CG: First Don, I want to thank you for taking the time to do this. Just to get name some of your credentials: you’re a doctor, a businessman, the president of ASAM (American Society of Addiction Medicine), you helped in the passing of the Parity Addiction Equity Act of 2008, in 2003 and you’re the Mayor of a mid-sized city in California; so I know your schedule is tight and I appreciate you taking the time to do this interview. So let me start right off – after that list of credentials, you’re actually in recovery yourself, correct?
DK: Absolutely!
CG: And how long have you been in recovery?
DK: I am sober over 16 years.
CG: You also served on The California State Health Care Coalition as chairperson for Presidential candidate John McCain in 2008. I take it that you’re a Republican?
DK: (laughs) I’m a Republican, yes.
CG: (laughs) I’m starting to become one, the way things are going!
DK: Well, you know, I’ve had concerns about the way our health care system has been moving for a long time, and I’ve been deeply involved in California and also nationally, in trying to improve access to treatment. But it has to be quality treatment. I don’t want to see us develop a system where everybody has access to care, but the care is such poor quality that it’s not effective.
CG: Of course.
DK: One of the problems is the fear that … let’s say you’ve got a six month program and it’s successful. Well, the next thing you know, the insurance companies are saying, ‘Okay, if 6 months is successful, let’s cut it down to 3 months.’ And if that works, they say, “Okay, well let’s cut it down to a month,” then, “Let’s cut it down to a week!” Soon you’ve cut the program so short and so thin that it’s not effective anymore. Then the insurance companies and the government come back and say, “Look, your treatment isn’t even successful, so why should we pay for it at all?”
CG: Well, that certainly happened with managed healthcare, didn’t it? Before they cut the programs, they used to average 60 to 90 days and they cut them down to 28 days!
DK: Right! That’s exactly what I’m talking about.
CG: What needs to be done, or should be done now, with the national healthcare reform?
DK: Well, I think, two things. First, in the private sector, with a private insurance company, they need to be providing a level of care that is going to be adequate for the problem that the patient presents with. Not everybody needs a 90 day program. Not everybody needs a 30 day program.
CG: I agree.
DK: But some people do, and ASAM has a patient placement criteria. It’s called the PPC2R, and that helps as a guideline to decide what level of treatment a patient needs. For instance, say, a secretary who hardly ever drinks, goes to a Christmas party and has 2 wine coolers and gets pulled over on the way home and gets a DUI. She’s probably not an alcoholic. She probably doesn’t need to be in a 90 or 180 day treatment program. It might be nice to have her go to an AA meeting or two and then the state might want to put her into a monitoring program just to make sure that the story is really what it is. But, someone coming out of treatment multiple times; being mandated by the court to AA over and over again, someone like that needs to be in a long-term residential treatment program. And 1 to 2 years is not that long.
CG: No, I agree; some people need a longer period of support to get stabilized and to be able to stand on their own and not fall back on their old habits. If life meets you head on all of a sudden, your normal reaction – because we are addicts — is to get high so we don’t have to deal with it.
DK: Right! And that’s part of the re-entry program or the phase that puts them back into society. That should be a part of any quality long term program. And let me mention something else. People that work in the field of addiction treatment should be paid adequately. Anywhere else in medicine, the staff — the nursing staff, the physical therapy staff, the radiology technicians, all of these people are paid pretty well. But in the field of addiction treatment, people get paid minimum wage. And we expect them to make careers out of this! If you want people to stick with this profession, to stay with it for the long haul, they’ve got to be paid adequately. They’ve got to have benefits like anybody else would have. Just because they are alcoholics or addicts in recovery doesn’t mean you can treat them poorly.
CG: And in treatment, the addict or alcoholic in recovery is usually the ones that are the most effective.
DK: Right! Right! And they have to make a living, too!
CG: What do you suggest? Do you think there should be a … I don’t know what the word would be … a coalition? Or a union? How do you incorporate
a fair and adequate pay scale for this type of career? Or this title as a counselor or Doctor of Addiction Medicine: because it is in the medical profession?
DK: Basically, it starts with the insurance company and the government, really. Medicare and Medicaid need to reimburse both inpatient and outpatient treatment and they need to reimburse it at the level that’s adequate to support the treatment needed, whatever that is. You can’t have extremely low levels of reimbursement which is the way it is now, or NO reimbursement, and expect people to be able to provide the care that’s necessary. Let’s say a CAT scan costs $800 dollars to do the test and the reimbursement is $1000 dollars. Ok, fine, so there’s a profit in there of $200 dollars. In inpatient treatment, there are lots of treatment centers where their cost … let’s say it’s a monthly cost of $5,000 just to have the professional care that people need. That might be $5,000 dollars a month and insurance or the
government program will reimburse $1200. How on earth can they stay in business if the reimbursement is $1200? You can’t do that; the reimbursement has to be adequate to provide the care that’s needed.
CG: Agreed. Now, ASAM. You’re the president elect of ASAM and past president of California’s CSAM. For those that don’t know, what is ASAM, what is it about?
DK: ASAM is the American Society of Addiction Medicine, and CSAM (which I am currently president of) is the California Society of Addiction Medicine. That’s the California chapter of ASAM. California’s a very dynamic chapter in ASAM.
CG: Are these counselors, or are these doctors that specialize in addiction?
DK: They are all either MD’s or CEO’s that specialize in the treatment of addiction disorders — alcoholism or drug addiction. It doesn’t matter if it’s meth or heroin, these are the doctors that specialize in that treatment. Some of the doctors will be involved with behavioral addictions also, like internet addiction or sex addiction. That’s typically not what our focus is. Our focus is on substance addiction.
CG: And most of these work for treatment centers or private practice?
DK: Well it’s a combination. Some work for treatment centers, others are a private practice, others work for the government in a variety of roles; like in the prison system for instance. Others work for universities, so it’s a wide variety of backgrounds. People come from different specialties; a lot of them come from family practice or internal medicine, some come from surgery, some from radiology.
CG: You said when a patient came in, that certain criteria need to be met … does someone looking for help contact ASAM? Is it that kind of a program where you refer them to the correct treatment center, or is this just for doctors to get together and figure out ways to either change public policy or to exchange information?
DK: All of the above. Our focus is on education; educating ourselves and educating other physicians, but also educating the public. Not every member has to be an addiction specialist. We want to try and educate the family doctor to deal with the addiction problems that he may be seeing in his office. We help to support research; we’re involved as an organization with the people that do research. We want to help them in the research and help point them in the right direction. And then, of course, we benefit by it, by being on the cutting edge of dealing with medication. There are things like craving medication and detox medication, and we’re involved in all that. We’re also involved in advocating for public policy and helping to educate our legislators at the national and state level. If they’re not passing the laws that make sense for the patient suffering from alcoholism and addiction, then that’s our fault as physicians. And it’s our fault, quite honestly, as recovering people. ASAM is involved in all of this — education, research, public policy and clinical treatment as well.
CG: Now as part of ASAM, I know you are trying to get board certification for addiction medicine physicians so it would be a separate kind of … specialty? Is that in place now? I mean you have arthroscopic, you have pediatric…
DK: Many years ago, CSAM created an exam. At that time it was the CSAM — the California Society of Addiction Medicine certification exam for addiction treatment and addiction medicine. So CSAM, over the years, gave that exam to ASAM — to the American Society of Addiction Medicine, and that became our national exam. In order to become certified in addiction medicine, you have to pass that exam — the ASAM certification exam.
CG: Is it nationally recognized?
DK: We are nationally recognized, yes. Many states recognize it. Many states require it for certain levels of treatment. And many treatment centers will require that somebody be ASAM-certified. Let me finish, though, for many years we had the ASAM certification exam, but just this past year we created a board exam — ABAM; American Board of Addiction Medicine. ABAM gave the exam to ASAM, so now it’s a board certification exam. The next step for us is to gain recognition in the National Organization of Certification Boards. So we have our own board certification that is now recognized by the national certification board. It’s just a political process.
CG: What do you think the achievement will mean in the scheme of addiction treatment if it is approved? And particularly for addiction physicians?
DK: A couple of things. By having the exam, it sets a base line. So if I talk to a doctor in Florida and I know that he’s ASAM-certified, I can talk about this patient on a certain intellectual level and he can understand what I’m talking about. Just like when 2 surgeons talk — you want them to have the same level of knowledge. But, it also means that hopefully this will, in time, improve reimbursement to the field of addiction treatment, as we have standards, otherwise….
CG: How does that increase reimbursement? In that it’s nationally certified?
DK: Correct. In the world of recovery we all know how devastating our past can be. You know when you apply for a job or when you apply for school and they find out you’ve got a drug or alcohol history, you might be exploited completely or put on the lower list of applicants.
CG: I have a sober house, and the girls get that a lot, and it’s terrible, because they are some of the most talented people you’d ever meet.
DK: It is terrible; it’s devastating to somebody early in recovery. It also affects those of us that work in the field of addiction treatment. I happen to be in recovery, but it doesn’t matter if you’re in recovery or not. It’s almost as if, because we work with people suffering from addiction, they don’t seem to pay us well. It doesn’t make any sense. My expenses are just the same as any other doctor; I’ve got malpractice, I’ve got staff that needs to be paid, I’ve got rent that needs to be paid, you know? The reimbursement for someone working in the field of addiction treatment is either a half or a third of what it is for a surgeon or intern of any other specialty.
CG: It’s true, and it’s a shame.
DK: When they do this, they discourage people from wanting to go into addiction treatment, and right now there’s a huge lack of doctors that are knowledgeable of treating addiction. I’ll give you another example — geriatric medicine is under-reimbursed (doctors that specialize in taking care of senior citizens).
CG: I believe that.
DK: And let’s say you go into training in a family practice; you’ll expect a certain level of pay, a certain level of reimbursement. If you specialize in geriatric care your reimbursement goes down. So why would anybody want to do that? Why would it make sense for anyone to want to specialize in the care of older patients if they’re going to get paid less for it? And it’s the same in addiction treatment. Why would you want to specialize in addiction treatment to get paid less? Why would you want to put more years of training in and get paid less for it?
CG: When the Parity Act was implemented … it acknowledges that addiction is a disease the same as any other disease like cancer or diabetes, but how can the legislation improve access to addiction treatment?
DK: That’s a huge question! When we started working on this about 10 or 15 years ago people said, you’ll never get parity, it’s impossible. It’ll never happen.
CG: They used to say that about breast cancer and now they have the pink ribbon campaign.
DK: Right! You can’t beat that. When I started working on it, I started going to Washington by myself, on my own time; talking to legislators, trying to educate them on the need for a level of clarity and reimbursement for treatment. And they finally got it. Is it perfect? No, not by any means, but it’s a start and we need to continue to build on that. Why should we be treated … and it’s almost a civil rights issue, why should people who suffer from addiction be treated any differently than anyone else? If I had diabetes or thyroid disease, they wouldn’t think of disregarding reimbursement.
CG: I will love to see the day when your doctor asks you, “How’s your recovery?” as easily as he would ask a diabetic, “How’s your blood sugar?”
DK: And that’s what should be done. The Parity Act for the most part deals with private insurance companies. But the federal government is not doing their share. They need to start with the reimbursement with Medicare and Medicaid. Those two huge reimbursement agencies need to fund addiction treatment on the full level as they do any other medical problems.
CG: Let me ask you a question: the Patient Protection and Affordable Care Act, what are some of the benefits of this legislation for someone that might be seeking addiction treatment. Is that part of getting Medicare or Medicaid to reimburse correctly?
DK: The promise has been that addiction treatment will be covered and included in all of that legislation.
CG: Is this legislation in California only or is it national?
DK: Oh no, it is national. It is Obama Care.
CG: This is the national health care policy?
DK: Yes. Addiction is supposed to be covered, but the reimbursement has to be adequate. It can’t be make-believe.
CG: I understand that. What do you believe are some of the benefits that this legislation will bring to those seeking addiction treatment?
DK: My hope is that we can begin to look at addiction and alcoholism as a public health problem and deal with it on a public health level. So that t
reatment is available to everyone no matter what their background or economic status is. Everyone should have access to treatment. So why should society have to pay for that? People will ask that question, why should that be society’s responsibility? So I go back to what I said before, it is a pay-now or pay-later disease. Think if we had adequate addiction treatment thirty years ago or forty years ago, we wouldn’t have 70% of the people who are in prison today. It’s mostly for addiction related problems.
CG: Right. Terry Gorski expounds on that in almost all of his columns, and it’s majorly non-violent drug-related.
DK: If we had kept even half of those people out of prison that would be a savings of billions and billions of dollars each year.
CG: Incredible isn’t it? We are basically warehousing, I think it’s 60% are nonviolent drug offenders, because of not having access to addiction treatment. I am going to use myself as an example before I use you as an example, Don. After I lost my daughter I … dove into alcoholism and addiction. I was hospitalized three times for alcohol-related illnesses. When I got pancreatitis, Tequila was my drink of choice, so I figured, “OK, I’ll switch to Vodka; it’s clear, so it should be better for me.”
DK: (laughing)
CG: Then I got colitis, so I switched to beer, but I got colitis again, and I finally thought, this isn’t working; maybe it’s not the liquor! I also did a lot of opiates – 25 to 40 a day, until I finally hit my bottom. When I went into treatment, I thought that no one could understand what I was going through. It is part of the disease; it wants to isolate us. But when I heard other people share, I realized that my pain was not the worst; it’s just a different kind; everyone’s pain is the worst – to them. And I started speaking. So, because of going to treatment, I now employ two people, I bought another house, I have health insurance, I pay taxes — I am contributing to society instead of taking from it. I truly believe that treatment, followed by a sober living house, to help in the transition with the support of others in recovery, works – and pays back society tenfold ….
DK: I own an Oxford House, if you know what that is.
CG: It’s a sober house that runs like a co-op.
DK: Yes. I don’t run it, I just own the building, and I set it up so that they can run it themselves, and it works well.
CG: Yes, I thought of making Joy’s House an Oxford House, except my Dad had to sign the mortgage for me; so it can’t be a non-profit. It’s funny how you ruin your credit when you are drinking and drugging!
DK: (laughs) Yeah, it sure is!
CG: Now one more question about the certification and then I’m going to the more personal. How much 12-Step knowledge do you think should be
expected for a physician to be successful in the ASAM certification?
DK: OK, well, they should have a working knowledge of 12-Step recovery. Not every physician is going to go into that. Some of them specialize in methadone treatment and some would specialize in research; nothing to do with real patient care. But, they need to understand 12-Step recovery and they need to have some working knowledge of it. Also, they should have some exposure to it. Now, Marc Gallanter is the chairman of our 12-Step committee. He is not in recovery. He is an addiction psychiatrist. He is the head of addiction psychiatry at NYU’s Bellevue Hospital.. But he has a special interest in spirituality in recovery. So he puts on workshops to help to educate our ASAM doctors about 12-Step recovery and to give them some exposure to it. One of the things that we do is put on 12-Step meetings kind of like in a fish bowl. So there will be a 12-Step meeting going on in the middle of the room, and they will be surrounded by physicians all around the outside, who are observing. Many of them have never seen an AA Meeting.
CG: That’s … different. My Art Director had never been to one, so I took him to an AA meeting and he was amazed. He said that everyone should go to one of these and see the bonding and to feel the feeling he had felt there. He really loved it. I would like to turn to your history. I have two outpatient detox centers that I allow to advertise in Journey Magazine which use Suboxone. The increased use of Suboxone maintenance by addiction physicians is controversial. It has been called a miracle and a menace. Like methadone’s nickname, “liquid handcuffs”. What pros and cons do you see in this practice?
DK: There are two methods; one is to use it for detox and one to use it for maintenance.
CG: I am opposed to maintenance, but I do think it is a miracle for detox.
DK: For those of us in recovery it is easy to have that view point, however … I believe that there are some people, for whatever reason, are not ready for 12-Step recovery. But to allow them to be on methadone or Bupranorphine maintenance; it buys time …. It allows them to work and to take care of their families and to be responsible citizens. I don’t think it is the same level of recovery as abstinence-based people. But I think that for some people it is important.
CG: It actually … especially with methadone, maybe not so much with Bupranorphine, where you can get a seven-day supply with the pill. But with the methadone, I have talked to people who can’t go on family vacations, they can’t leave a certain area because their clinic is there. If they miss the bus to get to the clinic they can’t go to work because they are tied to that clinic.
DK: That’s true.
CG: So it definitely has some restrictions to it. So it may be good short-term but over a long-term, years, I don’t think it is positive. You may have a different opinion.
DK: Well, as a recovery person, the goal for me as a standard is abstinence-based, spiritual-based recovery. As a physician, well, everyone that comes into my office is not willing or ready to do that. To tell them you need to keep on shooting drugs, living on the streets and stealing TV sets — I don’t think that is a good answer. You have to have another answer as a physician. If they can transition through methadone or bupranorphine and begin to see some of the benefits of a more stable life, then I may have the chance to guide them into a more abstinence-based life later on.
CG: That’s probably the best answer I’ve ever heard for that question.. I would like to go into a little bit of your history; I know you had a history of heroin addiction. I’m going to get a little blunt here, because people in the program know, but newcomers need to know; that ANYONE can become addicted to drugs or alcohol, and that ANYONE can recover from it.
DK: OK.
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