Noteworthy News Articles on Mental Health Topics, July 24-31, 2006 The researchers, led by Marica Ferri of the Italian Agency for Public Health in Rome, found little to suggest that 12-step programs reduced the severity of addiction any more than any other intervention. And no data showed that 12-step interventions were any more — or any less — successful in increasing the number of people who stayed in treatment or reducing the number who relapsed after being sober. Alcoholics Anonymous is a self-help group that offers emotional support for alcohol abstinence and holds that alcoholism is a spiritual and a medical disease. In some of the studies reviewed, A.A. was compared with other psychological treatments including cognitive-behavioral therapy, which encourages the conscious identification of high-risk situations for alcohol use; motivational enhancement therapy, based on principles of social and cognitive psychology; and relapse prevention therapy, a variation on the cognitive-behavioral approach. It was also compared with other spiritual and nonspiritual 12-step programs. One study compared brief advice to attend A.A. meetings to motivational methods for encouraging 12-step involvement. Another evaluated the effectiveness of hospital-based 12-step programs, compared with community-based 12-step efforts. The paper was published last week in The Cochrane Library, a journal devoted to systematic reviews of health care interventions. In all, the researchers examined eight trials involving 3,417 men and women ages 18 and older. None of the studies compared A.A. with no treatment at all, and the researchers said that made it more difficult to draw conclusions about effectiveness. About one-fifth of alcoholics achieve long-term sobriety without treatment. There is no single known cause of alcoholism, but the researchers wrote that about two-thirds of alcohol dependence could be attributed to genetic factors and one-third to environmental causes like stress or emotional problems. Men and women are equally affected, and age does not appear to affect prognosis. A member of the staff of the general service office of Alcoholics Anonymous said the organization did not comment on published studies of the program, but some experts objected to the methods and conclusions of the review. “Although the randomized controlled trial is the gold-standard methodology in comparing between conditions,” said Thomas G. Brown, an assistant professor of psychiatry at McGill University, “it washes out a factor that may be important in potentiating A.A.’s benefits, namely patient choice and preference.” In other words, having a patient choose the form of treatment, rather than being assigned to it as in most studies, could be an important factor. Despite the largely negative findings, John F. Kelly, a clinical psychologist at Harvard, said he still believed that A.A. and other 12-step programs were effective. A.A. and other 12-step programs “are not cure-alls,” Dr. Kelly said, “but I would say at a minimum, they help.” Dr. Edward V. Nunes, a professor of clinical psychiatry at Columbia, said research had demonstrated that certain elements of A.A. were effective. “Some of the wisdom embodied in A.A., such as the notion of persons, places and things that trigger drinking, are very much a part of cognitive-behavioral therapy, which is a scientifically driven, empirically validated treatment,” Dr. Nunes said. The review covered only carefully controlled trials. But Sarah Zemore, of the Alcohol Research Group of the National Alcohol Research Center, said studies that observed the results of a treatment without setting up randomized control groups could also be informative. “Does A.A. or some other mutual-help group work for people who seek it voluntarily?” she said. “Obviously, a randomized trial cannot address that question. But observational data can.” It is unlikely that substance abuse experts will widely reject A.A. on the basis of these findings. “A.A. has helped a lot of people,” Dr. Nunes said. “There are a lot of satisfied customers. On the basis of that, we have to take it seriously.” Andrew Rimas, Boston Globe- 7/25/2006 It's not often that the cell looks out of the microscope at the scientist. Researchers are not usually the former objects of their studies, but Iliana Ojeda-Rivera is no typical researcher. A licensed substance abuse counselor at the Mom's Project drug addiction program in Mattapan and a researcher at Northeastern University's Institute on Urban Health Research, Ojeda-Rivera spends her days meeting with and gathering data on homeless mothers with addiction problems. It's emotional work for her. She was once one of them. ``I had my first daughter at 16, and I started using drugs at 18," says the 43-year-old mother of four. She's soft-spoken because of recent oral surgery, but her manner is confident and professional, even when speaking about great personal misfortune. Her litany of hardships reads like a modern-day Dickens novel. Both of her parents were heroin addicts. They divorced when Ojeda-Rivera was a girl and shuffled her between the streets of Brooklyn and Worcester. ``It was not a very healthy upbringing," she says. ``I had a lot of gang involvement." The cocaine boom of the 1980s swallowed Ojeda-Rivera and didn't spit her out until many years later. ``I got crazy and out of control," she says. There were violent relationships, migrations between shelters, failed rehabilitation programs, to say nothing of the trauma her children suffered. ``But I knew I wasn't supposed to be a drug addict," she says. ``Other women would say they couldn't imagine getting out, but I had an inner voice that told me I wasn't supposed to be doing this." When she turned 31, her parents, who were by then clean of drugs, threatened to have a court remove her children. Spurred to action, she entered a detox program and then found a place at Boston's Portis Family House, a treatment facility that allowed her to keep her children with her during the hard months of withdrawal and rehabilitation. ``I never knew anyone who worked, or who didn't do drugs, and in the program I met women who were powerful and strong. They taught you to hold your head high. They taught me every aspect of being a woman and a mom." The program did the trick. Ojeda-Rivera has been sober for 12 years. But she wasn't one to turn away from the problems that had so recently consumed her. She felt compelled to help, so she dedicated her life to other women who were suffering through their own versions of the drug and homelessness cycle. ``In the beginning it was really hard," she says of her first years as a worker at the Mom's Project. ``You have to figure out how much to take home at the end of the day and how much to leave." She proved to be a good clinician with an empathetic touch. ``I'm not the most educated, but I'm the person to go to for a direct connection to the streets, to women's suffering." From Springfield to New Bedford to Lawrence, she now tracks down homeless women who are participating in a Northeastern University study on women battling substance abuse. Not surprisingly, they often drop out, disappear, or are otherwise hard to find. ``We need to have an 80 percent follow-up rate over the course of a year. It's not easy." For the Northeastern study, she has conducted interviews in the middle of drug dens. For Mom's Project, she has sat with weeping clinic patients as the courts ordered their children removed. In between, she continues pursuing her master's degree in counseling psychology and tries to balance the demands of family. Ojeda-Rivera's husband, whom she met at Portis House, is HIV-positive, as is her mother. ``Sometimes it gets overwhelming," she says. ``There's so much in life to deal with. But I'm happy. I feel very, very blessed." FACT SHEET Hometown: Woonsocket, R.I. Family: Husband Osvaldo Rivera and daughters Vanessa, 27, Tassia, 22, Jaylene, 17, and son Jonathan (Jaylene's twin). She also has three grandchildren. Ambitions: To conduct a study on alcoholism and the Latino population in Providence. To finish her master's degree. Also, to write the story of her life and share it with women undergoing addiction treatment. Member of: The Cathedral of Life Christian Assembly congregation in Providence. ``I have a strong spiritual base in my church." Moment of ambivalence: ``The more educated you become in this field, the more detached you end up being from the people who need help. But you need the degrees to get recognition." Soapbox statement: ``Treatment does work, which is why it's so important for the government to fund it."
The verdict upholding Yates' insanity defense comes after the jury deliberated more than 12 hours over three days. The decision also underscores the emotional debate on mental illness within the criminal justice system since Yates' first trial in 2002. "It's a shame it took us this long to get the right verdict,'' said Wendell Odom, one of Yates' attorneys. Yates appeared shocked and sat staring wide-eyed with her lips slightly parted as State District Judge Belinda Hill asked each juror individually shortly after noon today whether they agreed with the verdict. The acquittal in Yates' second capital murder trial followed nearly a month's worth of exhaustive testimony, capped by four hours of emotional closing arguments Monday, during which Yates broke down in tears and her former husband, Russell Yates, abruptly left the courtroom. The jury's verdict means Yates, 42, will be sent to a state mental hospital for treatment, rather than be sentenced to life in prison. Yates and attorneys will return to Judge Belinda Hill's courtroom at 10 a.m. Thursday for a hearing, formalizing the details of Yates' hospitalization. She will go to a maximum security hospital initially. "I just want to get her back home to Rusk,'' said George Parnham, Yates' lead attorney, in reference to the hospital where Yates had been receiving care before the start of her second trial. The children's father said outside the courtroom the jury had reached the right conclusion. "The jury looked past what happened and looked at why it happened,'' Rusty Yates told reporters outside the courthouse. "Prosecutors had the truth of the first day and stopped there. Yes, she was psychotic. That's the whole truth.'' Rusty Yates divorced Andrea Yates after the children's June 2001 deaths and recently remarried. He said they are still "friends'' and reminisce about the children. "This is about Andrea's quality of life for the balance of her life.'' Yates was critical of the prosecution and the amount of money spent by the state in trying his ex-wife since he says she was clearly "psychotic," when she killed the children. "This could have all been avoided," he said. Shortly before 10:30 this morning, the jury had sent a note requesting exhibits showing a family portrait and a photo of the children before their deaths. Over the past two days, the jury appeared to focus on medical expert testimony from both prosecution and defense witnesses. Tuesday, they asked to see video tapes mental-health experts made of their interviews with Yates after the killings as well as testimony from Park Dietz, a prosecution expert witness, about Yates' statements regarding Satan's presence. It is unknown how long Yates will be hospitalized, but she will be subject to periodic reviews by state District Judge Belinda Hill's court. The trial was the second time Yates had faced a jury. She was convicted in 2002 of the crime and sentenced to life in prison, but an appeals court last year threw out that conviction based on a forensic psychiatrist's erroneous testimony. Yates, a former nurse and housewife with a history of psychiatric hospitalizations and suicide attempts, called police and led them to the bodies of her five children Noah, 7, John, 5, Paul, 3, Luke, 2, and 6-month-old Mary after drowning them in a bathtub at her Clear Lake home on June 20, 2001. Defense attorneys had urged jurors to find that Yates' mental illness led to the children's deaths. Experts testifying for the defense said Yates drowned her children in an act of love to save their souls from eternal damnation. Prosecutors did not dispute that Yates was mentally ill, but argued that her condition did not keep her from knowing right from wrong. A death sentence could not be considered during her retrial since the first jury rejected that option four years ago. Andrea Yates' mother was one of about 75 to 100 spectators who had filled the courtroom to hear the verdict. She quickly left the room, avoiding media and her former son son-in-law, who congratulated her. That pleasurable buzz has seduced Mario Musachia into burning through nearly half a million cigarettes in half a century. Now the Madison man is among 300 people around the country who are testing an experimental vaccine that makes the immune system attack nicotine in much the same way it would fight a life-threatening germ. The treatment keeps nicotine from reaching the brain, making smoking less pleasurable and theoretically, easier to give up. The small amount that still manages to get in helps to ease withdrawal, the main reason most quitters relapse. If it works -- and this has not yet been proved -- the vaccine could become part of a new generation of smoking cessation treatments. They attack dependency in the brain instead of just replacing the nicotine from cigarettes in a less harmful way, like the gum, lozenges, patches and nasal sprays sold today. One such drug, Pfizer Inc.'s Chantix, is due on the market any day now. Another, Sanofi-Aventis SA's Acomplia, recently won approval in Europe as a weight-loss drug. If U.S. regulators follow suit, some doctors say they also will use it to help smokers quit, especially those concerned about gaining weight. ''The typical patient is a 30-year-old woman who says, 'If I gain 5 pounds, I'm going back,''' said Dr. J. Taylor Hays, a smoking cessation expert at the Mayo Clinic in Rochester, Minn., who helped test Chantix and other treatments. Other novel drugs are in development, but NicVax, by Nabi Biopharmaceuticals, a Boca Raton, Fla., biotech company with labs in Rockville, Md., is most advanced among the vaccines. After four smaller studies suggested it might be safe and effective, the new, larger study was started in Madison, Minneapolis, Omaha, San Francisco, Los Angeles, Boston and New York City. (People interested in participating must contact the company, but few volunteer openings are left.) The Food and Drug Administration has granted the vaccine fast-track status, meaning it will get prompt review, and the National Institute on Drug Abuse just gave Nabi a second $4 million grant to finance the study and NicVax's development. ''It's going to be a very good way to keep people from relapsing,'' predicts Dr. Frank Vocci, director of medications development at the federal institute. Relapse is the biggest problem quitters face. Of the more than 48 million smokers in the United States, 40 percent each year make a serious attempt to quit, but fewer than 5 percent succeed long-term. Nicotine replacement products combined with counseling can double that rate, but most quitters don't try them. Two-thirds go back to smoking within a month. ''When they have that first cigarette, if they really enjoy it, they're at high risk of relapse. If you can make that cigarette not so good, you've really got something,'' Vocci said. The possibility that a simple shot could do this is what lured Musachia to the Center for Tobacco Research and Intervention on the fringes of the University of Wisconsin-Madison campus earlier this month. He has tried many ways to quit but still smokes. ''I'm sick of it. I'm surprised I've lived this long,'' said the 75-year-old man. ''My kids -- they carry on like 2-year-olds when I smoke around them. My animals run and hide.'' He and other participants will get four or five shots, either four or six weeks apart, and will be studied for a year. Two-thirds will get the vaccine; the others, dummy shots. Neither they nor the doctors will know who got what until the study ends. They also will get counseling and must set a quit date, usually around the second shot, because the first shot is just meant to ''prime'' the immune system. Subsequent doses make it produce antibodies, which latch onto nicotine in the bloodstream and keep it from crossing the blood-brain barrier and getting into the brain where it maintains the addiction. ''They won't get the rush, the reward,'' but the small amount still getting in ''we think is an advantage,'' because it should lessen withdrawal symptoms, said Dr. Henrik Rasmussen, Nabi's chief medical officer. The antibodies should remain in the system for up to a year; booster shots may be needed after that, but this needs more study, Rasmussen said. The new drugs come at a time of heightened attention to helping smokers quit. Last month, the National Institutes of Health held a conference to review the scientific evidence for what smoking cessation techniques work. Earlier this month, two large scientific conferences were held in Washington, D.C., on the topic. Research money has increased because of tobacco lawsuit settlements, and insurers increasingly see the health burden of smoking and will pay for cessation treatments that work, said Douglas Jorenby, the psychologist who heads the NicVax study in Madison. Smokers also are demanding better results than those afforded by traditional nicotine replacement tools. Their desperation sometimes makes them prey to quacks. The FDA recently moved to block some companies promoting low-power laser therapy, or laser acupuncture, as a way to quit, and a consumer's group is seeking action against a bottled water product that contains nicotine. ''We've got 20 million Americans trying to quit. Among those trying, less than 20 percent are using evidence-based treatments,'' said Dr. Michael Fiore, director of the tobacco research center in Madison. The vast majority of these visit a doctor for routine care, yet ''few of them, less than a third, leave that encounter with evidence-based advice on how to quit smoking,'' he lamented. Regardless of whether the experimental vaccine or other novel approaches ultimately prove successful, they already have had a positive effect -- giving some smokers fresh motivation, Jorenby said. ''Every time there's a new treatment for smoking cessation, there are people who have never tried to quit, or haven't tried for a long time, who are going to give it a shot,'' he said. ''People benefit from practice. It usually takes several tries.'' On the Net: Tobacco research center: www.ctri.wisc.edu Associated Press, 7/27/2006 CHICAGO -- The American Psychological Association is under fire from some of its members and other professionals for declaring that it is permissible for psychologists to assist in military interrogations. An online petition against the group's policy has garnered more than 1,300 signatures from members and other psychologists. Protest forums are being planned for the APA's convention next month in New Orleans. And some members have threatened to withhold dues or quit. The unrest stems from an APA policy, issued last year, that says that while psychologists should not get involved in torture or other degrading treatment, it is ethical for them to act as consultants to interrogation and information-gathering for national security purposes. That stand troubles some members of the organization in light of the reported abuses at Guantanamo Bay, Abu Ghraib and elsewhere. ''The issue is being couched as psychologists helping out with national security at the same time that psychologists are opposed to the issue of torture,'' said Chicago psychologist William Gorman, an APA member who signed the petition and works with refugee survivors of torture. ''That stance in the present context appears to me incongruous.'' News reports have said that mental health specialists who are helping U.S. military interrogators have helped create coercive techniques, including sleep deprivation and playing on detainees' phobias, to extract information. The American Medical Association last month adopted what many view as a stronger stand against physician involvement in prisoner interrogation, echoing a position held by the American Psychiatric Association, whose members are medical doctors. The U.S. military has indicated it will therefore favor using psychologists, who are not medical doctors and are not bound by the other groups' policies. The Physicians for Human Rights, a Cambridge, Mass.-based advocacy group, issued a statement Wednesday urging APA leaders to ''explicitly prohibit psychologists from participating in interrogations.'' Salon.com reported Wednesday that six of the 10 people on the APA task force that drafted the psychologists' policy have close military ties, including four who have worked at Guantanamo, Abu Ghraib or Afghanistan. New York psychologist Steven Reisner, an APA member and vocal opponent of the policy, said those ties make the group's stance even more troubling. Gerald Koocher, APA's president, said that none of the task force members was involved in torture and that their military ties were not a conflict of interest. Some professionals, including Reisner, a faculty member at Columbia University's International Trauma Studies program and at New York University's medical school, want the 150,000-member organization to rewrite the group's ethics code to bar psychologists from any involvement in detainee interrogation. Reisner said fliers and forums are being prepared for the group's Aug. 10-13 convention ''to generate a momentum of embarrassment and outrage that the APA has thus far been facilitating these interrogations rather than stopping the violations of human rights.'' Responding to member concerns, the APA's ethics committee is drawing up guidance on what constitutes appropriate and inappropriate behavior by psychologists involved in interrogations, Koocher said. The APA also said that its governing council is expected to vote on a resolution on Aug. 9, a day before the convention, reaffirming the group's opposition to torture and other inhumane treatment. The group also has invited Lt. Gen. Kevin C. Kiley, the Army's surgeon general, to attend the convention and answer questions about military use of psychologists. APA: http://www.apa.org Web Gaming Addicts Face Legislated Fix Marni Goldberg, Chicago Tribune- 7/28/2006 WASHINGTON -- Pure curiosity is what drew Lauren Patrizi to online poker tables, where she placed her first $20 bet at age 19. She had watched her high school friends play the game and seen the World Series of Poker on TV, but when she clicked the mouse to make her first wager, Patrizi was hardly a seasoned player. Two years later, the 21-year-old senior at Loyola University Chicago openly discusses how what started as a game to pass the time left her in the throes of an addiction she's still struggling to overcome. "It became something, over the course of a year, where I went from playing once a week to a couple times a week to every day to all day to missing days of class," Patrizi said. "It's horrible. It really is. It's the worst feeling in the world." With online gambling on the rise in the United States, and the perceived threat it poses to vulnerable teens, college students and families, efforts to curb Internet gaming have gained new steam. This month, the House passed a bill 317-93 to make Internet gambling a federal crime. "The Internet is addictive for many people anyway, and online gambling can be doubly addictive," Rep. John Duncan (R-Tenn.), a co-sponsor of the bill, told the House. "We need to put modest and reasonable limitations in place on Internet gambling, and this bill does that." But the legislation has not been without controversy. Some critics complain that it exempts horse racing and state-run lotteries, while banning sports betting and wagering on poker and other card games. Groups like the Poker Players Alliance say the measure is unfair and would be ineffective if it became law. Political dimension The bill also has a political dimension. With the midterm congressional elections in November, it fits into what House Republican leaders are calling their "American Values Agenda," designed to appeal especially to religious conservatives. It includes House votes on such issues as a gay marriage ban and a proposed constitutional amendment against flag-burning. The gambling bill's prospects in the Senate are unclear and it may encounter opposition. Sen. Jon Kyl (R-Ariz.) has been the chief proponent of such legislation since he introduced the first bill to prohibit online gambling in 1995, and his office said he will continue to push the ban in the Senate. Since these gambling sites are operated outside of the U.S., critics have said that a ban on Internet gaming would be difficult to enforce. This legislation attempts to rectify that problem by creating policies to cut off the financial transactions that take place between institutions in this country and offshore sites, often located in the Caribbean or Central America. Internet gambling can be especially addictive, the bill's supporters say, because gamblers can avoid the embarrassment of losing in public. One online poker player, Greg Hogan, 20, a former class president at Lehigh University in Pennsylvania, pleaded guilty this month to robbing a bank in order to pay off $5,000 in online poker debts he had accumulated. But opponents label the legislation hypocritical, saying it unfairly rewards horse racing and state-operated lotteries by applying standards that would make online betting or wagering legal for these industries. Some have suggested that rather than outlawing Internet gaming, the U.S. should devise regulations for taxing it. "Outlawing Internet gambling is just going to push everything underground," said Michael Bolcerek, president of the Poker Players Alliance. "[People will go] from the larger sites that are financially stable and have age verification systems in place . . . to the other sites that don't have those controls." $12 billion industry Online gambling in the U.S. is growing at a rate of more than 20 percent a year, according to the American Gaming Association. Internet gambling is estimated to be a $12 billion industry, a significant source of revenue although that amount still falls far below the sums generated by commercial casinos, tribal casinos and state-operated lotteries. The horse racing industry supports the House legislation because the bill recognizes the Interstate Horse Racing Act, a 1978 law that made horse racing the only form of gaming that is regulated by federal statute. Other gaming interests have expressed concern. The Poker Players Alliance suggests that poker is an American tradition and a game of skill, which distinguishes it from chance-based gambling activity, like lotteries. The group thinks poker should be afforded special protection. The National Council on Problematic Gaming has taken a neutral position on the bill. "We think if you want to help problem gamblers, clarifying the law is helpful," said Keith Whyte, its executive director. "But what people who are suffering from this addiction really need is help in getting treatment." Authorities Weigh Drug That Stops Overdose Associated Press, 7/29/2006 PHILADELPHIA -- In the wake of more than 400 deaths nationwide from heroin laced with the painkiller fentanyl, some needle exchange programs are giving addicts prescriptions for a drug to keep on hand to halt an overdose. The antidote -- naloxone, which is sold under the brand name Narcan -- can save the life of someone who might not call 911 for fear of prosecution, treatment providers say. Even if a user does call, help can arrive too late. ''If people have to rely on paramedics, more often than not, the overdose is going to be fatal, just because of the amount of time for people to get there,'' said Casey Cook, executive director of Prevention Point Philadelphia, a nonprofit that runs the city's needle exchange program. The group recently began distributing naloxone prescriptions through a physician. But others say naloxone is best administered by trained paramedics and that the prescription approach might appear to condone drug use. ''We don't want to send the message out that there is a safe way to use heroin,'' said Jennifer DeVallance, a spokeswoman for the White House Office of National Drug Control Policy, which sponsored a symposium Friday on the fentanyl problem in Philadelphia. Fentanyl -- an opiate used legally in anesthesia and for some cancer patients -- is cheaper than heroin and 80 times more potent than morphine. That makes it an appealing additive for heroin distributors. At least 150 fentanyl deaths have been recorded in the Philadelphia area, 130 in Chicago and 130 in Detroit. John P. Walters, the director of the White House drug policy office, said investigators hope to learn whether a clandestine laboratory raided in Mexico last month was the source of much of the illegal fentanyl reaching the United States. ''We think and we hope that the production site taken down in Mexico was the (main) site,'' Walters said. Fentanyl can lead to respiratory failure so quickly that one addict in Philadelphia apparently died even before he finished shooting up. A syringe with some heroin still in it was in his arm when paramedics found his body, according to Capt. Richard Bossert of Philadelphia's Emergency Medical Services Administration. The case underscores the difficulty the medical community has faced in responding to the fentanyl crisis. Bossert said his unit has answered dozens of calls but has saved only two people. ''In other years, we were getting them (non-fentanyl heroin overdoses) to the hospital and they survived,'' Bossert said. 75 Police Officers Failed Boston Drug Tests Suzanne Smalley, Boston Globe- 7/30/2006 Since Boston police started annual drug testing in 1999, 75 officers have failed the tests, and 26 of them flunked a second test and were fired, newly released statistics show. Acting Police Commissioner Albert Goslin said an additional 20 of the officers who tested positive left the department on their own, which he said is because they could not handle the frequent follow-up checks. Of the 75 officers, 61 tested positive for cocaine, 14 for marijuana, two for ecstasy, and one for heroin, according to the figures, obtained by the Globe through a public records request. (Some officers had more than one drug in their system). Some specialists and department observers said they were alarmed by the number of officers testing positive for a ``hard" drug such as cocaine and questioned the department's policy that allows an officer to remain on the force after a positive drug test. An officer is not fired until a second positive test. ``It seems like it's a chronic problem," said Darnell A. Williams, president and CEO of the Urban League of Eastern Massachusetts. ``Here we're trying to deal with the guns and the drugs on the street level, but we have a more strident problem inside the department when we have that many people testing positive for drugs, especially cocaine." The department's drug testing policy is already under scrutiny, after reports that the alleged ringleader in a corruption case tested positive for cocaine in 1999, yet kept his job under the rules that call only for suspensions and treatment even for positive tests for drugs such as cocaine and heroin. Unlike Boston, the New York and Los Angeles police departments dismiss officers after a first positive drug test. Eugene O'Donnell, a former New York City police officer who is now a professor of police studies at John Jay College of Criminal Justice, said he believes the Boston police may have an unusually high number of hard-drug users because of its two-strikes policy. The New York Police Department has a very low drug test failure rate because of its zero tolerance policy, he said. ``Once you establish that people are fired, it does change the complexion," he said. ``If an agency says you can use drugs . . . it stands to reason you're going to have a higher rate of people using drugs." While 75 Boston officers failed drug tests out of a total force of about 2,000 sworn officers since 1999, at the much larger Los Angeles Police Department, 14 officers have flunked the drug test since March 2000. It employs 9,354 officers, of whom about 3,000 are subjected to random urine tests each year. A spokeswoman for the federal Substance Abuse and Mental Health Services Administration said that of the 150,000 federal employees who took random drug tests in 2004, 0.4 percent failed . In 1999, when the most Boston officers failed drug tests, the rate was more than double that, about 1.1 percent. Goslin said the testing policy and treatment have cut the number of positive tests since then. Boston police test for cocaine, heroin, amphetamines, PCP, and marijuana -- the standard list recommended by the federal government for workplace testing. Officers can also be tested for other drugs with reasonable suspicion. Officers are tested before they join the force, again while on probationary duty, then annually within 30 days of their birthday. They are also tested if they get promoted or assigned to a special unit such as narcotics or organized crime. If they test positive for any drug, officers receive a 45-day unpaid suspension and must get treatment. Once they return to duty, they are subject to random testing for three years, in addition to regular testing. Goslin said it is not fair to compare the department to other law enforcement agencies, which he said typically use a less sophisticated urinalysis test that does not detect drugs taken more than a few days before the test. He said the Boston police method of testing officers' hair is more reliable and can catch drug use dating back three months. ``I would expect our rate to be higher," Goslin said in an interview. Los Angeles police test urine for drugs, and New York police test hair. Goslin also said that Boston police test every officer annually, which is more regularly than many police departments, where a smaller number of officers are tested at random each year. Therefore, he said, all officers aren't screened consistently. The annual testing began in 1999 after years of negotiating with the city's powerful police unions, which had objected to the tests. In exchange for salary and benefit increases, the unions agreed to a system that gives officers warning by scheduling tests within 30 days of their birthday. The city's hair-testing method has also been disputed. Fifty-seven percent of officers who failed an initial drug test since 1999 were African-American, which troubles critics who believe blacks are more likely to get false positive results because of the texture of their hair. Last year, seven former Boston police officers -- all African-Americans who lost their jobs because of what they say were false positives -- sued the department, alleging the hair test is biased. The suit is pending . Goslin defended the test. ``The science is very good and can withstand any level of scrutiny," he said. Goslin said he is not surprised that the vast majority of officers who failed the tests had used cocaine. ``In the '60s it would be marijuana; now it seems to be cocaine," he said. But Mark A. de Bernardo, a labor lawyer in Virginia who is executive director of the Institute for a Drug-Free Workplace, said he is startled by the number of Boston officers who used cocaine. He said that while no one tracks national numbers on law enforcement officers who test positive for drugs, it is unusual for so many of the positive results to be for cocaine. ``In typical drug testing, the number of marijuana positives is going to be three, four, five times the number of cocaine positives," he said. ``That's alarming that cocaine would seem to be the drug of choice for the drug abusers in the Boston Police Department." He said the number of drug-using officers might be higher than what the testing shows because of the predictability of Boston's annual testing. ``Anybody who fails a drug test when they know a year advance within 30 days of when it's going to be . . . is a person who I consider to be an addict," he said. ``I'd assume that this is just a percentage of those that actually engage in actual drug use because it's not true random testing." He also said that by giving officers a second chance, Boston police are straying from the standard set by most other employees where workers are responsible for public safety. However, the Urban League's Williams said he believes the department is right to give officers a second chance, especially since in many cases it seems to work. Of the 75 officers who tested positive since 1999, only about a third failed a second test. Goslin said after the initial wave of positive tests in 1999, the policy has successfully cut drug use. ``People took the policy seriously and went to get help on their own, and that caused the numbers to drop drastically," he said. ``And it dropped every year the policy has been in existence." I Dulled Her Pain, and My Judgment A.J. Yim, New York Times- 7/30/2006 She was my favorite. We met at the clinic toward the end of a long August afternoon, just a few weeks after I had received my nurse practitioner license. Some people say hospitals are most dangerous in the summer, when so many of the residents are new. These were difficult times for me as well, dashing from room to room to keep pace with the waves of patients, stealing glances at reference books and drug guides, and feeling the dread of having to answer too many patients’ questions with, “I don’t know.” I was eager to earn their trust. That afternoon I walked into the room as if into a one-act play. The patient, a dirty blond in a wheelchair who looked to be in her mid-30’s, observed me coolly from behind sunglasses. Her husband, who had moody eyes under the rounded brim of a well-worn baseball cap, looked exactly like the daytime courier and moonlighting guitarist he was. They watched as I located the rolling stool, opened her chart, reviewed her vital signs and looked up. The encounter could now begin. She told me she was on an antidepressant (Paxil) as well as Toprol XL for an irregular heart rate. Until recently, she had also been on pain medication, the Duragesic fentanyl patch, which releases a low dose of narcotic over three days. Her relationships with doctors, she explained, had been contentious. A psychiatrist had refused to prescribe Paxil and insisted on switching her to another antidepressant. Another had tapered her pain medication against her wishes. And a third had made inappropriate comments and had begun to stalk her. I was easily charmed by her theatrical humor, colorful anecdotes (told in a deep Kathleen Turner voice), and seeming sincerity. I was touched by her stories of pain and depression. And she openly flattered me with lines like, “You seem different from the other doctors,” “You’re really listening to me,” and “Wow, you really know your medications.” A mentor had cautioned me that addicts are often creative, ruthless, persistent and even seductive to get what they need. But as a new practitioner, I was like a blossoming teenage girl, startled by my sudden power and vulnerable to experienced advances. I was still pretty green socially as well, having just re-entered the dating world after years of being cocooned by the intense work of graduate school. She suffered, she reported, from fibromyalgia, which rendered her nonfunctional and nearly bedridden, and she had come to the clinic seeking relief from the pain. Per protocol, I offered Ultram, a new drug that mimics an opiate without inducing addiction. In nurse practitioner school, they teach that pain is the fifth vital sign, as important to the assessment of apatient’s well being as blood pressure, pulse, temperature and respiratory rate. Although they urge us to treat pain as we might treat bronchitis or bad case of diarrhea, the reality can be more complex. As a rookie, I looked to the clinic’s head doctor for guidance. He was aggressive in treating pain, an anomaly in clinics that accept Medicaid patients. Most anyone who entered our clinic with persuasive medical records and an MRI report was prescribed a narcotic. Word of this traveled quickly and patients flocked to us like gulls to a beach picnic, some truly in pain and others with the voracious appetite of the addict. On her second visit, she came without her husband and wore a blue boa, as if for Mardi Gras. First I waited outside the door to the exam room for five minutes in slight pique as she chatted with the nurse. I was irritated by the delay in my schedule, but I also felt a pinch of jealousy. I’d been thinking of her between visits and concluded that perhaps Elavil, an antidepressant also used for insomnia and pain, might help. She reported minimal relief from the Ultram I had prescribed and requested something stronger. She accepted my suggestion of Elavil with a resigned shrug of the shoulders. On her third visit, she was unusually somber, answering my questions in monosyllables. When I asked her what was going on, she told me it was the anniversary of her fiancé’s death. He had died in a car accident a few miles from our clinic, on a notoriously dangerous highway. I offered her a box of tissuesas she regained her composure. The Elavil, she explained, had been great for sleep and mood but did little for her pain. She wanted something stronger and pushed for the fentanyl patch she’d had before. The negotiations continued as she pressed for a Class 2 narcotic, the strongest that may be prescribed under federal regulations, and I countered with a less potent, though still addictive, analgesic. I didn’t want to give in; the patch wasn’t appropriate. She pressed her argument, the subtext of which seemed to be: “If you really like me, if you really think I’m special, then you’ll give me something stronger.” And in a way she was right; our relationship seemed to grow stronger in concert with her increasing level of pain medication. I offered Vicodin.Before she left, there was paperwork: a signed pain-management contract, which almost seemed like a kind of prenuptial agreement; it established the rules of our relationship. There would be monthly visits for refills, random pill counts and random urine screens, no early refills, and no pain medications from other clinics. In narcotic affairs, we are jealous lovers and must be strictly monogamous. No extracurricular dating, ever. Every four weeks, like clockwork, she appeared for her Vicodin. When I saw her name in my schedule, I smiled at the expectation of a break from the parade of abdominal discomforts and asthmatic exacerbations. The conversations she and I enjoyed were rich and expansive: favorite books, recent movies, arguments with neighbors and family, philosophical reflections on the nature of pain and chronic disease. She knew intuitively the narrative I sought. After several months of office visits and referrals to various specialists, she actually walked into the office. No wheelchair. “I feel so good,” she began. “Thank you for helping me get to a place where I can stand and walk, without that damned wheelchair.” The wheelchair, we concluded, was a powerful manifestation of her inner fears and dependencies. Without it,she was making plans to re-enter the work force and pursue a degree in education. Over the next few months, our relationship deepened. One day she wore a pair of jeans that were decorated with whimsical hand-painted flowers and creatures. She was an artist, she revealed, and hoped someday to help children explore their creative potential. I told her of my travels, work abroad and literary aspirations, and she spoke of her childhood achievements as a figure skater and the ebbs and flow of her marriage. Of course, I should have seen the accumulating red flags. She called one afternoon in tears, claiming that her second cousins, who lived in Hong Kong, had driven off a cliff in the mountains and died instantly. She was deep in grief and in excruciating pain. I listened, pushing away my doubts. “What do you need?” “Please, more Vicodin, just for a week or two, to get me through this.” I called her pharmacy and prescribed 50 tablets, thereby breaking rule No. 3 of the pain-management contract: no early refills. I knew I was in too deep. Although I was troubled by my own actions and felt guilty about not trusting her, I was unsure about how to untangle this web even if I wanted to. If she indeed had been lying to me to obtain what she needed, it was equally true that I’d been complicit in my own seduction. As it turned out, things were already out of my hands: Our relationship was destined to end the same way so many dishonest relationships do, via a five-minute phone call from a stranger who discloses the truth. In our case, that stranger was a doctor with a long, lyrical Indian name who left a voice mail message, asking me to call. When I did, the doctor mentioned my patient’s name and asked, “Do you know her?” “Yes.” “I’ve been prescribing OxyContin to her,” the doctor said. “I confirmed it with two pharmacies. She’s been getting narcotics from both of us.” Shock gripped me, followed by disbelief, anger. “How long?” I managed to ask. “Two years.” From the beginning, she had had another. Reeling from this revelation, I found myself wondering:Had any aspect of our relationship been true, or was it all a con, a kind of emotional prostitution — her adoration in exchange for 7.5 milligrams of hydrocodone? Two months later, after countless phone calls back and forth, long messages on my voice mail, complicated explanations, pleas for a second chance, denials and recriminations, she again showed up in my schedule. Except now there was a bright red message on her chart: “No Narcotics.” She bore the ignominy of the “Scarlet NN.” The day before, one of the residents had denied her request for a cough syrup with a mild narcotic. During our appointment I also refused her request and, with as detached an air as I could manage, offered her instead a strong form of Robitussin. IS there anything I could do to change what happened?” she pleaded. “To make it like it used to be?” She launched into a convoluted justification of her actions, her issues with control and pain and doctors and trust. I heard her out, then handed her the prescription for Robitussin and politely excused myself. These days, I prescribe narcotics with greater prudence. The word on the street is that our clinic is out of the narcotics game, which means no more histrionic drug seekers, no more desperate calls late on Friday afternoon (“I left my pills at my aunt’s funeral! What if I go into withdrawal?”), and no more jilted patients stalking the clinic entrance until the police arrive. The doctor who couldn’t say “No” moved to a clinic down South, and now I promptly refer those who are in chronic debilitating pain to a pain management center. Every two or three months, a refill request from my patient, faxed from her pharmacy, crosses my desk; I am still, in name at least, her primary care provider. I sign off on her Paxil, noting that she must visit the clinic at least twice a year, and move on to the next patient. |