In Opioid Epidemic, Prejudice Persists Against Methadone
By Christine Vestal
When Rebecca Schmaltz found out she was pregnant with her second child, she tried to quit heroin cold turkey. She stopped injecting for a day or two, became sick with withdrawal symptoms, and relapsed. She kept trying, though, to kick the habit on her own.
Finally in her fourth month of pregnancy she passed out from severe withdrawal symptoms and ended up in a hospital. When she woke up, she learned a doctor had given her methadone to eliminate her symptoms, which can be life-threatening to the fetus.
Her doctor told her she would have to stay on daily doses of methadone for the rest of her pregnancy or risk more hospitalizations and possibly lose her baby. But methadone wasn’t available in her hometown of Minot, North Dakota. In fact, the nearest clinic was nearly 450 miles away in Billings, Montana.
Schmaltz’s predicament is not unusual.
Despite the nation’s decade-long surge in opioid addiction, large swaths of the U.S. still lack specialized opioid treatment centers that can dispense methadone, one of three medications available to treat addiction to heroin and prescription pain pills.
The other two medications, buprenorphine (approved by the Food and Drug Administration in 2002) and Vivitrol (approved in 2010), can be prescribed by doctors. But for some patients, particularly those who have built up a high tolerance for opioids through prolonged use or high doses, methadone can be the only addiction medication that works.
Although research has repeatedly proven methadone’s effectiveness at eliminating withdrawal symptoms, quelling drug cravings, and keeping people in treatment, it has been plagued by stigma and misinformation since its development in 1964. A long-acting opioid, originally developed and still used to treat pain, methadone normalizes the brain and satisfies the body’s physical dependence on opioids without producing a high.
Still, many in the medical community and addiction counseling field adhere to the discredited belief that because the methadone molecule is similar to heroin its use amounts to “trading one drug for another” or “one addiction for another” and does not mark true recovery.
Another common misconception about methadone is that it gets diverted from addiction treatment clinics to street markets and ends up killing people. According to data collected by the Centers for Disease Control and Prevention, the methadone that is killing people is the tablet form of the medication, which originates in pain clinics and is widely prescribed to low-income Medicaid patients.
Buprenorphine, also an opioid, is starting to garner a negative reputation because it is diverted to street markets and prisons in many parts of the country. But because the addiction medication can be picked up at a drugstore and taken in private, people who rely on it to stay in recovery are much less stigmatized.
The other alternative, Vivitrol, is a long-acting injectable form of naltrexone, a drug that blocks the euphoric effects of alcohol and opioids. Although research on its long-term effectiveness is not as conclusive as it is for methadone and buprenorphine, Vivitrol is favored by many, including drug courts, prisons and jails, because it is not a narcotic and the monthly injection cannot be diverted.
According to the American Society of Addiction Medicine, all three medications should be considered for people with an addiction to heroin or prescription painkillers. Just as with any other chronic disease, one medication may work for certain patients, while the other two may not.
In 2014, more than 28,000 people died of an overdose of opioid painkillers or heroin, and an estimated 2.5 million were addicted to opioids.
Methadone is highly regulated, requiring patients to show up at a specialized clinic every day to take their dose while a medical professional watches. Under federal rules, patients who take the medication consistently for six months and are able to stay away from drugs can be granted permission to take home a week to a month’s supply of methadone.
Regulated by the U.S. Drug Enforcement Administration and the Substance Abuse and Mental Health Services Administration, as well as state health agencies and opioid authorities, methadone clinics can be difficult to get started. And some, especially those with limited financial backing, find it difficult to maintain the paperwork and meet the standards for facilities and personnel that are required to stay in business.
For companies trying to open a new treatment center to meet growing demand, city and county zoning boards and licensing authorities also can get in the way.
Although most of the opposition to methadone clinics is based on accumulated rumors and misinformation, some clinics are poorly managed and do not operate in their patients’ best interests, which contaminates the industry’s overall reputation, said Dr. Kenneth Stoller, who runs a methadone clinic in Baltimore that is affiliated with Johns Hopkins Hospital.
Nationwide, roughly 350,000 patients receive daily methadone doses along with counseling and other health services from 1,460 opioid treatment centers, a number that has grown by less than 25 percent in the last decade, according to Mark Parrino, president of the American Association for the Treatment of Opioid Dependence. During the same time, the number of people misusing prescription opioids more than doubled, and opioid overdose deaths have quadrupled since 1999.
West Virginia, the state with the highest drug overdose death rate in the nation, has had a statewide moratorium on methadone clinics since 2007 over worries the medication was being diverted to street markets and killing people.
Georgia this year enacted a one-year moratorium over concerns that at least half of the state’s methadone patients were from out of state. And Alabama lifted a moratorium on new methadone clinics last year only to have one of its most populous counties block the first company to propose a new clinic.
For financial reasons, methadone clinic operators are also discouraged from locating in the 16 states where Medicaid, the federal-state health program for the poor, does not pay for the medication and related services. They are Arkansas, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Mississippi, Montana, North Dakota, Oklahoma, South Carolina, South Dakota, Tennessee, West Virginia and Wyoming.
Lack of funding is also a deterrent in the 19 states that have not expanded Medicaid to the low-income adults who make up a disproportionately large segment of the opioid-addicted population.
Until August, North Dakota had no methadone clinics. Wyoming still has none, and South Dakota, a state of more than 77,000 square miles, has only one.
In contrast, Baltimore, a city of less than a hundred square miles, has 20 clinics. Boston, Chicago, New York and Philadelphia also have an abundance of methadone clinics, as well as public transportation, making the daily commute less of an issue than it is in rural parts of the nation.
Historically opioid addiction was rare in most of the West and other sparsely populated parts of the country. But once overprescribing of prescription painkillers began to cause many to get hooked about 10 years ago, many small towns and communities saw an influx of heroin.
Schmaltz, 29, got started on opioid painkillers after abdominal surgery in 2010. Within a year, she said, she was addicted. She began doubling her doses and snorting them. At that point her doctor cut her off.
Starting in 2012, she tried treatment with buprenorphine and abstinence-based residential programs, but repeatedly relapsed, as many people with an opioid addiction do. In early 2014, she turned to heroin.
“In the two years that I was clean, heroin had taken over Minot. Pills were impossible to find and heroin was everywhere,” Schmaltz said. A city of 50,000 today, Minot experienced a population boom starting in 2010 when the oil industry began to flourish in the region.
During the same time, Minot Police Chief Jason Olson said the city saw an uptick in crime and illicit drugs. “About three years ago, we started seeing a huge spike in heroin and prescription opioids,” he said.
JoAnne Hoesel, who was director of the state’s substance abuse agency at the time, said “people started calling into the division looking for treatment starting about five years ago.” With the oil boom, she said, “We had people coming into the state assuming they could continue treatment, but they found out differently. One worker had to fly back to Wisconsin every month.”
Hoesel said the state agency was eager to attract methadone clinics and had the authority to do so. But rather than risk controversy, she said it decided to seek the Legislature’s endorsement, which came in 2011. By 2014 the agency had written regulations to govern methadone clinics.
A Three-Year Process
To protect her unborn baby, Schmaltz said, she decided to continue taking methadone no matter the price. It wasn’t feasible to commute from Minot for methadone, so she moved in with a relative in a tiny town, more than 700 miles away in northern Montana, where the drive to the nearest methadone clinic in Kalispell was only an hour and 15 minutes. Her fiance and 6-year-old daughter stayed in Minot.
After her son was born in January 2015, Schmaltz prepared to go home. The clinic in Kalispell helped her get federal permission to take home a two-week supply of methadone. But once she was back in Minot, she had to travel nearly seven hours — each way — to Billings every two weeks to replenish her supply.
Schmaltz didn’t know it, but the company that owned the Kalispell clinic, Community Medical Services, had been trying for three years to establish a clinic in Minot.
According to CEO Nick Stavros, it was relatively easy to convince the state health agency and the Legislature that North Dakota, with its booming oil towns, needed more addiction treatment options. Parrino of the national association flew out to testify on the industry’s behalf.
The hard part, Stavros said, was convincing Police Chief Olson, Minot’s mayor, and ultimately residents and city council members.
Looking back, Olson said most of his opposition was fear of the unknown. He had heard that methadone clinics attract an unsavory clientele, and that loitering and crime can increase in the surrounding neighborhood. But he said that after checking with Montana police in towns that already had methadone clinics he realized it wasn’t an issue.
Still the city placed a one-year moratorium on opening a methadone clinic shortly after city leaders heard about Stavros’ plans. After leasing a building and hiring staff, the company had to suspend operations until the city decided what to do.
To convince city officials to allow him to open a clinic, Stavros commissioned a poll that showed a majority of residents of Minot and two other North Dakota cities, Bismarck and Mandan, considered drug addiction in their communities a significant problem and supported opening a methadone clinic.
But a majority of Minot council members were not convinced. That’s when the director of the Kalispell clinic told Stavros about Schmaltz. She agreed to speak at a town meeting. She explained to city residents that it’s people who are addicted to heroin that they should be worried about, not people who are taking methadone to stay in recovery.
After she told her story, Stavros said, the room was silent. The council unanimously approved the clinic.
As of this week, Community Medical Services Minot had 30 patients with a goal of reaching 300 in two years, and plans were underway to start another clinic in Fargo, according to Stavros. And a Bismarck treatment center, the Heartview Foundation, has received the city’s permission to add methadone to its treatment options.
Aquatic Exercise for People with Dementia Appears to Refresh Body and Spirit
By Thomas Goldsmith
Two women in their 80s and another in her 70s and walked, jogged and practiced ballet moves recently in a Cary assisted living center’s covered swimming pool.
The women, who have neurocognitive disorders, did their exercises as late autumn sun lit the glass-roofed pool at Woodland Terrace. Sara Broadbent, 76, along with Pat Frew and Sandy Kirkland, both 83, hit the water for benefits that include heart rates that rise during the workout, improved balance, and greater mobility and strength, Woodland Terrace therapy staff said.
In what could be an even more important aspect, the time in the pool was fun for the women.
“This has to do with providing quality of life,” said Michele Cox, assistant activities director at the center. “This doesn’t treat dementia, but there are case studies that show [exercise] does improve cognition if it’s repeated. It elevates mood.”
The women, who are sometimes joined by a male resident, are taking part in an aquatic therapy pilot at Woodland Terrace. There’s no extra charge for the activity, but that could change if it’s adopted for more residents.
The labor-intensive sessions aren’t a simple matter, as the women often require persuasion before donning suits at the center and entering the adjoining pool.
No one is forced to swim if adamantly opposed, but sometimes fear takes hold even at the last minute.
“It’s torture,” Frew said, just before descending the steps of the pool with an aide’s help.
“She doesn’t like the cold,” said Jackie Green, dementia care coordinator at the center.
However, former swimming instructor Frew soon got with the program and enjoyed walking, jogging and performing dance moves in the warm water with Broadbent and Kirkland.
“They feel able to do things,” Green said. “It gives their lives value, because they have a purpose.”
Cox supervised the session and led exercises along with volunteer Allison Bailey, an aquatics instructor and personal trainer.
“They relax, definitely”
“I’ve always loved swimming,” Kirkland said after leaving the pool.
As in the conversation of many people diagnosed with dementia, her thought processes can be hard to follow.
“So many things are going through my head now,” she said.
The water’s buoyancy allows the aquatics participants to build balance and strength without the risk of falling as they exercise.
“They can pick up that knee and open up the hip, which is difficult on land,” Bailey said, lifting her right knee and turning her leg to the side in illustration.
Woodland Terrace is a private-pay facility with a secure unit for people with neurocognitive disorders, such as dementia and Alzheimer’s disease. Providing activities for residents is a requirement for adult care homes under state law, but facilities that serve Medicaid-financed residents have sometimes received sanctions for not meeting that goal.
At Woodland, helping residents enjoy time with friends is key to the program. It’s a break from the stress and anxiety that often accompanies daily life for people with dementia.
“You can’t be real serious when you’re in the pool,” Bailey said. “They relax, definitely, once they get in. They know the pool’s a playful place.”
What’s the evidence?
There’s no cure for Alzheimer’s disease. However, some scientific literature supports the benefits of aquatic exercise for older people, including those with dementia.
The authors of “Watermemories: A Swimming Club for Adults with Dementia” wrote in 2013 in the Journal of Gerontological Nursing:
“Physical exercise not only improves the functional capacity of people with dementia but also has significant effects on other aspects of quality of life such as sleep, appetite, behavioral and psychological symptoms, depression, and falls. Additionally, exercise can improve a person’s overall sense of well-being and positively enhance their sociability.”
Dr. Bruce Becker, a chief advocate of the benefits of aquatic therapy, wrote on the topic in 2009 in PM&R, the peer-reviewed journal of the American Academy of Physical Medicine and Rehabilitation: “Aquatic exercise has been successfully used to improve balance and coordination in older individuals, who face an increased risk of falling.”
Teresa Sawyer, wellness director at Woodland Terrace, has trained with Stacy Lynch, an Arizona therapist whose methods are available at www.inertiatherapy.com
Hospitals Head Steps Away
By Rose Hoban
For hospitals in North Carolina, the end of an era is at hand with the announcement that NC Hospital Association head Bill Pully will be resigning at the end of the year.
Pully, who has lead the hospital association for 17 years is only the third head of the 98-year-old organization. Before that, he was the lobbyist for the NCHA at the General Assembly.
“Bill is a great guy,” said Cody Hand, the organization’s current lead lobbyist. “I learned a lot from Bill and he took a chance on me and I appreciate all he’s done to help me and our clients.”
Hand said Pully set a solid foundation for the work of hospital advocacy in Raleigh.
“We represent, in the aggregate, some of the largest employers in the state,” Hand pointed out. “Without a solid trade association with good leadership our members would have to figure out how to navigate state and federal lawmakers’ various whims and desires while still providing care.”
Pully spent years on the board of the North Carolina Institute of Medicine, where he took some progressive stances, said Pam Silberman, former head of the NCIOM, who now teaches health policy at UNC-Chapel Hill.
Silberman said Pully and the hospital association sometimes took positions that other state hospital associations would not take, such as advocating for increasing the number of people who would become eligible for Medicaid, even if that meant hospitals didn’t get more money for each beneficiary.
“The priority for hospital associations tends to be to make sure they retain good reimbursement from their state Medicaid programs,” she said. “But in North Carolina, Bill was involved in making sure the hospitals fought equally hard to make sure that people weren’t cut off.”
Silberman also praised Pully’s ability to get hospital leaders to think creatively about the future of their institutions.
“He was very forward thinking about quality and creating the North Carolina Quality Center even before that was the thing to do,” she said, referring to an organization that has focused on improving patient safety and improving the quality of care at the state’s hospitals.
“He was forward in thinking about population health issues, not just who was in the hospital but how do we keep people healthy.”
According to a press release issued by the hospital association, Pully will remain as president of the hospital association board while the organization looks for a replacement.
‘Reflections’ Presents Memories, Realities of People with Dementia
By Thomas Goldsmith
At Candlelight Reflections, there’s no shame in shedding tears.
At the event recently by the North Carolina State Fairgrounds waterfall, organizers and volunteers had tissues ready for about 50 people who attended the event in honor of people with dementia and their caregivers.
The hour-long ceremony at sunset closed with people joining a large circle, all naming the people they honored — a spouse who has died, a relative living with the disease or caregivers for a person with neurocognitive disease. The event originated in Raleigh more than 20 years ago and has spread to cities including Asheville and Greenville.
“We wanted to have something to remember those who are living with Alzheimer’s and those that we have lost,” said Alice Watkins, former executive director of Alzheimer’s North Carolina. “It’s really a special time to get together and remember.”
According to a March report by the NC Institute of Medicine, about 160,000 people in the state have Alzheimer’s disease. That number is expected to reach 210,000 during the next nine years.
“We send our support to anyone who is touched by any kind of dementia,” Alzheimer’s North Carolina program director Lisa Levine said as she opened the event.
Violinist Karen Hall, of West Jefferson, played classical pieces as people gathered for the ceremony, and a keening “Over the Rainbow” as the circle formed. Former Triangle resident Hall is a caregiver for her mother, Joan Hall, who lived in Michigan when her condition was diagnosed.
Recently, Joan Hall entered a nearby assisted-living facility, a frequent destination for people whose disease has progressed beyond family members’ ability to provide primary care. Karen Hall remains a caregiver even though Joan is in long-term care.
“I took her to the mountains,” Karen Hall said. “She thinks she’s back in Michigan.”
She said making sure the facility is doing a good job is a task of its own.
During the first part of the event, relatives read poems and other memorials revealing the clamor of emotions that arise as a loved one loses her memories, becoming in effect a different person.
“This is not my home. Nothing here is familiar or reassuring,” Cary resident Jo Ann Pfirman read from the poem “Remember Me,” written from the perspective of a person with neurocognitive disease. “If I could go home, I would surely find my memory there.”
Pfirman’s husband, Tom, was diagnosed with Alzheimer’s disease in 2002 when he was 57; he died in 2007. The family has raised $120,000 for Alzheimer’s NC through the effort Tom’s Team, in which he participated for two years.
“I’ve been coming for 11 years,” Jo Ann Pfirman said of Candlelight Reflections. “Now I volunteer.”
Gary Fuqua was working as a state official when his mother, Doris, of Carthage, was diagnosed with Alzheimer’s disease. She was able to to remain in her home with the help of caregivers during the week.
“For five years, every Friday afternoon, I’d drive down and stay with her during the weekend,” Fuqua said.
The small crowd of people, many known to each other through years of dealing with this disease, dispersed in the growing dark after Candlelight Reflections, some to resume care of loved ones, some returning home only to memories.
Violinist Karen Hall, of West Jefferson, played classical pieces as people gathered for the ceremony, and “Over the Rainbow” as the circle formed.
Hall is also a caregiver for her mother, Joan Hall. Video credit: Thomas Goldsmith
What the Election Could Mean for Older North Carolinians
By Thomas Goldsmith
A new president in Washington and new governor in North Carolina — either incumbent Pat McCrory or preliminary general election winner Roy Cooper — will have plenty of public policy issues to address that affect older North Carolinians.
However, answers are yet elusive about specific steps President-elect Donald Trump will take at the national level, or how a new North Carolina governor will approach issues such as community-based care and the situation of people who are eligible for both Medicare and Medicaid.
“Certainly, if one looks at the data, Medicare would be an issue, just like Social Security would be an issue, that demands attention,” said Robert Clark, professor of economics and management, innovation and entrepreneurship at North Carolina State University.
With Republicans in charge in the White House, the U.S. Congress and potentially the U.S. Supreme Court, Clark said, there could be an opportunity for the federal government to make changes in the massive programs that help support the health and well-being of millions of older Americans.
Trump has called for maintaining Social Security and Medicare at present levels, but both programs face projected shortfalls especially as Baby Boomers age. Trump’s policy statements suggest reductions in Medicare fraud and waste, required price transparency from all health care providers, and the chance for consumers to buy “safe, reliable and cheap” drugs from overseas.
“While Trump vowed throughout his campaign to leave Social Security and Medicare untouched, congressional Republicans have targeted both programs and it is not clear whether the new president would resist their efforts to cut benefits,” Howard Gleckman, a resident fellow at The Urban Institute, wrote in Fortune this week.
Bill Lamb, executive director of Raleigh-based Friends of Residents in Long Term Care, said President Barack Obama and his predecessors had made a habit of delaying action on Social Security and Medicare.
“Everyone so far has been kicking that ball down the road and that ‘down the road’ is now,” Lamb said. “You only have two ways to fix it: You’ll have more money coming in or less money going out. You either have to raise taxes on somebody or you’re going to have to hose someone.”
Social Security changes mulled
Cuts in overall spending on Social Security could involve either limiting existing benefits or continued upward movement of the eligibility age. Candidate Hillary Clinton suggested lifting the cap on the amount of income on which earners have to pay Social Security tax, set at $118,500 for 2016.
A Pew Research Center report on Tuesday’s election found 53 percent of older voters preferred businessman Trump, while 45 percent chose former Secretary of State Clinton, a Democrat.
Check out our other stories on the implications of the election on NC health issues:
At the state level, changes in Medicaid could also affect older residents, as many are dual eligibles who qualify for both Medicaid, which covers health care costs for low-income and disabled people, and for Medicare, health coverage for people 65 and older.
A state advisory committee on dual eligibles will meet Thursday at the McKimmon Center at N.C. State University to continue its work to determine how this population should be covered under North Carolina’s proposed Medicaid reform plan. (The term “dual eligible” is used in other contexts to describe people who require treatment for both mental illness and substance abuse.)
North Carolina is waiting for a federal response to its application to convert the state’s Medicaid services from a fee-for-service to a managed-care approach.
“It doesn’t matter”
If Cooper emerges as governor when the vote is certified late this month, the Democrat will be able to replace department heads and division leaders throughout state government, including health and human services agencies crucial to services for older people. He would also propose a state budget, although the GOP-led state legislature is under no obligation to adopt it.
“Because Democrats didn’t pick up any seats in the house, it doesn’t matter who’s governor,” Lamb said. “They’ll do some face-saving, lip-service kind of stuff. It’s going to be anti-regulatory.”
The state Coalition on Aging, which represents 45 North Carolina groups, will be pushing for issues including increased spending on programs that allow older people to remain at home longer, such as adult day care and community-based care, said Mary Bethel, president of the coalition.
“I think advocates for aging people want to make sure there’s a robust continuum of care,” Bethel said.
How Teletherapy Addresses Mental Health Needs
By Jon Frandsen
An acute need for more and easier access to mental health treatment and improvements in communications technology have set off a boom in remote therapy, but strict licensing rules and varying state laws are hampering its growth.
Like telehealth in general, using videoconferencing, smartphones and other technology to treat mental illness has long been recognized as an invaluable tool for getting care to people in rural areas, where shortages of psychiatrists, psychologists and other providers are even more acute than in the rest of the nation.
Now, telemental therapy — also called virtual therapy, telepsychiatry or telebehavioral health — is more widely available outside of rural areas and is seen as a way to address two crises that aggravate each other.
First is a growing mental health crisis, made worse by the opioid epidemic and the urgent need for drug addiction treatment programs and counselors. Secondly, the U.S. is suffering a shortage of mental health providers, so people who do seek treatment can wait weeks or months for an office visit or be unable to find suitable, affordable care at all.
The result: About one in five American adults experience mental health problems each year but less than half of them receive treatment.
Telemental health services, using secure video hookups and high-definition cameras, make it possible for patients to get help without seeing a therapist in person. And the technology allows providers in areas with lower demand to treat patients in areas with higher demand.
“We tend to think about rural areas” when discussing telemental health care, said René Quashie, a health care and life sciences attorney with Washington law firm Epstein Becker & Green. “But we have trouble in metropolitan areas and the suburbs, too, and virtual care is a way to bring expertise to underserved areas and populations.
“I see nothing but growth in this area,” Quashie said. “We are light-years ahead of where we were just five years ago.”
Medicare and Medicaid, the federal health programs for the elderly and the poor, reimburse providers for many telemental health services, and they have been a driving force in that growth. The programs account for more than a third of national spending on health care and their decisions have tremendous influence on health policy and the health care industry.
An Early Push
Many state governments are turning to teletherapy to reach more people and to cut treatment costs.
South Carolina was a pacesetter, launching teletherapy efforts in 2007 to address one of the most nagging problems caused by the shortage of mental health treatment: The enormous strains placed on hospital emergency rooms by people with behavioral health issues who are unable to find help elsewhere. They often end up stuck in ERs for hours or even days.
With the help of nearly $8 million from the nonprofit Duke Endowment, largely to purchase equipment, South Carolina created a telepsychiatry network staffed by psychiatrists from within the state to serve ERs in hospitals that had few mental health providers and facilities.
The South Carolina Department of Mental Health now has telepsychiatry units in 24 ERs across the state that can connect with network providers 16 hours a day, seven days a week. The network treats an average of 400 patients a month, said Ed Spencer, the head of the state’s telepsychiatry program. As of October, the network had treated more than 30,000 patients.
Costly wait times for patients to be assessed and treated, which could be two to three days on weekends, have been reduced to an average of less than eight and a half hours, Spencer said. And the network is seen as a model approach for improving and lowering the cost of treating mentally ill patients in ERs.
Building on the ERs’ success, South Carolina expanded its network of teletherapy providers to 60 public mental health centers and satellite offices statewide.
The Duke Endowment helped North Carolina, a far larger state, set up a similar pilot program in 2010. In 2013 the state decided to expand the program statewide through 2017.
Licensing and Reimbursement
Companies that offer health insurance and private insurance networks are embracing telemental health as well.
The National Business Group on Health, a Washington nonprofit that represents large businesses on health policy issues, found in its annual survey that teletherapy was being offered by 34 percent of large employers. And in its most recent survey, BenefitsPro, a benefits industry newsletter, found that half of businesses of all sizes want to offer telebehavioral health services.
But practitioners, mental health experts, companies trying to build telemedicine and telemental health networks, and companies who want to offer teletherapy say their efforts are being slowed by state laws that can make it difficult to practice teletherapy across state lines.
The biggest barrier, perhaps, is licensing. States generally require that doctors be licensed in the same state as the patient they are treating. That could mean a mental health care provider would have to have multiple licenses to treat patients across state lines.
“It is a substantial financial and operational burden on telemedicine practices that provide services in multiple states,” said Dr. Talbot McCormick, CEO of Eagle Hospital Physicians, an Atlanta company that offers telehealth and telemental health services to hospitals.
To make sure Eagle has enough providers who can legally treat patients, the company has full-time staff focused just on licensing and related paperwork, and often pays for providers’ licensing costs to encourage their participation.
Some states work out license reciprocity arrangements, especially with neighboring states. New Jersey, which generally lags behind most of the rest of the country in updating its laws to address telemedicine, passed a law in 2014 that allows for reciprocity as long as the other state license is in line with New Jersey’s license requirements.
State compacts that make one license acceptable among all the member states are another solution backed by telehealth providers. Some critics, however, argue that the compacts give too much power to medical and other professional boards, which can make regulations more restrictive, not less.
Seventeen states have signed on to such a compact covering doctors, including psychiatrists. But compacts covering other types of mental health practitioners such as psychologists, family therapists and therapeutic social workers are still being drawn up.
State laws on how private insurance should pay telemental health providers — if at all, because some insurers still don’t recognize telemental health treatment — also vary widely. Providers have been pushing for reimbursement parity laws that ensure payment at or near what they would receive for in-person visits.
Thirty-two states and Washington, D.C., have parity laws in place now or have enacted ones that will take effect next year. Twenty-three of those and the District of Columbia require that payments to teletherapy providers be equal to what they receive for in-office treatment, according to the National Conference of State Legislatures. The remaining nine allow for somewhat lower payments that account for savings through reduced overhead and other factors.
Providers generally have pushed hard for parity laws, arguing that the promise of telehealth will never be delivered on if doctors and others are not sufficiently reimbursed. Others, however, say parity laws will blunt one of the chief benefits derived from telehealth, cutting costs.
Varying State Rules
Well beyond licensing and reimbursement, many state rules on telemental health also vary.
Some states have made aggressive efforts to update laws governing mental health and to spell out complete rules. Others have very loose standards, if any. New Jersey, for example, has no comprehensive law on telehealth, although a proposal is moving through the New Jersey Legislature.
Each state even has its own definition of telemental health, says Quashie and fellow Epstein Becker & Green attorney Amy Lerman, who together conducted a 50-state survey of state laws and regulations governing teletherapy.
Lerman pointed to Massachusetts, a state that through its licensing boards has very detailed rules governing teletherapy for each of the different types of providers, including psychiatrists, psychologists and social workers. Michigan, on the other hand, has no teletherapy rules specific to each class of provider.
Twenty-nine states have rules requiring informed consent of teletherapy patients, but they vary, too. Some allow verbal consent while others require it in writing.
Some states give psychiatrists wide latitude for prescribing drugs through teletherapy while some do not let them prescribe controlled substances. Some don’t allow for prescriptions through teletherapy at all.
States also differ considerably on what rules a psychiatrist or psychologist must follow when beginning teletherapy with a new client.
Florida has no restrictions on telepsychologists. But Delaware spells out a very detailed approach that requires them to run a risk-benefit analysis before proceeding, the Epstein survey said.
Officials Eye Water Quality As Floods Recede
By Kirk Ross
Floodwaters are starting to recede upstream along the Tar, Pamlico, Cape Fear and Neuse rivers, but an increasingly contaminated flow of freshwater is headed downriver, eastward to the coast.
The short-term prospects don’t look good for those ready for their first taste of local oysters this season.
Throughout the river basins, sounds and tidal areas of Eastern North Carolina researchers, environmental advocates and an array of state agencies are gearing up testing to get an idea of what effects the floodwaters are likely to have.
The template for anticipating Matthew’s continuing effects has been 1999’s Hurricane Floyd. And like the aftermath of that disaster, much of the concern right now is what happens to Pamlico Sound, the nation’s second largest estuary.
Ben Peierls, a researcher with the University of North Carolina’s Institute of Marine Sciences in Morehead City, said teams from the institute began sampling the Neuse River on Monday, looking for a range of effects.
He said researchers will be sampling for dissolved oxygen chlorophyll and measuring the amount of organic matter in the river. For now, he said, the sheer amount of moving water will probably reduce some of the possible effects.
“With Matthew, as in Floyd, there’s a lot of water coming down. It probably contains a good amount of nutrients as it washes through the watershed, but at the same time you can get a dilution effect,” Peierls said. “The more you wash out, the less that’s in there, so the concentrations aren’t always as extreme as they might be. But you’re still bringing a lot of water and a lot of particulate matter with that water.”
With heavy water flow, he said, the effects of additional nitrogen, which could lead to algae blooms, might not be as great. “If you have a lot of water moving through the system there’s not time for biomass to accumulate.”
How the surge of freshwater flowing down the Neuse will influence the estuary is also a focus, Peierls said. A major concern is stratification, in which a top layer of freshwater reduces the amount of dissolved oxygen in the saltier waters below. That can put stress on fish and potentially lead to fish kills.
“If the freshwater becomes more of a lens on top, and we get salty water underneath and the temperatures are high enough, that generally is a recipe for oxygen decline,” Peierls said.
Flying the rivers, planning for tests
Cape Fear Watch Riverkeeper Kemp Burdette is part of a group of North Carolina riverkeepers who have spent more time reviewing the effects of Hurricane Matthew from the air than from the water.
Riverkeepers and environmental advocates took to the skies shortly after Matthew cleared the coast, keeping an eye on hog waste lagoons and other potential sources of significant contamination.
In an interview Tuesday, Burdette said that although he hasn’t seen any breaches, there were several waste lagoons in the Black River and Northeast Cape Fear River watersheds that were surrounded by floodwaters.
“I saw lots of lagoons that were totally surrounded by water and there appeared to be just inches between the tops of the berms and the floodwaters,” he said.
Inundated lagoons have been spotted by riverkeepers in the Tar, Neuse and Cape Fear river basins. State agriculture officials estimated late last week that at least 11 waste lagoons had been flooded.
Burdette said the flights he’s made over southeastern North Carolina revealed just how widespread the flooding was, as well as the effects. He said that in addition to seeing flooded barns and fields, it was easy to spot petroleum slicks atop the water.
“When I was flying, the landscape was so flooded,” he said. “You could see something flowing into the water out of barns or from other sites, but you couldn’t get an idea of what it was or how much.”
Plans for testing for contaminants and the effects of Matthew have started, Burdette said, but for now the waters are too high to get an accurate sample.
“We’ve been waiting for the water to get down to a point where it is reasonable to start testing,” Burdette said. “It’s just everywhere right now.”
Another major concern is the disposal of massive numbers of livestock that died in the flooding. According to early estimates by the state, more than 2 million chickens and turkeys and several thousand hogs have been killed so far.
Oyster harvest delayed
Oyster season opened as announced on Oct. 15, but the harvest is halted at nearly every spot on the North Carolina coast.
That would have been certain given just the heavy rains the storm dumped on the coast and more than 100 miles inland, but with the prospect of a lot of nutrients flowing downstream, the state is stepping up testing as it reviews when it’s safe to reopen the oyster beds.
Shannon Jenkins, Shellfish Sanitation and Water Quality section chief for the North Carolina Division of Marine Fisheries, said four water-testing teams are working along the coast to determine whether beds can be opened.
Jenkins said some portions of Pamlico, Core, Back and Bogue sounds are open, but the most productive areas are not.
“Effectively, most productive oyster areas are closed due to the rainfall and coastal flooding,” he said.
Most were closed early because of the amount of rainfall, which in some areas reached 15 inches in less than a day.
Jenkins said given the stretch of dry weather, he expected areas to begin to open up soon. Harvesting areas where water tends to move faster, such as near inlets and in faster flowing rivers, are likely to be first to open, he said.
“Some water bodies and watersheds are quicker to return to normal,” Jenkins said. As an example, he said, a faster-moving river, such as the New River, is likely to return to satisfactory status sooner than the slower-flowing Newport River.
Crews began sampling in Brunswick County on Monday and were working Down East beds in Carteret County on Tuesday.
Jenkins said if the weather holds he expects most areas to be open by the start of the mechanical harvest period in mid-November.
This story originally appeared Coastal Review Online and is shared through a content-sharing agreement with N.C. Health News.
Medicare Suspends “Seamless Conversion” Practice, Allows For Re-enrollment
By Thomas Goldsmith
The Centers for Medicare and Medicaid Services is backing away from a controversial “seamless conversion” policy, temporarily suspending the practice for new applications from insurance companies and allowing those enrolled under it to re-enroll in other plans including traditional Medicare.
Under seamless conversion, an insurance company has been allowed to notify a beneficiary approaching 65 that the person had been automatically enrolled in a company’s private “Medicare Advantage” plan instead of traditional Medicare. The person who was notified — often as part of countless mailings from Medicare-related providers — had to take an active step to opt out of the Medicare Advantage coverage.
Advocates for older people and Medicare beneficiaries had spoken out against the practice on the basis that recipients could unknowingly be enrolled in plans that offered them less advantageous coverage than traditional Medicare. Medicare Advantage plans work well for some recipients, but people signing up for Medicare are advised to look closely at how well any plan meets individual needs before enrollment.
“If an individual wishes to select another Medicare health or drug plan, that enrollment will supersede the seamless conversion,” when the beneficiary makes the change before the end of the enrollment period, CMS wrote in policy guidelines issued Friday.
“Individuals who wish to enroll in Original Medicare need to contact the Medicare Advantage organization prior to the Medicare advantage coverage effective date to opt-out of the proposed enrollment.”
More than 15,000 people nationally have been enrolled in plans using this type of conversion, a CMS spokesman said Friday when announcing that the practice was being suspended. No North Carolina plan had opted to take part as of Friday. A CMS spokesman said by email this week the agency does not know the number of those who were enrolled through seamless conversion.
Companies that have already gotten approval to use seamless conversion may continue the practice, but CMS is planning more robust consumer education.
“CMS continues to look for ways to improve the seamless enrollment process and to ensure that automatic enrollment into the Medicare Advantage plan is line with the beneficiary’s wishes and is not the result of a lack of understanding on the part of the beneficiary of the need to deliberately decline the Medicare Advantage enrollment if it is not desired,” the agency spokesman said.
In addition, the spokesman wrote, CMS will soon release clarifying information about seamless conversion, including administrative steps to make sure that those already enrolled under it are properly protected.
Know your options
The Medicare enrollment period is underway. North Carolinians faced with a bewildering choice of options on basic, supplemental and prescription drug insurance can consult the free Seniors’ Health Insurance Information Program for individualized guidance.
Call: 855-408-1212 (toll-free)
Clarification: An earlier version of this story neglected to say the suspension was temporary and applied only to companies making new proposals to use seamless conversion.
Two New NC Counties Take on Paid Parental Leave
Durham adopts the policy, Wake considers adding six to eight weeks of paid leave for county employees.
By Thomas Goldsmith
Parents who work for Wake County government would be eligible for six weeks of paid parental leave under a policy presented Monday to the Wake County Board of Commissioners.
Following Durham County’s move earlier this month to offer employees 12 weeks of leave and Greensboro’s vote in August to offer six weeks, Wake becomes the third local government in North Carolina to move toward paying parents who take leave following the birth of a child.
Research published in 2011 found reduced infant mortality in families with paid maternal leave, and research by the Institute for Women’s Policy Research has found better breastfeeding rates in mothers on leave, higher vaccination rates in families where leave is an option and fewer illnesses in the babies of moms on paid leave.
The trend toward paid leave for new mothers and fathers is a national one, given President Barack Obama’s direction to federal agencies in February to allow workers six weeks of paid leave to look after a new child or ailing family member.
Wake County benefits manager Ashley Lategan rolled out the idea for Wake commissioners during a work session, with a vote likely to take place Nov. 7. Members had questions about the details, which included a provision that gives parents eight weeks of paid leave when a child is born with complications or via Caesarean procedure.
“I think this is great,” said board member Sig Hutchinson. “I do like the six weeks, with eight for the Caesarian. Should we be progressive and forward thinking and just go with eight weeks?”
That question was not resolved in the work session. Members learned that the policy would also cover employees who adopt children, welcome a foster child, or take on guardianship for someone.
Said outgoing board member Caroline Sullivan: “We’ve got to have it.”
Johnna Rogers, deputy Wake County manager, said the program, designed to start Jan. 1 if approved, would not create a shortfall in the budget, because the affected workers’ salaries are already included in planning. Lategan said the program was a good choice because it serves as a means for recruiting, promotes employee retention, and adds to current benefits.
“It’s really no additional budgetary impact, because we had to cover when people were out,” Rogers said.
The work usually done by workers on paid parental leave could be absorbed by other workers or carried out by workers on overtime, officials said.
Another study by the Institute for Women’s Policy Research report also said that the policy has real benefits to municipal employers as well as employees. The think tank report was sponsored by the U.S. Department of Labor Women’s Bureau.
“Research shows that paid leave increases the likelihood that workers will return to work after childbirth, improves employee morale, has no or positive effects on workplace productivity, reduces costs to employers through improved employee retention, and improves family incomes,” the 2014 report said.
Durham County commissioners acknowledged the policy at an Oct. 4 work session. It was described as a “policy to provide for approved time off with pay for the birth of an employee’s own child or the placement of a child with the employee in connection with adoption, foster care or in loco parentis.”
“I think the paid parental leave is a very important step for our county to take,” Durham County Commissioner Ellen W. Reckow said. “It will in fact make us family-friendly.”
Reckhow cited studies that have shown that paid parental leave leads to better productivity and more loyalty to an organization.
Paid parental leave: What is it?
A presentation to Wake County Commissioners on Monday defined paid parental leave as:
“The period of time in which an employee may receive paid leave for parental care of a newborn, a child placed for adoption, foster care, or guardianship within one year of the qualifying life event.
“Such leave would be in addition to any annual leave, sick leave or other leave provided by Wake County.”
National Partnership for Women and Families
Increase in Youth Suicide Prompts Some States to Act
By MIchael Ollove
When J.D. Goates was 17 and newly graduated from high school, he decided that he had had enough.
His thoughts of suicide, which had begun when he was eight, had become stronger. He was ashamed of being bisexual, especially because his Mormon church told him that homosexuality was abhorrent. His classmates and even his teachers in northern Utah heaped scorn on people like him. When he came out to people he thought were his friends, he was crushed by the hostility of some of them. With both his parents away on business trips, he tried to take his life.
“I thought, ‘If I’m going through this hell now is there a greater reason for all of this?’ ” Goates said. “And I came to the decision that there wasn’t.”
Goates’ suicide attempt failed, and now he is a 23-year-old senior at Brigham Young University. But many young people in Utah and across the country haven’t survived.
Between 2006 and 2014, the suicide rate among Americans 19 and under rose from 2.18 to 2.75 per 100,000 people. At least 36 states have experienced an increase, but the problem is especially dire in Utah, where the suicide rate rose from 2.87 to 6.83 during that period.
Among the possible causes cited by suicide experts is a decline in the use of psychiatric medicines and the rise of cyberbullying. Whatever the reasons, a number of states, over the last five years, have adopted measures to try to reverse the trend.
In Texas, for example, a 2015 law requires the state health department to identify and publicize the best practices used in all states for suicide prevention. All public school teachers, counselors and principals in the state must receive training in how to recognize and address signs of suicide risk in students, and schools must notify parents if there’s a concern their child might be at risk for suicide.
New York established an office to coordinate all state suicide prevention activities. The state also provides extensive training for teachers and staff, as well as student peer groups, in how to identify children who seem to be in distress and direct them to adults who can connect them to mental health services. This month, Wyoming established a statewide crisis text line for residents considering taking their own lives, especially teens.
And most states now deploy suicide response teams to schools where a student has committed suicide. Research has shown that publicity surrounding a suicide can prompt others, particularly young people, to take their own lives.
“You have to do everything to prevent contagion,” said Greg Hudnall, who created a program that trains Utah students to recognize classmates who seem isolated or depressed and direct them to help or tip off counselors or teachers.
It’s one of several steps Utah has taken since 2012 to try to stem the tragedies, including mandatory suicide prevention training for teachers and parents and similar outreach to pediatricians, coaches and others who interact with young people.
“For Utah, more has happened on the suicide prevention front in the last three years than in the 20 years before that,” said Doug Gray, a psychiatrist at the University of Utah who has studied suicide for more than two decades.
While the numbers continue to rise, Gray and others believe the prevention efforts are making a difference. But some suicide experts and advocates for children believe certain factors in Utah forestall more effective youth suicide prevention efforts.
The state has few restrictions on gun ownership, which suicide experts link to higher rates of suicide, and it has resisted expanding Medicaid eligibility, which critics say would make mental health services more available to those at risk for suicide. Utah also restricts discussion of homosexuality in the classrooms, which gay rights advocates argue further stigmatizes gay students, who are already more vulnerable to suicidal impulses.
Looking for Answers
Youth suicide declined in the 1990s, which many suicide researchers attribute to the growing use of antidepressants. But that trend came to an abrupt end in the mid-2000s, when the youth suicide rate began its upward trajectory.
Suicide rates are much higher among older Americans than they are among teens: For every 100,000 people, in 2014, there were 19.4 suicides among 40- to 59-year-olds, compared to 2.75 among those 19 and younger.
Some suicide experts, like Gray, associate the rise with the U.S. Food and Drug Administration’s warnings, starting in 2003, that the use of antidepressants may increase the risk of suicide in teens and adolescents.
The warning, Gray said, persuaded many pediatricians and family practitioners to stop prescribing the drugs to their young patients with depression. Some studies have linked higher rates of teen suicide to the decreased prescribing of antidepressants.
There may be other factors at work in Utah. Studies have found higher suicide rates in areas with low population, where people are more likely to be depressed and mental health services may be less accessible. Utah public schools are barred by law from “advocating homosexuality,” which, critics say, discourages any candid conversation on the subject.
Those “laws exacerbate the stigma that LGBTQ students experience,” said Troy Williams, executive director of Utah Equality, a gay rights organization.
The state does not track suicides by sexual orientation. Like all states, Utah periodically asks students whether they have considered suicide or made attempts, as well as if they take drugs, use alcohol, smoke cigarettes or are sexually active. Starting next year, those surveys will include questions about sexual orientation.
Some child and gay rights advocates say the Mormon church, which dominates the state’s culture, and its doctrinal objection to homosexuality, cause deep distress to young gay people, like Goates, who see themselves as outcasts who will fail to live up to the ideals of their church of marrying and having large families.
“The church is essentially telling gay youngsters, you are outsiders and will always be outsiders,” said Terry Haven, deputy director of Voices for Utah Children, a child advocacy nonprofit. “Of course there will be consequences from that message.”
A spokeswoman for the church, Kristen Howey, declined to address the question of whether the church’s views on homosexuality contribute to the greater suicide risk among LGBTQ youth. But she called suicide “tragic, no matter the explanation or circumstances.”
“We are concerned about the physical, emotional and mental challenges our members face, and the church is actively pursuing ways to help, including online resources and local leader training,” Howey said. “We invite youth, parents, friends and church leaders to take action to become informed on this subject, and we encourage communities to continue to partner on prevention and intervention.”
But the Mormon church has not become less tolerant of homosexuality in recent years and none of the other explanations account for the steep increase in youth suicides in Utah since 2006. State officials admit they are confounded.
The best guess, state officials say, is an increase in cyberbullying and increased computer screen time, which some suicide experts hypothesize is either a symptom of increased isolation or a cause of it.
Andrea Hood, the state health department’s suicide coordinator, said police officers stop investigating once they determine the cause of death was suicide, without delving into the psychological factors behind it.
To fill that gap, Republican state Rep. Steve Eliason said he would propose creating a position in the state medical examiner’s office to perform what he called “psychological autopsies” on suicide victims.
A suicide by a middle school student near his home spurred Eliason to champion most of the youth suicide prevention legislation in Utah in the last half decade. Some of the measures — like having a statewide suicide prevention office to disseminate information on best practices — were imported from other states. Others originated in Utah and have drawn interest elsewhere.
This year Utah passed legislation requiring all teachers and licensed school staff to take a suicide prevention course as part of their recertification. High schools are required to offer parents training on suicide prevention. And every high school and middle school was given $500 to create suicide prevention programs, which 130 used to create Hudnall’s “Hope Squads.”
Hudnall, a former Provo school administrator, said that he has done or will do training to put the student program into schools in numerous other states, including Alaska, Colorado, North Carolina Oklahoma, Texas and Wyoming.
The Utah Legislature also created positions for three full-time suicide prevention coordinators, one each in the departments of Education and of Health and Human Services, and a third in the state’s Division of Substance Abuse and Mental Health.
Earlier this year, the state also started to roll out a smartphone app that enables students to send text messages about bullying, threats and violence they have witnessed, to text with a counselor and to be directed to help. Eliason said that by mid-September this school year, the app had recorded 3,000 student contacts and led to interventions in the cases of six children who seemed to be close to attempting suicide. He said that other states have contacted him about obtaining the app.
Eliason is also planning to introduce legislation to establish a new three-digit emergency telephone line, manned by mental health crisis counselors, for anyone on the verge of a suicide attempt.
As much as Utah has done, Eliason acknowledges it is not enough. The state spends about $600,000 a year on its suicide prevention efforts. “It’s an extremely small down payment on a problem that needs to have a much larger appropriation,” he said.