Stigma and cost are ma­jor bar­ri­ers in­hibit­ing treat­ment and re­cov­ery

Opi­oid cri­sis per­sists de­spite in­creas­ing treat­ment and pre­ven­tion ef­forts

Maryland Independent - - Front Page - By DANDAN ZOU dzou@somd­news.com

Death is no stranger to Eric Fisher.

He had seen it many times. He him­self over­dosed more than a dozen times. His best friend died from an over­dose. Once, he drove an over­dosed stranger — who was at the time us­ing along with him — to the hos­pi­tal.

About six years ago, Fisher, now 34, made in­quiry calls to more than a dozen re­hab fa- cil­i­ties in and out of state. But he couldn’t get into a treat- ment pro­gram be­cause he couldn’t afford it, the Wal­dorf res­i­dent said.

Around the same time he made those calls, Fisher also com­mit­ted bur­glar­ies and was later sen­tenced to 80 years on four counts of first-de­gree bur­glary charges. Be­fore be­ing trans­ferred to Jude House to be treated for his ad­dic­tion in Oc­to­ber, he was locked up in a Hager­stown prison for six years.

Fisher con­sid­ered him­self lucky be­cause he didn’t be­come an­other name added to the more than 300 drug-re­lated deaths since 2007 in South­ern Mary­land.

The climb­ing fa­tal­ity rate re­lated to drug and al­co­hol mis­use, ac­cord­ing to the most re­cent data from the state’s health depart­ment, is show­ing no signs of slow­ing

down.

Sub­stances like heroin and Fen­tanyl now kill more peo­ple ev­ery year than car ac­ci­dents. In the past five years, the South­ern Mary­land re­gion saw a yearly av­er­age of 36 fa­tal­i­ties on the road. In the first three quar- ters of 2016, close to 50 peo­ple died from drug-re­lated in­toxi- cation. The num­ber in 2007, in com­par­i­son, was 23.

To re­spond to the deadly epi- demic, there are in­creas­ing pre­ven­tion and treat­ment ef­forts. More nalox­one train­ings and pre­ven­tion ef­forts are be­ing or- ga­nized through county health depart­ments. On March 1, Gov. Larry Hogan (R) de­clared the cri­sis a public health emer­gency and an­nounced $50 mil­lion ad­di­tional fund­ing to spend on pre­ven­tion and treat­ment ef- forts.

But the bar­ri­ers that block peo­ple from get­ting treat­ment or manag­ing re­cov­ery are still there. De­pend­ing on whom you ask, the types of bar­ri­ers vary: It could be the cost to get long-term treat­ment, ac­cess to trans­porta­tion or af­ford­able hous­ing, gaps of com­muni- cation be­tween pa­tients and health providers dur­ing the ear- ly pe­riod of re­lease time. The stigma is a ma­jor bar­rier, if not the big­gest one, that health pro­fes­sion­als say can in­hibit peo­ple from seek­ing treat­ment and can shadow them through­out their re­cov­er­ies.

The cri­sis

The re­cent cri­sis de­scribed by health pro­fes­sion­als and public of­fi­cials is re­fer­ring to the sharp rise of deaths from opi­oid over­doses.

“We are see­ing in the past five years a sud­den rise in the num- ber of fa­tal­i­ties associated with opi­oids, that is what ev­ery­body is re­fer­ring to as a cri­sis,” said Dr. Meena Brew­ster, St. Mary’s health of­fi­cer.

There are sev­eral fac­tors at play in caus­ing the climb­ing num­ber of deaths.

First, it has a lot to do with drugs like Fen­tanyl be­ing added to heroin, mak­ing the com­bi­na­tion much more pow­er­ful and deadly, ac­cord­ing to Kath­leen O’Brien, ex­ec­u­tive di­rec­tor of Waldend, a treat­ment cen­ter in St. Mary’s.

Fen­tanyl is a syn­thetic opi­ate drug sim­i­lar to mor­phine, but 50 to 100 times more po­tent. Five times more peo­ple died from Fen­tanyl in the first three quar­ters of 2016 than in 2015.

Other than the types of drugs be­ing used, a sec­ond fac­tor is the way they are be­ing used.

Based on re­quests for ser­vices, Walden saw higher de­mand of peo­ple need­ing res­i­den­tial treat­ment and higher num­ber of in­tra­venous drug users, ac­cord­ing to Walden’s chief op­er­at­ing of­fi­cer, Gary Lynch. In­tra­venous drug use in­volves nee­dle in­jec­tion, which is a dan­ger­ous form of drug use be­cause the sub­stances go di­rectly into blood­streams and put users at higher risk of over- dose, Lynch said.

“This fis­cal year start­ing last July to now, we have seen the most de­mand for res­i­den­tial beds that we’ve seen in the last three years,” Lynch said. “It’s pri­mar­ily opi­oid users. We are trend­ing prob­a­bly 10 to 20 per­cent more than we did last year.”

The higher de­mand for treat- ment may sig­nal a prob­lem, be­cause re­quests for ser­vice re­flect what’s go­ing on in the com­mu­nity, he said. At the same time, pre­scrip­tion use that of­ten starts with le­git­i­mate drug use pre­scribed by doc­tors af­ter a ma­jor surgery, for exam- ple, has also been on the rise.

That changed the peo­ple who are us­ing, O’Brien said. “It’s very dif­fer­ent than what we tra­di­tion­ally thought of heroin ad­dic­tion be­ing an in­ner-city, poverty-re­lated phe­nom­e­non. That’s not what the pic­ture is like to­day.”

Three coun­ties, dif­fer­ent sit­u­a­tions

If one of the calls Fisher made six years ago had landed him into a treat­ment cen­ter, things might have turned out dif­fer- ently for him.

“There’s a good chance that I would not have to go through what I did,” he said. “Peo­ple I made vic­tims would not be vic- tims.”

In South­ern Mary­land, treat- ment re­sources avail­able for peo­ple like Fisher are dif­fer­ent in each of the three coun­ties.

“The is­sue of ac­cess [to care] is very dif­fer­ent de­pend­ing on where a per­son lives,” O’Brien said.

If Fisher had called Walden six years ago, O’Brien said they would be able to work with him to get fund­ing to help him cover the cost.

Be­cause Walden is a pub­licly funded pri­vate non­profit that ac­cepts in­sur­ance and Medic- aid and is able to uti­lize grant fund­ing to help cover the cost of those who can’t afford the treat­ment, O’Brien said she doesn’t think the big­gest barri- er is peo­ples’ in­abil­ity to pay.

In Calvert, how­ever, Carol Porto said the pri­mary bar­rier for peo­ple to ac­cess res­i­den­tial care is cost. Porto is the pro­gram di­rec­tor at Calvert’s only res­i­den­tial treat­ment cen­ter, which is a pri­vate fa­cil­ity.

“We have 46 beds here, and half of them are empty be­cause no one can pay for them,” Porto said.

About half of her 26 clients pay out of pocket, she said. Some may have in­sur­ance cov- er­ing the cost of med­i­ca­tion. The other half are beds funded by public agen­cies such as Calvert’s health depart­ment, Prince Ge­orge’s health de­part- ment and Charles County’s fam­ily re­cov­ery court.

With in­sur­ance cov­er­ing the med­i­ca­tion of about $850, the Porto Treat­ment Cen­ter charges about $4,500 for a 28day pro­gram, in­clud­ing four vis- its to the doc­tor. An ad­di­tional month costs about $3,000.

Two days af­ter Hogan’s an­nounce­ment of declar­ing the opi­oid cri­sis a state of emer­gency, Porto sent the gov­er­nor a let­ter ask­ing for more funds to be di­rected to­ward treat­ment.

Porto said her fa­cil­ity re­ceives about 40 in­quiry calls a week, with about 30 of them opi­oid users. Most of them can’t pay for res­i­den­tial care them­selves, and she can only re­fer them to­ward the health depart­ment and pri­vate prac­ti­tion­ers in the re­gion who ac­cept Med­i­caid for out­pa­tient ser­vices.

Start­ing in July, Med­i­caid will be­gin cov­er­ing res­i­den­tial treat­ment, but Porto said de­tails of how re­im­burse­ment will be im­ple­mented are still un­clear, and she is fear­ful that the re­im­burse rate would be be too low to cover the cost and re­tain her doc­tors.

“We re­al­ize that for peo­ple who are not in­sured that pay­ing for treat­ment can be very dif­fi­cult,” said Dr. Lau­rence Pol­sky, Calvert’s health of­fi­cer. “Even for some peo­ple with in­sur­ance, if they have sub­stan­tial co-pay­ments or de­ductibles, that can

be a bar­rier as well.”

Pol­sky en­cour­ages peo­ple to con­tact the health depart­ment to get help with ei­ther en­rolling in in­sur­ance plans or get­ting some form of sub­sidy de­pend­ing on in­di­vid­ual cases.

Of the three coun­ties in the past three years, Charles saw the high­est num­ber of deaths re­lated to drugs and al­co­hol. Through Septem­ber last year, 34 peo­ple died in Charles, al­most three times as the 12 in St. Mar y’s.

“We are all con­cerned about it,” said Dr. Dianna Ab­ney, Charles County’s health of­fi­cer.

Ab­ney said the health depart­ment of­fers out­pa­tient ser­vices Mon­days through Fri­days and had 87 ini­tial as­sess­ments in Fe­bru­ary.

The Charles health de­part- ment doesn’t have any fund­ing for res­i­den­tial beds, but Ab­ney said they could work with fa- cil­i­ties and peo­ple who need treat­ment to try ac­cess state fund­ing.

Jude House, the only res­i­den­tial fa­cil­ity in Charles, takes in pa­tients from mostly from the pen­i­ten­tiary sys­tem from all over the state. The bulk of the res­i­dent body at Jude House, about 95 per­cent, come from the cor­rec­tional sys­tem, ac- cord­ing to Dr. Roshonda Davis, Jude House’s clin­i­cal di­rec­tor.

The re­main­ing five per­cent is made up of self-pay­ing clients and re­fer­rals from drug court and the health depart­ment, she said. Ex­cept for self-pay­ing clients, the cost for the rest of the res­i­dents is paid for through state fund­ing.

With a ca­pac­ity of 62, Jude House has about 56 res­i­dents. Ex­act num­ber fluc­tu­ates ev- ery day as clients check in and check out. But Davis said most times there are beds avail­able.

As of early March, Jude House doesn’t ac­cept any type of in­sur­ance or Med­i­caid. With self-pay, a min­i­mum of a 120-day pro­gram costs about $9,000.

With 56 peo­ple to dis­charge in a few weeks, Jude House’s Ex­ec­u­tive Di­rec­tor Mary Lynn Logs­don is con­cerned that there is not enough af­ford­able hous­ing in the area.

For peo­ple re­leased from the treat­ment cen­ter, if they are go­ing back to the same drug-in­fested area with the same en­vi­ron­ment and old ac- quain­tances, nine times out of 10 they are go­ing be right back in trou­ble, be­cause it’s not a good recipe for so­bri­ety, Logs­don said.

Step­ping Stones has two re­cov­ery houses — one for fe­males, one for males — in Wal­dorf, and most of the time, they are run­ning at full ca­pac- ity, said Jes­sica Di­et­rich, the com­pany’s con­tact per­son in the South­ern Mary­land re­gion. She said Step­ping Stones is look­ing to open two new lo­ca­tions in Charles County.

Di­et­rich said each re­cov­ery house hosts be­tween eight to 10 peo­ple. As of early March in St. Mary’s, there are five empty beds at two male sober homes and three va­can­cies at one fe­male house.

Calvert has two Ox­ford sober houses — one for each sex — and each has one empty bed, ac­cord­ing to Lori Hony, house man­ager of Project Echo that over­sees the two Ox­ford house op­er­a­tions.

Re­gard­less of peo­ple’s situa- tions, Logs­don said cost should never be the rea­son for not get- ting treat­ment. “In Mary­land, there are lots of ways to ac­cess fund­ing,” she said. And she rec­om­mends peo­ple start with the lo­cal health depart­ment.

O’Brien en­cour­ages peo­ple in need from all three coun­ties to uti­lize re­sources at Walden.

“Some­times peo­ple don’t think out of that box” in terms of bound­aries of coun­ties, she said. “Some pro­grams are re­gional. We should be uti­lized more by the other two coun­ties.”

A dis­ease, not a choice

The pri­mary bar­rier for treat- ment, in O’Brien’s opin­ion, is not the cost but the stigma associated with sub­stance mis­use.

“We are all vul­ner­a­ble to be­com­ing ad­dicted to opi­oids,” she said. One ac­ci­dent has the po­ten­tial of lead­ing to pre­scrip­tion drugs and a full-blown ad­dic­tion.

Brew­ster ac­knowl­edges that in some cases with drug use, “it may have been a choice to start the sub­stance.” But she em­pha­sizes that sub­stances al­ter brain chem­istry which re­sults in changes in be­hav­iors.

At that point, be­cause of the bi­o­log­i­cal process, it be­comes less of a choice and has noth­ing to do with will power or self-con­trol, she said.

Peo­ple of­ten make choices that may have ad­verse health ef­fects but there’s no stigma around them, she said.

“It’s a choice to eat un­healthy food, and that un­healthy food can con­trib­ute to hy­per­ten­sion and di­a­betes and cancer and a host of med­i­cal con­cerns,” Brew­ster said. “But we don’t say, well, OK, let’s blame the per­son in­volved and there­fore let’s not help them.”

As a so­ci­ety, Brew­ster hopes that “we rec­og­nize that this is a brain dis­ease.”

The hope

When Fisher was ad­dicted to heroin, he wasn’t afraid of dy­ing.

“When you are ad­dicted, you re­ally don’t care if you die,” he said. “Be­cause you are so de­pressed, it would be a re­lief if it hap­pens.”

Now he is afraid. Jude House has a small gar­den to mem­o­rize those who have been lost to ad­dic­tion, and he doesn’t want his name to ap­pear on the next rock.

He is sched­uled to be re­leased at the end of March, and he said he is “anx­ious to get a job, to be able to sup­port my­self, to sup­port mom, to get my life back.”

And he is hope­ful.

STAFF PHO­TOS BY DANDAN ZOU

Eric Fisher sits on a chair in the me­mo­rial gar­den at Jude House on Feb. 24. The rocks nearby memo­ri­al­ize for­mer Jude House res­i­dents who died from over­doses.

Two empty beds sit next to an oc­cu­pied bed in a male dorm room at Carol Porto Treat­ment Cen­ter in Prince Fred­er­ick on March 9. Pro­gram Di­rec­tor Carol Porto said half of her fa­cil­ity’s beds are empty be­cause peo­ple can’t afford to pay for the treat­ment.

STAFF PHOTO BY DANDAN ZOU

Natasha Kelly from Leonard­town is a res­i­dent at Jude House. The pic­ture shows her bed.

STAFF PHOTO BY DANDAN ZOU

Kath­leen O’Brien, ex­ec­u­tive di­rec­tor of Walden, sits in her of­fice in Lexington Park on March 8.

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