Previous jail chaplain Rev Herro Blair Jr has questioned Jamaica’s penal program, miracles if churches are truly geared up to offer with psychological well being, and lamented a lack of empathy.
In an interview with the Jamaica Observer, Blair Jr argued that self-righteousness is to be blamed for the mind-set of Jamaicans in the direction of men and women who go through from psychological wellness problems, which often lead to them to dedicate crimes.
“The selections for some individuals are past their own handling. They can’t manage what they are going as a result of. The everyday person on the outside the house claims, ‘No, he should really not have committed this crime or no, he should not have killed his spouse.’ But the reality of the issue is that the mental condition of the specific is what qualified prospects that individual to often commit the criminal offense,” Blair said.
“And that is why the Bible describes dealing with the entire person. The entire male is not just a non secular person and not just a physical guy, but also a man whose psychological state has to be dealt with. We have lost our empathy, not realising that we, too, can go as a result of the same problem,” he continued.
There is an difficulty to be dealt with, claims Blair Jr.
Blair pointed to reports of amplified psychological instability amid Jamaicans more than the very last two years, and explained to the Sunday Observer that the issue has crept about into 2023.
“So, there is an issue there to be dealt with. If a law firm goes to court and states a gentleman dedicated a criminal offense because of a [mental] condition, it desires to be dealt with, definitely. We, the Church, are not excellent both. From the pastors down to the users, we all go by way of our personal conditions and we have to deal with them.”
At the start out of the year, Prime Minister Andrew Holness implored Jamaicans to acquire treatment of their psychological well being and to find help if overcome, depressed, or unable to cope.
The information came from Holness in his address to the nation on New Year’s Day.
GULLOTTA … inmates are hostages captured between various businesses which are supposed to deal with their trials and them serving time
“Find an individual to speak to. We Jamaicans are inclined to think of ourselves as difficult, ‘tallawah’, equipped to take on and defeat difficulties bigger than ourselves. On the other hand, more than time, this challenging attitude has led to an ineffective reaction to personalized and social trauma in our life,” he stated.
Further, Blair said that oftentimes, Christians are inclined to deal with their difficulties by working with prayer only.
“That is not the way to offer with it. There needs to be approaches that we can identify and offer with our mental ability, our psychological condition,” he mentioned.
“Even me as a pastor heading through a divorce and declaring to myself, ‘I in no way planned to get divorced. I never planned to be in this article. I am a pastor.’ But then, it takes place and you have to face the realities of lifetime the decline of children, the reduction of a wife. It drives you to do issues you didn’t even assume you would do,” Blair went on.
In the meantime, Carla Gullotta, executive director of Stand up for Jamaica (SUFJ), stated it is necessary to admit that obtaining mentally ill inmates in jail carries on to be a worry.
She reported the circumstance of Noel Chambers, 81, who died in a facility following a 40-year wait for a trial highlights the urgent want for alter.
“Inmates are hostages captured between distinctive businesses which are meant to deal with their trials and them serving time. The Section of Correctional Companies may possibly be an insufficient executor, but fundamental focus has to be on justice technique and its lack of accountability. Mentally ill inmates are unable to be fit to plead and want to be diverted to community mental wellbeing treatment and for a modern forensic psychiatric facility to be created to give treatment for the most intense instances,” she instructed the Sunday Observer.
“The Department of Correctional Providers is only not equipped to deal with mentally sick inmates and as this sort of, it is up to the courts to uphold the human legal rights of these persons by ordering that they be removed from prisons and be supplied with the psychological well being companies that they require. Jail is no place for a person who is mentally ill. Jail requires to grow to be the area where inmates are nonetheless deemed as human beings and use the serving time to discover a better lifetime.”
The Mental Health Project is a Seattle Times initiative focused on covering mental and behavioral health issues. It is funded by Ballmer Group, a national organization focused on economic mobility for children and families. The Seattle Times maintains editorial control over work produced by this team.
The suits were in town, prepping for a Friday news conference on the brick steps of Western State Hospital.
A photo from that day in Lakewood in May 2018 shows a united front. Hospital officials shoulder to shoulder with state lawmakers, and at the center, Gov. Jay Inslee. These officials were ready to “transform the state’s mental health system” after years of underfunding, lawsuits and federal warnings that threatened to close down Washington state’s largest psychiatric hospital — nearly 800 beds that served some of the most vulnerable residents.
“This is a heavy lift,” Inslee said.
He presented a plan that by 2023 would focus Western State on only serving patients who had been accused of crimes and were coming from jails. State agencies would build new, smaller centers across the state to serve people who weren’t facing charges but were sent for psychiatric commitment by the civil courts.
“It’s an aggressive timeline,” Inslee acknowledged. “2023 is tough, but doable. And it’s necessary.”
It is now 2023. The state failed to meet its goals.
In a quest to revamp mental health care, state officials made a challenging transition even harder — shutting down some of Western State’s wards without the planned community facilities that were supposed to take the people who relied on the state hospital. Combined with the unexpected effects of the pandemic, the resulting logjams have overloaded both jails and psychiatric facilities and left hundreds of incarcerated people languishing without mental health services.
The repercussions have left families and advocates frustrated and have embittered local law enforcement. Often the only two options seem to be either letting people struggle on the streets without care or criminalizing mental health and warehousing them in jail.
Staff and advocates say they warned state officials that the plan needed changes. Mike Yestramski, a social worker by training, remembers that day at Western State in 2018 clearly because he and other hospital union staff were asked to stand in that photo alongside the smiling politicians.
They refused.
“It’s not that we were not supportive of the vision,” explained Yestramski — though union leaders were also concerned that the plan could lead to fewer union jobs in the future. “It was the details, the logistics being worked out … What we’re seeing now come true.”
“We’re moving along by shutting down the civil beds before the community beds were built and ready to go.”
Indeed, this June, another ward is slated for closure — and the patients must go somewhere.
The blueprint
Western State has historically served two main types of patients. Those coming from jails — the state calls them “forensic patients” — need basic mental health services, like evaluations to determine whether they’re competent to stand trial, and restoration treatment to get them back to competency. It also houses “civil patients,” who are not criminally detained but are so seriously sick that they meet the threshold for involuntary commitment through a separate civil court system.
In the past, most of the patients were on the civil side, but in 2015, moves began to shut down the wards where they stayed.
Washington officials were facing challenges on a couple of fronts: The Centers for Medicare & Medicaid Services was scrutinizing Western State more closely after patient-on-patient assaults, threatening a loss of accreditation and federal dollars.
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Around the same time, state officials at the Department of Social and Health Services faced a federal lawsuit over allegations they were violating incarcerated people’s due-process rights. People deemed potentially incompetent to stand trial were being held in jail for weeks or months because the state was failing to get them to Western State to get them evaluated or treated.
A federal judge ultimately ordered hospital officials to provide timely services within one to two weeks. Even today, the state is still failing to meet those timelines: In January it was taking about 100 days for patients to receive treatment. Currently, about 464 people are detained in jails across Washington state awaiting competency or restoration mental health services — an additional 344 are waiting out of custody.
In response to these ongoing issues, Washington legislators by spring 2016 had convened a special committee to improve the state hospitals.
Consultants came back with a lengthy report that fall that included nine recommendations. Among their suggestions: Transition the state hospitals into facilities that focus on patients coming from the jails. Build six more long-term civil facilities for patients transitioning out of state hospitals and into the community. Add three mobile crisis teams, and two new crisis centers to pull off the transition.
In May 2018, Inslee, state legislators and government officials announced a plan building off that blueprint, which included the construction of a new forensic hospital on the Western State campus with 350 beds for people coming from jail.
Today, while some of Western State’s last civil wards are set to close in June (delayed from a previous April 1 deadline), few of the other solutions recommended by the consultants exist. Washington has built two of the six civil facilities, most notably a 16-bed facility that debuted in January at Maple Lane near Centralia. Another treatment center in Snohomish County will break ground this spring — with two more facilities in Clark County expected in the winter of 2024.
Additional beds are expected to come online at the University of Washington’s new behavioral health teaching facility at the end of 2023 and at Western State’s forensic hospital in 2027, at the earliest.
In the meantime, however, there are no walk-in crisis centers in King County and by and large, hospital emergency rooms and jails take the responsibility of caring for people, despite the high cost and being ill-equipped to treat people in psychiatric emergencies. Mobile crisis teams are limited in size and are siloed among mental health service providers, police and fire services.
“Do I think everything that we contemplated five years ago is going to be done this year? No,” said Amber Leaders, the senior policy adviser on behavioral health, aging and disability with Inslee’s office.
“We are at a pinch point,” she said, with the civil wards winding down while other housing and treatment options are still coming on line.
“We have made a lot of progress in terms of building up the community capacity that we’ve talked about. But building a brand-new, shiny new forensic hospital takes some time,” Leaders acknowledged.
State Rep. Nicole Macri, who has been deeply involved in the transition of the mental health system since she joined the Legislature in 2017, acknowledged the plan is “behind schedule,” but said “we haven’t lost sight of the goal.”
“We invested over $800 million in behavioral health in the ‘21 and ‘22 sessions. We should have been investing at that scale for years before that,” added Macri, D-Seattle.
She points to the ripple effects of the Great Recession and how it led to significant cuts in funding for these services through the following years. Around that time, under former Gov. Christine Gregoire, state leaders similarly tried to “transform” Washington’s ailing mental health system but found limited success in restitching a complex, fragmented system.
Still, others note missteps in the latest iteration:
“Five years is never a long enough runway when you’re talking about problems that need to be faced with a complete systemic overhaul from top to bottom,” said Lauren Simonds, the executive director of the Washington chapter of the National Alliance on Mental Illness.
Kim Mosolf, director of treatment facilities with the advocacy organization Disability Rights − Washington — which sued over the delays in mental health evaluations and treatment for people in jails — points out that the new community beds that have come up are at best a replacement for what was lost.
“HCA [Washington Health Care Authority] has opened roughly 190 long-term community civil commitment beds since 2018 when they started this project,” she said. “However, they’re [closing] 180 beds at Western State Hospital. So it appears to be a zero sum game.”
Yestramski, the social worker and now president of the Washington Federation of State Employees, said the idea of small facilities closer to patients’ homes was a “great idea on paper” but as state officials soon found out, “the problem is once they set out to build those, you have a lot of issues with NIMBYism.”
Indeed, the construction of a new civil facility in Snohomish County faced “not-in-my-backyard” pushback from the community. Similar attempts to build enhanced services facilities for people with mental illnesses in Auburn and Burien were floated in the last few years but failed when local residents objected.
Kinks in the system
One of the biggest reasons for delays at Western State, though, is the rising number of a particular type of patient. In prioritizing patients coming from jails, officials didn’t account for the fact that the civil and forensic patient populations often intermingle; closing one door had ripple effects in the other.
One perfect example of that is called a civil conversion.
If a patient coming from jail cannot be restored to competency, their criminal charges are typically dropped. Prosecutors can then “flip” their case, kick-starting a separate process that sends the person back to a state hospital but this time for civil treatment. This occurs most often in serious, felony-level cases.
But flipped patients often take four times as long to go through treatment at Western State because they receive more thorough mental health treatment. In comparison, the medication and services given to their jail-based counterparts are often only enough to make them competent in court — meaning they can identify the role of a judge or how to communicate effectively with their attorney.
While a patient coming from jail may spend up to 90 days at the hospital for services, a civil patient can stay for a year or longer.
That valuable space at the hospital causes backlogs for people who are languishing in jail while they wait for a spot to open at Western State. The number of patients being civilly converted has grown dramatically.
On any given day, “That number in the last year has climbed from say traditionally about 30 to 175,” said Thomas Kinlen, the director of the DSHS Office of Forensic Mental Health Services.
Prosecutors increasingly opt for this practice to try to keep people who might be a public safety threat off the street. Both Seattle and King County prosecutors have told The Seattle Times that this method offers at least some treatment for people with severe mental illness — and some respite from community complaints.
However, even when community beds are present, another barrier exists for people discharging from state hospitals — especially if they have complicated backgrounds, like developmental disabilities or a history of violence. The facilities meant to house those civil patients can often decline to take certain people or rescind their placement, a practice common in other parts of the behavioral health system.
Often it’s not financially or logistically feasible for providers to take those patients because they require more staff time and services. That means some of the most vulnerable patients go without appropriate long-term care or housing.
Rick Deluga, a clinical supervisor on the community outreach and assessment team at Downtown Emergency Service Center, sees this first hand. Most of his clients are coming from jails or the hospital, and “they’re basically just getting stabilized and then being returned to where they came from,” he said.
“That’s usually an environment that continues to induce trauma, whether it’s because they’re on the street or they are released to a housing site or a shelter that may not be the best place for them to be due to the level of vulnerability,” he said.
In a 2021 report, the Washington Health Care Authority told legislators about those concerns, saying that some people’s “complex and challenging needs” exceeded what community-based resources could provide.
The report cites the need for better payment rates for these hard-to-place patients, further training for the staff handling their care, specialized facilities for geriatric populations or those with additional needs, and the creation of “no-refusal” facilities who would be forced to accept all patients — essentially, state-run services like those Western State and Eastern State used to provide.
Lisa Corthell, a psychiatrist working at DSHS’ Maple Lane residential treatment facility, said the Western State backlogs are trickling into her work as well.
“Historically, [Western State has] been pretty good about freeing up a bed for us,” Corthell said. Her facility typically takes patients who are considered less acute or sick than the patients who go to the state hospitals.
But in December, a patient of hers had to be transferred to a higher level of care at Western State and she found herself negotiating with the staff: “They said, ‘We can’t take them unless you take one of ours,’” she explained.
“We’re going ‘What?’ We’re not supposed to be getting patients from Western. We’re supposed to be taking patients in from the jails.”
Moving forward
For Western State, the 2018 plan was a little too much, too late. By that summer, the hospital lost the federal accreditation it had hoped to earn back, and with it, about $53 million of funding. Still, the state poured millions into programs to ameliorate delays for mental health services for incarcerated people, and those time frames were starting to improve at last.
Then the pandemic decimated the mental health sphere: More people sought care as workers simultaneously left the field for better pay and safety.
Nevertheless, in 2021 the Legislature tasked DSHS with closing six of Western State’s civil wards in order to make room for the construction of the new forensic hospital that would focus on people coming from jails. In total, 180 people have been or will soon be transferred to community settings.
King County behavioral health officials saw the challenge ahead and pleaded with state legislators not to close the wards before other facilities were in place
“Additional civil ward closures will leave individuals stuck on waiting lists, in community hospitals not designated for psychiatric care and, for some, in homelessness,” they wrote in a 2021 behavioral health agenda.
Mental health resources from The Seattle Times
Police and prosecutors say we’re seeing the effects now. To keep the public safe even as mental health resources remain limited and local jail and police staff numbers drop, law enforcement has relied on arrests to keep people considered dangerous off the street, even as those same people fail to get proper care and get sicker in jail.
Currently, at least 87 people in the King County Jail system are waiting for court-appointed mental health services, out of a population of about 1,200.
Seattle City Prosecutor Ann Davison, who ran on a platform of law and order, is especially frustrated with the inability to get misdemeanor-level detainees mental health services through the state hospitals. State officials chose to focus on providing mental health services to people accused of felonies instead, she said.
Often, if King County prosecutors don’t charge a person with a felony, their case “rolls downhill” to her office, she said. But then that person loses priority for restoration. If they’re not competent, that person will likely just cycle through the jail again.
“It’s as if we’re asking both the community and that person who is struggling to wait until they commit a more serious crime, “ said Davison.
“Only then will we step in and say ‘Well now you are worth it, the problem is worth it.’”
Residents, too, are reckoning with the consequences.
“We feel helpless,” said Tanya Woo, a local volunteer with the CID Community Watch, a group that organizes weekly walks and provides homeless residents with basic needs like socks and food.
Woo has seen residents with mental illnesses cycle through jails, hospitals, drug use and homelessness. While she doesn’t want police to be the first response, she also acknowledges the cycle takes a toll on the local neighborhood, especially when people in crisis become physically combative as a symptom of their illness.
In one instance, Woo tells of a 49-year old man with a history of mental illness who’s had over two dozen interactions with police since the early 2000s — at times he’s spat on people or been arrested for harassment and assaultive behavior.
His charges are often dismissed and Woo wishes there was a way to get him treatment — or at least a heads-up when he is released. Prosecutors or judges tend to dismiss “less serious” charges precisely because of the deadlines that kick in if the detained person is not competent.
Prosecutors then respond by focusing on offenders with the most serious charges, or by going the route of the civil conversion.
Most recently, however, DSHS sent a memo to local officials in December stating the “ability to admit new patients to Eastern State Hospital and Western State Hospital has reached a critical point.”
The state hospitals would no longer admit civil conversion patients, and those individuals could end up being “released from jail into the community.”
While crisis facilities are being floated in King County, and agencies like the state Department of Commerce have invested $160 million in the last biennium to build up facilities, the mental health system transformation promised in 2018 remains stunted with years left to go.
For Washington mental health professionals like Corthell, Yestramski and Deluga and their patients, change has been painstakingly slow.
Still, state officials seem keen with their Sisyphean task.
“This is the first time in quite a long time that I can remember that it feels like the Legislature is truly grasping that we are at an emergency sort of crisis level,” Yestramski said.
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This story was produced via a USC Annenberg Center for Health Journalism Data Fellowship.
Kayla Quinones began having contractions a few hours after midnight. Her baby, Jacarri, was on the way.
Quinones, 33, was homeless at the time and staying with a friend in upstate New York, and when she began to feel the undulating pains, spaced about 8 minutes apart, she called for help. Those pains, her friend told her, were contractions. They needed to get to a hospital.
Before staying with her friend, Quinones spent 6 years living on the streets of Sullivan County, about 2 hours north of New York City. She had been using heroin for 7 years, and cocaine for the last 4. She was homeless for the majority of her pregnancy. And using for all of it.
Doctors rushed Quinones to the delivery room, and the birth went smoothly. Jacarri was born healthy, but had developed neonatal abstinence syndrome. At the time of his birth, Jacarri had methadone and cocaine in his system, so doctors transferred him to the neonatal intensive care unit at a nearby hospital. The hospital where Quinones delivered him did not have one.
After Jacarri’s birth, Quinones was more motivated to get help for addiction than ever before. Jacarri’s father, Quinones’ longtime partner, died when Quinones was 4 months pregnant, and she was now learning that she’d lost custody of her baby. Jacarri would be going to stay with Quinones’ mother in Queens and would stay there until Quinones could get into a treatment program. She was again living on the street, searching for a program that would take her in.
It wasn’t the first time she had looked for help. She had been enrolled in a methadone program during her pregnancy, but continued to use heroin.
Now looking for a more comprehensive treatment program, Quinones ran into a new problem. Because she hadn’t received a postpartum check-up — which typically occurs between 4 and 6 weeks after delivery — many treatment centers wouldn’t take her, she said.
“They were denying me left and right,” Quinones told MedPage Today. “I was still running the streets, and miserable because they took my kid away. And I was worried that I wasn’t going to get into a program.”
In an underfunded, siloed mental healthcare system, pregnant and postpartum people with addiction face endless barriers to treatment. While patients typically come into contact with the medical system more frequently during pregnancy, those with addiction struggle to get adequate care, as insufficient numbers of behavioral health providers, logistical hurdles, and distrust of the medical system deter people from accessing treatment, according to providers, patients, and advocates.
“There is a presence of substance use that often gets overlooked and undertreated in pregnancy,” said Leah Habersham, MD, an addiction medicine specialist and ob/gyn at Mount Sinai Health System in New York.
Medication-assisted treatment (MAT), such as buprenorphine (Suboxone) and methadone, are the gold-standard treatment for pregnant patients with substance use disorder. These therapies manage cravings and prevent patients from going into withdrawal, which can result in preterm delivery or fetal growth issues.
But not all patients can access MAT, data show. Nationally, only half of pregnant patients with opioid-related substance use who received care at an addiction treatment center received methadone treatment in 2020, according to an analysis performed by MedPage Today.
Those who seek treatment in New York, where Quinones lives, receive it at a rate higher than the national average. In 2020, there were 635 episodes of treatment involving opioid use in pregnancy at New York addiction treatment centers. Of those treatment episodes, 75{35112b74ca1a6bc4decb6697edde3f9edcc1b44915f2ccb9995df8df6b4364bc} received MAT at discharge.
The data, which come from the Substance Abuse and Mental Health Services Administration’s (SAMHSA) treatment episodes database, is a compilation of addiction treatment center data reported by state agencies. Many of the treatment centers that report to SAMHSA receive state funds or federal block grants to provide drug or alcohol treatment services, the agency says.
Of the 6,200 times pregnant patients received opioid-related treatment nationwide in 2020, all received care at addiction treatment centers, such as methadone clinics or specialty behavioral health centers. However, providers say this is an underestimate of patients that receive care.
Many patients access treatment for substance use disorder outside of specialty care facilities, including from a family medicine provider, addiction specialist, or ob/gyn practitioner who prescribes buprenorphine — treatment that is not recorded in public databases.
Not knowing how many patients do or do not get treatment poses a host of issues, according to patients, providers, and advocates. Without an accurate count, it’s difficult to properly allocate resources to treat substance use disorder among the population of pregnant patients, they say.
“We don’t know how many people receive comprehensive services,” said Mishka Terplan, MD, MPH, a board-certified ob/gyn and addiction medicine specialist based in Maryland. “And that’s really kind of unknowable.”
Kayla Quinones, who lives with her son Jacarri at Greenhope Services for Women in East Harlem, New York, looked for treatment centers for a month before enrolling in the residential treatment program at Greenhope. Before having her baby, judgment and stigma from medical providers prevented her from seeking care, she says. Photo by Liam Quigley.
A Growing Problem
More than 1 million people have died of an overdose since the opioid epidemic began in the late 1990s. The crisis intensified during the COVID-19 pandemic, as isolation and interruptions to medical care led to skyrocketing overdose deaths.
Nationwide, there were an estimated 108,000 overdose deaths in 2021 — an all-time high, CDC data show. The majority of those deaths involved fentanyl, a synthetic opioid that’s 50 times more potent than heroin.
Opioid use disorder trends among pregnant patients are directly connected to patterns in the general population, Terplan said.
In total, 6,000 women had a maternal opioid-related diagnosis at delivery in 2017, the most recent year for which data are available, according to a study in JAMA. Self-reported data from the CDC suggest that 6.6{35112b74ca1a6bc4decb6697edde3f9edcc1b44915f2ccb9995df8df6b4364bc} of women used prescription opioids during pregnancy. One in five women who used prescription opioids reported misuse, the study showed.
“We all know that opioid use disorder is a rising problem, and it’s hitting the pregnant population as well,” said Wendy Wilcox, MD, chief women’s health services officer at NYC Health + Hospitals, New York City’s public hospital system.
The vast number of opioid-related deaths has left policymakers scrambling to solve a worsening addiction problem. Last October, the Biden administration released a plan to improve access to substance use disorder treatment for pregnant and postpartum people specifically.
The plan aimed to correct issues that were preventing patients from accessing MAT and looked to improve public reporting of access data.
Currently, there are no public databases that clearly show how many patients — pregnant or not — get medical treatment for substance use disorder. (Click here for more on the challenges of reporting data around substance use in pregnancy.)
Late last year, the federal government also deregulated buprenorphine to improve treatment access. Providers previously needed an X waiver — a special Drug Enforcement Administration (DEA) certification — to prescribe buprenorphine, which required an 8-hour training and restricted the number of patients a clinician could treat.
After years of rolling back restrictions, the federal government eliminated the X waiver entirely in December. The nixing of the rule allows any provider with a DEA license to administer buprenorphine, pending a one-time training.
Most ob/gyns are licensed by the DEA to prescribe controlled substances. But addiction medicine experts worry that though federal regulations on treatments for substance use disorder have begun to ease, there will remain a gap between the number of primary care providers and ob/gyns willing to prescribe buprenorphine and the number of patients who need it.
Should Ob/Gyns Provide More Addiction Care?
Medical organizations, including the American College of Obstetricians and Gynecologists (ACOG) and the American Society of Addiction Medicine (ASAM), have firmly said that they believe MAT is the gold-standard treatment for pregnant patients addicted to opioids.
Though there are three drug treatments available to all patients with opioid use disorder, methadone and buprenorphine are the most commonly prescribed treatments for pregnant patients. The opioid antagonist naltrexone (Vivitrol) is also safe to use in pregnancy, but is recommended less often because it requires patients to stop using opioids for about 2 weeks prior to initiating treatment.
Despite the recognition that MAT is widely believed to be the optimal treatment for opioid-addicted patients, providers who are not trained in addiction medicine still don’t feel comfortable administering it, said Daniel Rosa, MD, medical director of the Acacia Network, a human services organization in the Bronx that provides addiction treatment services.
“The problem has always been the buy-in from ob/gyns and primary care providers,” Rosa said. “It still falls on the very few people who happen to be board-certified in addiction medicine.”
Methadone can only be dispensed through a SAMHSA-authorized opioid treatment program. But now, most ob/gyns and nurse midwives can prescribe buprenorphine, as long as they have a DEA license.
Before buprenorphine was deregulated, ob/gyns did not get certified to prescribe it in large numbers. Less than 2{35112b74ca1a6bc4decb6697edde3f9edcc1b44915f2ccb9995df8df6b4364bc} of ob/gyns who treat patients on Medicaid had an X waiver as recently as 2019, according to a study in JAMA Network Open.
“That to me, is evidence that the workforce has failed,” Terplan said.
Addiction medicine is typically viewed as separate from reproductive healthcare, Terplan explained.
“Ob/gyns provide episodic care, and addiction is a chronic condition,” Terplan said. “That’s a clinical mismatch.”
Even then, asking ob/gyns to initiate care for patients with opioid use disorder puts the onus on the doctors to treat the highest acuity patients in a different specialty, Terplan added.
Take treating a patient with diabetes, Terplan said. “The first time you take care of somebody with diabetes is not the person who’s in a diabetic coma with a gangrenous foot in the emergency room. It’s somebody in the outpatient setting who’s on insulin, who brings their sugars, and you look at the sugars and you slightly adjust the insulin dose,” he said.
“Basically, we’ve been asking people for the last 20 years to take up a new domain of health and start with the sickest patient. And, there’s some DEA surveillance for the prescribing practices,” Terplan said. “I don’t think it’s a categorical surprise that uptake has not been what it could be.”
Until there is more training around the prescription of buprenorphine, experts are skeptical that the elimination of the X waiver alone will lead more ob/gyns and primary care providers to treat pregnant patients with opioid use disorder.
“I don’t think it’s going to be that … a ton more primary care doctors or ob/gyns are going to start prescribing,” said Amy Van Milligan, MD, an internist and pediatrician who provides MAT in Cincinnati.
Elimination of the X waiver takes away the mandatory 8-hour requirement, Van Milligan added, “but it’s not going to make people magically comfortable with substance use disorder.”
Why Treatment ‘Just Doesn’t Work’ for Pregnant People
Just as some ob/gyns and primary care providers may have difficulty treating pregnant patients with opioid use disorder, providers comfortable with treating patients with substance abuse may not feel comfortable treating pregnant patients. It all amounts to a siloed system that some say makes it difficult to connect patients with the various types of care they need.
“There’s still some confusion out there amongst MAT providers about how to care for pregnant people,” said Jaine Fairbairn, a wellness coordinator at the neonatal abstinence program at Margaretville Hospital in New York. “And trying to find an ob/gyn who is versed on the actual prescribing of MAT is very difficult.”
But once pregnant patients get linked to prenatal care and find an addiction treatment specialist, then the hard work begins: obtaining care.
Fairbairn works with around 10 pregnant patients at any given time. In addition to advocating for her clients in the exam room, Fairbairn connects her patients with resources like diapers or baby food, answers questions about what to expect at each stage of the baby’s development, and helps patients coordinate transportation to medical appointments, she said.
In Delaware County, where Fairbairn works, the sheer logistics of getting to and from doctor’s visits is one of the biggest challenges that patients face. The county is the size of the state of Rhode Island, but is home to around 45,000 people, she said.
“Here in the rural universe, methadone is almost impossible to maintain,” Fairbairn said. “These places are all an hour, an hour and a half, two hours from wherever you are.”
Medicaid transportation is available, but unreliable, Fairbairn added.
“Once a patient has been burned a couple of times, they just refuse,” she said.
Child care and other family responsibilities also pose barriers. “Addiction treatment isn’t easy if you have other kids at home,” Van Milligan said.
During pregnancy, patients are already overwhelmed with the number of appointments they need to make with their ob/gyn alone, she said. Factoring in a different provider that administers MAT, coordinating transportation, and figuring out who is going to watch the kids at home — it becomes nearly impossible for some patients to get treatment, she added.
“It’s not that they don’t want it, it just doesn’t work,” Van Milligan said.
In addition to the barriers to treatment posed by coordinating care, many pregnant patients with addiction may avoid treatment — both for prenatal and addiction care — because they don’t trust medical providers.
Quinones first went to an ob/gyn when she was about 8 weeks into her pregnancy.
“I was nervous at first, walking in and knowing that I was going to have to tell him that I was an IV user,” she said. On top of that, she used cocaine, had hepatitis C, and hadn’t been to a gynecologist in 5 years.
“The doctor basically told me I was a junkie and I had to stop using, otherwise I wasn’t going to be a good parent and my kid was going to come out just like me,” Quinones said. At one point during the appointment, her physician told her it was still early, and asked if she was certain she wanted to keep her baby, she told MedPage Today.
Quinones walked out of the healthcare facility before even putting on a hospital gown. She didn’t try to get prenatal care for the remainder of her pregnancy.
“I was disappointed, but already kind of knew that that was going to happen,” Quinones said. “Because I’ve been through it so many different times.”
While the stigma of addiction is enough to keep patients out of the doctor’s office, they also run the risk of losing custody of their child or children. (Click here for more on the relationship between access to treatment and the child welfare system.)
Fear of the medical system and child protective services (CPS) prevents patients from telling their providers the truth about their substance use, Habersham said. Fear and stigma not only impact a patient’s ability to get timely care — it affects the public health system’s ability to assess how many people may struggle with addiction in pregnancy.
Recently, Habersham saw a pregnant patient at Mount Sinai’s female-only methadone clinic in New York City. The patient became addicted to prescription opioids, and then heroin, and was now seeking addiction treatment before going to the ob/gyn for prenatal care.
Habersham encouraged the patient to come to a clinic she started at Mount Sinai last year called the Bridge Program, which provides integrated addiction and reproductive healthcare. She told the patient that she could get her an ultrasound and labs so that they could begin to assess her pregnancy and initiate prenatal care. But on the day of her appointment, the patient was a no-show.
“She ended up not coming,” Habersham said. Habersham reached out to the patient’s social worker, who told her that the patient was fearful that her children at home would be taken away from her.
“I think that as we change the narrative, as we decrease the stigma, and as we start linking patients with treatment instead of linking them with CPS, that we are going to see the true numbers,” Habersham said. “I don’t think that in the current climate, that we’re going to reach that point.”
Greenhope Services for Women in East Harlem, New York, which is an affiliate of the Acacia Network, provides residential recovery services to women and their children. Children up to age 5 are eligible to stay with their mothers in treatment. Photo by Liam Quigley.
The Push for Comprehensive Care
Habersham wishes there were more centers in New York for patients to receive a range of services at once — prenatal care, behavioral health counseling, addiction treatment, and more.
In 2016, David Garry, DO, a maternal-fetal medicine specialist at Stony Brook Medicine in New York, started the Maternal Opioid Management Support (MOMS) program. The outpatient clinic provides buprenorphine treatment, behavioral health counseling, social services, and prenatal care.
“I think medication alone is not the answer, and I think that counseling alone is not the answer,” Garry said. While medications can address the biochemical mechanisms in the brain that cause drug cravings, counseling helps patients work through mental trauma, he said.
Comprehensive care sites like the MOMS program exist throughout New York State, “but it’s tricky to get them paid for,” Terplan said.
Prenatal care is bundled, so it’s often reimbursed to providers as one lump sum per pregnancy. When an individual provider gets a bundled payment for prenatal services, it can be seen as double-dipping when they charge fee-for-service payments for addiction care on top of that, Terplan added.
“It makes this integrated care by the same provider really difficult to realize,” he said.
Some providers, like Garry, have gotten around that barrier. His program’s ability to provide prenatal and addiction treatment in one place is not only cost-effective for patients, but it also reduces the stigma of accessing addiction care.
“They are just like any other patient in the office,” he said.
Garry said that his clinic tries to follow up with patients 1 to 2 weeks after birth — the postpartum period is a time when many patients may fall back into drug use. More intervention during this period could reduce preventable deaths, he added.
Almost a month after Jacarri was born, Quinones found a treatment center that would take her in, despite the fact that she had not received a postpartum check-up. She became enrolled at Greenhope Services for Women, a residential, female-only addiction treatment center in East Harlem.
Greenhope, a part of the Acacia Network, allows children up to age 5 years to stay with their parents in treatment. A month after Quinones arrived at Greenhope, a judge granted her custody of her baby. Jacarri, now age 7 months, lives with Quinones full-time.
Quinones has access to primary, pediatric, and addiction care through Greenhope’s network of providers. She leaves the facility’s campus for methadone treatment, and is steadily decreasing her dose of the treatment until she can wean off of it entirely.
The death of Jacarri’s father, her fears for the future of her child, her unstable living situation — it all served as a pull into addiction, while simultaneously motivating her recovery.
“Every reason why I was using was pretty much a great choice for it,” she said. “But at the same time, everybody was also dying. I didn’t want Jacarri to grow up without his mom.”
But all the contradictions of addiction and every barrier to treatment were trumped by Jacarri, the boy who unknowingly provided the final push his mother needed to get care.
AMARILLO, Texas (KAMR/KCIT) — Officers with the Northwest Texas Health care Procedure unveiled details about a breach in late 2021 that involved secured health and fitness data for the system’s patients.
According to a “vendor breach celebration notice” printed on Thursday, officers explained that Adelanto Healthcare Ventures LLC, a consulting firm that is effective for just one of the system’s small business associates and a company that supplies “transactional advisory support” for the system, became mindful of two email accounts staying accessed as a result of a “phishing incident” in November 2021.
Officials claimed originally, they did not believe that the incident concerned the Northwest Texas Healthcare System. In December 2021, AHCV contacted a previous employee of the system that guarded health and fitness information and facts was discovered in the impacted email accounts and “potentially available through the incident.” It was not right up until August 2022 that a company affiliate of the method discovered that sure information and facts could have been concerned in the phishing incident.
Just after studying of the incident, the affiliate, not determined by the Northwest Texas Health care Process, commenced an investigation. But the associate did not obtain “sufficient information” to conduct the investigation until finally late December 2022.
“There is no proof to date to advise that the PHS was copied or misused, but our business enterprise linked notified our Corporation of the incident on January 28, 2023,” the observe reads. “Once we acquired this observe, we labored with our business enterprise affiliate to get the ways necessary to deliver notification to persons.”
Officers explained the email messages concerned in the phishing incident possibly contained some or all of the subsequent info from the system’s sufferers, including:
Patient’s comprehensive title
Facility title
Medicaid assert ID
Medicaid customer ID
Care program name
Medicaid program
Gender
Day of delivery
Admission and discharge day
Professional medical and analysis info
Psychological overall health comorbidity (if any).
Officers stressed that the e-mail did not comprise social stability numbers, credit history card numbers, or other financial facts.
The procedure explained that notification letters bordering this detect started to be mailed on March 29. They also mentioned that AHCV is reportedly expanding its safety steps and assessing more education for its workforce. The unnamed organization associate has also reportedly “counseled its personal workforce on the incident and greatest procedures.”
“While we are unaware of any precise or tried misuse of PHI, we are supplying impacted people 12 months of world wide web surveillance and identity restoration solutions through Experian at no charge,” the discover read through. “Individuals can refer to their notification letter for enrollment guidance.”
The notice said that people with added inquiries are questioned to contact 800-910-4035, a dedicated line open from 8 a.m. to 10 p.m. Monday by means of Friday, and from 12 p.m. to 7 p.m. on Saturday and Sunday, excluding holidays. Officials reported the line will remain open up until finally July 31.
“If you did not get a letter, but would like to know if you had been afflicted, you should get in touch with our devoted assistance line,” the see examine.
For the hottest Amarillo information and regional updates, check out with MyHighPlains.com and tune in to KAMR Area 4 News at 5:00, 6:00, and 10:00 p.m. and Fox 14 Information at 9:00 p.m. CST.
WHO has up to date its tracking process and working definitions for variants of SARS-CoV-2, the virus that causes COVID-19, to improved correspond to the present worldwide variant landscape, to independently assess Omicron sublineages in circulation, and classify new variants far more clearly when demanded.
SARS-CoV-2 continues to evolve. Considering that the commencing of the COVID-19 pandemic, many variants of worry (VOCs) and variants of curiosity (VOIs) have been designated by WHO primarily based on their assessed potential for expansion and substitute of prior variants, for triggering new waves with enhanced circulation, and for the have to have for adjustments to public health and fitness actions.
Based on comparisons of antigenic cross reactivity working with animal sera, replication studies in experimental products of the human respiratory tract, and evidence from scientific and epidemiological studies in people, there is consensus between gurus in WHO’s Specialized Advisory Group on SARS-CoV-2 Virus Evolution (TAG-VE) that in comparison to earlier variants, Omicron signifies the most divergent VOC found to day. Given that its emergence, Omicron viruses have continued to evolve genetically and antigenically with an expanding range of sublineages, which so much have all been characterised by qualities of evasion of existing population immunity and a desire to infect the higher respiratory tract (as opposed to reduce respiratory tract), as in contrast to pre-Omicron VOCs.
The Omicron viruses account for about 98{35112b74ca1a6bc4decb6697edde3f9edcc1b44915f2ccb9995df8df6b4364bc} of the publicly readily available sequences due to the fact February 2022 and constitute the genetic history from which new SARS-CoV-2 variants will probable emerge, even though the emergence of variants derived from previously circulating VOCs or of fully new variants continues to be achievable. The former process categorized all Omicron sublineages as portion of the Omicron VOC and therefore did not have the granularity needed to compare new descendent lineages with altered phenotypes to the Omicron parent lineages (BA.1, BA.2, BA.4/BA.5). Thus, from 15 March 2023, the WHO variant monitoring system will look at the classification of Omicron sublineages independently as variants beneath monitoring (VUMs), VOIs, or VOCs.
WHO is also updating the working definitions for VOCs and VOIs. The most important update is made up in building the VOC definition much more distinct, to involve major SARS-CoV-2 evolutionary ways that need main community overall health interventions. For the updated definitions, make sure you check out the WHO variant monitoring web-site.
In addition, going ahead, WHO will assign Greek labels for VOCs, and will no extended do so for VOIs.
With these alterations factored in, Alpha, Beta, Gamma, Delta as nicely as the Omicron father or mother lineage (B.1.1.529) are deemed earlier circulating VOCs. WHO has now labeled XBB.1.5 as a VOI.
WHO will also go on to challenge standard danger assessments for both of those VOIs and VOCs (see most recent risk evaluation for XBB.1.5).
WHO emphasizes that these changes do not indicate that the circulation of Omicron viruses no more time pose a threat to general public well being. Alternatively, the changes have been made in order to much better detect extra or new threats in excess of and above people posed by the latest Omicron viruses in circulation.
