed episodes associated with bipolar I disorder in adults and the treatment of irritability associated with autistic disorder in children and adolescents 5 to 16 years old.
Evidence to support this approval was collected through studies the FDA requested as part of its pediatric drug development initiatives.
The efficacy of Risperdal in the treatment of schizophrenia in adolescents was demonstrated in two short-term (6 to 8 weeks), double-blind, controlled trials. All patients were experiencing an acute episode of schizophrenia at the time of enrollment. Treated patients generally had fewer symptoms, including a decrease in hallucinations, delusional thinking, and other symptoms of their illness.
The efficacy of Risperdal in the treatment of manic or mixed episodes in children or adolescents with bipolar I disorder was demonstrated in a three-week, randomized, double-blind, placebo-controlled, multicenter trial in patients who were experiencing a manic or mixed episode. Treated patients generally had fewer symptoms, including a decrease in their elevated mood and hyperactivity, and other symptoms of their illness.
Drowsiness, fatigue, increase in appetite, anxiety, nausea, dizziness, dry mouth, tremor, and rash were among the most common side effects reported.
The American Psychiatric Association (APA) released the following statement in support of the FDA's approval of Risperdal for use in children and adolescents. (Source: http://www.medicalnewstoday.com/articles/80384.php, August 23, 2007):
The APA applauds the U.S. Food and Drug Administration (FDA) for its review of scientific evidence that led to the approval of a new treatment for two severe psychiatric disorders in children. The APA is pleased that the approvals are a result of the federal Best Pharmaceuticals for Children Act (BCPA), which was designed to encourage research that leads to this kind of approval, given that dosages, side effects and efficacy can vary significantly with children.
"Schizophrenia and bipolar disorder are severely disabling to patients and devastating to their families," said APA President Carolyn Robinowitz, M.D. "For many children suffering with psychiatric illnesses, medications are an important part of a comprehensive treatment program, which should include talk therapy and other interventions."
"For any medication there are benefits and potential risks," said Darrel Regier, M.D., M.P.H., director, APA Division of Research, and executive director, American Psychiatric Institute for Research and Education. "For many children with these disorders, the FDA's action today provides additional information to guide treatment options in these special populations. We anticipate that approval of this medication will encourage federal research agencies to accelerate urgently needed studies of mental disorders in children."
Physicians and parents must work together to evaluate the risks and benefits of any particular treatment. The APA recommends that all treatment for psychiatric illnesses are guided by a thorough evaluation and careful diagnosis, followed up with a treatment plan tailored to the needs of the child and the family.
October 7-13 is Mental Illness Awareness Week
From the National Alliance for Mental Illness (NAMI):
Since 1990, mental health advocates across the country have joined together during the first week of October to celebrate Mental Illness Awareness Week (MIAW).
Established in 1990 by Congress, the first week of October is designated as "Mental Illness Awareness Week" (MIAW) in recognition of NAMI's efforts to raise mental illness awareness. "Bipolar Disorder Awareness Day" (BDAD) is held each year on the Thursday of MIAW to encourage further understanding and promote early intervention and treatment for this mental illness.
MIAW and BDAD are NAMI's premiere public awareness and public education campaigns that link the organization nationally to the organization's over 1100 local affiliates across the country.
Over the past 16 years, MIAW has become a tradition in NAMI. It presents an opportunity for all three levels of NAMI –national, state and local – to work together in communities across the country in meeting the NAMI mission through a variety of outreach, educational, and advocacy efforts.
Bipolar Disorder Awareness Day was created by NAMI (National Alliance on Mental Illness) and Abbott Laboratories to increase awareness of bipolar disorder, promote early detection and accurate diagnosis, reduce stigma, and minimize the devastating impact on the 2.3 million Americans presently affected by the disorder.
BDAD activities focus on encouraging the community to:
For more information on activities in your community, see www.nami.org, and click on "Find Support."
SAMHSA has recently issued the following press releases on issues which may be of interest to NACBHDD members. To view these and other press releases, go to www.samhsa.gov, and see "Latest Headlines."
White House Drug Czar Awards $74 Million To Fight Drug Use At The Local Level
National Registry of Evidence-Based Programs and Practices Adds Information on Former Model Programs Initiative to Web Site
VA's Suicide Hot Line Begins Operations
SAMHSA Awards $2.88 Million to Link2Health Solutions to Manage National Suicide Prevention Lifeline
New Members Appointed to Center for Mental Health Services National Advisory Council
FY 2008 Forecast Provides Look Ahead at SAMHSA Grant Opportunities
HHS Provides $98 Million in Access to Recovery Grants
