Stigma and cost are major barriers inhibiting treatment and recovery
Opioid crisis persists despite increasing treatment and prevention efforts
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.