Follow the Money: Stories from Our Partners

In January The Granite State News Collaborative — a collective of  17 media and educational organizations from across New Hampshire — launched its Granite Solutions project. The goal was to take a look at the dual challenge of our statewide opioid crisis and its relationship to treatment of mental health issues. Working together as a team we have produced a series of multimedia story packages that do more than explore the problems; our aim is toward solutions. How? By working collaboratively to inform and engage you.  

We present the final installment off our Granite Solutions project: Follow the Money. In part 1, we examined the $64.5 million statewide Doorway system of referral and treatment for opioid addiction. We also focused on how the money’s been spent, what outcomes have been measured, and what’s next as the state considers how it will spend the second year of grant funding. In part 2, we looked at Safe Station and whether it has potential to expand into a statewide solution. We also heard from folks in recovery about what it’s like to use these systems.  

We also present these stories from our partners:

From Seacoast Media: Few people seek help at Dover police, fire stations

From the Concord Monitor: ‘No single solution’: First responders join in effort to combat N.H. opioid crisis

Follow the Money Part 2: Safe Station Remains on the Front Lines of Recovery

In January The Granite State News Collaborative — a collective of  17 media and educational organizations from across New Hampshire — launched its Granite Solutions project. The goal was to take a look at the dual challenge of our statewide opioid crisis and its relationship to treatment of mental health issues. Working together as a team we have produced a series of multimedia story packages that do more than explore the problems; our aim is toward solutions. How? By working collaboratively to inform and engage you.  

Today we present the final installment off our Granite Solutions project: Follow the Money, in two parts. In part 1, we examine the $64.5 million statewide Doorway system of referral and treatment for opioid addiction. We focus in on how the money’s been spent, what outcomes have been measured, and what’s next as the state considers how it will spend the second year of grant funding. Today in part 2,. we look at Safe Station and whether it has potential to expand into a statewide solution. We will also hear from folks in recovery about what it’s like to use these systems.  

By PAT GROSSMITH 

Granite State News Collaborative 

MANCHESTER, NH — Fire Chief Daniel Goonan is working on a plan to expand Safe Station services to the addicted in anticipation of receiving $225,000 in state funds in each of the next two years. Safe Station didn’t receive any of the $60-plus million the state received in federal funding to battle the opiate epidemic.

 “It’s [Safe Station] an idea that is still going across the country,” Goonan said of Safe Station. 

In March 2018, President Donald Trump visited the Manchester Fire Department and praised Safe Station, saying the entire country was talking about how it was saving lives. Safe Stations, he said, recently opened in Tacoma, Wash., Chattanooga, Tenn., Ohio, Virginia and Maryland. Yet, New Hampshire, where Safe Station began has not expanded statewide. 

The state opted to put in The Doorways, nine regional centers across the state, where people seeking help for addiction can go, be assessed and referred to needed services. 

However, smaller fire departments around New Hampshire inspired by Safe Station's mission but with fewer resources have found ways to allow local first responders to act as bridges for those in need to treatment. Concord Fire Department has tapped into federal dollars through Project FIRST (First Responders Initiating Recovery, Support and Treatment). Other towns, like Auburn, Berlin, Dover, Keene, Laconia and Portsmouth, are also using existing emergency response systems to connect people to recovery services. (For more on this story, click here). 

Push for Statewide Safe Station Access

“The relationship between the local doorways’ director and the Manchester Fire Department has always been good and I continue to work with them to improve the system,” Goonan said. “The real disconnect is the lack of transparency, information sharing competition and politics from state powers that be. We have been pushing for fewer hubs statewide, 24-hour coverage in all Doorways coupled with a Safe Station Access point in the remaining hubs. We need respite associated with all doorways because we are losing people in the system, waiting the few days for placement.” 

Goonan is hoping the Governor will allow a Doorways 2. 

“We know where the gaps are,” he said. Manchester pitched statewide Safe Stations — because fire departments operate 24/7 and helping people is the job of a firefighter who also has medical training — but the Governor opted for the Doorways which qualified for federal funding. However, Nashua and Manchester’s Safe Stations are expecting to share a total of $750,000 in state funds with Manchester receiving 60 percent or $450,000. 

Benjamin Vihstadt, communications director in the Office of the Governor, said the funding is from the state’s general fund, the result of the bipartisan compromise budget Gov. Chris Sununu signed into law this fall. The cities have yet to receive the funds, however, because the state Department of Health and Human Services is currently working with Manchester and Nashua officials to understand the needs of the community to determine and develop the scope of the contract, he said. When that is finalized, it will go before the Governor and Council for approval. Additionally, he said the Governor has provided state funding to cover the cost of Safe Station transportation to Doorway Hubs, which for Manchester is The Doorway at Granite Pathways. 

“Safe Stations are an important part of the solution, which is why in the budget I signed earlier this fall provided an additional $750,000 for safe stations in Nashua and Manchester, which will help individuals get the services they need,” the Governor said. 

There were growing pains when the Doorways opened last year across the state. Because they were new, people continued to go to Manchester’s Safe Station where they knew they could get help. That led to the city being swamped with people seeking help for their addictions. City officials complained more money was needed and that other communities needed to step up and do their part. 

Safe Station began in May of 2016 to address the opioid epidemic in the city. Anyone seeking help for addiction can go to any fire station in the city. Once there, an individual’s condition is assessed and he is linked up to needed services. The fire stations provide a stigma-free environment, Goonan said. 

“The fire department just made sense,” he said. “We’ve been here 180 years and it’s where people come when they need help.” We know where the gaps are. Hopefully the governor can allow a Doorways 2." 

Safe Station Expansion

Goonan now has drafted a plan for a downtown “fly” car or “squad” car “to roll out during peak times, which is noon to 8 p.m. He says it will be staffed by two firefighters, one an advanced EMT. That will result in a quicker response and provide a bigger presence in the inner city where most of the overdose calls take place and hopefully save lives. 

“This money gives us the opportunity to step up our game and provide better Safe Stations,” he said. “Instead of waiting for them to come, maybe we can do some outreach to the homeless.” 

Since it's been in operation, 6,422 people have sought help, an average of about 5 people a day, according to statistics compiled on Nov. 22 by Chris Stawasz, regional director, New Hampshire and Maine for AMR ambulance. If they are in need of medical attention, they are taken to a city hospital. If they need a detox program, they are taken to The Doorway at Granite Pathways. Goonan says if they arrive at the station after Granite Pathways closes at 11 p.m., they are taken to the Farnum Center. With winter here, the “Fatality Prevention Team,” consisting of the city’s fire, police and health departments, Families In Transitions, outreach workers, the Neighborhood Enforcement Team and the Greater Manchester Mental Health Center — currently is trying to identify the homeless and locate homeless encampments to reach out to that community. They hope to earn their trust and ultimately convince them to literally come in from the cold. Ideally, Goonan says he would like to have a GPS locator in areas where the homeless are sheltering to ensure workers can reach them “in the dead of winter” to bring them indoors. 

“We’re hoping for the best and preparing for the worst,” he says. “We have all really come together. We’re trying to put together the best response for the city. We’re keeping all our options open.” 

Goonan said it is not just the drug epidemic that emergency personnel are dealing with but the high number of homeless suffering from addiction and/or mental illness. Emergency personnel also are seeing an increase in methamphetamine on the streets with individuals mixing it with fentanyl or other opiates. He said no longer are individuals using only fentanyl; more and more they are using multiple drugs and/or alcohol. 

The biggest problem is that too often there is no bed available. The Farnum Center, Goonan said, has 16 beds. The New Horizons shelter has 24 — 12 each for men and women who are sober. Most nights, the shelter is filled to the limit. Goonan said he is talking with people who operate sober houses to see if they would take in those individuals when beds aren’t available. He said this has been an ongoing problem for years. 

“That’s always been the hole,” he said. 

More Emergency Shelter Needed 

Sometimes individuals end up being housed at local hotels. Safe Station operates as an access point, not a service provider, according to Lauren Smith, Policy and Strategic Outreach Director in the Office of the Mayor. She says those agencies that have the authority to place someone in a hotel, and cover the cost, is Granite Pathways, the 2-1-1 NH emergency service, which provides access to health and human services in times of crisis, and the city’s welfare office. 

Patrick Tufts, president and CEO of Granite United Way, said his agency was awarded the $200,000 state contract to provide short-term hotel and transportation. “It’s an avenue of last resort,” Tufts said. 

The hotel stay is capped at two or three days, he said and is designed to be used only until a shelter bed opens Still, each year every penny budgeted is spent. He agreed with Goonan that more beds are needed, not just in the city but statewide. Initially, he said when someone calls 2-1-1 NH, the operator checks to see where a bed is available. That is not restricted to Manchester only but other places across the state such as Cross Roads House in Portsmouth or the Salvation Army’s McKenna House in Concord. 

Charlene Michaud, Manchester’s welfare director, said her department is the last resort. It provides individuals with financial help for basic needs expenses when an individual and/or family does not have the ability to pay for it. “There is an eligibility process and no one is eligible simply because they are seeking substance use treatment,” she said. “As part of the eligibility process all other possible resources, including but not limited to tapping into programs utilizing state or federal funds, are explored. Expending local taxpayer dollars is the last resort. As a result, if someone came to our office specifically looking for shelter until they could get into treatment, we would refer them to Granite Pathways as they have funds for this purpose.” 

She said while the department does not collect statistics as to how much it spends on hotel expenses for someone coming through Safe Station needing a bed, “I doubt we have spent any money for this specific reason. Historically, we have been able to refer homeless individuals to shelter. We typically have only placed homeless families in motels after all other possible housing options have been explored.” Michaud said the welfare office has provided financial assistance to individuals who are suffering from substance use disorder issues but those individuals are more likely to seek and receive rental assistance.

Follow the Money Part 2: Turning the Tide and addressing NH’s Addiction Crisis

In January The Granite State News Collaborative — a collective of  17 media and educational organizations from across New Hampshire — launched its Granite Solutions project. The goal was to take a look at the dual challenge of our statewide opioid crisis and its relationship to treatment of mental health issues. Working together as a team we have produced a series of multimedia story packages that do more than explore the problems; our aim is toward solutions. How? By working collaboratively to inform and engage you.  

Today we present the final installment off our Granite Solutions project: Follow the Money, in two parts. In part 1, we examine the $64.5 million statewide Doorway system of referral and treatment for opioid addiction. We focus in on how the money’s been spent, what outcomes have been measured, and what’s next as the state considers how it will spend the second year of grant funding. Today in part 2,. we look at Safe Station and whether it has potential to expand into a statewide solution. We will also hear from folks in recovery about what it’s like to use these systems.  

By Susan Geier

Granite State News Collaborative

Across the state, substance abuse treatment providers are grateful for federal money the state received to address the opioid crisis but have made it clear it’s not the only issue they are treating.

Within the past year, New Hampshire received more than $64 million in State Opioid Response grants, which are limited to treating opioid-related substance use disorders. But that may be changing thanks to the introduction of the Turn the Tide Act, introduced by U.S. Senator Jeanne Shaheen (D-NH).

On December 16, Shaheen announced government funding legislation for fiscal year 2020 released by Senate and House leaders will include a provision that allows flexibility for treatment providers to be able to use opioid response grant dollars to help patients suffering from meth and cocaine dependency, in addition to opioid use disorder.

The announcement is timely as treatment providers say crystal methamphetamine misuse is on the rise.

“Even in the last six months, it’s been horrible,” said Carrie LaFlamme, admissions director at the Bethlehem-based Friendship House, which is part of the North Country Health Consortium.

Denise Elwart, director of operations for Southeastern New Hampshire Alcohol & Drug Abuse Services in Dover, agreed, “We’ve definitely seen an uptick in meth use.”

Shaheen, a senior member of the Senate Appropriations Committee, was involved in the efforts to release the SOR funding in 2018. The Turn the Tide Act originated from her discussions with New Hampshire treatment providers, according to the release.

“The substance use disorder epidemic we’re facing today isn’t the same one we were fighting a few years ago, so as this crisis evolves so should our response,” said Shaheen. “By empowering treatment providers with the ability to use these federal grants for a broader range of substance misuse, we can help ensure more Granite Staters get the help they desperately need.

Treatment for meth addiction is quite different from the treatment of opioid addiction. Those using meth may develop meth-induced psychosis, which may put the person and others at risk of harm, according to Dr. Seddon Savage, MD, MS, Dartmouth-Hitchock Substance Use & Mental Health Initiative and chair of the Opioid Task Force of the Governor’s Commission on Alcohol and Other Drugs

“It’s not like opioids at all, especially because of meth psychosis,” said LaFlamme. “People (with meth addiction)can be beyond our level of care.” 

Sara Lutat is executive director of Dismas Home of NH in Manchester, which serves women who have been in a substance-use disorder program while incarcerated and need additional treatment upon release. She said heroin and fentanyl have become too expensive so people are turning to meth, and many women use meth because it’s cheaper.

Also worrisome to treatment providers is the belief that meth is safer than opioids.

 “It’s a misconception,” Lutat said. “People think you can’t die from it, but you can.”

According to Shaheen’s office, the bill also funds the SOR grant program at $1.5 billion for the year and maintains the 15 percent set-aside for hardest-hit states like New Hampshire. Additionally, the state is slated to receive up to $1.7 million through the SUPPORT Act for housing assistance for those struggling with substance use disorders.

There is also funding the bill for Child Abuse and Prevention Treatment Act programs, which is needed in New Hampshire since it faces a backlog of cases partially due to the impact of the opioid epidemic on families, according to the announcement. 

Follow the Money Part 2: Once through the Doorway, “You Have to Want It”

In January The Granite State News Collaborative — a collective of  17 media and educational organizations from across New Hampshire — launched its Granite Solutions project. The goal was to take a look at the dual challenge of our statewide opioid crisis and its relationship to treatment of mental health issues. Working together as a team we have produced a series of multimedia story packages that do more than explore the problems; our aim is toward solutions. How? By working collaboratively to inform and engage you.  

Today we present the final installment off our Granite Solutions project: Follow the Money, in two parts. In part 1, we examine the $64.5 million statewide Doorway system of referral and treatment for opioid addiction. We focus in on how the money’s been spent, what outcomes have been measured, and what’s next as the state considers how it will spend the second year of grant funding. Today in part 2,. we look at Safe Station and whether it has potential to expand into a statewide solution. We will also hear from folks in recovery about what it’s like to use these systems.  

By ERICA SWALLOW

Granite State News Collaborative

MANCHESTER, NH — New Hampshire’s opioid crisis is among the worst in the nation, with the state ranking in the top five with the highest rate of opioid-involved deaths, according to the National Institute on Drug Abuse, more than twice the average national rate by population. Over the past year, the state has rolled out a referral and treatment program, called The Doorway, with hopes of providing a single-entry-point process for people seeking addiction treatment. 

Manchester residents Adam Dube, Carlos Zamban, Jason Barrows, and Anthony Simms visit the Hope for New Hampshire Recovery center for group meetings and community support. Photo/Erica Swallow

Manchester residents Adam Dube, Carlos Zamban, Jason Barrows, and Anthony Simms visit the Hope for New Hampshire Recovery center for group meetings and community support. Photo/Erica Swallow

More than $64.5 million in federally-funded contracts have been awarded since October 2018 to create the system. But how is it being used by patients who walk through its doors every day? We spoke with recovery community members to learn what changes, if any, they’ve seen over the past year in their experiences with finding and receiving opioid addiction recovery services.

The beginning of recovery

“The Doorway is the entrance into recovery,” says Jason Barrows, one of six recovery community members, all Manchester residents, we spoke with on a recent visit to the Hope for New Hampshire Recovery center in downtown Manchester. “They get you into treatment, and really it’s up to you after that to continue with it. You have to put in the work.”

The Doorway works under a “hub-and-spoke” model, wherein “hubs” assess patient needs and refer them to “spokes” for treatment as needed. In Manchester, the hub is Granite Pathways, a place from which all six interviewees had done intake assessment, many of them multiple times as a result of relapses.“In my experience, they helped me get into residential treatment, or into sober living,” Barrows continued. “But as far as continued recovery—meetings or whatever you’re going to do—that’s up to you.”

Hope for New Hampshire Recovery is one of the “spokes” in the Doorway hub-and-spoke model where that continued treatment happens. On a Thursday morning, the recovery community center was full of energy, with staffers welcoming each individual and directing them as needed. Colorful art covered the walls and an affirmation wall, covered with hundreds of sticky notes, greeted visitors, who are all encouraged to take an affirmation and add their own.

Many of those at the Hope center in recovery—attending peer-support meetings, signing up for art classes, or just socializing in the common area—had been referred to the center through a Doorway “hub.” Across the state, there are nine hubs which offer walk-in assessments and referrals for treatment at “spokes,” like Hope for New Hampshire Recovery. The six members of the Hope for New Hampshire Recovery community we spoke with had all been referred through the Manchester hub—Granite Pathways.

The referrals and treatment process

The need for persistence was a common thread among interviewees. Stated plainly, interviewee Anthony Simms added: “You have to want it.”Others shared that while the Doorway had got them into treatment, they “don’t follow up.” For the majority of those we spoke with, the process of recovery was strongly self-driven, though if they had the drive, recovery resources could be found.

All but one interviewee, who preferred to remain anonymous, agreed. She says over the past five months, she’s seen a system of greater involvement among treatment centers: “Even back in the past, they would call me when I was in rehab, asking if I stayed and how I was doing,” she says. But now, the intake process has become even more personal and sophisticated she explains:

“[Granite Pathways] has drastically changed. They helped me with the sober house. Before you used to meet with one recovery coach and one not-even-LADC [Licensed Alcohol and Drug Counselor], but a counselor… So, they had two people working in this office, and there’s only so much they can do.”In some instances, those two recovery center employees could be tasked with assessing a dozen or more people waiting for treatment, said Simms, who had participated in the described process.“Now, you meet with two recovery coaches, a LADC, and a case manager,” the woman explained. “That’s a huge difference. How I see Granite Pathways now, you go in there, and they get to know your whole history. The LADC assesses your treatment, and the case manager’s job is to help you with all of those resources.”Resources, she explained, could include treatment, a referral to sober living, or even money to help cover sober living. She had also received a list of providers from her case manager for mental health providers to pick up former treatment she had stopped.Other interviewees seemed astounded by the woman’s experience. They, all men, had not seen as careful attention in their own assessments and referrals.

Hope for NH Recovery - Affirmation WallErica Swallow_12.05.2019.jpg

The affirmation wall at Hope for New Hampshire Recovery in Manchester engages visitors to take an affirmation and provide another for someone else. Photo/Erica Swallow

More than anything, the recovery community members we spoke with saw the Doorway as a place to turn for help, not a guaranteed solution for their addiction recovery. More than anything, wait times for treatment played the biggest factor in whether these individuals stuck it out or walked right back out of the doorway they had just entered.

“[I came in] two or three months ago. I wanted to get into rehab, so a friend referred me [to Granite Pathways for an assessment],” said interviewee Adam Dube. “I left three times, because it was just taking forever. They had me waiting there. But, that was just me—patience really isn’t a virtue when you’re in that situation.”

Each time, Dube said paperwork and processing had been at least an hour up until the point he walked out. An hour seemed to be the agreed-upon processing time among the interviewees.

As Carlos Zamban put it: “As an addict, [an hour is] a long time. It’s like a week.”

Patience, yes, is required for any difficult journey, but what is the limit when it comes to recovering from opioid addiction in a state actively working against the crisis?It should be noted that two interviewees shared that they experienced expedited assistance when they came in through Manchester’s “Safe Station.” Launched in May 2016, solely in Manchester, the Safe Station program provides around-the-clock medical assistance at each Manchester firehouse. Firefighters provide medical assessments or referrals 24/7, including when Doorway hubs are closed. In its first three years, the program saw more than 5,000 visits, with all 10 firehouses in Manchester participating. As of July 2016, the town of Auburn also launched its own Safe Station program, while Nashua fire stations followed suit in November 2016. Meanwhile, other communities around the state offer other models—in Concord, the NH Project FIRST program enlists emergency response teams to provide support and resources. Other local models, too, can be found in Berlin, Dover, Keene, Laconia, and Portsmouth.

While the Doorway web portal focuses heavily on directing those who need help to call 2-1-1 to be connected to a hub (or “Doorway”), all of the members I spoke with had found there way into the center by simply showing up at Granite Pathways or visiting a Safe Station after-hours when they needed help. Of course, these were individuals who I met actively in recovery—the experience could be different for those who may be less aware of the hub and Safe Station locations.

Nothing greater than compassion

Those recovering from addiction are in search of compassion. There’s nothing more harmful than having someone treat you with disrespect when you’re reaching out for help.

What seems to be improving through the Doorway program is the infrastructure for getting patients into recovery—hubs are not only known in the recovery community, but some say the intake process and even the physical spaces have seen gains in the past year. What may be an area of development is a united sense of compassion among treatment providers.

“Some of the [Granite Pathways] staff understands what we go through,” says Zamban. “But if you’re not an addict, they don’t understand mentally what we go through. I’ve seen people come in totally [expletive] up, and people are laughing in their face about it. Some of them—not all of them—treat you as ‘once an addict, always an addict.’ We have to change that concept.”

“As soon as they know you’re there for some junky [expletive], you’re a second-class citizen,” Dube adds. “Since they’re in the medical field themselves, you’d think that if anyone is going to understand, they would get it.”

“There’s better support now,” says Zamban. “[Granite Pathway’s] building and facilities are a lot better.”

Similarly, interviewees also said spokes are seeing improvements, too. At the Hope center, the welcoming atmosphere and expanding programming were of particular note.

This wasn’t this before,” Simms said, gesturing around the room and out into the hallway. “I remember when this [part of the Hope center] was in construction,” says Simms. “We had to walk through [the side] door—couldn’t even go through the front door. There was [only] a meeting a day. This [center and its programming] has improved, and I think [Granite Pathways] is improving at a pretty steady pace, too. They have a lot of improvement to do, but I think they are improving.”

This story was produced by The Granite State News Collaborative as part of its Granite Solutions reporting project. For more information visit www.collaborativenh.org. Follow us on Twitter @NewsGranite and like us on facebook @collaborativenh.

Follow the Money Part 1: Doorways are working, but unmet need persists

In January The Granite State News Collaborative — a collective of  17 media and educational organizations from across New Hampshire — launched its Granite Solutions project. The goal was to take a look at the dual challenge of our statewide opioid crisis and its relationship to treatment of mental health issues. Working together as a team we have produced a series of multimedia story packages that do more than explore the problems; our aim is toward solutions. How? By working collaboratively to inform and engage you.  

Today we present the final installment off our Granite Solutions project: Follow the Money, in two parts. First, we examine the $64.5 million statewide Doorway system of referral and treatment for opioid addiction. We focus in on how the money’s been spent, what outcomes have been measured, and what’s next as the state considers how it will spend the second year of grant funding. In part 2, we look at Safe Station and whether it has potential to expand into a statewide solution. We will also hear from folks in recovery about what it’s like to use these systems.  

By SUSAN GEIER

Granite State News Collaborative

Across the state, addiction treatment providers – the spokes in the hub-and-spoke service delivery system – agree the Doorway is working. People are entering treatment and services are better coordinated, even if there have been some hiccups in rolling the Doorway system out. 

With one year left on the two-year federal grant, such hiccups are symptoms of a greater systemic dysfunction, something providers say needs to be addressed before the money runs out, including:

  • The need for brick-and-mortar treatment centers, especially in northern New Hampshire

  • A more robust public awareness campaign about the Doorway

  • More long-term prevention initiatives

  • More statewide affordable housing options 

Entering the Doorway

“It really helps us (at Concord Hospital) because we are able to have a place to send for additional referrals or if a person needs more services such as housing,” said Monica Edgar, APRN, director of substance use services at the hospital. She is also a care provider at the CHOICES program, which is part of Riverbend Community Mental Health Center (both are spokes), and sits on the Governor’s Commission on Alcohol and Other Drugs.

“It’s been able to create this access,” she said, which is a big improvement over how it used to work. 

Before, if someone came into the hospital needing treatment, the front-line staff had to manually look up providers and hand out phone numbers, Edgar said. Now thanks to the Doorway, there is a coordinated assessment, tracking and referral system. 

Each Doorway assesses individuals, assigns a case manager and refers those who enter to a treatment provider. They are also responsible for tracking each person’s progress and reporting on it at intake, 6-months in, and at discharge. Should someone go directly to a treatment provider, that provider refers them to the Doorway to get the process started.  Providers have different types and levels of care, and the Doorway keeps track of those options and determines which are appropriate for each individual. 

“The Doorway program is great, but there is always work to be done to make it better in terms of workflow,” said Noel Cassen, manager of peer support and admissions coordinator at CHOICES in Concord. 

For example, a Doorway may make a couple of referrals and send the person where they can start treatment instead of being on a wait list. Sometimes a patient may then be referred elsewhere and that initial provider doesn’t always know what has happened.

However, Cassen said, the main point is that the person is in the system and is being treated. 

Need for more resources continues

Edgar understands the state had to move quickly to launch the Doorway system because the money came so quickly, but a shortage of qualified staff is a significant factor. “I’m down two counselors right now at the hospital. Staffing is a big piece for the Doorways.”

Denise Elwart, director of operations for Southeastern New Hampshire Alcohol & Drug Abuse Services in Dover, said there aren’t enough spokes in the system. 

“That’s where the big hang up is. It’s hard to find programs that have openings,” she said. “There’s not a lot of funding for brick and mortar – this (SOR grant) is short-term funding. “

Elwart commended Peter Fifield, program manager for the Doorway-Dover, for his work finding staff and launching the Doorway. 

“I know they weren’t given a lot of time to get it up and going,” she said. “Kudos to him. He’s done yeoman’s work getting it running.”

Overall, providers say regional Doorways have simplified the process which takes the burden off of emergency room staff and primary care providers because they just have to remember one number (the Doorway) for patient assessment and treatment.

“It’s been a great partnership. We’ve been able to make referrals back to the Doorway, and it’s nice to have that resource,” said Edgar. 

Tym Rourke, director of New Hampshire Tomorrow at the New Hampshire Charitable Foundation, is a member of the Governor’s Commission on Alcohol and Other Drugs, said thanks to the Doorways thousands of people have been able to find a place to go and ask for help in a more equitable way across the state .

And tracking where people go for help and what the services they need – even beyond treatment for opioid addiction - informs the state about what services are needed.  

“I’ve said all along that many people choose to leave their community of origin to find recovery. We never want to force a person to stay,” Rourke said. “We want to protect patient choice. But at the same time, how do we build effective services for those who don’t want to leave their community?”

Nancy Frank is CEO of the North Country Health Consortium that works with the Doorways in Littleton and Berlin. “What this has provided for us is another avenue for our community health workers. They are already working with the population that would access the Doorways, and now we receive referrals from them, and we provide referrals to the Doorway,” she said.

It is, Frank said, a challenge for those who are farther north in towns such as Colebrook because the closest Doorway is an hour away in Berlin. And while there are some transportation services through Tri-County Transit and others, and some Medicaid reimbursement, it can still be difficult to access a ride. 

Getting the word out

Additionally, awareness of the Doorway system among the public and even treatment providers is still lacking. Frank and other providers said any kind of marketing or promotional campaign was slow to get out. 

“I think I just recently saw something the state put out,” Frank said. 

She said she understands the program had to be launched quickly, but the promotional campaign wasn’t there. “In my opinion, I still think providers have no idea what it is or a lot of providers have heard of it but don’t know what it is.”

Rourke said DHHS and Doorways do deserve a lot of credit for getting the Doorway system up and running in three months.

“This (SOR funding) was the biggest amount of money the state has ever received in one fell swoop and they had three weeks to figure out how to spend it,” he said. “I’ve never seen anything like it.”

Rourke explained once the state was notified SOR funds were available, it had three weeks to submit an application saying what it would do with the funds. When the funds were received, the state had three months to get that money out into the community. 

Awareness and understanding of the Doorway and services available is critical not just for the providers but for individuals, businesses, and community organizations across the state.

 “There is nothing easy about this,” said Eric Spofford, CEO of Granite Recovery Center in Concord. “It’s good that after years and years we have the public’s attention. Nothing has gone perfectly but lots of people are finding help and getting treatment.” 

“It has certainly expanded the system of care, but this is a problem that took a very long time to get like this,” Spofford said. “We’re not going to fix this in a year or two or an election cycle. This is going to be over decades or generations.”

Edgar agreed, especially since New Hampshire has been “last” when it comes to treatment and prevention. 

“We are talking about chronic illness,” she said. “It’s not going to go away in ten years.”

Long-term investment is needed. The system of care in New Hampshire is still fragmented, and one of the biggest issues – Spofford calls it a bottleneck - is the waiting list for in-patient treatment beds. 

“We get 500 calls a month just from New Hampshire Medicaid patients (for in-patient beds). That’s just people from New Hampshire,” he said.

Those callers are referred to the Doorways for services, and Spofford said there are about 40 to 60 people a day on a waiting list. 

Granite Recovery Centers has nine drug rehab facilities across New Hampshire, including two in-patient residential programs. Spofford and others are working on solutions to increase inpatient treatment beds for people in need that have New Hampshire Medicaid.

One of the most significant issues providers face is not knowing if the federal funding, which is set to expire in September of 2020, will be renewed. Providers are hesitant to commit to invest in additional capacity such as expanding services or adding beds because of the funding for treatment is uncertain.  

The contracts related to funding the Doorway program are reliant on federal funding, and it is noted in the contact language that, “In the event that the Federal Funds become no longer available, (state) General Funds will not be requested to support this program.”

In November, an additional $2,111,500 was awarded through the State Opioid Response grant to provide crisis respite beds for men which fills a gap identified by the Doorways. Granite Recovery was awarded $1,003,570, which Spofford said will mean an additional 11 respite beds, and $1,107,750 was awarded to NH Respite LLC in Nashua for 12 respite beds. Other centers received an increase in the amount they received per day for Medicaid patient beds although it still doesn’t cover the whole cost.

And while the current investment in treatment is helping, Spofford said the state needs to do a much better job at prevention. Opioids became a problem in the late ‘90s, but only on the radar of the media and general population within the last five years.

“New Hampshire has very high addiction rates with very low rates for addiction treatment,” he said.

Beyond treatment: Is a self-sustaining system possible?

Sara Lutat, executive director of Dismas Home of NH in Manchester, said the three-year-old nonprofit does get some referrals from the Doorway. However, Dismas Home only serves women who have been in a substance-use disorder program while incarcerated and need additional treatment upon release.  

Dismas Home has six beds (soon to be eight) and provides several months of transitional programming after those 90 days. 

“We do have SOR funding, but it is only for opioid (addiction treatment),” she said. “There’s a whole big picture beyond just the addiction. There isn’t enough money to fund building the infrastructure that is needed.”

One of the biggest needs, Lutat said, is housing. The women she sees at Dismas Home have felony convictions, are recovering from underlying trauma, and compared to men usually only get low-paying jobs which isn’t enough to afford decent housing — even if it existed. Child care adds another challenge for this population.

“There are so many issues tied to this population,” she said. “They need a whole spectrum of services.”

Rourke agreed, “Grants, no matter how big, don’t hit the fundamentals like housing, transportation, and child care. The real question is how scalable the system is to meet the needs not just of people seeking recovery today but in the future.”

Frank expressed a need for more infrastructure in the Doorway such as agreements between the hubs and spokes. “It would be good to know who the spokes are and what services they are providing.” 

A list of all the providers is not readily available, or on the state’s Doorway website. 

“Any resources we can get are great,” Frank said, adding that even if the Doorway went away the relationships that have been built through this process would remain, and this is a benefit to her organization and other health workers. 

“It’s all about the relationships,” she said. 

This story was produced by The Granite State News Collaborative as part of its Granite Solutions reporting project. For more information visit www.collaborativenh.org. Follow us on Twitter @NewsGranite and like us on facebook @collaborativenh.

Follow the Money Part 1: The $64 million question

Editor’s Note:

In January The Granite State News Collaborative — a collective of  17 media and educational organizations from across New Hampshire — launched its Granite Solutions project. The goal was to take a look at the dual challenge of our statewide opioid crisis and its relationship to treatment of mental health issues. Working together as a team we have produced a series of multimedia story packages that do more than explore the problems; our aim is toward solutions. How? By working collaboratively to inform and engage you.  

Today we present the final installment off our Granite Solutions project: Follow the Money, in two parts. First, we examine the $64.5 million statewide Doorway system of referral and treatment for opioid addiction. We focus in on how the money’s been spent, what outcomes have been measured, and what’s next as the state considers how it will spend the second year of grant funding. In part 2 we look at Safe Station and whether it has potential to expand into a statewide solution. We will also hear from folks in recovery about what it’s like to use these systems.  

While this wraps up the Granite Solutions project, The Collaborative is nowhere near done with its work. Together, we will continue to deliver public-interest journalism and report on New Hampshire’s most seemingly-intractable challenges, with a focus on solutions. 

You can view our work on this series at collaborativenh.org and leave us your questions or feedback. Share our stories across your social media circles. Keep the conversation going.

By DAVE SOLOMON

Granite State News Collaborative

Since October of 2018, New Hampshire’s governor and Executive Council have approved contracts for more than $64.5 million in federal money to create the Doorway system of referral and treatment for opioid addiction. 

The state was awarded $45.6 million for 2019 and 2020 in State Opioid Response funding from the federal Substance Abuse and Mental Health Services Administration, and almost $12 million in additional funding for year one. (Click to View SOR Contracts)

Another $6.9 million for the Doorway came from federal sources not linked to the opioid response grant, as the state continues to struggle with one of the highest per-capita rates of opioid addiction and fatal overdoses nationwide.

In its final installment of a year-long examination of the project, the Granite State News Collaborative set out to determine where that money has gone and what it has accomplished. A year into the two-year program, reviews are mixed.

There is widespread agreement that the investment has created a group of regional portals for those seeking treatment, but has done little to expand the availability of the treatment itself, particularly in the northern part of the state, and particularly in regard to residential treatment.

Meanwhile, city officials in Manchester have criticized Gov. Chris Sununu and the Doorway for failing to significantly expand treatment services,  which they say made the city, where such services exist, a “dumping ground” for other hubs. Mayor Joyce Craig has expressed concern — echoed by the city’s Board of Aldermen — that without a meaningful evaluation of how the opioid response grant was leveraged in 2019, year two will end without a significant return on the federal government’s $64.5 million dollar investment.

The Doorways in Manchester and Nashua are run by Granite Pathways, an organization that recently had its state contract to operate a residential youth treatment center revoked, while its Doorway contracts are under review, according to the DHHS.

That’s not to say the effort has not had some impact. Narcan is more readily available throughout the state, as is medication assisted therapy (MAT).

But overdose emergency calls remain at historically high levels, and the state is not likely to see a significant reduction in opioid-related deaths at the end of 2019 compared to 2018, when 471 people died of drug overdoses (down from 490 the year before).

The Office of Chief Medical Examiner puts the death total from drugs for 2019 at 240 as of the middle of October, mostly from opiates, with 72 cases “pending toxicology reports.” They almost always come back positive, which puts the more likely number at 312, with half of October and all of November and December still to be accounted for.

“Of course we have a very long way to go. We are only 10 months into a new infrastructure system,” said Sununu in a telephone interview. “I don’t think we are going to see the number (of fatalities) lower by that much. One thing I’ve learned is the majority of pending toxicology reports will be positive. We’re making progress, but don’t expect us to cut our number in half.”

The deaths that have been averted since the launch of the Doorway are largely attributed to one of its most successful outcomes — the widespread availability of the overdose reversal drug Narcan.

The funding directed to the hubs includes money for Narcan administration. “The state used to distribute Narcan directly, but now with hub and spoke, the hubs are responsible for distribution to all area partners, and that Narcan is at no cost,” said Jarrett Stern, vice president for administration at Littleton Hospital, which operates its hub at a freestanding location off Main Street in Littleton.

Anecdotal evidence has convinced Stern and others that Narcan is only part of the story. “The Doorways have been open for 10 months now,” he said, “and in Littleton, we have 300 people in our program. As far as I’m concerned, that’s 300 people whose risk has gone down significantly. Why the total number of overdoses is still at or approaching levels of the past … I wish I had a better answer.”

In addition to the creation of the hubs and expanded access to Narcan, the increased availability of medication assisted therapy with drugs like Suboxone is cited as another success story for the Doorway by Health and Human Services Commissioner Jeffrey Meyers.

“We had very few funds before for MAT, other than some small appropriations from the general fund,” he said. “Now there’s tens of millions of dollars paying for MAT. That’s a relief to thousands of individuals.”

New Hampshire was 48 out of the 50 states in terms of MAT providers per capita, with as few as 10 to 12 providers statewide. With the additional funding and a push for more training, the number now has grown to 70, with more in the pipeline.

As our analysis of expenditures reveals, the state has invested heavily in MAT, with more than $5.5 million in contracts approved for MAT administration or training for the two-year period.

Not all hubs are created equal 

The largest portion of spending on the Doorway program, almost $24 million, went to standing up the nine hubs. 

 “It’s like running any clinic,” says Stern. “You have infrastructure, real estate, electric, phone, cable and internet … just running a space on a day-to-day basis. Then the biggest is staffing: a physician on MAT, licensed drug and alcohol abuse counselors running group therapy, intake and triage, and customer service, clerical, recovery coaches.”

In the Littleton and Androscoggin regions the availability of healthcare providers or counselors to serve as spokes is so limited that the North Country hubs, in addition to Narcan, also offer medication assisted therapy.

“We’re the hub and the spoke,” said Christine Fortin, specialty practice manager for the Doorways at Androscoggin Valley Hospital and Littleton Regional Healthcare.

“As a hub, we have the assessments and case management support staff the other hubs have, but we also have a therapist here full time, and a MAT provider four days a week.”

The Doorways are all affiliated with local hospitals, except in Nashua and Manchester. The vision for the program was to have hospitals lead the charge in every region, but the two hospitals in Nashua and two in Manchester all declined, without ever saying why.

With four of the largest hospitals unwilling to play a lead role in one of the most ambitious public health initiatives in New Hampshire history, the state turned  to Granite Pathways.

The New Hampshire subsidiary of a national federal contracting firm known as Fedcap has been jumping in where others fear to tread on behalf of the Department of Health and Human Services since 2016. That’s when Fedcap took over Granite Pathways, then a faltering peer support organization, as part of an effort to expand its footprint in New England.

In September of that year, the state awarded Granite Pathways a $1.2 million no-bid contract that was needed, according to state officials, to speed up the opening of what were then called regional diagnostic centers “to assist individuals with substance abuse disorder.”

Granite Pathways, operating out of the state’s two population centers, has drawn the largest chunk of Doorway funding directed to a single organization. In addition to its $5 million share of the $16 million initially allocated to the eight hub operators, Granite Pathways later was approved for an additional $90,000 as the “only organization in NH that provides residential treatment for youth diagnosed with opioid use disorder,” and another $1 million for “targeted prevention programming for DCYF involved families.”

More recently, Granite Pathways was approved for a $195,234 contract to provide “workforce readiness and vocational training programs for individuals with opioid use disorder.”

The organization in late November lost its contract to provide residential treatment for youth diagnosed with opioid use disorder, after reports of drug use and overdoses among patients.

“A 30-day review on all contracts the state has with Granite Pathways is underway and additional actions may be necessary based on that review,” according to DHHS spokesperson Jake Leon.

Granite Pathways and Dartmouth Hitchcock, by far the largest recipients of opioid response funds at more than $6 million each, were the only two hub operators who declined to be interviewed for this report, referring questions to DHHS.

The treatment gap

Patricia Reed, the state director of Granite Pathways, provided a written statement, in which she confirmed many of the observations made by the smaller hub operators.

 “Individuals come to the Doorway at their worst and receive initial services in a supportive and non-judgmental environment,” she wrote. “At the same time, implementation of the Doorway system has revealed other system gaps that must be addressed to truly solve this public health crisis. 

“As expressed by one Doorway director ‘We do a great job assessing people and figuring out what they need — and then we wait’ largely due to wait lists for residential treatment or safe respite beds.”

According to all hub operators, the wait times for residential treatment, about two weeks or more, have not improved in the year the program has been in operation, despite more than $16 million in contracts for residential treatment.

The Doorway has drawn more people to seek treatment, without a significant increase in certain treatment options.

“If I am going to positively reinforce an individual’s behavior, there has to be something more than the first step,” said Peter Fifield, hub coordinator for the Seacoast region out of Dover.  “There has to be the second, third and fourth. The state is open to hearing this and we now have to build more spokes.”

There has been some progress in expanding treatment options, although most of it has taken place in the south and central part of the state. More than $6 million has been poured into recovery services. One example, a $1.4 million contract with Harbor Homes, based in Nashua, to serve pregnant women and parents with young children in recovery.

Harbor Homes was already providing these services in Tilton, Portsmouth and Dover under a previous $515,198 contract, and is using the additional funding to expand to three other locations.

But the demand for services is growing faster than expansion can accommodate.

“There’s been improvement from years past,” said Fifield. “We are making strides forward and are at capacity that could have met historic needs, but not new needs.”

Access times at issue

The Doorway’s promise of 24/7 access to referral and assessment rolled out with an official “Anyone, Anytime can ask for treatment” campaign has been misinterpreted as a promise of ‘round-the-clock access to treatment.

“I don’t think they promised treatment; they promised a place you can go for referral for treatment, and I don’t even know if that’s realistic,” said Keith Howard, executive director of Hope for New Hampshire Recovery, a peer-based recovery and support organization that operates in Manchester and Berlin.

Howard and his team work face-to-face with people in addiction crisis every day, and the feedback they get on the Doorway has been less than encouraging. 

“The experience folks have had has not lived up to the hype or the promise,” he said, referring to the Manchester Doorway in particular. “People who are working there have nothing but good intentions, but there are systemic problems in terms of getting folks into treatment right away. There is no place to send them, and if there is, there’s a long waiting period.”

The problem with addiction, says Howard, is that once the crisis forcing someone to seek help has abated, “Most of us in addiction think we really don’t have to quit after all,” amplifying the need for immediate intervention.

Sarah Gagnon, vice president of clinical operations at Riverbend Community Health Center, believes expectations may exceed what is realistically possible when it comes to 24/7 access.

In addition to its $1.5 million share of the $16.6 million hub-setup fund, Dartmouth-Hitchcock got another $2.5 million after it reached an agreement with the other hubs to provide 211 clinical coverage off-hours, on holidays and on weekends.

“Anyone dialing 211 after hours, Dartmouth-Hitchcock will answer. So someone is still able to speak to a clinician at any time,” Gagnon said. “We’ve talked a lot about what it would mean to go 24/7 (at all hubs), but the fact remains, if someone calls or walks into a doorway, even with 24/7 coverage, there are no facilities taking admissions at 2 a.m.”

Marketing campaign

Despite the investment of state and federal resources, and regular reports on the initiative in print, broadcast and digital media, many of those directly or indirectly touched by the addiction crisis claim to be unaware of the Doorway.

The state increased an existing $3.4 million contract with JSI Research & Training by $1.4 million  to include restarting the Anyone/Anytime public advertising campaign, which was rebranded as the Doorway once the system was launched. The work on advertising, social media, etc, falls under this contract.

A $200,000 contract was awarded to Portland Webworks (winner of three bids submitted) to develop, design, implement, host and manage a consolidated website for the initiative .

“I think our marketing has been good,” said Gagnon. “We are on the TV news, radio, there are fliers everywhere urging people to call 211.”

While the fire station-based Safe Station programs in Nashua and Manchester continue to serve large numbers of people in addiction crisis, the Doorway has been the go-to option for friends and family, according to Gagnon.

“Word of mouth is definitely a big thing and people are calling to get resources for people they care about. Up to half of our calls are friends and family,” she said.
Whatever marketing has been done has had some effe

ct. In its original SAMHSA grant application, the state predicted the Doorway would serve 5,000 clients per year, a prediction that was surpassed as of Oct. 31, the most recent report on the Doorway website.

The report states that 5,910 individuals were seen in person or assisted by telephone. As of Oct. 31, hubs conducted 2,645 clinical evaluations and provided 4,091 individuals with treatment referrals. What happens after those referrals is not well-documented, although the Doorway program is required by federal law to report on the status of its clients at intake, six months and discharge – at least for the clients it can keep track of.

Future of funding

As the project moves into the second year, the state will be focused on adding more beds for respite and residential treatment, as well as services to keep individuals who’ve detoxed from sliding back into drug use. Those include transitional housing, ongoing therapy and one of Sununu’s favorites, the recovery-friendly workplace.

The Executive Council approved only $613,096 in contracts for transitional housing in the first year of the program.

Expanding treatment options will require more providers, which has proven to be the highest hurdle. “The biggest barrier we have is workforce,” said Sununu. “It isn’t that we don’t have the money or that it isn’t going to the right places. It’s hiring the people we need.”

Health care providers in the addiction field are hard to come by, and much of their work is paid for through Medicaid. New Hampshire, with some of the lowest Medicaid reimbursement rates in the nation, has been at a disadvantage with neighboring New England states when it comes to recruiting providers from a dwindling pool.

Last year the state increased Medicaid payments for medical detox services and will be increasing Medicaid payment rates across the board by 3.1 percent in fiscal years 2020 and 2021.

“Is that going to solve every gap in every corner of the state? No. But it’s moving in the right direction,” said Meyers. “We’ve added money now three years in a row.”

Meyers will soon leave DHHS and hand the project off to his successor, but he’s confident the state will continue to receive federal funds, given the scope of the crisis in the Granite State and the need to create national models for best practices.

“I don’t think it’s a question of whether we’re going to get more funds,” said Meyers. “I think it’s a question of what we are going to get and how much flexibility we’ll get to use the funds in New Hampshire.”

Next Sunday, we will conclude our two part series with a look at Safe Station and whether it has  potential to be a statewide solution. We will also hear from folks in recovery about what it is like to use these systems.

 This story was produced by The Granite State News Collaborative as part of its Granite Solutions reporting project. For more information visit www.collaborativenh.org. Follow us on Twitter @NewsGranite and like us on facebook @collaborativenh.


Two Roads Diverged: Reconnecting substance abuse disorder and mental health

By Melanie Plenda

Project Editor

Granite State News Collaborative

Zachary Brewster was 12 years old when he started smoking pot. By 15, he and his friends were sharing prescription pain killers. By 17, he was sent to therapy. He told his psychiatrist he was getting high every day before school —that he was high all the time, in fact —and had a problem.

The counselor diagnosed him with ADHD and prescribed Adderall.

“He asked me, do you have trouble paying attention in school and I’m thinking to myself, ‘I go to school high every day, of course I do,” said Brewster, now 32, of Hooksett. “And so, that’s where it happened.”

That was his first exposure to stimulants and what it felt like to be “sped up,” Brewster said.  The Adderall made him superhuman. Suddenly he could stay up all night, go school, go to practice, get straight As

“But the thing was I started abusing it right off the rip,” Brewster said. “And I knew how to manipulate [the therapist] and I thought, ‘Ooh this stuff is great. It keeps me awake and amped and now I can use pot and really not get tired from it.’”

Brewster graduated high school and went to college where he graduated to cocaine. That line led to smoking crack and eventually heroin.

“I didn’t have any depression problems or misbehavior issues or anxiety issues really,” Brewster said. “But after going through several years of drug addiction, everybody wanted to diagnose me with x, y and z as far as mental health disorders and they wanted to treat that, but were very cautious in diagnosing me with substance abuse.”

Brewster had a mental health disorder, for sure, but not one any of his counselors or physical medical professionals diagnosed.

“You look in the diagnostic manual for mental health disorders and they all revolve around: Is it affecting me in my personal relationships with others? Is it preventing me from going to work or school? Is it preventing me from basically functioning as a human being?” Brewster said. “All of the above were for me.”

After nearly 15 years of active addiction, Brewster has been sober since 2013 and is a Biological Sciences major at UNH Manchester. He’s hoping to graduate in the spring and head to medical school. He also works full time as a counselor at Teen Challenge, a 15-month, residential rehab center in Manchester and the place he credits with changing his life. He said he’s not sure that getting an accurate diagnosis earlier would have necessarily changed his path, but it could have shortened it.

The reticence or even inability to see and treat substance abuse as a mental health issue is not unique to Brewster’s situation — it’s actually very common, according to Peter J. Evers, Chief Executive Officer of Riverbend Community Mental Health Inc.

“The lack of education — and this happens in primary care offices —- around a lot of behavioral health disorders being a disease; and the lack of education, even sometimes from mental health counselors, to see where addictive behavior fits in with the overall clinical impression, is prevalent,” said Evers, “We need to have cross-training both in physical — primary care — mental health and substance abuse disorder, because if we don’t, we miss.”

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), most people only receive care for one disorder while the others remain untreated. In 2017, they found that about half of the adults with co-occurring substance use disorder and mental health issues did not receive either mental health care or specialty substance use treatment in the previous year, and about one in three adults with both co-occurring disorders did not receive either type of care.

The lack of appropriate diagnosis and care can be dangerous.

“The consequences of undiagnosed, untreated, or undertreated co-occurring disorders,” according to SAMSHA, “can lead to a higher likelihood of experiencing homelessness, incarceration, medical illnesses, suicide, or even early death.”

The connection between mental illness and substance abuse has been known and recognized for decades but there are still barriers to patients getting comprehensive care. Local experts say the shift is happening, albeit slowly in New Hampshire.

Why does this happen?

In 2017, about 29.3 percent of kids aged 12 to 17 who used illicit drugs also had a major depressive episode in the previous year. Similar trends are found among adults. Among the 18.7 million adults with a substance abuse disorder in 2017, according to SAMSHA, 8.5 million — or 45.6 percent — also had a mental illness in the previous year.

“People with mental health disorders are more likely than people without mental health disorders to experience an alcohol or substance use disorder,” according to SAMSHA. “Co-occurring disorders can be difficult to diagnose due to the complexity of symptoms, as both may vary in severity.”

Although the concept has been around since at least the mid-1990s, for a variety of reasons, the public, practitioners, and treatment models have been slow to reflect the notion that these are often interlinking diseases of the brain that can be successfully treated.

This lack of understanding happens for a variety of reasons, including the fact that behavioral health issues can result from a mix of biological, psychological, and social factors.

“The parts of the brain connected around the chemical imbalances in depression and schizophrenia as well are also connected to the likelihood to succumb to addiction,” said Evers. “When I say that, I mean to actually develop an addiction rather than be able to use substances in a recreational way — in a way most people do. So yes, they are incredibly connected.”

Further, the symptoms are not easy to distinguish from one another.

Jacqui Abikoff, executive director of Horizons Counseling Center in Gilford, explains it this way: when substance use disorders are active, they can mimic symptoms of mental illness. They can also trigger symptoms of mental illness or  mask the presence of a legitimate mental illness that causes a patient to self-medicate through substance abuse.

And, there comes a point in the process of misusing a substance that, regardless of how it started, the addiction takes on a life of its own and becomes its own diagnosable disorder.

When a patient finally reaches out to get help, they are left at the mercy of the service they choose.

“One of the problems is that traditionally that we have siloed the services for substance use disorders and mental health disorders,” Abikoff said. “And because of that, depending on which door you walked into, you would be looked at from the perspective of that service rather than as the whole person.”

In addition to a lack of cross-training of practitioners, stigma still plays a huge role . Fear of how others will see them can keep a patient from coming forward and being honest about the symptoms they are experiencing.

“We stigmatize mental illness in this country,” Abikoff said. “We see them as less-than the general population.

“When you talk about people with substance abuse disorders, we stigmatize them even more because we see them as people who caused their own problems … It’s the idea that if you’re mentally ill, you couldn’t help it; [but]if you have a substance use disorder, you shouldn’t have used in the first place.”

Even practitioners have their own subtle biases, Evers said.

“[W]e hire peer-support specialists both on the mental health side and the substance use disorder side and there is stigma between those two groups,” Evers said. “They can get somewhat judge-y with each other sometimes … these are people who’ve been through a training that says, ‘These are diseases of the mind,’ and … they aren’t personal choices. But it’s so deeply rooted in our history that people who are crazy are a danger to society and people who use substances have a characterological weakness.”

Changing Minds

Evers said the field should recognize that the treatments for both diseases are very similar. He said this was something psychiatrist Ken Minkoff, an expert in dual diagnosis, recognized in the 1990s and it still holds true today.

“[H]e said, ‘Look at the similarities between the treatments,’” Evers said. “This is all about being strength-based, being individual-based, meeting people where they are at in terms of their addiction and their depression, and supporting them through that with peers, with medications and individual therapy.

“And really there’s not too much difference between treating addiction and treating mental health.”

Abikoff would like to change the way communities talk about substance abuse disorders. She pointed out that while we talk about sleeplessness, lack of energy, and change in appetite as symptoms of depression, we don’t often refer to the use of marijuana, methamphetamine or fentanyl as symptoms of a problem — we see it instead as a behavior.

If these “behaviors” were instead treated as symptoms of a substance abuse disorder, more people could be properly diagnosed and treated.

Ultimately, Evers said, the key to treating these illnesses together is more cross- education and training among the professions and an integration of care.

“If you don’t integrate, you fail,” [W]e [need] the patient or the client at the center of the puzzle so that they feel that they are the expert in their own recovery and that the addiction specialist and the mental health specialist and the primary care specialist are all on the same page. That way you get the best outcomes ….”

Are we there yet?

New Hampshire is on the road to better, more integrated treatment for substance abuse disorders in the context of mental health but the changes are a big lift, Evers said.

That said, there are some glimmers of hope.

For example, Evers said community health centers across the state are in the process of applying for Section 1115 Medicaid Demonstration Behavioral Health Waivers. This is a waiver that allows practitioners to use federal funds on treatments not typically allowed under the provisions of Medicaid.

According to the Kaiser Family Foundation, this waiver will allow states to use Medicaid funds to pay for substance use and/or mental health services in “institutions for mental disease; will expand community-based behavioral health benefits; expand Medicaid eligibility to cover additional people with behavioral health needs; and finance delivery system reforms, such as physical and behavioral health integration or alternative payment models.

Riverbend, for example, could put behavioral health clinicians in primary care practices so that doctors are supported, Evers said. The organization could provide provide psych consultation to the primary care providers and ask primary care providers and psychiatric providers to apply for waivers in order to be able to prescribe Buprenorphine — the standard of care for outpatient opioid detox.

“All of these things are integration,” Evers said. “In some ways, all of the community mental health centers are doing this, because they’ve all been pulled into this 1115 waiver, but it’s on a very small scale.”

“… [W]e’re making an effort and we’re trying to show this is the way to go forward but really there hasn’t been a wholesale … allocation of funds towards value-based care yet — that comes in a few years I’d bet.”

And despite the small amount of money the waiver would provide, it has the potential to generate outcomes that show this method of care is better for the overall health of the patient. Then, Evers said,  “that’s sort of irresistible to insurance companies and the federal government who say, ‘Oh yeah there has to be a different way of providing healthcare other than just generating encounters of care and then not measuring anything.’”

However, Abikoff said that integrated care is still a ways off

“[W]e’re not there yet,” she said. “Not enough of our workforce is trained in the nuances of truly integrated care.

As for Zachary Brewster, he’s hoping that his minor in psychology and his experience with addiction and recovery will make him a better doctor someday.

“You may have someone in there that you are treating as a primary care doc for diabetes, yet they’re already diagnosed with anxiety or depression,” he said. “So, having a knowledge of that background and having a level of empathy for that kind of thing, makes you a better provider.

“I think the more well-rounded and balanced you can be, the better you are at caring for another human life. At the bare essentials of it, that’s what medicine is and it’s a very, very high calling.”

[This story was produced by The Granite State News Collaborative as part of its Granite Solutions reporting project. For more information visit www.collaborativenh.org.]













A journey through NH's mental health system

By Roger Carroll, Laconia Daily Sun

Part 1 -- Emergency Room 

It was the week before Thanksgiving and my world had changed from that of a working journalist with the freedom to come and go as I pleased to being held in a locked psychiatric facility where staff checked on me every 15 minutes to make sure I was OK.

“Are you here voluntarily?” one of the other patients asked warily.

I was, but I wasn't free to leave.

Read the full story and view video at our partner outlet The Laconia Daily Sun

From Abstinence to Harm Reduction Advocates Say Medication Assisted Treatment for Substance Abuse is Saving Lives

Those suffering from asthma, diabetes and heart disease can pick up medications to treat their chronic conditions at any number of pharmacies — without stigma. Yet, those with substance use disorder, another chronic condition, are treated differently even in accessing their medications.

“To have to go to an identified location every day to get medication for your chronic illness is just discriminatory on its face,” said Kevin Irwin, director of operations for the Seacoast-area Integrated Delivery Network, speaking specifically of methadone clinics that dispense a synthetic opioid as part of medication assisted treatment (MAT) for those addicted to opioids.

“Lots of people receive medications for chronic illnesses, whether it’s for a month or it’s for a lifetime or any time in between,” Irwin continues, “and we would never make people do that for their depression medication, for their diabetes medication, for their tobacco patch. Right? We would never make people do that.”

Irwin leads one of several regional networks, or IDNs, which aim to improve care transitions between providers, promote integrated physical and behavioral health as well as build mental health and substance use disorder treatment capacity. His work has led him to advocate for easier access to MAT services.

“It’s fundamentally discriminatory and in as much as it is discriminatory, it has a lot of built-in limitations,” he said.  “A lot of people can’t, or don’t want to, or aren’t able to do that. Who the hell would want to?”

Methadone is not the only medication assisted treatment available in New Hampshire. In fact, methadone clinics are relatively rare in New Hampshire —there are only about a dozen throughout the state — because of the high regulatory hurdles that need to be cleared to start and maintain one.

Providers who have been authorized by the federal government, such as doctors, nurse practitioners and physician assistants, can also prescribe buprenorphine and naltrexone. The process for getting this medication requires weekly check-ins at first to refill the prescription. These visits are reduced as the patient stabilizes and ideally continues with treatment. But access to this therapy, and specifically to providers offering it, isn’t always easy to come by.

And access is critical to the $45 million hub and spoke opioid treatment model rolled out by the state earlier this year — the success of similar models historically relies heavily on MAT and easy access to it.Read the whole story at partner outlet NH Bar News

After years of neglect state seeks to restore mental health services

Once ranked among the nation’s best, New Hampshire’s mental healthcare system has steadily eroded since the turn of the century, and grown more distressed in the past decade as the demand for mental health services has far outrun the capacity to provide them.

In January, the NH Department of Health and Human Services released a 10-year plan to restore the system — the third of its kind in the past decade. The plan proposes an initial investment of $21.7 million in the next biennium to jump-start the process.

In his budget address, Gov. Chris Sununu said, “We’re not going to slow-roll this plan over 10 years,” adding that with budgeted funds and executive actions, two-thirds of the recommendations will be addressed immediately. He acknowledged that “these efforts will not fix the system overnight,” but expressed confidence that New Hampshire would once again “set the gold standard for the rest of the nation.”

Read more in our partner publication The Laconia Daily Sun