Mental Health Association of Portland

By Harry Esteve, The Oregonian, May 14, 2013

A group of unionized mental health workers in the Oregon state prison system wants a pay raise that even they acknowledge is big enough to cause a public relations problem.

About 50 mental health specialists who handle inmates with addictions and other mental health problems want to be reclassified because their job descriptions have changed, including a requirement of a master’s degree. Under their current proposal, they’re seeking raises between 25 percent and 26 percent, which would result in a maximum salary of more than $80,000, according to a memo obtained by The Oregonian.

Like most correction workers, the mental health specialists are represented by the American Federation of State County and Municipal Employees. The memo, written by Brad Holt, one of the prison mental health specialists, urges his colleagues to keep quiet about the proposal.

“Again, my gut feeling only is that with the budget having been so bad over the last 5-6 years, with step-freezes, layoffs, furloughs and increased costs of our health insurance, we are the only positions that are looking to be reclassified with a very substantial increase in pay,” Holt wrote in an email dated April 30. “I am afraid that if enough staff outside of BHS (behavioral health services) were aware, it could become a huge issue for the state and AFSCME to deal with if it became public knowledge or hit the local news media.”

Public employee unions are in the middle of bargaining over new labor contracts with state government agencies. To date, the negotiations have been kept largely under wraps.

The Department of Corrections is under a brighter spotlight this year because Gov. John Kitzhaber has singled it out as one of the reasons the state doesn’t have enough money to spend on education. Kitzhaber has asked for policy changes that ensure the prison population doesn’t continue to grow, as a way to hold down costs.

About a month ago, the state offered to reclassify the prison mental health specialists because of the new requirements, said Matt Shelby, spokesman for the Department of Administrative Services. Under the new classifications, they would become psychiatric social workers, and the state offered an undisclosed wage increase. The union made a counter offer of a bigger increase.

“It’s unresolved at this point,” Shelby said.

The reclassificiation is necessary, Shelby said because of a 2011 law that splits mental health duties. Some of the duties are more complex and require a license and more education, while others don’t, he said. Most of the prison mental health specialists fall under the higher classification, Shelby said.

According to the email, mental health specialists in the Corrections Department earn a starting wage of $3,859 a month, which tops out at $5,328, or $63,936 a year. Under the new classification proposed by the union, the starting wage would be $4,853 and a top scale of $6,747, or $80,964 per year.

Those at the top end would see an annual pay increase of $17,028, or 26.6 percent.

By way of comparison, a similar position of psychiatric social worker at the Oregon Youth Authority, which supervises juveniles and some young adults convicted of crimes, pays $66,288 a year.

Tim Woolery, who is negotiating the contract for AFSCME, defended the proposed wage increases.

“We’ve asked for more, but that doesn’t mean the state’s going to give it to us,” Woolery said. “Those people have been underpaid for a number of years.”

He said they should be paid what other psychiatric social workers make, plus some extra because of the risky nature of their work. He said he isn’t worried about public response to the request for higher pay.

“Of course the state budget and the state revenue picture are factors that come into play in this,” Woolery said. “But my job is to advocate for the members, and to be reasonable about it. And I think we are.”

From the New York Times, April 12, 2013

Some say America has been homogenized, a chain-store nation bereft of regional distinction in dialect or dinner. But now this state, at the pioneer’s end of the road, is testing the idea that local community difference is alive and well, and that grass-roots leadership holds the key to fixing health care in America.

Under an agreement signed with the Obama administration last year, and just now taking shape, Oregon and the federal government have wagered $1.9 billion that — through a hyper-local focus on Medicaid — the state can show both improved health outcomes for low-income Medicaid populations and a lower rate of spending growth than the rest of the nation. If Oregon fails on either front, the consequences are grave, potentially tens of millions of dollars in penalties a year, bleeding a state budget still wounded from recession.

Gov. John Kitzhaber, a former emergency room doctor, said, “We’re building something that’s never been built before.”

Fifteen Community Advisory Councils have been established across the state, charged with setting local goals. One of them, around the college town of Eugene, will take aim starting July 1 at smoking by pregnant women, hoping to cut neonatal costs through a system of rewards, like gift cards at the doctor’s office for women who go tobacco free. Another council, in Portland, is focusing on something that might sound ho-hum in health care, but that local leaders have identified as a care-and-cost driver: mold in low-income housing. Another group, in an economically depressed rural swath in the state’s center, will try getting people out of their cars, aiming for a payoff in reduced cardiovascular care that is both measurable and relatively quick. Hands-on work with patients is common to all the efforts, including one that is using “patient guides,” to talk through care options with people who stack up in emergency rooms with often routine medical problems.

Other states, notably Massachusetts and Vermont, are experimenting with new models as well, mainly through regulation. But Oregon’s way — one ear to the ground, health care with local input — has always been different, and the Medicaid experiment, health care experts said, has now sharpened those distinctions to an incisive edge.

“We’ve got essentially 15 experiments going around Oregon,” said Gov. John Kitzhaber, who was an emergency room physician before entering public life, and still signs his official correspondence with an M.D. next to his name. “They all have to meet the same metrics in outcome and quality,” he added, but after that the new Coordinated Care Organizations, to which the advisory councils report, are largely being left to their own devices in finding a way that makes sense for them.

Local, interventionist, hands-on attention — reducing health problems before care is warranted or billed — means breaking deep tradition in a system that thinks mostly about treatment and response. “We’re building something that’s never been built before,” Mr. Kitzhaber said.

Steve Weiss, chairman of the advisory board at Health Share of Oregon

National health care experts are divided about whether the Oregon Experiment, as many people call it, can achieve real, measurable goals within the five-year timeline of the federal agreement. Some say that to expect once-competing hospitals, in some cases with different cultural traditions and billing systems, to pull together for a common goal — a pattern in some of the new organizations — runs contrary to human or institutional nature.

Others say that Oregon’s path through the health care wilderness is so idiosyncratic that what happens here might stay here, untransplantable to other locales even if it does succeed.

The state has been tweaking its Medicaid system for years under Mr. Kitzhaber, a Democrat who served two terms starting in the mid-1990s, then ran again and won in 2010. Nonprofit organizations with a collaborative bent, like Kaiser Permanente, also run deep in the health care culture, with a big presence and market share. And Oregonians tend to be joiners, with some of the highest rates of volunteerism in the nation, especially in liberal Portland, which has 40 percent of the state’s Medicaid patients, and where words like “community” and “social justice” get repeated in public life like mantras.

“One thing unique about the C.C.O. process is the degree to which it focuses on all the elements of an Oregon Health Plan recipient’s life,” said Steve Weiss, the chairman of the advisory board at Health Share of Oregon, a Coordinated Care Organization in Portland. Mr. Weiss, 70, is disabled and gets by, he said, on $864 a month.

Mr. Kitzhaber, in an interview in his office at the Capitol, said the anecdotal interventionist health care story he imagines is that of a poor 92-year-old woman who develops congestive heart failure in a heat wave because she has no air-conditioner.

“Under the current system, Medicaid will pay for an ambulance and $50,000 in the hospital,” he said. “What it won’t pay for is a $200 window air-conditioner, which is all she needs to stay in her home and out of the acute medical system.”

Getting to that $200 decision, though, is not easy. It means both having a community health care worker able to check in on the woman, he said, then having a system flexible enough to send someone down to the local Target store with a credit card.

It also requires a paper trail of measurements and procedures, officials said, to ensure that local decisions are fair and based on predictable outcomes, so that something like the purchase of one air-conditioner does not open the door to questions of bias, or claims that every poor family is entitled, in the name of fairness or social equity, to cooler air at state expense.

Mike Bonetto, a health policy adviser to Mr. Kitzhaber, said: “How do you maximize the value of the tax dollars that are being spent on health care? If it’s to pay for the air-conditioner, so be it.” He says the public understands that linkage — that savings on many small things can mean greater support for big things like public safety and education — and the Democratic-controlled State Legislature has endorsed it with bipartisan votes on elements of the health package.

The state has also developed 33 performance measures to aim to show to the public and the federal government how the project is working, with financial incentives to local Coordinated Care Organizations for meeting goals like rates of adolescent well-care visits and colorectal cancer screening.

The first reports of baseline data are scheduled to start coming in this spring.

Mark V. Pauly, a professor of health care management at the Wharton School of Business at the University of Pennsylvania, says he thinks coordinated care of the sort Oregon is embarking on might seem a little too interventionist in parts of the country where people are expected to mind their own business.

“We don’t know whether Americans are ready for coordinated care,” he said. “But Oregon keeps trying. God bless them.”

By Christopher David Gray, The Lund Report, March 5, 2013

A pathway has appeared to the game-changing funding levels that Senate President Peter Courtney signaled for community mental health — at least for children – when the increased funding made a list of priorities when the co-chairs released their two-year spending plan Monday morning.

Courtney’s proposal called for a funding increase of $331 million for community mental health, including $46 million for children and adolescents — $28 million more than what Gov. John Kitzhaber had earmarked.

“We’re gonna get there or we’re gonna get close,” said Courtney’s spokesman Robin Maxey after the press conference.

Part of that increased money would be included in the $4.3 billion dedicated to human services, while the rest would be part of the $275 million in new taxes by eliminating some unspecified corporate and individual tax write-offs.

“We should treat our tax expenditures and deductions the same way as we see our regular expenditures,” said Sen. Richard Devlin, D-Tualatin.

The co-chairman’s budget projects $75 million from these new resources for children’s mental health and other healthcare priorities such as the tobacco prevention program, the Farm to School program, the Oregon Health & Science University Rural Scholars Program, mandated physical health education and an increase in payments to home care workers.

The details for the budget still must be worked out through the various Ways & Means subcommittees and could definitely change, according to Devlin.

That budget also keeps the funding levels consistent with the governor’s budget for coordinated care organizations and the state mental hospital. The proposal also presumes the Medicaid expansion will take place, giving Oregon Health Plan coverage to 250,000 newcomers next year however those dollars will come from federal coffers, not the state’s general fund.

Devlin and fellow co-chairman Rep. Peter Buckley, D-Ashland, called for a $16.6 billion discretionary budget over the next two years, which assumes $705 million in savings to the Pubic Employee Retirement Savings — which is more modest than the $865 million in the governor’s budget.

“It’s trying to thread a needle in the dark,” Devlin said. “We need to find a path that is both fair and proposals that will have both short-term and long-term savings. … Higher levels that don’t hold up in court don’t do anyone any good.”

The budget also assumes the savings projected by Kitzhaber from prison reform.

Education funding would be $6.55 billion over the next two years, an increase from Kitzhaber’s $6.15 billion and local districts would realize $50 million less in savings from PERS reforms than the governor proposed. Meanwhile, the human services budget would bump up by 9 percent.

The minority Republicans also presented their own budget proposal, one that would hold revenues at current levels while promising $1.8 billion in PERS savings, despite the tricky legality of scaling back public employees’ promised pensions.

Republicans including Rep. Dennis Richardson of Central Point and Sen. Doug Whitsett of Klamath Falls said they were shut out of the budget discussions brought forward by the majority Democrats, unlike last session, when the House was split between the two parties.

“I think it’s unfortunate that the Republicans have chosen to politicize the co-chairs’ budget,” said House Speaker Tina Kotek, D-Portland.

The Republicans matched the Democratic co-chairmen’s numbers on education funding but sought to hold the line to roughly 2 percent annual increases for human services, roughly the current rate of inflation.

Richardson argued that the number of people seeking social services should decline as the economy recovers. “The caseloads should be decreasing,” he said.

He pointed out that human services represented 21 percent of the budget in 2005-07, yet absorbed 26 percent of the general fund last biennium because of the 2008 economic collapse. At the same time, the percentage of discretionary funds spent on education has declined from 44 percent to 38 percent.

“We’re placing the expansion of social programs on the backs of our children,” Richardson said.

Rep. Mark Johnson, R-Hood River, said the Republicans would be hard pressed to support any tax increases as Oregon’s unemployment rate clung to 8.3 percent.

But while tax increases require a bipartisan three-fifths majority vote, allowing tax expenditures already scheduled to lapse to actually expire does not require a similar majority.

By Erin Fenner, Willamette Week, March 6, 2013

Dr. Gary Oxman

Dr. Gary Oxman spent his career trying to save people who don’t care whether they live or die.

Oxman—who just retired as health officer for Multnomah, Clackamas and Washington counties—has long wanted to do more to rescue drug users.

He was one of the earliest supporters in Portland of free needle exchanges, aimed at stopping the spread of HIV among addicts who share syringes. That idea, first floated in the late 1980s, was often met with derision: Why should we condone the use of dangerous drugs by making it safer for addicts to keep shooting up?

Oxman helped champion a needle-exchange program in Portland, and he says it’s the reason the city never saw the explosion of HIV among drug users as other communities did.

“Pure and simple,” Oxman says. “Something that went very right.”

But Oxman, who retired last month, has been unable to reverse another epidemic: opiate addiction.

In Oregon, unintentional drug overdoses now kill more people than car accidents. The drugs that are driving up those numbers and killing most often are opiates—heroin and prescription pain medication, including methadone. In 2011, Oregon saw nearly 300 people die because of opiate overdoses—the highest year yet for heroin deaths. The rate of people dying from opiate-related overdoses has more than tripled in the past decade.

In fact, Oregon has the highest rate of opiate abuse among people under 25 than anywhere else in the country.

More than half the drug overdose deaths in Oregon are linked to prescription opiates such as OxyContin and Vicodin.

In Multnomah County, the top killer is heroin. Nearly half of drug users addicted to heroin here say they got hooked first by taking prescription pain pills.

Gov. John Kitzhaber has called the state’s addiction to these drugs “calamitous.”

Oregon has tried to battle drug addiction with education and treatment programs.

But Oxman wants the state to go further.

He wants to expand the use of another drug that will snap users out of an overdose of heroin, methadone or pain pills.

It’s commonly called Narcan, and for more than four decades paramedics and emergency-room personnel have injected it into people dying of opiate overdoses to give them a chance to hang on.

Across the country, recovery agencies and treatment centers have been making Narcan (also known by its generic name, naloxone) available to drug users’ friends, families, counselors and even addicts themselves—giving them a chance to deliver a life-saving dose before paramedics arrive.

Considered radical when it started, the wider use of Narcan has saved as many as 10,000 lives by reversing the effect of overdoses.

But Oregon—once in the forefront of helping protect the health of drug addicts—has not joined in.

Now, Oregon senators are considering a bill to make it easier to distribute Narcan. By doing so, lawmakers will shift the state’s efforts to fight drug overdoses not just with education, prevention and treatment, but by giving addicts a safety net even as they practice self-destructive behavior.

“These overdoses are individual and community tragedies,” Oxman says. “They can be treated, and so we don’t need to have people dying needlessly.”

A native of Minneapolis, Oxman came to Oregon after graduating from the University of Minnesota Medical School in 1978. When he was in private practice in the early 1980s, he recalls seeing patients he suspected were describing problems with pain that didn’t exist.

“They were trying to manipulate me into giving them opiates,” Oxman, 60, says. “That’s always been there in the community. It’s just way worse now than it was a few decades ago.”

Oxman was named Multnomah County medical director in 1984, and the county’s public health officer three years later. Around 2000, Oxman helped reverse the spike in heroin deaths, in part by targeting addicts themselves with information about how to use the drug more safely.

The overdoses the Portland area sees now are not driven by heroin alone. The long line of drug deaths often begin at the prescription pads of doctors.

Nearly half of the prescriptions tracked by state officials last year were for opiates. That amounted to 3.7 million painkiller prescriptions—nearly one for every resident of Oregon.

Drug users say painkillers lead to addiction—43 percent of heroin users in Multnomah County say they were first hooked on prescription painkillers. (Heroin is often cheaper and easier to get than prescription drugs.)

These drugs have created a widespread occasion of death. More than 60 percent of current opiate abusers say they’ve seen someone overdose in the past year.

“The docs are sort of trapped in this situation where patients are in pain and there’s no logical alternative,” Oxman says. “It’s not bad doctors. It’s the structure of the health-care system that’s really driving this.”

Tom Burns, director of pharmacy programs for the Oregon Health Authority, says in many cases physicians and dentists overprescribe pain meds to avoid having to write repeat prescriptions.

But Burns says the state has no intention of challenging physicians’ autonomy when it comes to making medical decisions. “We’re not Big Brother,” Burns says.

Instead, the state has tried educating doctors. In 2009, the Oregon Legislature created the Oregon Prescription Drug Monitoring Program, intended to help physicians track their patients’ prescriptions, no matter who writes them. A medical professional who’s concerned about a patient’s use of OxyContin, for example, can log on and see if the patient has been “doctor shopping” by getting prescriptions from other sources.

Ryan Lufkin is a deputy district attorney in Multnomah County who focuses primarily on drug crimes—he estimates he’s handled 1,100 drug cases in the last three years. He says too little money spent on recovery and treatment programs makes matters worse.

“The solution that seems to be the gold standard from a criminal-justice perspective is a treatment bed straight from a jail bed,” Lufkin says. “The ultimate goal is not conviction, but treatment.”

Last fall, Vero Majano came to Portland to help organize a film festival at the national convention of the Harm Reduction Coalition, an organization that works to help protect the health—and the rights—of people who use drugs.

Majano manages a drop-in center for the homeless in the Mission District of San Francisco. A social activist for years, Majano says most people don’t understand the goal of harm reduction—in part because they demonize the drug-using community.

“There’s this thing around drug use being evil,” she says. “So the idea is that drug users are also bad. If people were to look at trauma, how people self-medicate—people use [drugs] for good reasons.”

Majano’s views reflected the message at the conference, which drew hundreds from around the country: Drug users should have no fewer rights to have their health and welfare protected than anyone else.

Yet proponents say society should do more than simply jail people who use drugs, or try to combat addiction through education and treatment programs. It also means helping keep addicts alive and healthy, even when they show no signs of stopping their drug use.

Jake Rhew

Take the case of Jake Rhew.

Rhew was born in Pullman, Wash., in 1982, and attended Sam Barlow High School in Gresham. His family recalls Jake as a kid who loved to fish, raft the Clackamas River and stood up for people who were powerless—even as a kindergartner, he protected other kids from school bullies.

“He had a good heart—a compassionate soul,” Rhew’s stepmother, Kathy Thomes-Rhew, says.

Before he was out of high school, Rhew got hooked on pain pills and stole medication from his family.

Rhew earned a GED diploma and enlisted in the Army National Guard, only to get kicked out. He moved to his father’s house in Troutdale, stole to buy drugs, and tried to hide track marks on his arms. From 2009 to 2011, Rhew was arrested and charged five times for theft and once for possessing heroin.

“Jake was desperate,” Thomes-Rhew says. “It wasn’t the Jake we knew, and that’s what heroin can do to a person.”

Rhew often recorded his battle with drugs on his Facebook page. “5 months sober,” he wrote in June 2010. Two weeks before his last overdose, he wrote, “Damn going to sleep is a lot harder then [sic] passing out.” And three days before he died, he posted a photo of himself: short-cropped blond hair, broad nose, clean white T-shirt, cautious smile. “Lookin’ good Jake,” a friend wrote.

On Aug. 23, 2011, Rhew, 29, was living at the men’s residence center run by Volunteers of America in Northeast Portland when he and another client slipped into a bathroom to shoot heroin. Rhew was already in full nod by the time the center’s staff found him.

They couldn’t revive him and he choked on his vomit. It’s the center’s only death.

“The counselors did everything that could be done,” Thomes-Rhew says, but the staff didn’t have access to Narcan. “At least he would have had a chance.”

Greg Meenahan, director of development and communications for Volunteers of America, said medical privacy rules prevented him from talking about Rhew’s death. But he says he would want Narcan in the hands of the organization’s staff.

“We view this as a life-saving medication,” Meenahan says. “If we were able to have it, there’s little doubt that we would use it.”

Narcan is a brand name for naloxone, developed in New York in 1960 by researchers who found the drug had a remarkable ability to block the effects of heroin and other opiates.

The use of Narcan isn’t quite as dramatic as perhaps the most famous scene of reviving someone in the throes of a drug overdose: the stabbing of Uma Thurman’s character in the heart with an adrenalin-filled hypodermic needle in Quentin Tarantino’s Pulp Fiction.

The drug is often injected into the skin or a muscle, such as the biceps or thigh, and also comes as a nasal spray. Narcan throws the overdose into reverse—people can go from being blue and not breathing, to gasping for air in an instant withdrawal.

John Sanborn (who asked that his face not be photographed)

John Sanborn knows how it feels.

He says he’s been “Narcanned” by paramedics during heroin overdoses. Like the time he cooked up shot after shot in a Portland State University restroom. Or the time other junkies dragged him into a downtown apartment hallway and left him for dead.

“It’s horrible if you’re living with an addiction,” Sanborn says of Narcan’s effects. “It brings you right down to where you were before you started shooting.”

Narcan, Sanborn says, gave him a new chance at recovery. He’s currently in Central City Concern’s Community Engagement Program and is reconnecting with his 9-year-old son. “I realized that if I ever wanted to have any kind of a life,” he says, “I was going to have to stop using drugs.”

Sanborn got Narcan the way almost everyone in Oregon does: from a medical professional. But nearly 20 years ago, activists in other states realized the greater potential of the drug to save lives.

Dan Bigg, executive director of Chicago Recovery Alliance, says his organization had already seen harm-reduction strategies work with needle exchanges, slowing the AIDS epidemic among IV drug users.

“[We] turn to the next big issue, which is overdose,” Bigg says. “Why not use the existing pathways to get [Narcan] into the hands of people who overdose?”

In 1996, Bigg’s organization began to train and distribute naloxone to laypeople. He says he has administered naloxone to an overdosing person at least six times.

In 2010, Illinois finally made it legal to do what Bigg’s group had been practicing, but he says he’s frustrated that other parts of the country are behind.

“It’s a pure antidote,” Bigg says, “and you’d think it’d be available to scores of people suffering from premature death.”

By that time, according to the Centers for Disease Control and Prevention, the use of Narcan by nonmedical professionals had broadened: Nearly 200 programs in 15 states and the District of Columbia were making Narcan more available. A 2012 CDC report said these programs helped reverse the effects of drug overdoses in more than 10,000 cases.

The CDC also found “many states with high drug-overdose death rates have no opioid-overdose prevention programs that distribute naloxone.” That includes Oregon.

Allan Clear, executive director of the Harm Reduction Coalition in New York, says Narcan should be ubiquitous, especially in a city like Portland that has an opiate-overdose problem and has been a leader in needle exchanges.

“Overall, nationally, it’s not that well-known as a community intervention program,” Clear says. “In New York City and San Francisco—when the health department got on board—it really added that level of legitimacy to it. There’s always been this level of caution because naloxone is one of those drugs you prescribe to use on someone else.”

Dr. Sharon Stancliff, medical director of the Harm Reduction Coalition, says Narcan hasn’t proved controversial in many communities.

“In New York, we actually have it set up so different kinds of agencies can distribute it to whoever they want,” she says. “It has gone from being this sort of edgy thing to really becoming mainstream.”

Dr. Sandro Galea, chairman of the epidemiology department at Columbia University, says Narcan was controversial in New York because people believed making it widely available would encourage drug users to indulge in opiates.

Galea’s studies showed that drug users were not encouraged to be more reckless with heroin by having Narcan handy.

“There is no excuse for not making naloxone widely available to the [drug-using] community,” Galea says.

If drug-overdose deaths are so common here, why is Oregon so far behind in the movement toward Narcan?

Oxman says cities and states that moved ahead with making Narcan more available also have more vocal and organized groups advocating for the welfare of drug users.

“I think when you get a critical mass of folks who believe in a particular issue, that makes organized action easier,” Oxman says. “It’s not that Portland lacks the drug users—we have lots and lots of drug users.

“Government is not in a position to be the leaders of harm reduction. It’s really a community activity. And it is really bewildering why that hasn’t been more prominent here.”

Kathy Oliver, executive director of Outside In

In Portland, the organization that helped pioneer the needle-exchange program, Outside In, has been the obvious place to experiment with making Narcan more available.

Outside In works with homeless youth and what it calls “marginalized people.” Kathy Oliver, Outside In’s executive director, says health-care workers in the organization’s clinic on Southwest 13th Avenue near Main Street are allowed to both inject and prescribe Narcan to people for use only on themselves.

Oliver would like to see Narcan more widely available. “The reason I want to do it is the same reason I wanted to open the syringe-exchange program,” she says. “Death by overdose is preventable, so giving people the means to protect themselves makes sense.”

But Outside In has been largely silent on the issue, despite the high overdose rates in Multnomah County. Oliver says she’s aware that scores of other organizations like hers around the country have distributed Narcan or promoted its use.

“We did think the best way to achieve [a community pathway for naloxone] would be through the legislative and not through Outside In being a political advocate,” she says.

In Salem, state Sen. Alan Bates (D-Medford) has introduced a bill to expand access to Narcan. Jackson County, where Bates lives, saw 30 people die in 2012 from opiate drug overdoses, according to Dr. Jim Shames, the county health officer.

Ashland, a community known for staging the Oregon Shakespeare Festival, was stunned recently by the death of three men within six weeks of each other—all from opiate overdoses.

Maxwell Pinsky, 25, the son of a local blues musician, died Jan. 15 of a suspected opiate overdose; the Jackson County sheriff’s office says the toxicology reports aren’t finished yet. A month earlier, Ashland had two heroin-overdose deaths within a day of each other: Pinsky’s friend Jordan Roth, 34, the son of a retired physician; and Colin McKean, 36, son of actor Michael McKean.

Bates’ bill would make Narcan a drug that anyone—from social workers to drug users—can get training to use and be able to purchase to have with them in the case of an emergency. Part of the bill also makes people who administer Narcan in an overdose situation immune from civil prosecution.

Emergency-room physicians have warned legislators the drug can cause a powerful reaction in people coming out of an overdose if the dosing isn’t done properly.

“It’s still a large question as to whether the public should have access to this powerful drug,” says Jim Anderson, lobbyist for the Oregon Chapter of the American College of Emergency Physicians. “We have mixed emotions about it.”

Oxman says passage of the bill will mark a big step in Oregon moving toward accepting the idea that government has a role to play in helping drug users stay alive, regardless of whether they stop using.

“I think people have really come around,” he says, “to seeing what we’re trying to do is help people who have problems with drug abuse, and there’s a variety of different pathways to get there.”

 
Leaders of the House and Senate have boosted support for the EASA program, which assists youth after a psychotic break. Gov. John Kitzhaber has earmarked a $1.8 million increase for the program, while the dramatic increase envisioned by Sen. Peter Courtney awaits a funding source.

If left improperly treated, someone suffering from psychosis can have a bleak life ahead of them: years of drifting in and out of the medical system or the prison system. A psychotic break can often set up a person for a life on the margins living off meager disability payments.

The Early Assessment and Support Alliance aims at changing that. By working with teens and young adults during the first year of a psychotic break, the program can help guide clients toward accepting and managing their condition, helping them to stay out of the hospital, out of prison and in school while removing environmental barriers that may be exacerbating their disorder.

“Our goal is to provide support to people as early as possible,” said Tamara Sale, the program coordinator at the Mid-Valley Behavioral Health Network in Salem. “It’s not easy for families to find the help that they need. Half of people who call us have no signs of psychosis, but they do need some kind of help.”

Sale said clients are treated in an evidence-based but holistic fashion, tailored to the individual’s needs. A number of people who have gone through the program are not only staying out of taxpayer-funded institutions but working toward college degrees. Program coordinators also work to stay in touch with clients after they finish the two-year intervention.

“It’s really about helping people gain some context,” for their condition, Sale said. “Our goal is to avoid them ever going to the hospital again.”

The program served 600 families between 2008 and 2011, but it’s still not funded statewide. Three Western Oregon counties that recently joined the program — Clackamas, Lane and Douglas — were funded by one-time private grants.

In a state with millions of dollars in unmet mental health funding needs, House Speaker Tina Kotek, D-Portland, pointed to EASA as a high priority.

“She’s called that out as a successful program, and the kinds of programs we ought to be funding,” said her spokesman, Jared Mason-Gere.

Senate President Peter Courtney, D-Salem, specifically mentioned the EASA program when he called for a “game-changing” increased mental health investment of $331 million at the start of the legislative session. Added revenue in the governor’s proposed budget would boost EASA, but the money that Courtney suggested would allow for a greater expansion.

“We need services that can intervene and make a difference in someone’s life before they wind up in the Oregon State Hospital or one of our prisons,” according to an earlier press release from Courtney. “More than half of the adults with mental illness are slipping through the cracks.”

Courtney’s proposal is roughly six times what Gov. Kitzhaber submitted in his 2013-2015 budget to legislative leaders, while funding for Courtney’s proposals was unclear.

“The governor strongly supports Senator Courtney’s mental health initiative and appreciates his leadership for taking on an important issue that’s been neglected for too long,” said Tim Raphael, the governor’s spokesman. “The governor stands ready to help in anyway possible.”

While Kitzhaber’s proposals could come from the general fund, Courtney’s “game-changing” investment would require a new revenue source — and bipartisan approval of two-thirds of the Legislature or a direct vote of the people.

At the press conference, Courtney cited raising the beer and wine taxes as one possible revenue source, but said he was open to other ideas. Courtney’s spokesman Robin Maxey told The Lund Report this week that there have been discussions with players behind the scenes, but nothing he was ready to make public.

“We have to do something,” said Rep. Jim Thompson, R-Dallas, who’s the ranking Republican on the House Health Committee. But he hadn’t been privy to any discussions over funding sources and was noncommittal to raising revenues. “New taxes — those are always so popular with the people.”

The governor’s budget predicts that the Medicaid expansion in 2014 — thanks to the Affordable Care Act — will save Oregon roughly $44 million for what’s currently spent from the general fund on indigent mental healthcare because those people will eventually come onto the Oregon Health Plan.

But instead of cutting that money from the general fund or allocating it elsewhere, Kitzhaber has proposed rolling the dollars back into state community mental health programs, and adding another $12 million.

The governor’s budget also includes $1.8 million for the EASA program from the general fund, which Sale said would allow the program to become statewide. All the EASA sites do receive some support from the state’s 15 coordinated care organizations, but those sites require more revenue to remain sustainable, she said.

Chris Bouneff, the executive director of the National Alliance on Mental Illness of Oregon, said it was encouraging to see Kitzhaber increase mental health funding after several years of flat funding, but the system still was not properly funded as well as it should be.

“You have a mental health system that is stretched to the limit,” Bouneff said. “We have some programs that we know work, they’re just not widely available.” He also stressed the serious need for housing for people with mental illnesses.

EASA started in Salem in 2001 and has since expanded to 19 counties around Oregon. But it’s still not available in much of Eastern Oregon or two of the state’s largest cities, Medford and Corvallis. Once funding becomes available, Sale said they had agencies ready to go east of the Cascades and in Benton County.

Although the CCOs are tasked with integrating mental and physical health services, Bouneff said it’s too early to credit much success to them, other than diverting some patients from the emergency rooms.

“I think it’s overly optimistic to expect the CCOs to have much impact in the first year on mental illness,” he said. “The CCOs came into existence before we had any plans … If they work as intended, there’s a lot of potential.”

From OPB.org, January 22, 2013

Recent mass shootings in Oregon and Connecticut have thrust mental health issues into the spotlight. Some Oregon lawmakers and mental health advocates hope there’s enough momentum to keep the conversation front and center. Unlike gun control, there is a consensus that appears to be emerging on funding mental health programs.

First, there was the Clackamas Town Center mall shooting. Then, just days later, the tragedy at Sandy Hook Elementary. Some Oregon lawmakers responded with proposals to ban high capacity ammunition magazines and implement other gun control laws. Oregon Governor John Kitzhaber says he’s open to a wide range of gun-related legislation.

“But even if you do all that, you really do need to invest in community mental health,” Kitzhaber says.

Programs that serve people on the local level, as opposed to centralized institutions. The Democratic governor has put more money into community mental health programs in his proposed budget. And he’s not the only one in Salem talking up the need for more mental health funding. Republicans may be wary of gun control legislation, but they have been talking up the same mental health programs Kitzhaber wants to fund. Democratic Senate President Peter Courtney is a long-time advocate of services for the mentally ill.

“It just doesn’t get to the forefront. It never gets to be in front of the parade. In fact sometimes it’s not even made part of the parade. It’s just not there,” Courtney says.

But Courtney says it’s clear that there’s a new level of interest in the issue.

“If because of this tragedy I can get to mental health, then why shouldn’t I do it? We gotta do this. We gotta do a lot better than we’re doing it. A lot more than we’re doing now,” Courtney says.

That’s welcome news to many who work on mental health issues. John Van Dreal helps assess the threat posed by troubled students in the Salem-Keizer School District.

“It’s good that we’re paying attention to this problem—a lack of mental health services and access to folks that really need it,” Van Dreal says.

But Van Dreal isn’t comfortable using the school and mall shootings as a way to kick-start the conversation about mental health.

“I think we’re quick to try to find a reason and blame that reason, and for some reason the folks with mental health issues end up getting the brunt of that blame when these things happen,” Van Dreal says.

Van Dreal says linking mass shootings to mental illness just perpetuates a stereotype. Take, for example, these comments from Wayne LaPierre of the National Rifle Association. LaPierre was speaking at a press event held by the gun rights group in the days following the deaths of 26 children and teacher at Sandy Hook Elementary.

“People that are so deranged, so evil, so possessed by voices and driven by demons that no sane person can ever possibly comprehend them. They walk among us every single day,” LaPierre said.

LaPierre called for a new national database of people with mental illness. That’s not on anyone’s agenda in Salem. And actually, some mental health advocates in Oregon say the state is already turning around decades of neglect on mental health services. Bob Joondeph of Disability Rights Oregon says he doesn’t think the new momentum over mental health funding will quickly dissipate.

“I think in Oregon it’s going to just add steam to a train that’s already moving down the track,” says Joondeph.

But Senate President Peter Courtney isn’t so confident. He sees this as perhaps a once-in-a-generation opportunity to tackle an issue he holds dear.

“It’s not going to happen unless we barge ahead. It’s time to barge,” Courtney says.

But Courtney says to truly transform Oregon’s mental health system would take hundreds of millions of dollars. And he’s not sure where the money would come from.

Gov. John Kitzhaber

In 2011, Oregon Gov. John Kitzhaber faced a vexing problem: The state had a $2 billion hole in its Medicaid budget and no good way to fill it.

He could cut doctors’ pay by 40 percent, but that might lead to them quitting Medicaid altogether. He could drop patients or benefits, but that would only compound costs in the long run. A former emergency room doctor, Kitzhaber remembers culling the Medicaid rolls in the 1980s, when he served as a state senator.

“When I went back home, and went back to the emergency department, I saw a couple of people who came in who lost coverage under that decision,” he said. “One of them was a guy who had had a massive stroke. These people don’t disappear.”

So Kitzhaber did something that many before him have done in desperate times. The governor who favors cowboy boots over dress shoes made a bet that Oregon could not afford to lose.

The deal Kitzhaber struck was this: The Obama administration would give the state $1.9 billion over five years, enough to patch the budget hole. The catch: To secure that, Oregon’s Medicaid program must grow at a rate that is 2 percent slower than the rest of the country, ultimately generating $11 billion savings over the next decade. If it fails, those federal dollars disappear.

Oregon is pursuing the Holy Grail in health-care policy: slower cost growth. If it succeeds, it could set a course for the rest of the country at a pivotal moment for the Affordable Care Act. Under the law, many states will expand Medicaid programs to cover everyone below 133 percent of the federal poverty line, adding 7 million Americans to the program in 2014 and leaving states looking for the most cost-effective way to cover that influx of patients.

In Oregon alone, Medicaid is expected to enroll 400,000 new patients by 2022, nearly doubling its current numbers, according to an Urban Institute analysis.

As Oregon’s population grows, the state has come to realize that Medicaid is not a bottomless bucket of money. The state’s budget cannot sustain that. Instead, it strives to deliver what health policy experts call “the triple aim”: higher-quality care that leads to better outcomes, all delivered at a lower cost.

“Oregon is trying to change the way that health care is delivered with incentives to deliver smarter, better care, instead of just imposing budget changes that cut back on health care,” said Cindy Mann, director of the Center for Medicaid and State Operations. “They’re doing this statewide and it’s very exciting for us.”

Under the new deal, Oregon does not get a lump-sum payment. Instead, the federal government doles out the $1.9 billion over five years. If the state cannot deliver cost savings up front, while hitting certain quality metrics, it’s cut off. The money it needs to keep doctor salaries stable and patients’ benefits covered dries up.

“In terms of cost-control experiments, the likes of this are something we have never seen in health care,” said John McConnell, a health policy researcher at Oregon Health & Science University who is studying the Oregon Medicaid waiver. “The natural questions are: Is it going to work? Is the state going to fix the budget? And if they do fix the budget, how are those savings accomplished?”

As Kitzhaber sees it, failure isn’t an option. The state’s Medicaid program needs that $1.9 billion to make ends meet now, even if it means paying big dividends back to the federal government later. It’s not unlike a payday loan, with a quick influx of cash and a large obligation to follow.

“There’s no more money,” Kitzhaber said. “This is one where you really have to change how you do business in order to survive.”

The phone started ringing, Kitzhaber said, when he landed that $1.9 billion. Other states wanted to know the trick. Then he explained what he committed to.

“We got a lot of calls, things like ‘How did you get all that cash and how can we get some?’” he said. “They never called back.”

30 years and no solution

Oregon has a long history of leadership when it comes to the Medicaid program, which covers nearly 62 million low-income and disabled Americans nationwide. In the early 1990s, it was among the first to use a federal waiver to expand limited coverage to all Oregonians living below the poverty line. Oregon’s uninsured rate quickly dropped, from 18 percent in 1994 to 10 percent in 1998.

Maintaining a robust health plan, however, hasn’t been easy. The state’s tax revenue dropped during the economic downturn of the early 2000s. To keep the Medicaid program afloat, the state charged significantly higher co-pays for some: $50 for an emergency room visit and $250 for a trip to the hospital.

Medicaid enrollment shrank by 46 percent as patients affected by the changes left the program — likely relegated to the ranks of the uninsured — between February and December 2003, according to research published in the journal Health Affairs.

Separate research has found that when Medicaid premiums rise by 1 to 5 percent of an uninsured family’s income, their odds of participating drop from 57 to 18 percent.

“For the last 30 years, both the private and public sector have done the same things to manage health-care costs,” said Bruce Goldberg, the Oregon Health Authority director who oversees the Medicaid program. “They’ve cut people from coverage, cut payment rates or cut benefits

“It’s been 30 years of doing that, and we haven’t solved the problem.”

This time around, Oregon wanted to try something different. Instead of dropping patients, the goal is to make high-quality health care less expensive.

Goldberg says that a small experiment in Oregon last year gave the state clues about a better way to reduce health spending. It took place at St. Charles Hospital in Bend, a mountain town known for its snowboarding, white-water rafting and microbreweries.

St. Charles noted that 144 patients tended to use the emergency room the most. Taken together, they averaged 14.25 trips each over 12 months. These patients drove much of the area’s Medicaid spending.

Researchers focused on them. Despite the frequent visits to the ER, these patients tended to be disconnected from the system.

More than half did not list a primary-care doctor. Some didn’t even have a preferred hospital: 27 percent had visited multiple ERs. The majority had unmet mental health needs, even though most had Medicaid, which provides mental health coverage.

Much of that seemed to have to do with the fragmented nature of Oregon’s Medicaid program.

“In our old system, we had people who had a physical health plan, a mental health plan and a dental plan,” Goldberg said. Patients would have three insurance cards, one for each type of service.

Where health-care services tended to be siloed, providers in Bend decided to integrate. It stationed community health workers in emergency rooms, who could help assess why patients had turned up.

Behavioral health specialists were embedded in clinics that traditionally dealt only with physical issues, in order to give patients a point of contact when they walked in the door.

The program was not a complete success. Of the 144 patients in the study, only 62 percent agreed to work with a community worker on a plan for their care. The others proved difficult to track down or did not want to participate.

Still, it did significantly change how the most-expensive patients used the health-care system. Emergency department visits fell by 49 percent. On average, the program generated about $3,000 in savings per patient.

Now, the Oregon aims to bring an approach that worked with 144 patients in Bend to Medicaid’s 564,470 patients across the state.

Oregon divided the state into 15 region and gave each one a set amount to care for each patient. These regions can divvy their dollars however they please, so long as patients hit certain quality metrics, like ensuring that adolescents get well-care visits and that steps are taken to control high blood pressure.

The hope is that each of the 15 regions, known as coordinated care organizations, will invest only in the most cost-effective health care. A behavioral health worker who can prevent emergency admissions becomes a lot more valuable, the thinking goes, when Medicaid funding is limited.

In this way, the Oregon plan has some parallels to Republican ideas to “block grant” the Medicaid program, and give states a set amount to run their programs. Both rely, in part, on a fixed budget to put downward pressure on health spending.

“You can call it what Oregon calls it, a global budget, or you can call it a block grant,” said Tevi Troy, assistant Health and Human Services secretary under George W. Bush. “There’s a semantic aspect to it. At the end of the day, we’re talking about putting limits on what we’ll spend on Medicaid.”

Democrats have typically opposed block grant proposals out of fear that they could lead states to skimp on care to meet spending targets. Safeguards in the Oregon plan, like the quality metrics, however, have made the approach more palatable to liberals.

“The idea of a global budget is to try to wring those costs without actually making consumers or seniors bear the heaviest burden,” said Neera Tanden, the Center for American Progress president who has advised President Obama on health policy.

Hope in Prineville

At the Mosaic Medical clinic in Prine­ville, a tiny Central Oregon logging town of 9,192, Juana Martinez and Michelle Ortiz are practicing the type of medicine that Kitzhaber thinks could fix the system. They are community health workers, the ones who make sure that patients do not slip through the cracks.

“Back there, you just get patients’ vitals,” said Martinez, motioning toward the exam rooms. “Here, it’s more knowing about them and making sure you can help them.”

That’s what she and Ortiz have done with Rebecca Whitaker. The 53-year-old Medicaid patient moved to Prineville last year, after shuffling through three Arizona nursing homes in six years, while recovering from a stroke.

Doctors had prescribed her 28 medications. Her social anxiety would get so bad that, sometimes, she rubbed her hands raw. By the time Whitaker got to Prineville to live with her cousin, she had given up on the health-care system.

“I tried to make it on my own for three months,” she said. “I was a diabetic without insulin. I wore a size zero pants. I tried suicide twice. I swore I’d never see another doctor.”

At Mosaic Medical, Whitaker received care for her diabetes and blood pressure. She also began seeing the clinic’s behavioral health specialist every week, who helped tend to her anxiety and depression.

Community health workers aided in other ways. They helped to ease her social anxiety by attending bingo night together. When Whitaker expressed an interest in moving out of her cousin’s house, Martinez helped her find an apartment.

“They have been the most moral support I’ve ever had in my life,” Whitaker said. “They cared, and that made me want to care. Little by little, when things got too frustrating in life, I’d see one of them. They changed my whole life.”

Worry in Portland

The governor’s gamble looms large for those who have to execute his plan: When you have a fixed number of health-care dollars, who gets the biggest slice of the spending?

The question weighs heavily on the doctors at Richmond Clinic in Portland, a federally qualified health center that is run by Oregon Health & Science University and sees a large load of Medicaid patients. Doctors there are pleased about the opportunity to be paid for some of the services they wouldn’t now, like having a long talk with a patient about diabetes management.

“What we’re excited about, with this whole transformation process, is having the mental space and time to address our patients’ needs,” said Nick Gideonse, the clinic’s medical director. “If we can get off the reimbursement system that is totally dependent on face-to-face visits, we might have more space to anticipate our patients need, rather than respond to them as they happen.”

The Richmond clinic recently added a behavioral health specialist to its staff. Rather than have the patient schedule a separate appointment at a different location, the specialist can pop in for a visit where a doctor notices unmet mental health needs.

“Almost every day, whoever is on for mental health will come down to the doctor’s pod and say, ‘Hey, does anyone have someone on their schedule we should talk about?’ ” Gideonse said. “They’ll literally go through every provider’s schedule and see who will benefit from a mental health touch.”

At the same time, others at the Richmond Clinic worry about how big their share of the lump-sum payment will be.

“I’m reassured by people talking about the role primary care providers need to play,” said Ern Teuber, the clinic’s executive director. “Still, when we start talking specific dollars, the perception is there isn’t enough money to go around and that somebody has to lose.”

The worry is especially acute for the hospitals that tend to deliver more expensive types of medicine. Their business model has traditionally relied on keeping beds full, as each patient brought in new payments.

“If we can’t reduce the cost of hospital care, we become a cost center rather than revenue generator,” said Greg Van Pelt, chief executive of Providence Health. “If Medicaid is going to grow slower, you have to figure out a way to get it to cost less.”

That process isn’t always easy: Van Pelt notes that he has had to oversee workforce reductions, as the hospital has become more efficient. His providers, for example, started a program to reduce elective Caesarean-section births before 39 weeks, which can lead to costly medical complications. Fewer babies ended up in neonatal care and, suddenly, a smaller neonatal staff was needed.

“There’s some tension since we haven’t figured out how the funding breaks down yet,” Van Pelt said. “Everyone is a little anxious.”

To alleviate some of that worry, Kitz­haber is looking at creating an innovation fund for the state’s hospital, one that rewards steps taken to reduce the care it provides.

“It’s a huge issue, and there’s no doubt that hospital business models are going to have to change,” Goldberg said. “We’ve started an open, frank conversation about that fact.”

Van Pelt thinks the potential rewards make the risks worthwhile.

“The first few years are going to be very difficult financially, politically and culturally,” he said. “It’ll be about hanging in there. We know this is the right thing for us to do. We all complain about health-care spending, but nobody does anything about it. Now, that’s changing.”

For Kitzhaber, the Medicaid experiment is just a beginning. If the state can achieve savings with this population, he could see using global budgets in the health plans that cover state workers and teachers. The private sector might get on board, too, if it sees proof that quality health care does not have to bankrupt employers.

Kitzhaber estimates that, if every state cut its Medicaid costs as Oregon plans to, the federal government would save $1.5 trillion.

“Medicaid by itself isn’t enough to change things,” he said. “For a lot of hospitals, it’s maybe 7 percent of their business. We have another 600,000 people the state covers. If their health-care costs grow slower, it’s just a game changer for state budgets.”

It’s too early in the game to know whether this bet will pay off.

From the Salem Statesman Journal, Dick Hughes’ Blog, January 17, 2013

I think state Senate President Peter Courtney is right.

But I challenge Oregonians to prove him wrong.

Courtney contends the Oregon Legislature lacks the political will to confront the overriding factor behind many of the mass shootings that have struck our state and nation: mental illness.

“You have to make a commitment to mental health that we have never, ever made in this country at any level,” the Salem Democrat said.

This comes from a politician who has done more to foster improved mental health care than any other leader in recent state history. Courtney was the driving force behind the rebuilding and reforming of the Oregon State Hospital to bring its facilities and programs into the 21st century, emerging from its legacy as the filming site for “One Flew Over the Cuckoo’s Nest.” He continues to push for building a second, smaller state psychiatric hospital in Junction City. That hospital is included in the proposed 2013-15 budget that Gov. John Kitzhaber sent to the Legislature, as are increases in mental health spending.

But Oregon’s mental health system needs a complete overhaul, and those steps are mere tinkering. Which is why Courtney said the current legislative session is ill-prepared to grapple with such a monumental issue.

“You see all these politicians talking mental health? They don’t know what they’re talking about,” he said. “You’ve got to say, ‘This session, before anything else, it’s mental health.’ And everybody else says, ‘All right.’”

One irony: This issue has widespread support among Republicans and Democrats, regardless of whether they represent rural or urban constituencies. “There is no doubt Oregon has failed on this,” said Sen. Larry George of Sherwood, the state Senate’s deputy Republican leader.

The impediments: money and power.

If the state finds the courage to invest more in mental health care, that will mean less money for other programs. And changes in providing that care will mean winners and losers within the current system.

As an example, the coordinated care organizations (CCOs) required under Oregon’s health-care reforms should — over time — improve the integration of mental and physical health care. But independent physicians, Salem Health and other health-care providers in the Mid-Valley can’t even agree on how to establish their regional CCO. How then can we get people statewide to rise above their self-interests and agree to make mental health care the priority for this Legislature?

Again, our failure to act is ironic: Mental health care works.

It can benefit every segment of society and improve the livability for all Oregonians. Almost all of us know someone who suffers from mental illness, just as we know someone who suffers from cancer or heart disease.

These days mental illness is in the news because of the recent mass shootings. (Of course, I would argue that almost any murder is an irrational act and anyone who commits murder is insane; but the law doesn’t see it that way.)

There are great challenges in getting mentally ill, potentially dangerous individuals to receive treatment and to follow their treatment protocols on a daily basis. Medication can be expensive and can carry unpleasant side effects. A person with certain mental illnesses may prefer the unmedicated, albeit irrational, euphoric high … until the crash comes. And in a society that values freedom, few patients can — or should — be forcibly treated.

But huge obstacles are no justification for shirking our even bigger responsibilities.

Medication works in many instances, although not always. Counseling, communication- and family-training programs, anxiety-relieving meditation and exercise, and other approaches also are important.

Consider how each of us would benefit if the state made a massive commitment to improving mental health: Families would be stronger; employees would be more effective. Fewer police officers would face the trauma of “suicide-by-cop” calls. Workplaces, malls and schools would be safer. In addition, teachers would be better prepared to deal with unruly kids — and would have fewer of them.

Simply, countless lives would be improved, and many would be saved.

To some, the above will sound like a mindlessly irrational and unrealistic nirvana.

But what’s irrational is our failure to remove the stigma of mental-health treatment.

What’s unrealistic is to expect that we can ever end mass violence, as well as many lesser societal problems, without addressing mental health.

And Nirvana is a band ripped apart by suicide.

Dick Hughes — who takes medication for anxiety, participates in Tuesday and Friday prayer sessions, and wants to learn meditation — is editorial page editor of the Statesman Journal. Contact him at dhughes@StatesmanJournal.com; P.O. Box 13009, Salem, OR 97309; or (503) 399-6727. Read his blog at StatesmanJournal.com/DickHughes or follow him on Facebook or at twitter.com/DickHughes.