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Shawn Vestal: A referral to drug treatment is the first step on a long, complicated journey
Spokesman-Review - 5/23/2023
May 23—James Tillett did not quit using drugs when he went to jail for three months.
Nor did he quit the first time he was hospitalized for an IV-related infection. Tillett, who had been homeless and using "every drug I could get my hands on," had friends sneak in substances as he recovered.
His change came only after a second near-death crisis landed him in the hospital in early 2021 — suffering from endocarditis, pneumonia and other problems stemming from an infection caused by licking the tip of a needle to catch a drop before injecting. He was in Sacred Heart's cardiac unit for two and a half months at a time when COVID protocols prevented visitors.
During his stay, a caregiver asked him, 'If you live, would you be open to getting treatment?' "
Tillett lived and entered a 30-day inpatient program, followed by continued outpatient treatment and peer support programs. He's been sober since then, and working as a peer counselor. He's recently been serving on a state advisory committee that made recommendations to the Legislature on drug policy.
Tillett's road was not unique. Relapse is common for people trying to get sober, and especially for those without a place to sleep. Some 85% relapse within a year after receiving treatment, according to the National Institute on Drug Abuse. Around two-thirds return to drug use within weeks of starting a program.
"It can take some people a dozen times," Tillett said.
That is one of the complicated truths underlying the new chapter in Washington's drug-possession landscape. State lawmakers, after failing to pass a "Blake fix" at the end of the regular session, passed a new law last week that stiffened drug-possession and drug-use penalties, and paired them with a suite of proposals and funding for treatment-oriented diversions.
The package drew praise for balancing the interests of the jail-versus-treatment divide, but was criticized by those who wanted even tougher criminal penalties — and by those who said the new law criminalizes addiction and does too little to address the care needed.
Senate Majority Leader Andy Billig described it as a "treatment-centered bill" with a criminal justice component.
"Addiction is a health disorder, so it makes good sense to take a health approach," he said.
But he acknowledged what is widely understood within the recovery community — even with a boost in funding, our capacity to provide that treatment falls well below the need.
Treatment programs are hard to get into, and staffing shortages plague the behavioral health field. The availability of the most effective, evidence-based programs, relying on medication and harm-reduction strategies, are in even shorter supply.
"If you want to get into a substance-use program right now, you're looking at a two-week wait, minimum," said Justin Johnson, director of the Spokane County Community Services Department, which provides a range of behavioral health services including court-ordered treatment.
That challenge is deepened by a network of insurers and providers — each operating with contracts that limit and define what is covered and who is treated — that create a seemingly impermeable bureaucratic thicket. Any given individual relying on Medicaid to pay for treatment faces a complex gauntlet made up of differing rules, payment schedules and partnerships among insurers and providers.
"The No. 1 question we get is how do we even navigate this?" Johnson said. "It's a much more complicated issue than saying there are a certain number of beds. It's a really, really weird and complex system."
'Begging for help'
Four years ago, well before the state Supreme Court's Blake decision upended Washington's drug possession laws, Hallie Burchinal was working with people who are homeless on Spokane's streets.
Burchinal was trying to "navigate them into services" — to find detox and treatment options to help begin the recovery process. She became known among people living on the street as someone who was understanding, and they would approach her for help.
"I had to fight hard to get them into any treatment facility," Burchinal said.
Availability was scarce. On top of that, she was surprised to find that one of the major obstacles was an attitude among some treatment providers themselves — those who had seen people fail in treatment and were skeptical that they truly wanted to change.
"People were begging me for help and I was facing a system that was saying back to me, 'They don't want help,'" Burchinal said.
That prompted Burchinal to form her own nonprofit, Compassionate Addiction Treatment, in 2019 to provide peer counseling and treatment. Burchinal just opened a new 16-bed sobering center — a kind of detox facility — to help with the final stages of clearing out Camp Hope.
Like many who work in the field, Burchinal believes that the push to toughen criminal sanctions could thwart efforts for some people to quit using — particularly those using drugs openly in public spaces, many of whom are homeless and facing a wide range of problems including mental illness.
The intention to coerce treatment will likely fall short, they say, and jail then becomes the default — a default that stigmatizes people and puts barriers in the path to recovery.
"It's really a revolving door with homelessness, substance use disorder, and the jail system, and the jail is very expensive," she said.
The opioid crisis, now driven by potent, lethal synthetic fentanyl, has driven up overdose deaths across the country, and the public use of the drugs — whether they're being shot or smoked — contributed to a sense of public urgency arising from concerns about crime and homelessness.
Leaders in cities and counties across Washington, as well as law enforcement leaders, called for strong criminal sanctions for drug use to protect the public and leverage drug users into treatment. But researchers say incarceration has proven to be ineffective as a response to drug addiction over the past 30 years, even as the research establishing substance-use disorder as a treatable brain disorder has grown.
Between 1980 and 2015, the number of people in federal prison for drug offenses grew more than tenfold, from 25,000 in 1980 to more than 300,000, according to a report by Pew. During that period, self-reported drug use continued to increase and recidivism — that revolving door — didn't budge.
"As the federal prison population soared, spending ballooned 595 percent between 1980 and 2013 without delivering a convincing public safety return," Pew concluded, adding, "The rate of federal drug offenders who leave prison and are placed on community supervision but commit new crimes or violate the conditions of their release has been roughly a third for more than three decades."
At the state level, the picture has been similar. Among states with widely varying approaches to drug penalties, Pew found no significant differences in the levels of drug use, drug arrests or overdoses, no matter how tough the penalties.
Fifteen years ago, the National Institutes of Health published a review of the research on incarceration and drug addiction. It found that an estimated half of all people imprisoned in the country met the criteria for drug dependence, and called for a shift in policy away from jail and toward treatment.
It found no effect from tougher jail sentences on recidivism. In addition, it noted that drugs are commonly used in jails and prisons, and that the threat of a relapse upon release is very high — and that when people are released, they face a gauntlet of challenges contributing to relapse, from returning to old environments to a lack of stable housing or employment.
The "molecular and neurobiological adaptations" that those with SUD experience don't just go away while someone is jailed, the NIH found, and the "compulsive seeking of drugs" returns powerfully even long after withdrawal.
"This could explain why many drug-addicted individuals rapidly return to drug use following long periods of abstinence during incarceration and highlights the need for ongoing treatment following release," the NIH reported.
As Burchinal put it, "If jails worked we wouldn't have anybody out here struggling with substance-use disorder."
'Huge pinch point'
Repeated studies show that drug treatment is cheaper and more effective in reducing drug-use and drug-related crime. One example, the Washington State Institute for Public Policy estimated that every dollar spent on community-based drug treatment resulted in $18 savings in future costs related to crime.
A state analysis in 2017 estimated that every dollar spent on treatment services within the criminal justice system saved between $5 and $13 overall, and reduced recidivism by as much as 9%.
So what is the realistic availability of such treatment? It's hard to gather a single, simple picture of our community's capacity. There are several different private and nonprofit providers who offer outpatient counseling services; the availability of long-term care is limited, and has shrunk in recent years.
Detox beds, particularly for medical detox for the most seriously addicted, are very limited. Burchinal said that "if all the stars align," there is a bed available at the moment of need. Often, the stars don't align, she said.
"We drove someone across the state last week to access medical detox," she said.
Spokane County opened a Mental Health Crisis Stabilization Center in 2021, the first facility of its kind in the state. Officers who encounter people they might otherwise arrest for low-level crimes can direct them to the center, where there are withdrawal beds, medical services, counseling and medical staff, and other services.
It was celebrated when it opened as a step toward recognizing and dealing with the untreated disorders at the heart of so much recidivism.
Still, the gap between the need and the capacity remains large. A county survey taken over three months in 2020 — before the center opened — showed that 37% of those booked into jail met the criteria for mental health or drug use treatment.
That amounts to about 2,000 people. The facility has 47 beds. Not everyone needs an inpatient detox period to receive treatment, and even those who do will move into outpatient services at some point, but the numbers are telling.
The Spokane Regional Health District runs an outpatient methadone program for opioid addiction. Some 1,100 people are enrolled, with 500 to 600 a day coming in for medication.
Misty Challinor, director of the treatment services division at SRHD, said fentanyl has changed the recovery landscape dramatically. The synthetic opioid has rapidly become prevalent, and it's frequently cut into other substances so people don't even know they're taking it.
"It becomes a much harder monster to work with because it's so much more potent than any other substance," she said.
She said that there is a resulting need for more capacity in the methadone program, but that a labor shortage makes it hard to hire sufficient staff even when there is funding.
That's been a major challenge facing the entire field of behavioral health, and it's one roadblock to turning the legislative proposals into on-the-ground realities.
Jeff Thomas, the CEO of Frontier Behavioral Health, said high vacancy rates and turnover among workers in the field make it difficult to expand services. A survey of Washington's community-based behavioral health providers in November found that the average staffing vacancy rate was 29% and the average turnover during the year was 32%.
Frontier is not currently contracted to provide substance-use disorder treatment, but does provide services that are adjacent — and often intertwined — with that need, including homeless outreach and teaming up with local police agencies to respond to people in crisis.
As the number of people seeking treatment for some form of behavioral health problem has grown, and as the expansion of Medicaid and further investments in public health have arrived, the work force has not kept pace, he said.
So state investments in new programs and hiring don't automatically produce services on the ground. For example, the recently passed state budget included a 15% increase in funding to boost behavior health hiring — an important and needed investment, but one that doesn't instantly produce the staffing, he said.
"It's great that there is more investment and it's great that there is less stigma for people accessing these services," Thomas said. "It just creates this huge pinch point."
The limited treatment landscape has frustrated the final stages of clearing out Camp Hope, which had shrunk to around 30 people by the end of last month. Getting the hardest cases into treatment has been difficult — part of the reason for CAT's new sobering center.
Julie Garcia, who runs the camp, said she agrees with a prohibition against open drug use.
But she said that while the goal of responding with treatment referrals sounds good — and everyone on all sides say they want to encourage it — there simply isn't enough capacity on the other side of that encouragement.
When she sees lawmakers discussing diverting arrestees into treatment, she thinks: "Cool. Where do they go?"
Without a concrete answer, the default becomes a jail sentence or criminal punishment that might help encourage some people to seek help — but will become an obstacle for many others, making it harder to get housing, find a job, and otherwise stabilize their life enough to get sober.
'We need another model'
Caleb Banta-Green, a research professor at the University of Washington School of Medicine's Addictions, Drug & Alcohol Institute who is among the state's leading experts on addiction and recovery, began his work in the field 28 years ago in a methadone program.
At the time, the emphasis was on setting strict rules, and screening out those who did not follow the rules or stop using drugs immediately. The prevailing public attitude — still widespread — was that drug use was a poor choice, and quitting was a good choice, and people should simply make the right choice.
Decades of research have made it clear that addiction is a brain chemistry disorder, and one with a strong genetic component. It's a treatable medical condition, though not one with a simple, direct cure.
Today, Banta-Green advocates for a different approach — one that focuses on addressing each individual's needs, attempts to address contributing factors such as a lack of housing or medical care, and recognizes the reality of relapse and works to keep people connected to the recovery, rather than denying treatment for breaking the rules.
"The chance of recovery is higher if you keep people in care, even if they continue to use substances," he said.
The need for such care far outstrips the availability. Two-thirds of Washington counties do not have an opioid-treatment program that can provide medication for withdrawals. The vast majority of people who are addicted to opioids — whether living on the street or living in a mansion — are not receiving treatment.
"The treatment system works OK for some people," he said. "The traditional health care system works OK for some people. But our treatment gap is over 80%. We need another model."
A harm-reduction approach that keeps people alive, understands the reality of relapse, uses the appropriate medications and helps to address other problems in people's lives is the most effective approach, he said.
"The evidence for mandated treatment is poor," he said, "and the health impacts of incarceration are very bad."
Banta-Green has served on advisory panels for the Legislature and governor's office. The top recommendation he and his colleagues on the Substance Use and Recovery Services Committee made heading into the last legislative session was the creation of health-engagement hubs to provide immediate walk-in services for drug use disorder and other needs such as general medical care, housing and employment.
The services committee recommended funding one such hub for every 200,000 people in the state. That was stripped from the legislative proposal that broke down at the end of the regular session; the package passed in the special session included funding for two such pilot projects.
The evidence shows that harm-reduction strategies, such as safe-needle programs, works to move people toward recovery, he said. But it faces political opposition that grow from ingrained social attitudes toward drug use that stigmatize the user and underestimate the long road to recovery. He calls the philosophical divide ingrained in the jail-versus-treatment debate "the ultimate wedge issue."
Some people can "white-knuckle" it to sobriety, he said. Most simply can't.
'You have to want it'
A continual theme echoed by people working in drug treatment is the corrosive effects of stigmatizing people with addiction and mental health problems.
The stigma follows people through their lives and makes it harder to find housing, get a job, and avoid the stresses and cues that cause relapse.
"If people would think of addiction as an array of symptoms rather than a character defect, then we'd have a better understanding of the recovery process," Burchinal said.
Tillett, 36, said that when he was convicted and sentenced to jail — for drug distribution and related charges, not simple possession — it didn't result in him getting treatment. It did, however, make him start to think about the possibility.
It planted a seed.
For him and others he has counseled, he said that moving toward recovery often happens in such stages. His jail sentence and hospitalizations were part of a stop-and-start process that is common for those addicted to drugs. The fact that someone doesn't succeed right away is typical, but it doesn't mean that success isn't possible.
The key is an individual's commitment, he said. And that isn't created by a legal threat or an offer of help or even major interventions such as months in jail.
Tillett isn't opposed to having a criminal sanction for drug possession and public drug use, though he said such laws might be more effective at simply moving drug use out of sight rather than actually changing behaviors.
He said when he was using drugs, he would not have used them in the open, simply because he knew it was against the law. Instead, he would find hidden places to use — in restrooms at local businesses, for example.
"You have to want it," he said. "That's the hard thing with this. (Offering treatment) is a great concept, but the individual has to want it."
Editor's note: This story has been updated to include the first name of UW professor Caleb Banta-Green.
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