Drug Legalization and Tax Revenue

Ugghh!

I hate this argument for legalization. I also think it's the wrong way to go about it if legalization were to come to pass.

Think for a moment about the power of the alcohol and tobacco lobbies. (In Michigan it's been impossible to raise liquor taxes.) Think about their marketing power. Think about their place in our culture.

Is that what we want for marijuana?

I fear that capitalism, legalization and out political system are likely to be an ugly combination.

If we were to legalize, I like Mark Kleiman's proposal to keep sale illegal and legalize people growing their own on a limited scale.

Salience

I've posted before about the role of salience in addiction. This is a great illustration:

More on recovery without abstinence

Oops. I meant to add more to that last post and didn't.

The commonly held belief about addiction is that addicts won't seek help without a gun held to their heads. Our experience just shatters that.

I meant to introduce the quote with the statement that Dawn Farm would say exactly the same thing. More than ever, I have faith that, given a menu that includes good options, addicts will migrate toward recovery--whatever that looks like for them. Some may be able to quit heroin and continue to drink while achieving the same quality of life as another who chooses to abstain completely. I believe that the former person is the exception to the rule and that it's a risky experiment--if this path doesn't work, they may not survive or their illness may progress in a manner that makes it more difficult to stabilize and achieve recovery the next time around. However, if a person chooses to pursue this path after reviewing the risks, it's their choice to make. What I fear is programs or systems that don't offer hope for recovery, don't offer accurate information, don't offer treatment/support of adequate duration and intensity and celebrate any positive change without encouraging addicts to keep moving in the direction of full recovery--whatever that means to them.

Recovery without abstinence

I'm not about to start recommending this as a path to recovery, but I really like the tone of this guy. Fascinating story.

The commonly held belief about addiction is that addicts won't seek help without a gun held to their heads. Our experience just shatters that.

The book that started it all

"more than 5 pounds"

only $13 a pound! 

That's cheaper than Starbucks Anniversary Blend!

Let's hope they offer a cheaper version in the near future. (They offer a more expensive version.)

Social network mapping and recovery facilitation

This begs some fascinating questions.

Could targeting specific roles in the culture of addiction bring others into recovery with them--a kind of domino effect?

How many of your friends drink alcohol? How many might say they used alcohol problematically? What about illicit drugs? Probably a smaller proportion of the people you know take drugs, but perhaps a few have experienced problems with drug use at some point in the life.

For the 160 current and former drug users who took part in the RSA’s User-Centred Drug Services Project survey, answers to these questions are, I presume, rather different to yours. ...30 per cent said that all of the people they know use drugs, with most of them using problematically. Similarly, around a third reported that all of the people they know used alcohol, and around half of them had problems because of it.

...The average probability of smoking, for example, is found to be 61 per cent higher if a friend smokes (one degree of separation), 29 per cent higher at two degrees of separation, and 11 per cent higher at three degrees of separation.

A recent RSA paper on problem drug use suggests that recovery may be ‘contagious’ in the same way. This is an important insight, but problematic: if all of the people you know take drugs, how do you get out of this networked influence that entrenches drug use? A study (external PDF) of drug user networks in Connecticut found that, on average, 85 per cent of the people in a drug user’s personal social network (or ego-network) used drugs. Piecing together the community-wide drug using network, the researchers found clustering of drug users into African American, Puerto Rican and White communities. Interestingly, the mapping also revealed who the key influencers were in the drug using network;  those ‘nodes’ at the centre of the network most strongly connected to large numbers of other users.

The RSA is extending its work on drugs to look at how we might similarly map drug using networks in Peterborough, with a view to identifying and working with these potential ‘recovery champions’ to transmit recovery through the network. There is good reason to try this: intervention programmes to tackle smoking and alcohol use that deliberately employ peer effects and social network ‘modification’ are found to be more effective than those that do not.

Stigma Unaffected by Acceptance of Disease Model, Study Finds

This doesn't surprise me. So much of what fuels stigma is fear. Calling addiction an illness or disease doesn't really get at the question, "Am I and my loved ones safe with you around us?"

Psychiatric fads

Allen Frances, Chair of the DSM-IV Task Force, deconstructs the  phenomena of psychiatric fads:

To become a fad, a psychiatric diagnosis requires 3 preconditions: a pressing need, an engaging story, and influential prophets. The pressing need arises from the fact that disturbed and disturbing kids are very often encountered in clinical, school, and correctional settings. They suffer and cause suffering to those around them--making themselves noticeable to families, doctors, and teachers. Everyone feels enormous pressure to do something. Previous diagnoses (especially conduct or oppositional disorder) provided little hope and no call to action. In contrast, a diagnosis of childhood Bipolar Disorder creates a justification for medication and for expanded school services. The medications have broad and nonspecific effects that are often helpful in reducing anger, even if the diagnosis is inaccurate. 

The "epidemic" of childhood Bipolar Disorder fed off the engaging storyline that it: 

1. Is extremely common
2. Was previously greatly under-diagnosed
3. Presents differently in children because of developmental factors
4. Can explain the variety of childhood emotional dysregulation
5. Has diverse presenting symptoms (eg, irritability, anger, agitation, aggression, distractibility, hyperactivity, and conduct problems)

The prophets were "thought leading" researchers who encouraged child psychiatrists to ignore the standard bipolar criteria and instead to make the diagnosis in a free-form, over-inclusive way. Then enter the pharmaceutical industry-- not very good at discovering new drugs, but extremely adept at finding new markets for existing ones. The expanded reach of childhood Bipolar Disorder created an inviting target. The bandwagon was further advanced by advocacy groups, the media, the internet, and numerous books aimed at suffering parents. 

[hat tip: David Mee-Lee]

Hope

This comment on a previous post caught my attention:

Drugoholism is a field, a combination of various processes, internal and external. "As the twig is bent the branch doth grow." is an old adage. I have realised that IN PRACTICE this is true for many. At times the only PRACTICAL solution, apart from the exceptional few is amelioration.

I'm reminded of this post from a few years ago:

Ideas like this are rooted in despair, rather than hope. (see here, here, here) We get overwhelmed by the problem. (here) We're too cheap to offer adequate help. (here) We don't believe that these people can recover. We think they have no chance. We're scared that they'll hurt us and get us sick. (here)  So, we offer them these kinds of interventions. Often, these programs represented in the name of choice, (here) when, the addicts themselves, want better from us. (here, here) They actually want to get well, but often lose hope that it's possible for them. The system starts patting them on the head an encouraging them to be more realistic. (here, here, here) What they need from professional helpers is for us to lend them our hope to cultivate some of their own. (here, here) They need a system that stops talking about if they recovery and starts talking about when they recover. (here)

"If you want to treat an illness that has no easy cure, first of all, treat them with hope." --George Vaillant

Smoking and recovery

PeaPod just posted on one of my pet causes--smoking among recovering people.

The situation is very similar in the U.S. and we are trying hard to address this within Dawn Farm for a few key reasons:

• In Michigan, 23% of the population smokes while 85% of our clients smoke.
• Addicts and alcoholics have a harder time quitting than other smokers.
• Addicts and alcoholics experience greater physical harm from smoking than other smokers.
• Quitting smoking at the initiation of recovery is associated with improved treatment outcomes. Quitting smoking is good for recovery.
• 15% of nonsmokers who enter programs that allow smoking become smokers by the time they leave treatment.   

One of our handouts is available here.

A slidecast is available here.

Ecstasy, meth and marijuana

New drug use survey findings.

Stuck on ... dopamine

In attempting to explain attention and ADHD, Jonah Lehrer explains dopamine's salience function:

But the caricature of dopamine as simply the chemical of hedonism is woefully incomplete. For instance, studies have shown that the dopamine reward pathway is also extremely active when people are forced to eat something disgusting, or when a subject is gasping for air after holding their breath. These are intensely unpleasant experiences, and yet our dopamine neurons are pumping out neurotransmitter. This leaves two possibilities: 1) We are all secret masochists, and take pleasure in pain or 2) Dopamine is really about attention and motivation, and is not just the chemical of pleasure and rewards.

I don’t know about you, but I’m betting on hypothesis number two. I think there’s a growing body of evidence suggesting that the real purpose of the dopamine is to help us efficiently assess the outside world. Many dopamine researchers, for instance, refer to the chemical as our “neural currency,” since it allows us to quickly assign a value to the multitudes of things and ideas we perceive. (In other words, dopamine is the price tag of sensory information, and it attaches hefty prices to things that are delicious, beautiful, or reflect some urgent homeostatic need.) When we see something we want  - and it doesn’t matter if it’s a chocolate cupcake or a glass of water – the mere sight of the object triggers a wave of emotional desire, which motivates us to act. (Emotion and motivation share the same Latin root, movere, which means “to move.”) The world is full of possibilities, and it is our dopaminergic urges that help us choose between them.

Put simply, dopamine's salience function makes certain stimuli nearly impossible to ignore.

Previous posts here.

Is abstinence best? redux

The link I posted to Peapod's post about abstinence prompted a few comments on this blog and several on Wired In.

Many of the comments could be summarized as, "abstinence is best for some, for other's it's not."

I think this misses the forest for some of the trees.

The real questions is, in general, what goal should the treatment system treat as the ideal, achievable outcome--abstinence or maintenance?

To me, if the choice is between elimination of symptoms or management of symptoms, the choice is clear.

To be fair, a maintenance advocate might reframe the question this way, "which treatment is likely to lead to the most improved quality of life for the most people?"

I think, as Peapod pointed out, Laudet's research responds to this question:

“We conducted a study among former substance users, the Pathways Project, to examine the question. 289 participants had had a severe history ofDSM-IV dependence to crack or heroin lasting on average 18.7 years, and had not used any illicit drugs for an average (mean) of 31 months when they entered the study. They were asked to select the statement best corresponding to their personal definition of recovery – 86.5% endorsed total abstinence (Laudet, 2007).

Because the treatment system in the US is strongly influenced by 12-step ideology (McElrath, 1997), we repeated the study in Melbourne, Australia, where the approach to substance user services focuses on a harm-minimisation ideology. Australian participants were also people who had experienced a long and severe history of dependence, mostly to heroin, but who had not used any drugs recently. 73.5% of Australian participants endorsed total abstinence from both drugs and alcohol as their personal definition of recovery (Laudet & Storey, 2006).”

Further, whenever I'm confronted with a health question (for myself or a loved one), my first question is this, "what treatment do doctors with this problem receive?"

In the case of addiction, the answer to that question is abstinence oriented treatment, recovery support and monitoring that lasts years. And, the outcomes are outstanding.

Why would we focus on a different goal for other populations?

Is abstinence best?

I'm in a time crunch, so no time to write anything about it, but this post from Peapod is a must-read.

Parental drug use and adolescent treatment outcomes

A study of juvenile drug court participants finds one powerful predictor of poor outcomes:

Results indicated that youth whose caregivers reported illegal drug use pretreatment were almost 10 times as likely to be classified into the nonresponder trajectory group. No other variable significantly distinguished drug use trajectory groups.

Meta-analysis of acamprosate

Money quote:

Compared to placebo, acamprosate increased the number of days drinkers stayed abstinent by about 11%, and reduced the odds of their return to drinking by 9% during a 3- to 12-month follow-up period. Combining naltrexone and acamprosate increased the odds of sobriety by 30% — but this drug cocktail had so many side effects that many patients simply dropped out.

A well defended smoker

As a former smoker, I can relate to irritation when my smoking was brought up, but I think it's only going to get worse for smokers in the public eye.

Alcohol first aid

The British Red Cross is recommending that alcohol first aid be taught to school age kids.

Makes sense to include in any first aid course, and looks like it's part of comprehensive first aid education. I like that aspect.

Drug problems and domestic violence screening

This study found that patients with diagnoses related to alcohol and other drug problems were MUCH less likely to be screened for interpersonal violence. Why is that?

Crash course on dopamine and addiction

Crash course on dopamine and addiction:

First, Nora Volkow:


Next, Adam Kepecs:

E-cigarettes and a random thought

The FDA has weighed in on some of the marketing strategies being used for e-cigarettes.

It's amazing how this industry has exploded. Locally, it seems that one of the things driving sales is this year's smoking ban in Michigan. Bars are selling them so that people can "smoke" in the bar.

Tangential thought: I was driving this morning and was stopped at a light. In front of me were a police car and next to the police car was another car. The driver of the other car was smoking and tossed their butt out the window while waiting for the light to turn green. This struck me as an incredibly stupid thing to do right next to a police officer.

What is that all about? I suspect the smoker doesn't even think of tossing a cigarette but as littering. (I didn't until someone confronted me.) Why is that? Further, I suspect the smoker thought nothing of tossing his butt next to a cop.

I'd guess that it's some combination of semi-conscious autopilot behavior and cognitive defenses around smoking.

Whatever it is seems as though it would be a significant barrier to quitting.

Funding Recovery Support Services

One of the big challenges in treating chronic illnesses is that they don't fit well into tradition funding models. With any chronic illness, one of the most important goals is to facilitate behavior change and then provide long term support to maintain those behavior changes. There are no billing codes for these activities and they are not "procedures" as we are used to thinking about them. Practitioners who choose to engage in these activities often have to do so on their own dime.

So...it's good to see that the federal government is thinking about how to fund these activities.

Heavy drinkers outlive abstainers?

Interesting post about the relationship between drinking and longevity.

A recent study found that heavy drinkers outlive nondrinkers. Other bloggers suggested that drinking is a proxy for social connectivity and this explains the difference in longevity.

Maia follows up on these posts and wonders whether membership in AA for alcoholics might serve a similar function as drinking for non-alcoholics.

So, that got me to thinking: could the life-extending benefit of drinking be extended to nondrinkers, minus the alcohol? For instance, couldn't AA's social network offer similar health advantages to teetotalers?

The reasoning here is that abstainers are on the whole a lonelier and more depressed bunch, compared with their tippling peers (though, again, there are exceptions to every rule: many abstainers don't drink for religious reasons and still have strong social networks through church). Lehrer notes a spate of recent research connecting loneliness and lack of friends and family to higher risk of illness and death. One major study even found that loneliness may just as bad for your health as smoking. That helps explain why the harm done by staying home alone may be greater than that from binging in bars.

It would be very interesting to see follow-up on this study. Do these findings hold in geographic regions with more abstainers? Do these findings hold for people affiliated with religious communities that discourage drinking?

She also points to one big hole in attempts to generalize the findings from this study:

Incidentally, another possibility that hasn't been much considered in the debate over whether heavy drinking really is a boon to health is that the recent study [pdf], published in Alcoholism: Clinical and Experimental Research, included only people who were 55 or older. As a result, heavy drinkers who died early — in car accidents, bar fights, falls, alcohol poisonings, from liver disease or other alcohol-related incidents — would not have been captured by the research.

So, the real conclusion might be not that heavy drinking increases longevity — only that if you're a heavy drinker and you make it to 55 without being killed by it, you're probably a hardy survivor for other reasons, possibly social ones. Nonetheless, even this may not explain the results because other research finds that the leading killer of alcoholics is cigarette smoking, to which people typically succumb in their 50s or later.

Stigma lit review

A lengthy review of research on stigma and addiction:

A key conclusion from this review is that stigmatisation matters. We feel rejection exquisitely because we are deeply social in our makeup and are unavoidably responsive to the behaviours, expressions and words of others. Stigmatisation therefore has a serious impact on the lives of those it afflicts. . . . To be a problem drug user, addict, junkie or drug abuser is to have a master status that greatly affects one’s interactions with others: with members of the public, nurses, doctors, pharmacists and police officers alike. It is a status that obscures all others, and it is a status that frequently incites disgust, anger, judgment and censure in others. No wonder then that stigmatisation has a profound effect on drug users: certainly on their sense of self-worth and probably on their ability to escape addiction.

New resource

Bill White has added a Friends and Favorites page to his website. I'm looking forward to watching him highlight the efforts and writing of lesser known advocates, researchers, practitioners and thinkers.

How many families have tried this?

What is there to say? What feeds the interest in creating these programs?

IT IS only 11am, but already Cora, a friendly, attractive woman in a colourful top and tight trousers, has downed two half-litres of beer and is thinking about her third glass. A chronic alcoholic who lost her home and contact with her family, and was roaming the streets, she proudly tells how her intake of alcohol has been reduced, and her dependency on spirits to get through the day has also gone down.

The Maliebaan centre, in the large town of Amersfoort, east of Amsterdam, opened last October. The first centre of its kind in Europe, it is based on a unique concept regarding the care and rehabilitation of alcoholics.

Far from aiming to dry out its residents – those with no work, no home and no desire to stop drinking – the clinic takes the view that they will never stop consuming alcohol. Instead it aims to help them to end dangerous binge-drinking and to control their intake of alcohol, with noticeable improvements to their health and wellbeing as a result.

Cora and the 19 other clients – 15 men and four women in their mid-20s to late 50s – are allowed to order up to five litres of beer daily, with an hour between each half litre, which costs 40 cent per serving (this is the wholesale price to the centre, which gets through 4,500 half-litre cans per month).

The bar opens at 7.30am and closes at 9.30pm, and the only criterion for being served is that the drinker must be able to get up themselves from their chair, walk to the counter and be able to hold their half-litre glass steady.

My not drinking bothers friends

Though there are aspects of the writer's social circle that I have some difficult relating to, this article does a really good job of describing the social mines one must navigate as a non-drinker:

I couldn't figure out why the roommate kept bringing up my dryness that evening, but I suspect the threat of having a non-drinker in the midst is that, when folks are drinking together, everyone -- except the abstainer -- is going somewhere. Together. On a journey. Booze softens the edges. It massages the ache of unspoken words. It dissolves the perceived boundaries among people. When you're sober, especially if you want to stay that way, you have to be at peace with where you are. You have to believe you're already where you need to be.

There are a lot of young recovering drunks out there who could be benefit from their drinking peers' acceptance and support -- or at from their least social tact. I chalked up the roommate's behavior to callousness or insecurity. Her nightlong needling didn't send me shuttling to the bottle, but someone with less time sober might not have the same tools, the same carefully constructed self-respect, or the same support network as I.

For many, drinking versus not drinking is the difference between life and death. Harping on a vegetarian for not enjoying meat at a barbecue is galling and insensitive, but if the vegetarian breaks down and heads out for a hamburger after the party, she won't die.

An addict who picks up a drink after being nit-picked by her peers might despair and throw herself off a building or just sink back into the groove of self-destruction and self-hatred that could come to define her life.

Stigma and the other

Dirk Hansen included this quote in a post on stigma:

“Psychological theories of illness are a powerful means of placing the blame on the ill. Patients who are instructed that they have, unwittingly, caused their disease are also being made to feel that they have deserved it.”--Susan Sontag, Illness as Metaphor

It brought to mind this quote from Bill White:

How alcohol and other drug problems are constructed are not merely a theoretical issue debated by academics. Whether we define alcoholism as a sin, a crime, a disease, a social problem, or a product of economic deprivation determines whether this society assigns that problem to the care of the priest, police officer, doctor, addiction counselor, social worker, urban planner, or community activist. The model chosen will determine the fate of untold numbers of alcoholics and addicts and untold numbers of social institutions and professional careers.

It's been on my mind because of this post in the Guardian:

The most miserable aspect of Labour's methadone policies is that they encouraged people to believe that in switching from illegal drugs to methadone, they have become "clean". This is a delusion. The most defeatist aspect is that the policies foster the idea that drug addiction is virtually impossible to overcome. Another delusion. . . . I'm not in favour of removing medical crutches that make addicts less of a threat (and I'd advise Cameron to think twice before doing it). But I'm not in favour of leading addicts to believe that they are not capable of doing any better by themselves.

Her use of the word "clean" really bothers me and it's stuck with me all week. I'm not one to get too hung up on language and I often fear that recovery advocacy movements will hurt themselves by focusing on things like language and adopt a victim position that does little to advance the cause. However, the insinuations lurking in her quotation marks and calling it a delusion stirred very protective feelings toward these methadone clients. In the final sentence, her choice of the words, "by themselves" raises suspicions. Is she implying that they just need to pull themselves up by their bootstraps?

I suspect that the writer and I share a lot of common ground on policy positions (as they relate to methadone) and I agree with her concerns about the pessimistic message sent by methadone programs and policies, but I'm not sure I want her as an ally. I hate to sound cynical and tribal, but I often struggle with the influence of non-addicts in policy and the development of services for addicts.

That sentiment brings to mind this Malcolm X story:

Several times in his autobiography, Malcolm X brings up the encounter he had with "one little blonde co-ed" who stepped in, then out, of his life not long after hearing him speak at her New England college. "I'd never seen anyone I ever spoke before more affected than this little white girl," he wrote. So greatly did this speech affect the young woman that she actually flew to New York and tracked Malcolm down inside a Muslim restaurant he frequented in Harlem. "Her clothes, her carriage, her accent," he wrote, "all showed Deep South breeding and money." After introducing herself, she confronted Malcolm and his associates with this question: "Don't you believe there are any good white people?" He said to her: "People's deeds I believe in, Miss, not their words."

She then exclaimed: "What can I do?" Malcolm said: "Nothing." A moment later she burst into tears, ran out and along Lenox Avenue, and disappeared by taxi into the world.

I can relate to his sentiment that the most helpful thing others can do is leave us alone. ("Other" can be a pretty ugly word, no?) Then, when I'm a little less emotional, I'm left to consider my own cognitive biases and 

creeping certitude. I have to think about the contributions of people like Dr. Silkworth, Sister Ignatia, George Vaillant, A. Thomas McLellan, etc. 

Malcolm X had a similar experience to this too:

In a later chapter, he wrote: "I regret that I told her she could do 'nothing.' I wish now that I knew her name, or where I could telephone her, and tell her what I tell white people now when they present themselves as being sincere, and ask me, one way or another, the same thing that she asked."

Alex Haley, in the autobiography's epilogue (Malcolm X had since been assassinated), recounted a statement Malcolm made to Gordon Parks that revealed how affected he was by his encounter with the blonde coed: "Well, I've lived to regret that incident. In many parts of the African continent I saw white students helping black people. Something like this kills a lot of argument. . . . I guess a man's entitled to make a fool of himself if he's ready to pay the cost. It cost me twelve years."

Malcolm X realized, too late, that there was plenty this "little blonde coed" could have done, that his response to her was inconsistent with what he, his associates, and his followers wanted to accomplish.

Bill White wrote about the things that have allowed practitioners to avoid the cultural traps in working with addicts:

Four things have allowed addiction treatment practitioners to shun the cultural contempt with which alcoholics and addicts have long been held: 1) personal experiences of recovery and/or relationships with people in sustained recovery, 2) addiction-specific professional education, 3) the capacity to enter into relationships with alcoholics and addicts from a position of moral equality and emotional authenticity (willingness to experience a “kinship of common suffering” regardless of recovery status), and 4) clinical supervision by those possessing specialized knowledge about addiction, treatment and recovery processes. We must make sure that these qualities and conditions are not lost in the rush to integrate addiction treatment and other service systems.

Recovering Jewish Addicts/Alcoholics, 12 Steps And Rosh Hashanah

A nice reminder of all the tribes within the recovering community. (hat tip: Rabbi Pinson)

A breathe of fresh air on policy

A great sense of perspective from a treatment provider. I'm a fan!

As an advocate for abstinence, Oliver might be expected to defend this option to the detriment of others. On the contrary, she refuses to be drawn into a dispute that, she says, is not only divisive, but misses the point. Abstinence is not about telling all addicts that the only way to "move forward" is to stop suddenly, she says – "it's about providing choices".

Any limits on the prescribing of methadone would, she says, be the "antithesis of individualised care" and "may actually put lives at risk". There is no need for a fissure in drugs policy, she argues. The first treatment an addict receives is about "stabilising the chaos", and if that means something other than abstinence, so be it.

...

As she puts it: "[Drug policy] has been very good at getting people into treatment. We've been very, very good at stabilising them [with methods] such as methadone. What we haven't done and must do is look at what can be done next."

Referring once more to her own struggle to give up drinking, she adds: "The reality is, you can't just put the drink or the drug down. Something has to go with it – people need support as well."

Marijuana for pain

Findings from a study of medical marijuana for treatment of pain:

The study had screened 113 participants but only 23 were eligible. Out of these, 21 completed all four cycles.

The researchers found that the average pain intensity was significantly lower on 9.4% THC cannabis (score 5.4 out of 10) than on 0% THC cannabis (6.1 out of 10) (p=0.023). However, no other comparisons between the different doses were found to be statistically significant.

Participants using 9.4% THC cannabis reported finding it easier to fall asleep and had better quality of sleep than those taking 0% THC. No differences in mood or quality of life were seen with the different THC potencies.

Of the reported side effects, none were serious or unexpected. The most frequent side effects reported by participants when taking 9.4% THC cannabis were headache, dry eyes, burning sensation, dizziness, numbness and cough. Feeling “high” and euphoric was reported once in the 2.5%, 6% and 9.4% THC cannabis treatment periods.

Medicare to cover smoking cessation

Good news. Hopefully Medicaid is not too far behind.