On September, the Louisiana Department of Health announced a law suit filed against several leading opioid manufacturers for their role in escalating the opioid crisis in Louisiana. The lawsuit, filed in the 19th Judicial District Court in East Baton Rouge Parish, alleges that the drug
companies engaged in fraudulent marketing regarding the risks and benefits of prescription opioids, which helped fuel Louisiana’s opioid epidemic.
“These drug companies led prescribers to believe that opioids were not addictive and even suggested that treating physicians prescribe greater dosage units to those who had already
become addicted to opioids,” said Gov. John Bel Edwards. “As evident by the hundreds of Louisiana families that have lost loved ones due to this crisis, nothing could be further from the truth. We intend to hold these pharmaceutical companies responsible for the lasting damage they have caused upon our people and the millions of dollars their wrongful claims have cost our state.”
The Louisiana Department of Health is seeking damages for the amounts it has already paid for excessive opioid prescriptions and treatment costs as a result of those prescriptions.
Louisiana joins dozens of other cities, counties and states that have filed similar lawsuits in response to the alarming number of cases of opioid addition and opioid-related deaths
throughout the country. Lawsuits were also filed last week by local sheriff’s offices in Avoyelles, Lafayette, Jefferson Davis and Rapides Parishes.
“By all means necessary, we are fighting the opioid epidemic in Louisiana. All indicators of this problem – opioid prescriptions, overdoses and deaths – are up. Recognizing that a key
contributor to opioid addiction is prescription medications, where 110 prescriptions for opioids are written for every 100 Louisiana residents, we are addressing a fundamental cause of this
problem,” said Dr. Rebekah Gee, secretary of the Louisiana Department of Health.
Dr. Tracey Rizzuto and colleagues are helping those in the hardest hit storm affected areas to rebuild the local business communities, through a group composed of leadership and members of the Society for Industrial-Organizational Psychology and the Society of Consulting
Psychology, two Divisions of the American Psychological Association.
The effort began recently as the Harvey Organizational Psychology Effort or HOPE, Dr. Rizzuto told the Times. However, the project quickly evolved into an effort between the two Divisions of APA, to be called the Catastrophe Aid and Rebuilding Effort, or CARE.
The group “… is now positioned to respond to a broader range of disaster events,” said Rizzuto, Associate Director, School of Leadership and Human Resource Development, at the LSU College of Human Science & Education.
The interdivisional APA taskforce is working to provide pro bono business recovery services to those in the stormaffected areas, explained Rizzuto. The growing taskforce has over 30
volunteers at present and is working to link with regional leaders in the hardest-hit areas, she said.
The original group, HOPE, started working to connect to local Industrial-Organizational psychologists in the Texas and Louisiana area, to local government administrations, and to
identify businesses in need of services, she explained.
“We’re reaching out to our professional base to inquire about needs for assistance,” such as housing/food donations, replacing books, assist with academic lectures if possible,” said
The current project is modeled after Rizzuto’s work on the Katrina Aid and Relief Effort,” called KARE, Rizzuto said. In the wake of Hurricane Katrina, the leadership of the Society of
Industrial-Organization (SIOP) called on its membership to deliver needed resources to people and businesses affected by the storm. “The Katrina Aid and Relief Effort (KARE) became SIOP’s
first outreach taskforce designed to deliver pro bono business consulting services with the goal of aiding disaster recovery,” explained Rizzuto.
Along those same lines, the current effort will likely help with a host of services including emotional management, hiring/selection tools, training programs, recruitment, etc.
According to a report in Industrial-Organizational Psychology, KARE provided assistance in managing stress and adversity, change, motivation, and healing from the disaster. Also some of
those served voiced interest in hiring, leadership, training, team management and general business issues.
KARE received commendations from the Louisiana State Senate, the American Society of Association Executives, and the Center for Association Leadership for the work.
Dr. Rizzuto and her team are welcoming voluteers. CARE group volunteers will be placed in complementary teams composed of individuals with a wide range of experience and expertise. Dr. Rizzuto explained that volunteers will work alongside colleagues. “You will not be alone,” she said. The group meets every Wednesday on Zoom.
For those interested in volunteering, the site for the Castastrophe Aid and Rebuilding Effort (CARE) site is: https://www.facebook.com/CARECatastropheAidandRebuildingEffort
Dr. Christoph Leonhard, PhD, ABPP, Professor in the clinical PsyD program of The Chicago School of Professional Psychology at Xavier University of Louisiana, met recently with the Medicaid Integrated Assessment Task Force, a group created by Representative Barbara Norton and others, with the goal to “make a thorough study and evaluation of Louisiana’s current statewide system of healthcare delivery for Medicaid enrollees with serious mental illness.”
Dr. Leonhard is a member of the Louisiana Psychological Association’s task group to study innovations in healthcare, a committee chaired by Dr. Lacey Seymour. Leonhard is also the Chair of the Health Psychology Interest Area for the Psychological Association.
Representative Norton’s 2017 House Concurrent Resolution No.55 created the Medicaid Task Force, and had noted, “…the mental health and well-being of the residents of Louisiana is a vital issue that affects not only quality of life, but also the health of communities, families, and economic stability.”
According to the Department of Health and the Resolution, the purpose of the Medicaid Integrated Assessment Task Force is to study and evaluate Louisiana’s current statewide system of healthcare delivery for Medicaid enrollees, and especially with concern for those with
serious mental illness.
The task force members should strive to “render objective, fiscally feasible recommendations to the legislature for the implementation of policies that could be adopted by the state for the delivery of integrated primary and behavioral health services for Medicaid enrollees,” according
to the agency officials.
Data from the Substance Abuse and Mental Health Services Administration indicates that people with mental illness are more likely to have chronic health conditions, such as high blood pressure, asthma, diabetes, heart disease, and stroke, than those without mental illness, and those individuals are more likely to use costly hospitalization and emergency room treatment.
Individuals with primary health conditions such as asthma and diabetes report higher rates of substance use disorders and serious psychological distress.
According to the Centers for Medicare & Medicaid Services (CMS):
1) Fifty percent of Medicaid enrollees have a mental health diagnosis;
2) People diagnosed with mental illness and common chronic health conditions have healthcare costs that are 75% higher than those without a mental health diagnosis;
3) for individuals with a co-occurring mental illness or substance use disorder and common chronic condition, the cost is two to three times higher than what an average Medicaid enrollee pays for healthcare;
4) and costs of treating those with diabetes is as much as four times higher when a cooccurring
condition such as depression or alcohol addiction is untreated.
The members of the Task Force will be asked to give ideas for innovations that can address these and other issues, and work with the existing programs where feasible.
Dr. Lacey Seymour will be working with a group of psychologists, including Dr. Leonhard, to develop responses for the Medicaid team, according to several sources.
Dr. Chris Leonhard is a health psychologist and originally earned his degree from University of Nevada and completed his internship and postdoc at Harvard Medical School (McLean and Mass General Hospitals). He is Board Certified in Behavioral Psychology and currently is
conducting research in Behavioral Medicine and physical activity promotion
by J. Nelson
In an example of flawed decisions in the medical/pharma industrial complex, over-prescribing has catapulted overdose deaths to the top, compared to peak years for auto fatalities, HIV or gun deaths.
“We now know that overdoses from prescription opioids are a driving factor in the 15-year increase in opioid overdose deaths,” writes the Center for Disease Control (CDC).
The National Institute on Drug Abuse says opioid overdoses account for 60% of those deaths.
Researchers from the University of Virginia say these statistics are underreported by 24% for opioids and 22% for heroin overdose deaths, and with particularly large errors in certain states, one being Louisiana.
Overdoses are trending up, not down, by almost 20% for last year. STAT News predicts that
opioids could kill nearly 500,000 people in the next decade.
At the peak of the prescribing frenzy, 2013, doctors wrote nearly 250,000,000 opioid prescriptions––enough for every adult in the United States of have his or her own bottle of pills, reports the CDC.
Despite the flood of legal opioids into the society, the CDC reported no change in pain that would meaningfully drive the prescribing: “…there had not been an overall change in the amount of pain that Americans reported.”
Last year, 20 years after the opioid marketing blitz and prescribing ramp-up began, the
CDC found that there was no long-term benefit for opioids compared to no opiods. However, they did find ample evidence for harm, a fact that the FDA had failed to discover when they approved drugs like OxyContin in the 90s.
Not surprisingly, at least for psychologists, the CDC did find that psychological and physical treatments for pain were beneficial (“CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016,”). This despite the fact that these non-medical approaches are rarely integrated into treatment programs.
Echoing the overprescribing of antidepressants, citizens hoping for genuine healthcare appear to have once again become the unwitting lab rats of a commercial, profit–driven industry, where they and many providers are lulled into quick fixes that ignore long-term consequences and the psychology of the whole person.
Depth of the Problem
Opioids are derived from the same type of compound as heroin, and morphine-like effects for pain relief. The effects also include feelings of relaxation and euphoria. One recreational user described it as “Bliss.” Another as, “Physical––warmth, relaxation. Mental––Joy, boost in self-confidence, loss of anxiety…”.
Schedule I and II drugs have been determined to have a high risk for physical and psychological addiction. Schedule I are illegal and Schedule II are considered to have medical value and so legal by prescription. Heroin is a Schedule I opioid. Drugs like oxycodone, hydrocodone, and methadone are Schedule II opioids.
With continued use, tolerance and dependence result. Increased dosages are needed for the same results. Researchers say that dependency can occur after as few as seven days. Overdose risks go up.
In the 1990s drug manufacturers launched new opioid formulations, assumed to be safe. They expanded markets to non-cancer pain and moderate or temporary pain. Building on a new theme that all pain should be eliminated the opioid market quadrupled from 1999 to 2010, according to the General Accounting Office (GAO).
Physicians for Responsible Opioid Prescribing (PROP) found that the supposed safety of the new formulations in the 1990s was based, not on research, but primarily on a letter to the editor in a medical journal. The sound-bite idea began to circulate in the medical communities and was uncritically accepted as fact, notes PROP researchers.
The risk of addiction is serious. Among new heroin users, approximately 75% report having abused prescription opioids before turning to heroin, notes the CDC. The National Institute on Drug Abuse places the figure at 80%. PROP researchers reported that people get hooked by a prescription and then turn to street heroin.
Heroin use has been increasing among men and women, in all income levels. Those historically low in rates of heroin use––women, the privately insured, and those with higher incomes are seeing the greatest increases, says CDC. While addictions were up overall, those mainly affected were whites, especially those with less education.
In 2015 two Princeton researchers, Anne Case and Angus Deaton, presented findings to the National Academy of Sciences that drug and alcohol poisonings, suicide, and chronic liver diseases and cirrhosis, had increased so dramatically that all-cause mortality was up for US
middle-class whites, while declining for Blacks, Hispanics and for those in other countries.
“Over the 15-year period, midlife all-cause mortality fell by more than 200 per 100,000 for black non-Hispanics, and by more than 60 per 100,000 for Hispanics. By contrast, white non-Hispanic mortality rose by 34 per 100,000.”
“This is a disturbing trend,” said Dr. William Schmitz, Jr., Past-President of the American
Suicidology Association The addiction chips away at the person’s hope and adds to the
burdensomeness they experience,” he said. “There is overlap between the accidental overdose and the intentional. The person may think, ‘I’m taking this and if I die, I die and if not, I’ll be here tomorrow.’ What this really speaks to is the increasing need for collaboration in mental and physical health,” he said.
The Problem in Louisiana
Louisiana is in the middle of the crisis, with some of the highest opioid prescribing rates and an escalating death rate from overdose.
In a Louisiana House Health and Welfare Committee hearing this past April, Representative Helena Moreno told members that there are “… more opioids prescribed in Louisiana than are people in this state.”
In 2007, Louisiana prescribers gave out 110.1 opioid prescriptions per 100 persons, based on numbers from the CDC. Only five others were higher: West Virginia (135.1), Kentucky (130.8), Tennessee (128.8), Alabama (120.3), and Oklahoma at (114.4).
Little change has occurred in recent years. In 2012 the map of southern rural states was the
same, with Louisiana a 112.4 rate, with a slight drop to 108.9 in 2015. The rate again dropped
slightly last year, down to 100.4.
The Louisiana Commission on Preventing Opioid Abuse, looking at internal figures from the state’s Prescription Monitoring Program (PMP), says that the number is even higher. “Over the last six years, since the PMP began monitoring narcotic prescribing behavior, Louisiana has
averaged 122 prescriptions per 100 persons. This rate is 39% percent higher than the national
Addictions have rocketed up along with prescriptions. Ed Carlson, CEO Odyssey House
Louisiana, testified at a Senate hearing that, “All of the drug and alcohol treatment programs
throughout the state were overwhelmed with the amount of the people who were seeking
and needing treatment. We currently have waiting lists for all of our programs,” he said.
Louisiana has also experienced a significant increase in overdose deaths, with a 12.4%
increase for 2014 to 2015, according to the CDC.
Another characteristic of the opioid crisis is the inconsistency in prescribers, not accounted
for by the illness level of those being treated.
Prescribing varies widely across the nation from county to county. In 2015, six times more
opioids per resident were dispensed in the highestprescribing counties than in the
lowest-prescribing counties, notes the CDC. Characteristics such as rural versus urban,
income level, and other demographics, explain only about a third of the differences
found in prescribing rates across the country.
In Louisiana, highest parishes include Evangeline (192.1), St. Landry (145.5) Rapides (144),
Richland (139.3), Washington (136), and Tangipahoa (129.5).
Examples from ProPublica, using Medicare Part D information, shows that Hydrocodone Acetaminophen was the first ranked drug prescribed in Louisiana with 812,468 claims.
Highest prescribers were physicians in Pain Medicine and Physical Rehabilitation. The top
prescriber wrote 14,223 prescriptions for opioids. Of his 866 patients, 91% filled at least
one prescription for an opioid. The review by ProPublica rated his patients as less sick than
Another prescriber in Alexandria reported 1,333 patients receiving prescriptions from Medicare Part D and 98% of these filled at least one prescription for an opioid.
True Believers: A Bad Idea Gains Momentum
According to a 2003 report by the GAO, several national pain organizations issued new
guidelines in the mid-1990s, based on their belief that pain was undertreated in non-cancer
In 1995, the American Pain Society, led by Dr. Russell Portenoy, a New York pain doctor, recommended that pain should be treated in a special category. In an investigative
report by the Wall Street Journal (“A Pain-Drug Champion Has Second Thoughts”), said
Portenoy urged the tracking of pain as a “Fifth Vital Sign.”
The idea of a 5th vital sign was adopted by the Joint Commission on Accreditation of Healthcare Organizations, the Veterans Administration, and the Federation of State Medical Boards who provided reassurance to doctors who wanted to more freely prescribe opioids. The Federation drew up recommendations with the help of individuals linked to drug manufacturers, including Purdue Pharma (OxyContin), according to WSJ. The federation received nearly $2 million from opioid makers.
Around the same time, OxyContin was approved by the FDA, but lists no research on the drug.
An explanation by the FDA states: “At the time of approval, FDA believed the controlled-release formulation of OxyContin would result in less abuse potential, since the drug would be absorbed slowly and there would not be an immediate “rush” or high that would promote abuse. In part, FDA based its judgment on the prior marketing history of a similar product, MS
Contin, a controlled-release formulation of morphine approved by FDA and used in the medical community since 1987 without significant reports of abuse and misuse.”
In a Los Angeles Times investigation, based on sealed court documents, the physician who led the agency’s review of the drug, declined to speak with the press. The Times noted that shortly after OxyContin’s approval, the physician left the FDA and in two years was working for Purdue Pharma.
As enthusiasm grew the then Agency for Health Care Policy and Research, part of the national Department of Health, offered reassurance to prescribers about their “exaggerated concerns.”
The GAO noted that providers and hospitals were further required to ensure that patients received pain treatment. The Joint Commission implemented its pain standards for hospital
accreditation in 2001, a guide sponsored by Purdue Pharma.
Reassurances of safety appeared to be based on limited scientific research, a letter to the editor to JAMA, according to PROP and others, and perhaps a small study of 38 individuals.
How could such a gap in scientific decisions occur?
“Most doctors and virtually all patients are unschooled in how meaningfully to compare the
risks of foregoing versus undergoing treatment, and the patient’s frantic desire to ‘do
something now’ often trumps the doctor’s ancient commitment to ‘first, do no harm,’” wrote law professor John Monahan in a special report on statistical illiteracy in medicine, published by the Association for Psychological Science.
Dr. Jason Harman, a decision science expert at LSU, notes, “Doctors have very complex jobs. I know from some of my work on learning in complex systems that accurate and timely feedback is essential for optimal performance in a complex task.”
Some outcomes however have delayed or obscured feedback. In terms of opioids, the
immediate feedback a doctor receives is generally positive––pain is reduced––while
feedback about negative consequences is delayed if it is received at all. This basic
structure of feedback in the environment makes it very understandable to me how
doctors, who have the best intentions, could fall into such an ultimately harmful practice
Marketing Blitz on Doctors’ Psyches
In 1997 Purdue Pharma created a marketing effort that overshadowed anything previously and catapulted sales of OxyContin.
“Purdue directed its sales representatives to focus on the physicians in their sales territories who were high opioid prescribers,” said the GAO. “This group included cancer and pain specialists, primary care physicians, and physicians who were high prescribers of Purdue’s older product, MS Contin. One of Purdue’s goals was to identify primary care physicians who would expand the company’s OxyContin prescribing base. Sales representatives were also directed to call on oncology nurses, consultant pharmacists, hospices, hospitals, and nursing homes.”
By 2003 primary care physicians had grown to constitute nearly half of all OxyContin prescribers, based on data from IMS Health, an information service providing pharmaceutical market research. The GAO report stated that the DEA expressed concern that this resulted in OxyContin’s being promoted to physicians who were not adequately trained in pain
Purdue doubled the total OxyContin sales force by 2000 to nearly 700 and reached up to
94,000 physicians. Bonuses topped at $240,000, on a salary of $55,000.
Purdue expanded its physician speaker bureau, conducted speaker-training conferences,
sponsored pain-related educational programs, and issued OxyContin starter coupons for
patients’ initial prescriptions.
They also sponsored pain-related Web sites, advertising OxyContin in medical journals, and
distributed OxyContin marketing items to health care professionals–fishing hats, stuffed plush toys, coffee mugs with heat-activated messages, music compact discs, luggage tags, and pens containing a pullout conversion chart.
Purdue conducted over 40 national pain management and speaker training conferences,
usually in resort locations, to recruit and train health care practitioners for its national speaker bureau. Over five years, more than 5,000 physicians, pharmacists, and nurses, whose travel, lodging, and meal costs were paid by the company, were engaged. By 2002, Purdue’s speaker bureau list included nearly 2,500 physicians and over 20,000 pain-related educational programs.
“For the first time in marketing any of its products, Purdue used a patient starter coupon program for OxyContin to provide patients with a free limited-time prescription,” and by 2001 34,000 coupons had been redeemed nationally.
Purdue’s market share increased fourfold for cancer pain and tenfold for non-cancer pain by 2002.
Outdated Medical Model of Pain
“It is now widely accepted that pain is a biopsychosocial phenomenon,” clinical health
psychologist and Past-President of the Southern Pain society, Dr. Geralyn Datz, told the Times.
“For many years the biomedical model of treatment has prevailed as a way to treat pain patients,” Datz said. “This model is based on some very early research about acute pain and basically states that there is a one-to-one correspondence between the extent of injury and the amount of pain experienced. Therefore, large injuries lead to large pains and small injuries lead to small pains,” she said.
Datz explained that this model also assumes that surgery and medications can fix pain. “While
this is sometimes true, this model fails to appreciate what we now know about the central nervous system,” she said.
“We know that chronic pain is a complex and dynamic process, and it involves a person’s
thoughts, beliefs, experiences and these all can influence pain for better or worse. In addition, conditions such as depression and anxiety can arise from the presence of pain, and these also can worsen pain through interactions of the brain with the body.”
“In order to really address chronic pain, we must address the persons reactions to it and teach ways to overcome it, including retraining the brain away from the unpleasant pain signals. This is a psychological process involving education and training and coaching,” Datz said.
“We know that cognitive behavioral treatments create quantifiable changes in the brain, and
that these are distinct to this type of treatment. So these effects are lasting and result in long
Dr. Datz says that the “best results are achieved through collaborative care,” but too often, insurance companies make it difficult for patients to have this type of help.
Treating with inappropriate drug therapy, is costly,” said Dr. John Caccavale, author of Medical Psychology Practice and Policy Perspectives. The cost for adverse drug reactions in 2001 was $72 billion to $172 billion while the cost for the drugs was $132 billion. “Actually, it’s now worse,” Caccavale said. “The incidence of hospitalizations from adverse events has risen substantially because of the growing use of medications in all categories.”
Failed Health System
The opioid crisis suggests one more area of poor outcomes for the U.S. healthcare system.
Bloomberg has reported that of 55 countries in a measure of life expectancy and high medical
care spending, the U.S. ranks 50th, dubbing the U.S. the “least-efficient” health- care system in the world. In a comparison of age–adjusted deaths from all causes, the World Health Organization ranks the United States last in similar countries.
Medical care is the largest industry in the U.S., accounting for almost $3 trillion in sales in 2015, according to the National Health Expenditure Data from CMS. At the same time, life expectancy in the U.S. is only 78.9 years, falling behind all other nations except for those such as Jordan, Colombia, and Russia, said Bloomberg.
Likewise, Louisiana ranks 50th of all the states, according to the Louisiana Department of Health and the 2015 Report from America’s Health Rankings.
“Health is a misnomer, because most activity involves illness,” say authors of “The Anatomy of Health Care in the United States” in a 2013, JAMA article. “Prevention requires tools that are often unfamiliar because educational, behavioral, and social interventions, not usually considered to be part of medicine, may be most effective for many diseases,” the authors write.
The system is politically closed to innovation. Three hundred “Advisors and Experts,” primarily from the American Medical Association’s House of Delegates, representing 109 medical specialties, lobby an “Editorial Panel,” composed of representatives from medical societies,
insurance companies and the government, decide on what is paid for, by way of codes.
The “Current Procedural Terminology” or CPT codes, and how much is paid for each service, is decided behind closed doors of the Relative Value Scale Update Committee,” or “RUC,” by those who stand to profit the most.
The system includes the FDA. Dr. Irving Kirsch, Associate Director of the Program for Placebo Studies at Harvard Medical School, has laid out the damning evidence that drug companies and the FDA skew research to approve drugs that have little actual value. The FDA receives 40 percent of its funding from the pharmaceutical companies, Kirsch said.
Add to this the political force of the top spenders for lobbying in Washington: Blue Cross/Blue Shield (3rd), American Hospital Association (4th) the American Medical Association (5th), and the Pharmaceutical Industry (6th).
This closed system is not surprising. In 2002 the 10 drug companies in the Fortune 500 made $35.9 billion in profits, more than all the other 490 companies profits combined.
Legislators in Louisiana are trying. In 2017 there were numerous bills and resolutions put forth to stem the tide of prescribing.
Senators Mizell and White asked for medical societies and hospitals to eliminate pain as the 5th vital sign, in Resolution 21. House Bill 192 led by Representative Moreno and 43 others, put some restrictions on prescribing opioids, became law as Act 82.
Act 88 by Representive Leger and others established the Drug Policy Board’s Advisory Council on Heroin and Opioid Prevention and Education, and Act 76 led by Senator Mills encourages prescribers to use the Prescripton Monitoring Program, where currently only about one third use the system.
The enforcement of these measures will depend on the professional boards. The Department of Health has filed a suit against drug companies.
It will be seen if this can help in the opioid prescribing crisis or the “underlying epidemic” suggested by Case and Deaton that may have contributed what author Christopher Caldwell calls, “American Carnage.”
by Susan Andrews, PhD
For generations traditional medicine has refused to consider “stress” and
other emotional problems as having a direct effect on our body and health.
The doctor might nod sagely and say things like, “it’s all in your head or that
is just your imagination.” Slowly, persistently, the evidence built up showing
many direct effects of stress on the body. Then, the stress was shown to be
transmitted across generations – from a parent to the child, not just
environmentally, but also physically – in the developing brain of the neonate.
But, today, it appears as if stress as a topic of real consideration has come
of age. Cardiologists and internists are now overheard as saying, “next visit
we will talk about stress.” It is like the physicians have decided that stress
and its many “physical friends and relations” really should belong to
medicine, as much as if not more than it does to psychologists. This may
afford psychologists an opportunity to build working relationships with
medical practices. Medical professionals may be able to talk about stress in
physical and medical terms but stress is still best treated without medication
and before it causes illness.
Not only can physicians now be heard talking about stress to their patients,
but also more and more continuing education programs are focusing on the
topic. Most recently, the serious connection between stress and
inflammation is being taught around the world. This is hugely important as
unresolved inflammatory responses are fingered as the root cause of many
chronic illnesses and dis-eases, such as diabetes, metabolic syndrome,
age-related changes and neurodegeneration, heart disease, cancer, MS,
ulcerative colitis, Crohn’s Disease, and Rheumatoid arthritis.
You can appreciate how close the relationship between chronic stress and
chronic inflammation is when you look at the potential causes of just one
chronic inflammatory illness, such as chronic inflammation in the digestive
tract. The #1 cause is often listed as Emotional Stress in the form of panic
attacks, rapid pulse, with night sweats. This constellation of symptoms is a
sign of a cortisol-prompted inflammation. When cortisol remains high in the
blood (immune system and adrenals on overdrive), it results in dilated blood
vessels that force blood to your organs in preparation of an attack. The #2
cause is Physical Stress.
Another indicator that Stress has come of age is the number of related hits
Google gives you for a search on “stress.” Any guess between 115,000,000
and 150,000,000 is acceptable. Actually, today the result was 131,000,000.
The results range from causes and triggers of stress to Symptoms of
Anxiety and Stress to things stress is associated with to ways to manage
It is the ways to manage stress that we do best as psychologists. The bulk
of the 131 million websites that came up are focused on ways to reduce,
manage, get rid of, or lower stress. Many of these websites are very
superficial and even misleading. Or, they are aimed at selling their product.
Stress can almost never be properly managed by simply reading an article
or book or looking at a website. It takes time, determination and good
coaching or therapy for a person to begin to drop bad habits, learn how to
live a more healthy life, and then finally put what they learned into real
action. The techniques to reduce stress only work if you use them.
by Alvin G. Burstein, PhD
Well, Steven King, abetted by director Andy Muschietti and a
stable of screenwriters, has done it again. His 1986
publication, It, has appeared on screen, and has audiences
lined up waiting to experience horror. The plot is slick. A
group of school kids, each of whom is weighed down by a
social disqualification, struggles with rejection and bullying in
and out of school. The group coalesces, aptly calling
themselves “The Losers.” Their leader stutters badly,
another is an overweight nerd, there is a sexually abused girl
seen as promiscuous, a hypochondriac, a loudmouth, a
Jewish kid being coerced into rabbinic studies, and a black.
As a group and individually, they are the target of vicious
bullying by school mates.
Then worse erupts. The younger brother of one of The
Losers is lured into a sewer by an evil creature who calls
himself Pennywise the Dancing Clown. The film takes us into
The Losers’ battle against victimhood at the hands of real life
bullies and the surreal, cannibalistic, shape shifting It.
Rather than rehearsing the twists, turns and outcome of the
tale, I will remark that the movie’s title is a promise that if you
enjoyed chapter one, you will be titillated by the prospect of
more to come. Beyond that, the film epitomizes the horror flic
genre, and raises the question of what attracts viewers to this
film and its counterparts. Where does horror or terror fit in
the panoply of emotion? Why would one pursue an
opportunity to experience that feeling? How is it that a clown
might be an apt focus for that feeling?
That the experience of fear and terror, independent of an
objective threat, is universal is attested by the phenomenon of
night terrors and nightmares in children and by their beliefs in
boogiemen and toilet monsters. King tips his hat to that latter
by It’s residence in the sewer system and It’s eruption out of
drain pipes. Inadvertently or deliberately, King also gestures
toward Freudian theory in Pennywise and the eponymous
account of his doings by naming Pennywise “It.” Of Freud’s
three mental agencies, Ego, Superego and Id, the last is the
arena of hidden and stormy passions—and Freud knew well,
and so might King, that “Id” is Latin for “It.”
From a psychoanalytic point of view, maternal empathic
soothing and protection in the earliest months of life transmutes
into a sense of safety and self-assurance in dealing with the
world. The obverse of that mothering, early ruptures of that
bastion, is a catastrophic experience. Otto Rank, one of the
early psychoanalysts, posited that the universal and traumatic
experience of ejection from the womb lays down an
inescapable fearful template that is part of the human condition.
Thus each of us, it can be argued, have somewhere within us,
in the darkness of the Id, that template of terror. From a cultural
point of view, the story of the eviction from Eden in Abrahamic
societies can be understood as a literary endorsement of
But why clowns? There was an explosion of concerns about
evil-doing clowns in 2014 and again two years later. The
concerns were amplified by social media and were of
questionable authenticity. But they parallel the persistent
rumors of poison and razor blades in Halloween treats. Clowns
are intended to give us something to laugh about. But there is
also something eerie and artificial about them. Something
might be hidden under that mask of grease paint, that carmined
Life and living involve dire risks on which we do not like to
dwell, lest they trigger an eruption of a well of terror that swirls,
deep and hidden in our minds. Horror films provide an
opportunity to play with those fears, to entertain them—briefly
and under our control.
According to Boards and Commission budget tracking for the Louisiana Board of
Examiners of Psychologists (LSBEP), the psychology board is projecting a fund
balance of minus $400,595 for 2018.
This comes after several years of overbudget spending that appears to be due in
large part to legal fees. The psychology board is self-funded, and it operates with
income supported by license fees and other service fees.
Based on the budget and financial tracking provided at the Boards & Commissions
website, the LSBEP stayed approximately within budget for most years and carried a
“fund balance” of around $100,000, which appears to function as a savings reserve.
For 2014, the board took in $262,582 and spent $249, 517. The fund balance was
And in 2015, the board took in $263,691 in fees and spent $275,147. For 2015, the fund
balance was listed at $120,188.
However, in 2016, the board spent $336,677 while proceeds remained steady at $265,945. Budget tracking indicates a fund balance of minus $214,818.
The change in the fund balance from 2015 to 2016 is not clear, based on the tracking numbers as given.
For the current year of 2017, expenses are projected to be $388,903. Income continues at the same general level, projected to be $263,265.
The budget figures indicate that board’s projected budget for 2018 will be a fund of minus
$400,595. Expenses for 2018 are projected to be $327,871 with income again holding
steady at $269,755.
The Boards & Commissions site also provides information and various breakdowns of the
budget items, with data from 2010 to the present.
According to the tracking of expenditures from 2014 to 2017, the employee salaries
and benefits have increased from $125,839 in 2014 to $148,946 in the current year.
This amounts to an 18 percent increase.
Over this same time, operating expenses decreased from $66,974 in 2014 to $57,858 in
2017, a drop of 13.6 percent.
Professional services, another category of expense, has increased from $56,704 in 2014
to $135,767 for 2017. This is an increase of 139 percent. For 2018 the total for professional
services is projected to be $182,099, or an increase of 221 percent.
For the budget figures, the professional services category includes four subcategories:
Accounting, Management Consulting, Legal, and Other. From 2014 to 2017 all increased, while legal increased the most at 247 percent.
In 2014 Accounting was $1,331, Management Consulting was $4,495, Legal was $37,882, and Other was $12,996.
For 2017, Accounting is projected at $9,849, Management Consulting is $15,600, Legal is $131,500, and Other is $25,150.
This information is available at
At the LSBEP regular meeting, held on June 16 at the offices in Baton Rouge, Chair Dr. Darla
Burnett reported that she reviewed the bank and financial records.
According to the minutes, “Dr. Burnett also reported that she had reviewed the current financial state of the Board with Ms. Monic, noting the two biggest expenses are employees and
legal fees. Dr. Burnett thanked Board Members for waiving their Per Diem and Travel
reimbursements in FY 2016-17 to attend Board meetings, committee meetings, and LPA,
and recommended, in an effort to remain fiscally responsible, that the Board continue to waive reimbursement and travel in the 2017-18 fiscal year given the anticipated deficit.
“Dr. Burnett further recommended that the Board continue to actively consider revenue
development initiatives including review and approval of continuing education programs, inactive status, additional licensure types or registration of psychological assistants, providing continuing education workshops, and as a last resort, changes to staff.”
The LSBEP called a special meeting July 7, held in New Orleans, and met in Executive Session, apparently to deal with personnel and financial matters. According to the agenda and
minutes, “The Board reviewed and discussed applicant qualifications for prosecuting
attorney. The Board reviewed and discussed layoffs. The Board reviewed and discussed
qualifications and affirmed the current list of evaluators as approved to perform
psychological/neuropsychological evaluations/fitness for duty examinations under LA R.S. Ch.
37 §§ 2356, 2356.1, 2356.2, and 2356.3: […]”
“The Board reviewed proposals for a contract for prosecuting attorney for the 2017-18 Fiscal
Year due to the current financial status of the Board. Dr. Henke reported receiving proposals and vitas from three well qualified prosecuting attorneys. By motion of Dr. Henke, the Board voted to award the contract to Attorney Courtney P. Newton beginning July 7, 2017 – June 30, 2018, in an amount not to exceed $28,000. The fee schedule should reflect the following rate of pay: $100 per hour plus travel and expenses that are preapproved in accordance with
Policy and Procedure Memo 50.”
Previously the prosecuting attorney, Mr. James Raines, charged $250 hour. While unclear, it appears that Mr. Raines may no longer be with the board.
The July 7 minutes also note, “The Board revisited the need to have a second contract for
Complaints Coordinator. Dr. Boggs moved to offer a contract not to exceed $5,000 for an
auxiliary Complaints Coordinator to Dr. Joseph Constans for overflow or for matters unable to
be handled by Dr. Lambert.”
The board also moved to lay off the administrative assistant. According to the minutes, “The
Board continued discussing its current financial status and outlook. Recognizing that the
Board could no longer delay action given the current financial state versus the time it will take to recover and/or further develop revenue sources, Dr. Henke, moved that in addition to the
recommendations presented in June 2017, the Board temporarily layoff the Administrative Assistant position. The motion passed unanimously.”
A group of state officials and health advocates are petitioning the
Food and Drug Administration to ban the production of high-dose
opioid medications, saying that the pills when taken as directed
are a daily dose of 90 milligrams of morphine.
The petition was signed by leaders of the Association of State
and Territorial Health Officials (ASTHO), reported ABC News.
The ASTHO is national nonprofit organization representing public
health agencies in the United States and over 100,000 public
health professionals these agencies employ. ASTHO members,
the chief health officials of these jurisdictions, formulate and
influence sound public health policy and work to guide statebased
public health practice.
Parham Jaberi, MD, MPH, Assistant Secretary for Public Health
in the Louisiana Department of Health, is listed for the Louisiana
The petition was also signed by Physicians for Responsible
Opioid Prescribing, the National Safety Council and the American
College of Medical Toxicology. Dr. Andrew Kolodny, physician
advocate for opioid reform, said, “The existence of these
products implies that they’re safe. They’re not,” said Kolodny,
founder of Physicians for Responsible Opioid Prescribing and an
outspoken advocate for opioid reform.
More than 15,000 people died from overdoses involving
prescription opioids in 2015. Various sources report that 80
percent of those addicted to illegal opioids became hooked
through a legal prescription
In June Governor Edwards signed measures to help curb the
opioid crisis in Louisiana, where more prescriptions are written
each year than there are residents in the state. Louisiana ranks
#7 in the states with opioid problems.
Louisiana lawmakers passed legislation this year to help deal
with the problems. Act 76 forced limitations on prescribers of
opioids. For acute pain conditions, prescriptions are limited to a
Act 76 also restricted prescriptions to minors. “… a medical
practitioner shall not issue a prescription for an opioid to a minor
for more than a seven-day supply at any time and shall discuss
with a parent, tutor, or guardian of the minor the risks associated
with opioid use and the reasons why the prescription is
Another new law, Act 82 set up a monitoring program and
requirements and continuing education requirements. Physicians
must review the patient’s record in the Prescription Monitoring
Program prior to initially prescribing opioids.
In House Concurrent Resolution 21, lawmakers urged health
officials to help undo the attitude changes from drug company
marketing that began in 1996, branding pain as a “5th vital sign”
and a problem to be medicated aggressively.
Authors of the Resolution point out that the Veterans Health
Administration, the Joint Commission on Accreditation of
Healthcare Organizations, and the Federation of State Medical
Boards all embraced the marketing, now resulting in an epidemic
of 180 thousand deaths from overdose, from 1999 to 2015, and a
quadrupling of prescriptions, according to the CDC.
Dr. Michael Chafetz, invited speaker for the Swedish Neuropsychlogical Society in Stockholm,
August 22, presented his research and other scientific advancements in the area of disability
assessment and malingering.
He also presented his work at the Karolinsk Institute, Danderyg Hospital, and Rehabilitation
Clinic in Stockholm on August 23.
Chafetz is a board certified clinical neuropsychologist working in independent practice
in New Orleans. His research program has involved validity assessment in low functioning
children and adults being assessed for Social Security Disability, state rehabilitation, and child
protection. He has authored numerous peer-reviewed articles on these topics, challenging
assumptions concerning individuals with intellectual disability.
At the Neuropsychological Society Chafetz’s presentation was titled, “The Long and Short of Malingering in Neuropsychological Assessment: Ethical, Scientific, and Practical Concerns.”
He also presented “Validity Assessment in Public Disability Claims,” at the Karolinsk Institute,
Danderyg Hospital on August 23. Dr. Chafetz covered many ethical and scientific issues for the
Swedish neuropsychologists, including understanding the definitions and background
regarding malingering, biological bases, adaptation and behavioral biology, and the rigorous
development of the field. He also reviewed validity and base rates and important metrics for the neuropsychologists in evidence-based methods.
Dr. Chafetz also covered ethics and boundaries regarding the validity examination in disability and numerous case examples, along with the special case of low IQ, malingered pain-related disability, costs of malingering, andmalingering in children.
Also presenting at the conferences were Muriel Lezak, whose book on Neuropsychological Assessment is required reading in the field, and Grant Iverson, who is a leading researcher on validity and on traumatic brain injury.
The conference was organized by Dr. Christian Oldenburg, President of the Eastern Region of the society. Dr. Oldenburg is a neuropsychologist who, along with his colleagues is working to assist the Swedish disability system.
Dr. Chafetz has consulted for a United States Senator on Social Security policy concerning validity assessment, testified at hearings at the Institute of Medicine, and consulted for the Office of the Inspector General on these issues.
He has presented invited addresses at the American Psychological Association, National
Academy of Neuropsychology, American Academy of Clinical Psychology, several state
psychological associations, the Association of Administrative Law Judges, the Federal Administrative Law Judge Conference, and various bar associations.
In 2015, his book on Intellectual Disability in the forensic arena was published by Oxford University Press.
On August 28, the President approved Gov. Edwards’ Federal Emergency Declaration request
for Beauregard, Calcasieu, Cameron, Jefferson Davis, and Vermillion Parishes and ordered Federal assistance to supplement state, tribal and local response efforts due to the emergency conditions resulting from Tropical Storm Harvey.
But Louisiana appears to have been mostly spared, even though rain gauges showed up to 22 inches in some areas. There was some major flooding in the southwest area, but then mostly moderate flooding or minor elsewhere.
In Texas the rainfall topped records with over four feet of rain being reported and deaths have edged up over 60. Estimated loss in property damage continues to climb and USA Today reporting that the $190 billion loss would make it the most costly natural disaster in modern history.
The property loss, along with the psychological impacts, will be the most significant for many. The average person in the US does not have $500 in savings, and when the flood victims say they’ve “lost everything,” they mean it just that way.
Many from Louisiana rushed to help in Texas, with donations, services, cash and setting up shelters.
Dr. Mark Crosby, who led in recovery for the Watson, Louisiana community, ground zero for the Flood of 2016, told the Times, “We’re sending supplies.”
Crosby said, “The first thing people want is to know someone cares,” he said. “Teams, crews, family and friends coming in to help is important. Next, financial assistance, gift cards, cash. No clothes. No clichés. Someone to listen.”
Houston’s woes follow on the heels of what some in the Baton Rouge area are still attempting to recover from, the Flood of 2016. Like in Harvey, the August ‘16 flood was bizarre rainfall event that was, “…unlike anything we have ever seen before,” Crosby said last year. “The Flood of 2016 will go down in the history books as one of the worse natural disasters in our community, Crosby said. Harvey, however, has rewritten the history books with over 50 inches
of total rainfall being reported.
However, over the last generation, Katrina remains the most expensive and fatal of all the storms. Using data from the National Oceanic and Atmospheric Administration, Moody’s analytics, and New York Times, the website fivethirtyeight.com lists the top five storms:
1. Hurricane Katrina, Aug. 25, 2005. Damages were $160.0 billion and deaths at 1,833. 2. Hurricane Sandy, Oct. 30, 2012. Damages were $70.2 billion and deaths at 159. 3. Hurricane Rita, September 20, 2005. Damages were $23.7 billion and deaths at 119. 4.Hurricane Ike, September 12, 2008. Damages were $34.8 billion and deaths at 112. 5. Hurricane Hugo, September 21, 1989. Damages were $34.8 billion and deaths at 112.
Harvey stands to top Katrina in property damage, but many predict that Houston will recover, driven by its economic stability and business culture. But twelve years later, New Orleans is still not fully recovered. Today, the city is only 80 percent of the population prior to Katrina.
A US attorney for the Eastern District said that many companies left after Katrina and did not return because of the state’s acceptance of corruption. Former Representative Billy Tauzin characterized the state: “Half of Louisiana is under water and the other half is under
indictment.” Following Katrina a Senate seat flipped to Republican and so did the governor’s office. The New Orleans Mayor was sent to jail for bribery charges and the Democratic congressman was also convicted.
Rebuilding, even for Houston will take time. “The problem for so many is rebuilding,” said Crosby, “relocating and restarting their lives as schools try to reopen, as businesses try to salvage their operations and as neighborhoods …” he said. And just as the clean-up starts in Texas and Louisiana, here comes Irma and Jose.
Psychologists well understand the consequences of trauma and forms of severe stress. And, even though they may not have all the words to describe what happens to them, almost every person who is intimately involved with a crisis, such as Harvey, knows the effects – “first-hand.” Property loss, health consequences for some, environmental devastation, and likely changes in schedule and lifestyle are just some of the more physical consequences. The
dollar cost of Harvey will be staggering.
However, the emotional impact will be far greater and impossible to place a “price tag” on. There is no recovering a lifetime of memories when your family photobooks or your mom’s china or your child’s school records are swept away by floodwater. I remember friends and family digging through the stench after Katrina’s floodwaters finally subsided, looking for anything that might have survived. Some of us can set that aside and not let the grief and
traumatic memories of the losses evolve into depression and anxiety-related disorders. Others are not that resilient.
But, there is another less known and understood consequence of trauma that I want to talk about today. Research I found when I was writing Stress Solutions for Pregnant Moms indicated that an unnamed group of victims can be the unborn children of women who are pregnant in the midst of a crisis. Medical historians long ago identified that war and natural disasters have significant effects on the children born to women who were pregnant during such events. The van Os study (British Journal of Psychiatry 1998) revealed an increase in schizophrenia among children born to women who were pregnant during the May 1940 invasion of the Netherlands. Laplante et al (Journal of the American Academy of Child and Adolescent Psychiatry 2008) explored the cognitive and linguistic functions of 5-year-old children whose mothers had been stranded in a Quebec ice storm. There are several important findings from this study: (1) Children of mothers who experienced high stress during the severe ice storm scored significantly lower on Full Scale IQ and on scales that measure verbal abstract reasoning and information as compared to children of mothers who experienced moderate or low stress during the same natural disaster. (2) The study suggests that timing of the exposure to the natural disaster is important, with poorer outcomes associated with first and second trimester exposure. (3) The negative effects associated with prenatal stress were seen at 2 years, 5 ½ years, and 8 ½ years of age, indicating relatively long-lasting effects.
Countless articles are being published in international journals on this topic leading the American Academy of Pediatrics to issue a landmark warning on January 1, 2012. In their report entitled “The Lifelong Effects of Early Childhood Adversity and Toxic Stress,” they reviewed converging lines of scientific evidence that illustrate how different types of stress can leave a lasting mark on a child’s developing brain and long-term health. The American Academy of Pediatrics’ position paper acknowledges that the period of time from conception through early childhood is critical. They include prenatal stress in their definition of toxic stress and say that children exposed to early stressful conditions are more likely to struggle in school, have short tempers, manage stress poorly, and tangle with the law.
And, while we know how damaging natural disasters are, we do not really know how to mitigate the consequences to people. I hope people can at least be conscious of the effects and work on solutions
By Dr. Alvin Burstein
The events that unfolded at Dunkirk May 6 to June 4, 1940 were pivotal in World War II, and, perhaps, for modern times. The Nazi war machine had swept through most of Europe, trapping nearly a half million French, British and Belgian troops in a pocket on the French coast. Had the beleaguered defenders been killed or captured, an Allied defeat could well have become inevitable.
But that didn’t happen. A surprising pause in the German advance permitted the evacuation of over 300,000 troops, and the trajectory of the war changed decisively.
The British regrouped. Hitler made the catastrophic error of invading Russia. Japan’s attack on Pearl Harbor brought the United States into the war. And five years later, the Axis powers
unconditionally surrendered to the Allies.
Churchill called Dunkirk “the miracle of deliverance.”
The movie, Dunkirk, does a stirring job of immersing its audience in this historic moment.
The narrative style in which it does so is remarkable in several ways. Although a struggle is pictured, we almost never see the antagonist. The German pilots are invisible; the only German
soldiers that appear are a few shadowy figures toward the film’s end.
Incongruous elements are given screen time—a British soldier fleeing from capture or death, stops to move his bowels.
Although we admire the determination of the captain of one of the small boats involved in the evacuation effort as well as the willingness of one of the Spitfire fighter pilots to forgo his opportunity to return to his airbase, neither seems much transformed by their experience.
I think Dunkirk is about more than war.
The movie begins with a flat announcement that it takes place in three arenas and in three time spans: on the mole, the massive pier where the evacuees huddle for a week, on the sea, the day of rescue, and in the air, where we focus on Spitfire pilots engaging in an hour’s dog fight.
These three timelines are continually intermixed.
And then there is the unspoken and unexplained—even by military historians—circumstance of yet another timeline: the pause in the German attack.
And then we watch, repeatedly, the Spitfire pilot recalculate the flight time he has remaining.
And most remarkable of all, is the moment in the film when the Spitfire, out of fuel, in a strikingly vivid metaphor, begins its seemingly, endless, timeless, silent glide to earth.
Dunkirk is about war, its horror, maybe about war’s capacity to test and challenge. But it also keeps calling our attention to time. It wants us to think about time and the human
experience of time. In Time and Narrative, Paul Ricoeur reminds us that the human experience of time critically involves our knowing we are mortal, that we all, like the
Spitfire pilot, run out of time.
Dunkirk calls time to our attention to remind us of our mortality.