Noteworthy News Articles on Mental Health Topics, December 26-31, 2000

New Jersey Moving to Restrict Locations of Heroin Treatment Clinics
Associated Press, 12/26/2000

RIO GRANDE, N.J. (AP) A feud between two doctors in this section of Middle Township has sparked a statewide debate over the location of methadone clinics. Dr. James Walsh operates his podiatric clinic in a building that also houses the offices of Dr. James J. Manlandro, who specializes in drug treatment. Since Manlandro moved in a year and a half ago, Walsh has complained about the drug clinic and the traffic it brings to the working class neighborhood with a school bus stop. For three hours each morning, Manlandro's Family Addiction Treatment Services dispenses the reddish-brown tonic that helps heroin users break their addictions. The drug is closely controlled and is not available in several states. Department of Health officials said the 27 state-licensed methadone clinics in New Jersey, 16 of which are funded by the state, treat about 9,800 patients a year.
    The state Assembly is considering a law that would reclassify for zoning purposes the clinics that distribute methadone. The clinics would have to be placed in areas designated for businesses and could not be considered part of doctors' offices. The Assembly bill is likely to come up for a vote next month. The state Senate has already passed an identical bill. The bill would affect only new clinics not Manlandro's or any other existing ones.
    Walsh is fighting his neighbor in the courts as well. He's filed a lawsuit in state Superior Court seeking to overturn the local zoning decision to allow the methadone clinic. Neither Walsh nor Manlandro was available for comment Tuesday. But Ronald LaMorgese, who serves about 700 addicts at the methadone clinics he runs in West New York and Irvington, said he sees both sides of the argument. He said he ran into opposition both times he opened clinics. He said a court ruled in 1983 that methadone clinics should be allowed in the same zones as doctor's offices. ''I think it just makes it quite a bit harder to get a foothold in an area that needs a clinic,'' LaMorgese said. ''The old concept is: We need them, just not in our town.'' But LaMorgese said it's probably not a good idea for a methadone clinic to locate in the same building as another business. ''They're not the best of clients,'' he said.
    Assemblyman Nicholas Asselta, R-Cumberland, is one of the sponsors of the bill now working its way through the Legislature. He would rather see the clinics in county complexes or hospitals. He said those places are usually accessible by public transit and have better security than areas like the one in Rio Grande where Manlandro is set up. Twice this year, police have charged suspects arrested near that clinic with heroin possession. Opponents of the clinic believe that's a reason it should be moved. Manlandro told The Press of Atlantic City in Tuesday's editions that police have singled out his clinic because of public opposition to it. He said there is probably no more drug activity near his clinic than there is elsewhere in Cape May County. Meanwhile, a state Department of Health official is trying to find a new site for Manlandro's clinic. Middle Township Mayor Charles Leusner said that isn't enough. ''If there is a death or injury in that neighborhood, then I'm going to hold (state officials) personally accountable,'' he told The Press.

Akron Seeks Justice in Treatment of Mentally Ill
Associated Press, 12/26/2000

AKRON, Ohio (AP) The city is opening the state's first mental health court, seeking to dole out more treatment than punishment to the mentally ill.  As of Jan. 2, defendants with a documented history of mental illness may forgo contesting charges against them in favor of entering a two-year treatment program. The charges would be dropped upon program completion.  ''Jail is not meant to be a treatment setting and is not the ideal place for the mentally ill,'' said Dr. Mark Munetz, a psychiatrist with the Alcohol, Drug Addiction and Mental Health Services board.
    A 1998 federal study showed about 16 percent of inmates are mentally ill. In Summit County, where Akron is located, about 9 percent of mentally ill individuals end up in jail, Munetz said.  The program is aimed at people repeatedly arrested for minor crimes while not taking their prescribed medications. Participants will be monitored by a probation officer and will be required to appear regularly before a judge.   Advocates say the $300,000 cost to start the court is a worthwhile investment.   ''This will move mentally people out of jail more quickly and reduce costs throughout the system with a more appropriate treatment,'' Judge Elinore Marsh Stormer said.

Maryland Police Are Trained to Respond Better to Mentally Ill
Phuong Ly, Washington Post- 12/27/2000

Sgt. Ron Smith's first task was to buy a newspaper, get his change in nickels and ask the clerk her name. Easy enough, usually. But this day, screaming voices filled his head, channeled through a headset he was required to wear. And when he started talking, the 7-Eleven employee stepped away from him, wondering about his requests. Other Montgomery County officers -- all with voices screaming in their ears -- tackled other tasks. Two read a story and then answered questions; another pair slowly composed geometric shapes with toothpicks. One officer recited a list of words, hesitating a little as he spoke. "Here's a situation where you can't blend in," Smith said later, with the earphones off. "You're a public spectacle."
    The exercises were part of a revolutionary training course for Montgomery police officers that simulates the everyday reality of many of the mentally ill. The goal is to teach police how to better handle emergency calls involving mentally ill citizens and reduce the use of deadly force. Such training is being considered by law enforcement agencies across the country, as police increasingly are the first to respond to mentally ill people in crisis. Montgomery is the first police department in the Washington area and one of a small number nationwide to offer a weeklong course and create a group of trained officers, called the crisis intervention team, that will handle the calls. The course introduces officers to mental health service providers such as the county crisis center, reviews basic symptoms of illnesses and teaches negotiation techniques. It also includes a visit with patients at Springfield Hospital Center in Sykesville, who critiqued the police techniques. Smith said that by teaching officers to have more empathy for the mentally ill, the training could help prevent barricade or hostage-taking situations in which the SWAT team is called. "You might be able to divert someone before it gets to that point," he said.
    As many as 20 percent of the people held in the Rockville detention center are mentally ill, according to jail officials. Nearly every day, the police media office sends out a public appeal for help locating a mentally ill person who has left home. Surveys by national mental health advocates indicate that as many as 10 percent of police calls involve a person with a mental disorder. Most police officers, however, receive only a few hours of training on how to deal with people who may be suicidal or violent as a result of depression, schizophrenia or other disorders.
    Esther Kaleko-Kravitz, executive director of the local chapter of the National Alliance for the Mentally Ill, said the extra training is overdue. She said she and her staff know of incidents in which police officers have taken into custody mentally ill people who were not allowed to get their medication. She said officers often have used more force than needed, expressed disdain for the mentally ill and called them names. The program "allows people with mental illness to be handled by people who are more informed and aware," she said. "They need to have people who do not have a stigma about mental illness."
    Montgomery's training is modeled on an award-winning program of the Memphis police. The Memphis initiative was prompted in 1988, when police shot and killed a man wielding a knife who had a history of mental illness and substance abuse. The shooting was decried by community activists, who said it was preventable. Since Memphis began its program, its SWAT team has been called to fewer assignments, because officers specially trained to deal with the mentally ill have been able to defuse situations, according to an article this year in the Journal of the American Academy of Psychiatry and the Law. Before the crisis training program began, the SWAT team was called in for about 42 of every 1,000 incidents. Four years after the program began, SWAT calls had been reduced by more than half, to about 19 out of every 1,000 incidents. The program also has reduced the rate of officer injuries, according to the article by Randolph Dupont, a University of Tennessee psychologist, and Lt. Sam Cochran, of the Memphis police. And out of 100 randomly selected calls, an average of two mentally ill people were arrested, compared with a national average of 20 percent, the article stated. Cochran credited the success not just to training, but also to the relationship between police and mental health advocates. "You need something more than generic training," he said. "You literally need to change attitude and behavior." The program has been copied in seven cities, including San Jose, Seattle and Albuquerque, and plans for programs are underway in other places, such as Orlando and Salt Lake City.
    Montgomery Police Chief Charles A. Moose said his department's initiative wasn't sparked by a particular incident. He had started such a program in Portland, Ore., when he was chief of that city's police force. Moose has pushed the idea of a crisis intervention team since he came to Montgomery last year, and in police meetings, he encourages officers to volunteer for the training. "It doesn't mean we're never again going to use physical force or deadly force," he said. "It just increases the odds that we'll have a much better chance of understanding the crisis." The department plans to train 25 officers each month, said Officer Joan Logan, the program's coordinator. Eventually, 20 percent of officers will be trained, and there are plans for an internal newsletter to give updates on mental health issues. Officers from the Gaithersburg and Rockville police departments will be offered the training, and eventually, police in counties other than Montgomery can sign up, too.
    At the recent training, officers practiced scenarios. How can they help a depressed lawyer contemplating suicide? How do they react when they receive a call about a homeless transsexual sleeping on other people's cars? What about a man who keeps calling 911 because he imagines that someone is burglarizing his house? Sgt. Rodney Hill, a training participant, said he was most struck by the visit to Springfield, where patients gave police advice on how to treat them. Simple things matter most, they said. Ask them their opinion. Talk to them, not over them. Hill said officers kept asking the patients questions because they had never spent that much time at Springfield. "It just amazed me," Hill said, "getting to that other side."

Oakland County to Create Juvenile Drug Court
Detroit Free Press, 12/27/2000

PONTIAC, Mich. (AP) -- Oakland County Circuit Court's Family Division has been awarded $100,000 to create a juvenile drug court, officials announced Wednesday. "Our goal is to look closely at our chronic drug abusers, and work together to permanently break the grip of drugs on (young offenders') lives," Circuit Judge Edward Sosnick said in a written statement. The drug court team will consist of prosecutors, defense attorneys, treatment agencies and probation specialists in addition to the judge. Some members already have attended state and national training sessions to learn about strategies used by existing drug courts to reduce repeat offenses.
    Drug court will differ from the regular juvenile justice system by using a thorough substance abuse assessment and referral process, and faster response time for accepted cases. "Unique to a juvenile drug court is family involvement," Sosnick added. "Parents themselves will be asked to participate in the program, or their child might not be included. Sometimes this is the only way we can help a child become well."
    The percentage of Oakland County drug offenses involving juveniles doubled between 1994 and 1999, said Dr. Pamela Howitt, deputy administrator for court services and the project's director. "When 70 percent of the young people who are convicted of drug use are known to reoffend, we clearly have an obligation to explore alternative measures," she said. ------ For more information about Oakland County's juvenile drug court initiative, contact Dr. Pamela Howitt at 248-858-0247.

Insanity Defense Likely to Figure in Wakefield Slaying Defense
Theo Emery, Associated Press, 12/28/2000

BOSTON--The details that have emerged about Michael M. McDermott his battle with depression and use of medications for psychological problems are early indications he may use an insanity defense as he stands accused of gunning down seven co-workers.  But defense lawyers say it's a long-shot legal strategy. ''It's always been looked at skeptically. Insanity is the last refuge of desperate defense attorneys,'' said Joseph S. Oteri, an attorney with the firm of Oteri & Lawson in Boston, adding he has little doubt
    McDermott's lawyer will use an insanity defense. ''How else do you explain this?'' he said. ''The IRS put the pressure on him, they garnish the wages, and they push the kid over the edge. He's a sick man. He marches to a different drummer than we do, and everyone's his enemy.'' Kevin Reddington, McDermott's defense attorney, did not return calls The Associated Press left at his office Thursday. However, at an arraignment in Malden District Court on Wednesday, Reddington disclosed that McDermott who has been charged with seven counts of murder had been undergoing treatment and taking medications for an undisclosed psychiatric condition.
    On Tuesday, McDermott allegedly brought a semiautomatic rifle, a shotgun and a pistol to his office, Edgewater Technology Inc. in Wakefield, and systematically shot four women and three men, his co-workers at the Internet consulting firm.  When it was all over, McDermott sat in a chair in the building's lobby, with the weapons and one of the bodies nearby. The Boston Herald reported that as police approached him, his only words were cryptic: ''I don't speak German.'' Prosecutors say one of the deadliest workplace shootings in the nation may have been sparked by a dispute over the impending withholding of wages to pay back taxes owed to the IRS. In a search of his Haverhill apartment, investigators said they found bomb-making materials and chemicals. But there are few hints that have been uncovered so far that warned of any deadly rampage being plotted. NBC News reported Thursday that the federal Bureau of Alcohol, Tobacco and Firearms has finished tracing the weapons used in the attack. The ATF declined to comment on the results of its investigation.
    The question that must be answered and upon which his defense will likely hang is why the slayings took place and whether McDermott's mental state played a role. In another high-profile Massachusetts case, John Salvi's 1994 trial for killing two women in a Brookline abortion clinic, his lawyers put on an insanity defense, but failed. Salvi was convicted and later committed suicide in prison.  ''There are very striking similarities between this case and the John Salvi case,'' said Andrew D'Angelo, one of the attorneys who worked on Salvi's case. ''(The McDermott case) doesn't seem like a case about how it was done, or whether Mr. McDermott did it, but why did he do it.''
    It's extremely difficult to convince juries that because a defendant has a mental disease or defect, he was unable understand the wrongfulness of his act or control his impulses, D'Angelo said. ''The fact that he has already been diagnosed with some kind of mental illness certainly helps that kind of defense,'' D'Angelo said. ''In no way does that at mean that the mental illness or insanity defense will be successful it's just a stepping stone.''  In fact, very few defense attorneys are able to convince jurors that insanity is reason to find a defendant innocent.
    Lisa B. Kemler, a partner with the Alexandria, Va., law firm of Zwerling and Kemler, did just that when she successfully argued the high-profile trial of Lorena Bobbitt. The jury found Bobbitt was innocent by reason of temporary insanity for cutting off her husband's penis in 1993 because he was abusive. Outcomes like Bobbitt's are extremely rare. About 1 percent of criminal cases use the insanity defense. And, of those cases, about 1 percent are successful, according to Kemler, citing data from the National Association of Criminal Defense Lawyers.
    In several other high-profile office murder cases, the insanity defense was used and, as in Salvi's case, failed.  Copier repairman Byran Uyesugi, 40, presented an insanity defense against charges that he shot seven people at Xerox Corp. in Honolulu on Nov. 2, 1999. He was convicted and sentenced to life in prison. Alan E. Miller, 35, also pleaded innocent by reason of mental disease or defect in the shooting deaths of two co-workers and a former co-worker in Aug. 5, 1999. Miller, a truck driver who killed three people in Pelham, Ala., was convicted and sentenced to death. Many members of the public are extremely skeptical of the defense, Kemler said. ''I do think that people are skeptical. You have to educate people throughout the trial about the defense. You have to demonstrate a strong causal relation between the illness and the crime,'' Kemler said.

Prozac Defense Hits Home
Anne Barnard, Boston Globe- 12/30/2000

When Michael M. McDermott's lawyer suggested he might use a so-called ''Prozac defense'' - one that would argue that side effects from antidepressant drugs may have led his client to allegedly gun down seven co-workers - he stepped squarely into a medical hornets' nest. As soon as the news of McDermott's alleged rampage hit the airwaves, fax machines began whirring at the Los Angeles headquarters of a Scientology-based group. The group blames psychiatric drugs for crimes such as the Columbine High School massacre, and it alerts the media whenever an alleged killer is reported to have taken drugs, such as Ritalin or Prozac. Phones started ringing in the Cambridge office of Dr. Joseph Glenmullen, a psychiatrist and instructor at Harvard Medical School whose book, ''Prozac Backlash,'' accuses manufacturer Eli Lilly & Co. of downplaying rare side effects, such as extreme agitation and violent, suicidal behavior.
    Meanwhile, psychiatrists who believe that critics exaggerate Prozac's dangers braced themselves for what they view as another round of misinformation. ''That defense has never worked,'' sighed Cambridge Hospital psychiatrist Dr. James Beck, when he heard of attorney Kevin J. Reddington's strategy. Dr. Ron Schouten, director of Massachusetts General Hospital's law and psychiatry service, was succinct: ''The antimedication folks out there are going to come down very hard on this.'' While Prozac, like many other drugs, can cause extreme reactions in some people, those reactions have been over-dramatized, Schouten contends. The drug is popular and widely prescribed, he said, ''so even if you have a very rare reaction, the likelihood that you're going to see it [more often] is greater.''  The stakes are enormous. About 35 million people worldwide have taken Prozac, which produced 25 percent of the $10 billion Eli Lilly grossed last year.
    Since their introduction in the late 1980s, Prozac and its class of antidepressants have become embedded in US culture, winning over millions to psychiatric medication and removing much of their stigma. They also have attracted vociferous critics who argue that medications have crowded out nondrug treatments and that drugmakers have downplayed dangerous side effects. It's a debate that has figured in scores of prosecutions and lawsuits, including a 1989 Kentucky workplace massacre that both sides of the debate have cited to bolster their cases.
    If Reddington goes through with his plan, McDermott's may be the case with the highest profile yet to center on Prozac. It has hit many of the key players where they live: the Boston area. It is home to Glenmullen and many of his critics, like Dr. Jerrold Rosenbaum, a Harvard psychiatrist and onetime Prozac researcher. Dr. Martin Teicher works at McLean Hospital in Belmont; in the early 1990s, he linked Prozac to extreme agitation and suicide. Now, in a twist, he holds a patent for an improved version of the drug.
    The patent application states that the new version reduces side effects of the old version, including ''intense, violent suicidal thoughts and self-mutilation'' and a form of anxiety called akathisia. Eli Lilly has bought the rights to the patent, but denies that it proves the old version was dangerous. ''There is no credible evidence that establishes a causal link between Prozac and violent or suicidal behavior,'' company spokesman Jeff Newton has said. ''There is, to the contrary, scientific evidence showing that Prozac and medicines like it actually protect against such behavior.''
    Prozac is one of a class of antidepressants known as selective serotonin reuptake inhibitors, which maintain the brain's level of serotonin, a beneficial chemical. These drugs have fewer side effects than earlier drugs they have largely replaced. Prozac and similar drugs were praised in books like ''Prozac Nation'' and ''Listening to Prozac,'' then derided in other books, like ''Talking Back to Prozac,'' billed as ''the book Eli Lilly doesn't want you to read.'' That book was written by Dr. Peter Breggin, whom Schouten dismisses as ''the anti-psychiatry psychiatrist.'' After Joseph Wesbacker, who worked in a Louisville, Ky., printing press and was taking the drug, gunned down eight co-workers and killed himself, the victims' families sued Eli Lilly. Schouten cited a 1995 jury verdict in favor of Eli Lilly, but Glenmullen's book details how in 1997, state courts ruled that Lilly had paid the families a settlement in secret.
    For now, it's impossible to know how Prozac will figure in McDermott's case. Reddington has said his client was on Prozac and other selective serotonin reuptake inhibitors, but has not explained the diagnosis that led a mental health professional to prescribe it for his or her client. Some have speculated that McDermott was suffering from schizophrenia. Selective serotonin reuptake inhibitors are not used as a primary treatment for that disease, but are commonly prescribed for concurrent depression, psychiatrists said. Glenmullen said it would be healthy to explore the issue at trial. ''A terrible thing has happened, and it's important for all the families involved and for the public to know as much as possible,'' he said. Schouten disagreed. He compared the Prozac defense to the positions that gun control and death penalty groups staked out soon after the shootings in Wakefield. ''It's troubling,'' he said, ''that [a tragedy] becomes a launching point for people to go out there and trot out their pet cause.''

State Challenges Doctor Over Drug Detoxification Method
Linda A. Johnson, Associated Press- 12/30/2000

MERCHANTVILLE, N.J. Dr. Lance L. Gooberman has devoted his medical practice to perfecting ''rapid opiate detoxification,'' designed to reduce the agony of drug withdrawal and get more addicts into recovery. Himself a recovering addict long drug-free, Gooberman says his practice which unlike similar rapid detox programs doesn't require a hospital stay has successfully detoxified about 2,350 patients over seven years and guided them into long-term recovery programs. But over four years, seven of his patients died within days of the procedure. Gooberman says they had undetected heart problems or took cocaine, triggering a heart attack.
    In a civil trial beginning Wednesday, state regulators will try to strip the medical licenses of Gooberman and his former employee, Dr. David Bradway. ''We just want to make sure these `cutting-edge treatments' aren't cutting off life,'' says Mark Herr, director of New Jersey's Division of Consumer Affairs, which oversees the state board regulating physicians. Gooberman and his attorney, John Sitzler, have lined up medical experts to testify that accepted medical standards were followed and Gooberman's procedure was not the cause of any patient's death. Sitzler says their patients' death rate was just 0.3 percent, lower than for many surgical procedures, and that outpatient procedures involving anesthesia are commonly performed in physicians' offices.
    Gooberman's program U.S. Detox Inc. uses medications to rapidly flush the opiate drugs heroin, morphine, methadone and prescription painkillers out of addicts' bodies to ease withdrawal symptoms such as diarrhea and tremors. The patients are anesthetized during the approximately four-hour procedure in his office. He then implants a pellet of medicine in the abdomen that prevents patients from ''getting high'' if they take opiate drugs during the crucial first two months of recovery. ''I'm just trying to come up with a better way to do detox,'' Gooberman says.
    Gooberman, 49, for years was addicted to the stimulant methamphetamine but says he has been drug-free for 14 years after a six-week stay in a hospital psychiatric unit triggered by a drug binge. Rapid opiate detoxification was first performed in the late 1980s in Europe. Gooberman and other doctors who pioneered it in this country have appeared on television talk shows and magazine programs praising the method. The procedure also has been depicted on TV medical dramas. At least a dozen other U.S. physicians perform variations on rapid detox, but in a hospital and with an overnight stay required. Some have published articles in medical journals indicating many more patients were drug-free after six months than with traditional detoxification programs. And a handful of insurance plans have begun paying for the procedure.
    But even doctors who perform rapid detoxification say it severely stresses addicts' ravaged bodies, and at least a dozen of the thousands of American and European patients who underwent the procedure in a hospital also died. The slower, traditional detoxification and initiating methadone maintenance therapy both have been documented to kill some patients as well.  New Jersey's lawyers are expected to stress that Gooberman and Bradway are the only doctors known to perform detoxification as an outpatient procedure. The state alleges, among other things, that the doctors did not have sufficiently trained support staff and adequate emergency equipment, warn patients enough about the method's risks or properly instruct the caregiver taking the patient home. The doctors deny all of that.
    Rapid opiate detoxification has been approved by the professional organization for doctors in their specialty, the American Society for Addiction Medicine, as long as it's ''performed by adequately trained staff with access to appropriate medical equipment,'' according to the society's executive vice president, James F. Callahan. Former society president Dr. David E. Smith, a San Francisco addiction specialist, says he regards Gooberman's program as the best in the country. ''There is no evidence of a cause-and-effect relationship between the procedure and any of the deaths in question,'' Smith wrote in a report for Gooberman's defense.
    Several patients treated by Gooberman and Bradway have promised to testify on the doctors' behalf. One four-year heroin addict said she was well enough to tour the Grand Canyon three days after the procedure. Danielle, 19, says Gooberman gave her and her parents extensive information about the procedure's risks and aftermath. ''My parents and I pretty much think we owe my life to that procedure because I had tried rehab eight different times,'' says Danielle, who says she has been drug-free for 19 months.
    Bennett Oppenheim, a psychologist who once oversaw treatment at several U.S. rapid detox centers run by a for-profit company, says he now believes the procedure should be done in hospitals, not for-profit centers. ''It cannot be an assembly line,'' says Oppenheim, whose company offers the procedure at a northern New Jersey hospital. The chief medical officer of Oppenheim's company, Dr. Clifford Gevirtz of Mount Sinai School of Medicine in New York, is expected to testify against Gooberman. Gevirtz says he expects the procedure eventually will gain wide acceptance. ''If it's done properly, it brings people a humane, safe approach to detox,'' Gevirtz says. The experts do agree on one thing: More research is needed. Under a grant from the National Institute on Drug Abuse, the first national trial comparing rapid detox with two forms of slow detoxification began in September and is to last three years.
On the Net:
National Institute on Drug Abuse: http://www.nida.nih.gov
American Society of Addiction Medicine: http://www.asam.org

Heroin Addiction Rising Amid Too Little Treatment
Associated Press, 12/30/2000

Heroin addiction is on the rise in this country, especially among young people. One reason is that it can now be smoked or snorted instead of having to inject it in a vein, risking infection with HIV and other viruses. Meanwhile, addiction specialists say there are too few treatment programs, particularly detoxification programs meant to start addicts on the road to permanent recovery. ''Three out of every four chronic opiate users are not in treatment,'' but many would be if more slots were available, says Frank Vocci, director of the Division of Treatment Research and Development at the National Institute on Drug Abuse.
    According to the federal Office of National Drug Control Policy, there are an estimated 810,000 chronic abusers of opiate drugs, predominantly heroin addicts. Only about 180,000 of them are currently in methadone maintenance therapy, which critics say simply exchanges an illegal addiction for a legal one that sometimes last for life. It's also not an option for people subject to workplace drug testing. Another 20,000 to 40,000 American addicts undergo detoxification each year. Meanwhile, heroin addiction kills about 5 percent of addicts annually. Many physicians are now arguing U.S. drug policy should focus on treatment, not law enforcement. They say treatment is far cheaper in the long run than the costs the public bears for drug-related theft and other crimes, lost productivity of addicts, emergency medical treatment for them, drug prosecutions, incarceration and parole supervision.

Facts About Opiates and Rapid Detox
Associated Press, 12/30/2000

Facts about opiates and rapid opiate detoxification:
In the United States, there are an estimated 810,000 chronic abusers of opiate drugs, predominantly heroin addicts, but also users of morphine, methadone and prescription painkillers.
About 180,000 of them are now in methadone maintenance therapy, which critics say simply exchanges an illegal addiction for a legal one.
An additional 20,000 to 40,000 American addicts undergo detoxification each year, mostly the traditional way.
Rapid opiate detoxification's potentially fatal risks include allergic reactions to medications used, heart complications, pneumonia, and, rarely, anesthesia overdose.
Patients who were heroin addicts are warned detoxification has eliminated their built-up tolerance to the drug, so if they relapsed and took their usual dose, it could be fatal.
Sources: Office of National Drug Control Policy, National Institute on Drug Abuse, physicians who perform rapid opiate detoxification

Brain Changes, Not Hormones, Explain Many Adolescent Behaviors
Matt Crenson, Associated Press, 12/30/2000

Every parent dreads it. Almost overnight a sweet, cheerful, obedient child mutates into a churlish monster prone to recklessness and unpredictable mood swings. This is not ''The Exorcist.'' This is adolescence. Parents and experts have always blamed the same hormones that catapult young bodies into adulthood for the sleeping until noon, the reckless driving, the drug use and the other woes of adolescence. But recent research shows that what's going on above teen-agers' necks, not raging hormones, explains the changes.
    Beginning around age 11, the brain undergoes major reorganization in an area associated with things like social behavior and impulse control. Neuroscientists figured this out only in the last few years, and the discovery has led them to see adolescence as a period when the developing brain is vulnerable to traumatic experiences, drug abuse and unhealthy influences. ''The adolescent brain is different. It's still growing,'' says Fulton Crews, a neuroscientist at the University of North Carolina in Chapel Hill.
    Not long ago, neuroscientists thought that the brain stopped growing by the time a child entered nursery school. By then, it was thought, nearly all the brain's wiring had been connected and the only remaining task was to program that hardware. But new brain imaging technologies have shattered that notion. Using techniques like MRI and positron emission tomography, or PET scanning, researchers have detected brain growth throughout childhood and well into adolescence. Because their brains are not yet mature, adolescents do not handle social pressure, instinctual urges and other stresses the way adults do. That may explain in part why adolescents are so prone to unsavory or reckless behavior. ''The adolescent brain is just in a different state than the adult brain,'' Crews says.
    This year in the scientific journal Nature, researchers presented a series of time-lapse images depicting brain growth from age three to 15. The images showed a tangle of nerve cells sprouting in the part of the brain that sits above the eyes, then a period of ''pruning'' after puberty, when about half of the new fibers are cut away to create an efficient network of circuits. All this action happens in a part of the brain known as the prefrontal cortex, an area responsible for what neuroscientists call the ''executive functions.'' Those functions are practically a laundry list of the qualities adolescents often lack goal-setting, priority-setting, planning, organization and impulse inhibition.
    Adolescence is a time of risk-taking, says Lynn Ponton, a psychiatrist at the University of California-San Francisco and author of ''The Romance of Risk: Why Teen-agers Do the Things They Do.'' ''A big part of adolescence is learning how to assess the risk in an activity,'' Ponton says. ''Part of the reason teen-agers aren't good at risk-taking is that the brain isn't fully developed.'' Looked at that way, it is no big surprise that accidents are the leading cause of death among adolescents, or that teens are more likely to become crime victims than any other age group. It's no wonder that the vast majority of alcoholics and smokers get started during their teen years, or that a quarter of all people with HIV contract it before age 21.
    It's no big secret that things like criminal records and sexually transmitted diseases can really mess up your life. But neuroscientists are learning that less serious stuff can have lasting effects too. Scientists conduct most of their research on adolescent brain development using animals, because it would be unethical to experiment with human teens. Animals don't all go through a transitional period between childhood and adulthood, but most mammals do exhibit some kind of adolescence. ''They don't hang out at malls and spike their hair and stuff, but their social behavior and social structure changes dramatically,'' says Linda Spear of Binghamton University in New York state.
    Adolescent rats, for example, show more interest than adults do when strange objects are put into their cages. They start hanging out with their peers more, exploring their surroundings intensely and flitting from one activity to the next. Craig Ferris, who studies golden hamsters at the University of Massachusetts Medical Center in Worcester, says that in the wild his study subjects enter adolescence when they are ejected from the nest at about 25 days of age. For about two weeks they wander the wheat fields of Syria, looking for a nest that will take them in or founding one of their own.
    Ferris' experiments show that a golden hamster's experiences during this stage can determine how it will behave for the rest of its life. If an adolescent golden hamster is put in a cage with an aggressive adult for an hour each day, it will grow up to become a bully that picks on animals smaller than itself. But it will cower in fear around hamsters its own size. Those golden hamsters raised in the presence of aggressive adults also grow up to have lower than normal levels of vasopressin, a chemical associated with aggression, in the brain's hypothalamus. And they sprout more receptors in the hypothalamus for serotonin, a chemical that blocks vasopressin.
    Ferris and his colleagues aren't sure yet exactly what to make of the chemical changes they observe. But they are certain that at least for golden hamsters, the experience of being intimidated by an adult during adolescence has permanent effects. ''The take-home of all this stuff is that the brain is constantly interacting with the environment,'' Ferris says. During adolescence, he and his colleagues hypothesize, the developing brain picks up cues from the environment and uses them to help determine ''normal'' behavior. ''If the environment provokes or encourages aberrant behaviors, those behaviors become the norm,'' says Jordan Grafman of the National Institute of Neurological Diseases and Stroke.
    To neuroscientists, one of the most disturbing behaviors among today's adolescents is binge drinking. Studies have already shown that alcohol exposure in utero can have devastating effects on the developing brain, and many researchers fear the period of vulnerability could extend through childhood and into adolescence. Researchers at the University of North Carolina recently decided to test the sensitivity of the adolescent brain to binge drinking by subjecting rats to an alcohol bender. Four times a day for four days, they gave both adolescent and adult rats 10 grams of alcohol per kilogram of body weight. After the rats had sobered up the researchers looked for brain damage and found more in adolescent rats compared to adults. Most importantly, the adolescents sustained damage in brain regions associated with addiction. ''My hypothesis is that this damage is a component of the development of alcoholism,'' says Crews. He and four colleagues published a paper describing the research in the November issue of Alcoholism: Clinical and Experimental Research.
    Researchers who study cigarette smoking tell a similar story. The vast majority of smokers start during their teen years, but until recently nobody had thought to look at how the adolescent brain responds to nicotine. When they did, researchers at Duke University found that adolescent brains respond more intensely to nicotine. The scientists injected rats with nicotine every day for more than two weeks, a dose comparable to what a typical smoker receives. In all of the rats the number of chemical receptors dedicated to nicotine increased a sign of addiction. But in adolescents, the number of nicotine receptors increased twice as much compared to adults.    ''What we found is that the adolescent brain gets a lot more bang for the buck,'' says Theodore Slotkin, one of the scientists who performed the research.
    A follow-up study published in the October issue of Brain Research showed that adolescent nicotine exposure caused permanent behavioral problems as well, especially for females. Even after two weeks with no nicotine, female rats were less interested in moving around and raising their young than counterparts who had never been exposed. That may be because nicotine retards cell division in the hippocampus, a brain region that continues growing into adulthood in females, but not males. It may also be that the nicotine-exposed rats were depressed. Nicotine decreases the brain's production of norepinephrin and dopamine, two chemicals that tend to be lower in depressed people. And epidemiological studies have shown that smoking early in life greatly increases a person's chances of suffering depression later on. That doesn't mean that people who begin smoking at a young age are doomed to live out their days depressed and in thrall to nicotine. ''A person isn't a slave to one's genes or biology,'' Ferris says. But even at this early stage of research, he added, it is clear that things like violence and drugs can permanently alter a teen-ager's brain. And that may make an often difficult period even tougher.

Care Shift by HMO Will Test For-Profit Concept
Liz Kowalczyk & Alice Dembner, Boston Globe - 12/31/2000

A company promising to cut costs and intensely scrutinize patients' visits to therapists and hospitals will take over mental health care services for financially troubled Harvard Pilgrim Health Care tomorrow, sweeping about 900,000 members into the controversial world of for-profit medicine. The takeover by Value Options, a national firm that already manages mental health services for the state's 500,000 Medicaid recipients, is a major test for managed care, making nearly one-quarter of Massachusetts residents dependent on a company that profits in part by controlling the cost of their treatment for depression and other mental illnesses.
    Some therapists and patient advocates fear an acceleration of trends already seen in the Medicaid system: increased reliance on medication and shorter hospital stays for patients, and reduced payments to providers. Those trends may be contributing to a spike in reports of sexual assaults, injuries, and perhaps even deaths among Medicaid patients over the past year, according to advocates and state officials. In addition, Value Options and the state have been unable to solve a crisis in care for children, who are increasingly stuck in locked psychiatric wards in part because there are not enough outpatient services.
    Yet, over the 41/2 years of the Medicaid contract, the company also has built a reputation for efficiency and responsiveness. It has a record of promptly paying claims, allowing outpatient care without prior approval, empowering patients, and including difficult clients such as homeless people. ''This has not been a bad company. People have rated it as an above-average managed care company,'' said Richard Sherman, director of public policy for the Massachusetts chapter of the National Association of Social Workers. But, even in business terms, Value Options' record is mixed. Rather than cutting costs at Medicaid, according to the state Division of Medical Assistance, the firm overspent its state budget by $22 million last year and is under pressure to control spending this year as it bids to renew the contract. ''The result of moving to a ... for-profit [company] has been a tremendous squeeze on reimbursement both for inpatient beds and for professionals,'' said Dr. Michael Jellinek, chief of child psychiatry at Massachusetts General Hospital. ''Inpatient units adapted with more aides, fewer nurses, and more patients per doctor. The quality went down.''
    To be sure, the increase in reported assaults and deaths - not previously revealed - can't be blamed entirely on quality of care. While the increase was dramatic, the number of cases remains relatively small, and part of the spike reflects better reporting. But the state's top mental health official says the jump to 73 sexual assaults last year, from 25 the year before, may be a warning sign. ''The gross number of incidents in and of itself is not alarming, but I worry about the trend,'' said Mary Lou Sudders, state commissioner of mental health. ''The trend suggests we have to look at the staffing issue.''
    The question now is how Value Options will alter services for Harvard Pilgrim members as the company is paid a set amount of money per patient regardless of how much it costs to treat each individual. Already, dozens of psychiatrists and psychologists have quit Harvard's network, sending some patients scrambling for new therapists. Those therapists cite growing paperwork in managed care, concerns about confidentiality, and Value Options' plan to reduce the fees Harvard Pilgrim paid them, giving psychiatrists, for example, $80 instead of $87 for a 50-minute session. ''Value Options' arrival was the last straw for me and I quit,'' said Dr. Jonathan Weinberg of Cambridge, whose 40 Harvard Pilgrim patients will have to pay his $50 to $150 sliding-scale fee if they want to continue therapy with him.
    Richard Sheola, president of the Massachusetts Behavioral Health Partnership, Value Options' subsidiary here, defends the company's record and says the Medicaid trend toward shorter hospital stays is appropriate for a population better served in the community through multidisciplinary care offered in clinics. ''We have never made a penny by limiting access to care,'' he said. ''I don't believe there's any pattern of behavior that would suggest we're denying medically necessary care. My staff kiddingly refers to us as the anti-managed-care company.''
    But, with the Harvard Pilgrim contract, for-profit companies will have taken over mental health care services for half of the state's population. The for-profit Magellan Health Services has managed mental health care for 1.8 million members of Blue Cross and Blue Shield of Massachusetts for five years. ''The quibble is with the whole notion of farming out to a for-profit company,'' said Sherman, of the social workers association. ''Money that would go to service instead goes to bonuses and investors.'' In the coming months, just as it takes on the Harvard Pilgrim contract, Value Options will be under pressure to reduce spending on its $280 million Medicaid contract. Over four years, as membership expanded by 37 percent, costs have risen 51 percent, in part reflecting attempts to address the children's care crisis. The company was penalized $6 million for overspending last year, but that was more than offset by nearly $14 million in performance bonuses in the first three years and another $5 million expected for fiscal year 2000.
    While Medicaid clients use more costly services, reducing spending is also crucial to Harvard Pilgrim, which is under state supervision after losing $226 million last year. Harvard Pilgrim executives said Value Options will save the HMO about $2 million annually on administration, which the company began overseeing earlier in 2000. But they don't know if there will be savings on clinical care because of a new state law requiring that mental health benefits be equal to those for physical illnesses. ''People in other states can't believe the level of [Harvard Pilgrim's] spending is as high as it is,'' said Sheola, of Value Options' Massachusetts subsidiary. ''Given their situation, they needed to save a lot of money on this program.''
    Based on interviews with Sheola, Harvard Pilgrim executives, therapists, health care specialists, and consumers, this is how the three-year Harvard Pilgrim contract is expected to work: Harvard Pilgrim will pay Value Options a flat per-member per month fee. If Value Options overspends, it loses money; if it spends less than the total, it profits. Value Options will receive a bonus if it improves care by specific measures and will be penalized if it fails to meet administrative goals. Some observers say similar goals set for Value Options under Medicaid are too easily attained and aren't followed closely once the bonus is won.
    The company will reduce costs by refusing to pay for visits to out-of-network providers, Sheola said. It also is paying psychiatrists and psychologists less than Harvard Pilgrim did for most services, but paying social workers more. Value Options will clamp down on therapists who depart from the recommended number of sessions for particular illnesses. Sheola said he also will try to reduce ''medically unnecessary'' hospital stays.
    So far, about 2,150 of 3,550 Harvard Pilgrim providers have joined the new network, Sheola said. Dozens have quit, according to the associations representing the therapists. But Sheola said that applications are still coming in and that most of those who haven't joined were not actively seeing HMO members. Providers have until March 31 to sign up. Hundreds of additional therapists will be available through clinics. ''Our members' biggest concern is whether there is going to be a reduction in benefits,'' said Peter Adler, Harvard Pilgrim's senior vice president of network management. ''There isn't.''
    Fewer than one in five hospital and outpatient clinic administrators question Value Options' clinical decisions for Medicaid patients, according to a recent survey by Richard H. Beinecke, a Suffolk University management professor. On the other hand, only 42 percent of respondents said Value Options allowed patients to stay long enough in the hospital - a concern echoed by consumers like Linda Lewis of Rockport. Lewis's 30-year-old son, who suffers from manic depression, was hospitalized in July. His medication was changed and he was discharged in four days. Within a week and a half, he was back. ''The stays are far too short for anyone to become stable,'' said Lewis, a social worker and president of the North Shore chapter of the Alliance for the Mentally Ill.  Yet, while adult hospital stays fell, the average for children rose from 12 to 21 days as hundreds were ''stuck'' in locked units for longer than medically necessary because there was no less restrictive treatment available for them. Sheola has tried to address the problem by adding beds, but acknowledges that, along with the state agencies that supply residential facilities, he has failed these children.
    A recent rise in reports of sexual assaults, serious injuries, and deaths among Medicaid patients suggests other problems. The reported number of ''critical incidents'' rose from 58 in fiscal year 1999 to 177 in 2000, according to Value Options. Sexual assaults by or of patients increased from 25 to 73. The number of deaths increased from 22 to 47, largely due to new reporting on outpatients.  Although some of the deaths were from natural causes, they included suicides of inpatients, and of outpatients soon after discharge.
    In one case in December 1999, a woman overdosed on Percocet a day after she was evaluated and sent to a day hospital program, rather than an inpatient facility. Given the thousands of patients served, the numbers of incidents are low, and both Sheola and state officials said much of the increase reflected sicker patients and better reporting that began in December 1999. But Sheola said there is still underreporting, and observers said the increases are a red flag. ''It's cause for concern especially if it keeps up in coming years,'' said Christopher Hudson, a professor of social work at Salem State College who has studied the Medicaid system. Sheola acknowledged that ''incidents are an indicator of quality of care.'' ''That's why we insist that our providers err on over-reporting,'' he said. ''If a facility is not meeting our standards, we jump on that facility and insist on corrective action. But I don't think there's a significant trend.'' About one-quarter of incidents led to corrective action.
    Despite the problems, many consumers praise the Partnership. ''They've given consumers a place at the table and that is really uplifting,'' said Bernard J. Carey, executive director of the Massachusetts Association for Mental Health. Laurie Ansorge Ball, director of behavioral health programs for Medicaid, said the for-profits offer some advantages. ''They have the ability to count the incidents and complaints, to measure length of stay, and find out how quickly people get care after they leave the hospital,'' she said. ''They can develop a service in a month and pay for it. And they really do manage care so people don't languish in hospitals for longer than they should.''

A Matter Of Violent Death and Little Girls
Neely Tucker, Washington Post- 12/31/2000

The torture of 13-month-old Alaizah Charles began just after Thanksgiving. She was burned, beaten, bruised and severely malnourished. Her tiny body was squeezed so tight that six ribs snapped. The edges were pushed inward until they pierced her lungs. She suffocated. "I have to reach the conclusion this child was tortured," said Russell F. Canan, the D.C. Superior Court judge conducting a hearing into Alaizah's death two weeks ago. "Someone inflicting such pain absolutely must be aware the victim was suffering intense pain. . . . The events were harrowing in their intensity toward such a small creature." Joseph E. Young, 22 -- the child's godfather and a former boyfriend of her mother -- is charged with felony murder in the Nov. 28 death. He has pleaded not guilty.
    The case is one of a spate of slayings of little girls coming to trial in the District in the coming months. They reflect a sad and little-known fact of American life: A female is most likely to be a homicide victim in her first year of life. An analysis of FBI crime reports shows that, year in and year out, females are more likely to be killed before reaching their first birthday than at any other age. In 1997, the last year for which statistics are available, about 115 infant girls were slain, which works out to about 5.8 per 100,000. That rate is higher than for females of any other age, a consistent fact of murder statistics for a decade. A three-year span starting at age 22 forms the stage of life at which women are most at risk of homicide, with an average rate of 5.43 per 100,000, but no single year is higher than the year after birth.
    The suspects in nearly all infant homicides are parents, family friends or guardians. Females may ultimately face greater danger from abusive spouses, boyfriends or even strangers, but in the 12-month period in which they are most likely to be slain, their killers are almost always their caretakers. "The riskiest age for a woman to be murdered is in her first year of life," said Howard Snyder, director of systems research for the National Center for Juvenile Justice, a nonprofit agency analyzing crime information for the Department of Justice. "It says something about the level of child abuse." Susan H. Howley, director of public policy for the National Center for Victims of Crime, said that while parents correctly focus on instructing youngsters to be cautious of strangers, the number of infant homicides illustrates that the most pressing dangers often come from within the home. "We don't like to think this type of crime takes place within families, so sometimes it's easy not to look too hard," she said. "There's a tendency to overlook the fact that family members and acquaintances are more often the perpetrators of violence against children."
    Homicide by the Numbers FBI statistics show the detailed pattern of murder in the United States. More infant boys were murdered in 1997 than girls, for example, about 158 to 115, but because most male homicide victims are slain in their early twenties, the infant death rate is not as conspicuous. In fact, the rate of male homicides in their first year is less than one-quarter of its peak. Males are most likely to be slain at age 21, when the homicide rate is 35.48 per 100,000 -- nearly six times the peak rate for females. The highest risk of homicide for all U.S. residents is age 20, with a rate of 20.24, nearly four times that of infant girls. Yet, while mortality rates drop off after the first year, the period from birth to 24 months remains especially perilous for girls.
    Tommy Wells, executive director of the D.C. Consortium for Child Welfare, said infant homicide cases are extreme examples of unprepared parents or caretakers trying to cope with situations that spiral out of control. "The risk to infants is not so much whether they are boys or girls, but the fact that their parents have little or no parenting skills," Wells said, making it clear he was not referring to any specific case. "We don't teach kids how to be parents, and we're seeing a new generation of young parents who were not raised properly themselves."
    In D.C. Superior Court, an unusual cluster of trials scheduled for the coming months offers a disturbing window into the alleged murder of four infants and toddlers, all girls. There's Antjania Diamond Lovett, 18 months old and no longer breathing at 3 in the afternoon Dec. 10, 1998, when paramedics rushed to her home in the 1200 block of I Street SE. Her father, Antjon C. Lovett, 22, said she drowned in the bathtub when he stepped away for a moment.Questionable infant deaths are some of the most difficult homicides to investigate, police and prosecutors say. As in Antjania's death, there are few, if any, witnesses. The cause of death is often not clear -- as opposed to 85 percent of adult homicides, which are caused by a gun or knife -- and there's the question of whether a child's injuries were accidental or intentional. But little bodies often hold clues to their last moments of life, secrets often told only to coroners. Antjania's lungs had no fluid in them, as would have been the case in a drowning. D.C. Chief Medical Examiner Jonathan L. Arden, a national authority on child homicide, noted bruises to her scalp and the inside of her mouth and signs of sexual abuse. Her body temperature when she was rushed to the hospital was too low for a child who had just stopped breathing. The medical evidence showed that Antjania had been dead for several hours, Arden wrote, and the cause of death was smothering, not drowning. Prosecutors charged Lovett with first-degree murder. His trial is scheduled for January.
    Akiba Coleman, 23, is charged with second-degree murder in the Nov. 21, 1999, death of her daughter, Dakerra Minor. The infant, 39 days old, had a skull broken so severely that Arden testified the injury was consistent with falling from a two-story building. Coleman, scheduled for trial in March, has pleaded not guilty. She told police that the child went to sleep and did not wake up. She said that a 4-year-old child had dropped Dakerra accidentally several hours earlier.
    In a case that has prompted an overhaul of the city's foster care system, Charrisise Blackmond and Angela T. O'Brien are charged in the slaying of Blackmond's 23-month-old daughter, Brianna. Prosecutors say O'Brien, 32, killed Brianna by slamming her head on the floor at least twice Jan. 5, two weeks after the child had been returned to their home from foster care. Both women have pleaded not guilty. Their trial is scheduled for April.
    And there's the death of Alaizah Charles. Her mother, identified in court records only as Joylita, dropped the toddler off with Young on Friday evening, Nov. 24. He was unemployed, living in the 700 block of Quebec Street NW, and would sometimes care for Alaizah for several days at a time. Alaizah was not in good health when she was dropped off, evidence introduced in court suggests. She was almost clinically malnourished and suffered from a chronic lack of protein. She was with Young for four days before she died and apparently was given nothing more substantial than water, according to Deputy Medical Examiner Wendy Gunther. Young told police that when Alaizah would misbehave, he would make her stand in the center of the floor until she got tired. When she tried to sit, he would "pop her" on the legs and make her stand some more. Police said that Young at first told them that on Nov. 27, the child fell against his portable heater. But he later said he pressed her body against it. He said he intended to warn her that it was hot so she would stay away from it. "I held her sideways. And I pressed up -- I put her up against it so that she can feel the heat . . . her body did touch the radiator. When I felt her body touch the radiator, I pulled her back." How long did you hold her against the radiator, police asked. "Two or three minutes," Young said. An examination of her body showed a grill-like set of third-degree burns across the little girl's stomach.  The next day, Alaizah reached into a chest of drawers and pulled out items belonging to Young's girlfriend. He said he picked her up and shook her for "two or three minutes. . . . If I didn't hold her tight, she probably would have flown out of my hands. Now, I might have applied more pressure than, than probably she, maybe she could take or, or not knowing my own strength versus her being a baby," he said. Prosecutor June M. Jeffries, citing Gunther's testimony, said that incident caused the fatal injury to the girl's lungs.
    Defense attorney Renee Raymond, who was not required to present a full defense at this early stage, pointed out to the judge during this month's hearing that police had not read Young his Miranda rights, raising the possibility his statements might not be admissible at trial. The slightly built Young did not speak during the hearing. But toward the end of his two interviews with police, the last one on the morning of Nov. 30, he groped for words to try to explain what happened. "I'm not a bad person. I'm not a murderer. I took care of this child out of the kindness of my heart," he said. "It's not like I had a personal problem with the child, or I had had a personal problem with her mother. It's just that she's small, and she gets into a lot of stuff. . . . [Since her death] I don't eat. I haven't really slept. She's all I think about."