Doorways of Nashua. Image/Southern NH Health Facebook
Part 1 of a two-part series
RELATED STORY ⇒ Getting on-site clinician for Manchester Doorway a priority
By the time Nicholas Bickford sought help for addiction in Manchester two years ago, he said he had suffered about 12 overdoses over decades of addiction. He had been through several rehab programs and in and out of probation and parole.
“I finally had had enough,” he said. “I took every suggestion. And it just started clicking,” he said. Like so many, his addiction began with painkillers and led to illicit drugs, including heroin.
This July, Bickford marked two years of sobriety and graduated from the state’s drug court program, which provides an alternative to prison. He is no longer on probation and recently bought a truck after restoring his credit; he’s a self-employed carpenter with many plans.
As Bickford tells it, timing was also key to his progress. When he was ready to change, he received the level of care he needed. He was placed in respite housing, which provides temporary shelter for those awaiting treatment, until a spot opened up in an intensive inpatient program. Next, he entered a 90-day residential program called Turning Point, run by Southeastern New Hampshire Services in Dover. In the past, he’d come to expect delays. “I’d wait a couple of days and then I couldn’t take it any more and I’d relapse. And then I’d be on another run,” he said.
Turning Point is among many programs that receive funding through a federal State Opioid Response (SOR) grant. Even with federal money, however, the program, which provides support while people transition back into the community, has struggled. “Ultimately we get by because we get a lot of donations. We can’t break even without having community support,” said executive director Denise Elwart. Hiring staff at all levels has been difficult. The program has been unable to compete even with certain service jobs that pay more, she said.
Some of the largest amounts in SOR grants have gone to Doorways around the state that serve as entry points to a network of services. These nine sites serve as “hubs,” which provide a range of services, such as crisis stabilization, as well as referrals to various treatment and recovery programs – the so-called “spokes” of a hub-and-spoke system of addiction treatment.
The federally funded statewide initiative was established in 2019 to address the opioid addiction crisis. The total awarded amount for SOR to NH to date is $114,231,915.00. Another SOR grant was announced recently – this one for $28.5 million, an increase of $400,000 over last year, according to the state’s Congressional delegation.
Meanwhile, the addiction problem has worsened both nationally and statewide. The federal government estimates more than 100,000 people died from drug overdoses in 2021, the highest number of annual overdose deaths ever recorded. The vast majority of those deaths involved opioids. From March 2021 to March 2022, overdose deaths in New Hampshire increased by an estimated 26 percent, according to the National Center for Health Statistics. (This provisional data is based on available records and may not include all deaths that occurred during a particular time period.)
As of June, according to the Chief Medical Examiner of New Hampshire, there were 230 overdose deaths, with fentanyl a factor in 125 or those cases. Opioid-related emergency department visits increased by about 20% from April to May of this year, according to the New Hampshire Drug Monitoring Initiative.
In the state’s two largest cities, Manchester and Nashua, there were 84 suspected opioid overdoses during August, according to the American Medical Response Ambulance Service. Preliminary data shows Nashua experienced 32 suspected opioid-related deaths through August, compared with 30 suspected opioid-related deaths during all of 2021. Nashua was on pace to have the highest number of suspected deaths from opioids in a one-year period since the epidemic began in 2015, according to AMR, and Manchester was on pace to have the highest number of suspected opioid-related deaths in a one-year period since 2017.Chris Stawasz, regional director for American Medical Response. Courtesy Photo
Chris Stawasz, AMR regional director, said the trend is “singularly” related to fentanyl, the highly potent synthetic opioid. “What we are seeing is people unwittingly consuming fentanyl,” he said. State officials recently issued warnings about an increase in drug overdoses, with fentanyl increasingly found in drugs unrelated to opioids, such as cocaine and marijuana.
Repeat encounters typically account for about half of AMR’s visits, according to Stawasz. “Sadly that is indicative of the disease of addiction,” he said. “It’s a lifelong challenge people have to struggle with.”
These visits also raise questions about why many repeatedly end up in emergency rooms, despite having access to the Doorway network. According to several people involved in addiction services in the state, the hub-and-spoke system has made strides, but challenges persist, including a shortage of drug and alcohol counselors, bureaucratic hurdles, and difficulties accessing certain intensive inpatient and medical detoxification programs. In some instances, Doorways have come up with stopgap measures to try to keep people on the path to recovery.
The Sobriety Window
The moment a person seeks help for addiction can be fleeting, a fast-closing window, as Kimberly Ducharme describes it. A drug and alcohol counselor based in Nashua, Ducharme’s private practice includes referrals from the Doorway program. She said she works ten-hour days and sometimes beyond that when clients are in crisis.“There are not enough providers,” Ducharme said. “A lot of us have wait lists,” she said. “We have a very big caseload.” (An upcoming story will focus on workforce issues, including the divide between mental health and substance use disorder treatment.)
Medical detox – the first stage of treatment when a patient takes medication in a clinical setting to manage acute withdrawal symptoms – is often necessary before entering inpatient programs. Although considered a requirement for alcohol addiction due to life-threatening effects of alcohol withdrawal, medically managed detox can also help with opioid withdrawal, which can be excruciating, according to Kristin Makara, director of the Nashua Doorway.
“If someone is feeling they’re going to die, they have a high risk of using, which of course right there is a risk of death in and of itself, “ she said. “So while it’s not medically required, certainly they could benefit from being in a medically monitored setting – whether it’s having comfort medication to help with the various symptoms, and, also, some programs use Suboxone taper to help someone withdraw more comfortably.”
For Nicholas Bickford, Suboxone made detoxification “bearable,” he said. “It helped calm my brain,” he said. “So I could concentrate on worrying about staying clean.”
But medical detox has been a particularly hard prescription to fill, often involving weeks of waiting, Ducharme said. “That’s very discouraging because that short window of time when they’re looking for sobriety closes while they’re waiting,” she said. “Some of these substances people are addicted to, they really need to be monitored by a medical provider.”
‘Where do they go?’
The state has been tracking Doorway activity since 2019. In the first quarter of 2019, 1409 people (those seeking help for themselves or for friends and family) were served from January to March, compared with 2,900 for the first three months of 2022. State numbers show that, all told, about 32,876 contacts have been made since the program’s inception. Most clients were seen for opioid-related reasons. (The number may include duplicates if individuals visit more than one Doorway.)
Shanna Large-Reusch, director of Substance Use Disorders at Riverbend Community Mental Health, oversees the Concord Doorway and Riverbend’s intensive outpatient treatment program. “The Doorway was founded on getting people at the moment they decide to get into treatment,” Large-Reusch said. “And yes, now we have them, that’s great, but where do they go? So we have found that we need to create more because there might not be a place for them to go for a while.”
Large-Reusch said there’s a need for more inpatient services for people who require intensive care, as well as programs for those who are further along on the road to recovery but need community support. These are, in a sense, on opposite ends of the continuum of care. The Concord Doorway meanwhile has found ways to help those who might otherwise fall through the cracks, including an expanded recovery skills support group, she said. The Concord Doorway also provides “bridge therapy” for those waiting to see an outpatient counselor – another way to stay connected during crucial periods when people are open to receiving help. Several Doorways, including Nashua’s, provide “bridge therapy.”
(To help address the need for more inpatient care, the Department of Health and Human Services has proposed using $15 million in federal funds to help build a new behavioral health hospital. Under the plan, SolutionHealth – which includes Elliot Hospital in Manchester and Southern New Hampshire Medical Center in Nashua – would build a 130-bed facility for children and adults with mental health and substance use disorders.)
Even when higher levels of care are available, however, people needing those services are sometimes unwilling to participate, Large-Reusch said. “You could do more, but they don’t want to, and they have a job or they have kids or they just don’t have that willingness to devote that time it takes,” she said. In these cases, too, staff find ways to stay connected. “So there are eyes on them,” she said.
‘Got to get it right’
”I think the biggest problem with the Doorway is that people aren’t being sent to the level of care that they’re assessed for, so, due to various reasons, people are going to a lower level of care than what is recommended by the person doing the evaluations,” said Jessie Hurlbert, executive director of Chucky’s Fight, a nonprofit organization on the Seacoast that offers recovery and prevention education, as well as recovery support and advocacy on substance use disorder issues.
If people requiring more intensive treatment prematurely end up in settings with less supervision and support than they need, they can end up relapsing, said Hurlbert, who is herself in recovery and recently earned a master of social work degree. She has called for more oversight on the part of the state to ensure people are getting the level and quality of care they need. (In response to a recent federal audit, the state outlined some plans for strengthening oversight, including a clinical audit of Opioid Treatment Programs by the Bureau of Drug and Alcohol Services.)
“If we want to actually reduce the loss of life, we need to take a closer look at treatment and how we’re navigating that,” she said. “If it’s your loved one, you might only have one shot to make the treatment stick. They may not ever try again. So we’ve got to get it right.”
Hurlbert has high praise for Doorway staff. “The majority of people in all these positions are great people working really hard at making a difference. But they can only do so much with lack of resources and lack of structure around who is holding people accountable.”
The pandemic also posed a challenge when it comes to inpatient or residency programs, given its impact on staff and contagion concerns about congregate living.
Southeastern New Hampshire Services closed its inpatient program after a COVID outbreak among staff, according to executive director Denise Elwart. “We basically had to be almost completely shut down for two weeks, and then at that point we ran out of funds to bring the 28-day program back,” she said.
Elwart said getting people into treatment expeditiously can be a challenge for the Doorways, in part because it can take several days to complete a full assessment, which can include a physical exam, a COVID test, and insurance pre-authorization. “All of that just takes a couple of days, and sometimes we lose them in that couple of days,” she said.
In addition, facilities accredited by the Commission on Accreditation of Rehabilitation Facilities must do their own assessments, separate from the Doorway, Elwart said. Shanna Large-Reusch also said various types of paperwork can cause delays.. “Why are we making things so difficult? I get it – that things need to be done. But is there a way for all of us to work together to streamline these things?”
For Hurlbert, another concern is that Doorway locations are only open 8 a.m. to 5 p.m., Monday through Friday, while addiction is a 24/7 affliction. The 2-1-1 phone service is available any time day or night for immediate help, but Hurlbert said it was a mistake to close the Safe Station program established in 2016 by Manchester firefighters to provide 24-hour help for addiction. Although the program officially ended after the Doorway became established, people still show up at Manchester fire stations seeking help, according to data provided by the state. (See CMC sidebar for more on the role of Safe Stations.)
“If someone decides they want to go to treatment at 11 p.m., they should be able to do that,” said Nicholas Bickford. He said he walked into a Manchester fire station two years ago before ending up in respite housing in Nashua. In Nashua, Bickford was connected to the Nashua Doorway, which arranged to have him driven to an inpatient program.
More Doorway hours would present staffing challenges, however, for programs already struggling to fill positions, suggested Large-Reusch, who said the state’s 2-1-1 service has helped fill the gap. “They cover weekends and holidays. I think it works fairly well.”
Still, it is not easy to place someone in treatment over the weekend, according to Kristin Makara of the Nashua Doorway. “Some programs do admit over the weekend, but not many, so there is a respite to go to.”
Dr. Luke Archibald is psychiatrist and director of Addiction Services at the Dartmouth Hitchcock Medical Center, which runs the Lebanon Doorway and handles 2-1-1 calls from all parts of the state.
“Anybody can call 211 anytime and get connected to at least start the process,” he said. In addition, Doorway sites provide easy-to-identify points of entry, he said, and anyone can seek treatment anywhere in the system. He has also found that people are more likely to receive the level of care they need than when he first arrived in the state in late 2018.
“The system doesn’t always work perfectly, and a certain level of care isn’t going to be immediately available – and in many cases we’re not going to solve the problem of limited safe, affordable housing and a lot of these deeper issues – but I think it’s done well for when people find that they have that moment of insight where they’re reaching out for help to be able to access that by calling or walking in.”
And because that moment can be transitory, he said, “The sooner you can take advantage of that the better. It’s not always possible, but if you can at least get the process going and offer some hope that that level of care is on the horizon, that can go a long way.”
The Lebanon Doorway, which serves Grafton County and part of Sullivan County, can also access Dartmouth Hitchcock’s intensive outpatient treatment and individual therapy services.Shawn LaFrance seen here discussing the state’s hub and spoke model at a public forum in 2019. Photo/Liora Engel-Smith
Among areas for improvement, according to Archibald: more transportation options to help deliver people to treatment programs around the state. This is a particular challenge in rural areas.
The Doorway at the Cheshire Medical Center in Keene had been sending patients as far away as Laconia for Medication Assisted Treatment, before applying for a grant through the N.H. Bureau of Alcohol and Drug Services to establish its own MAT program.
“What we found was that the waiting times were longer and longer. We had more people and fewer places to send them. And so it made sense that we had to change our model a little bit to add that opportunity to get people started,” said Shawn LaFrance, Vice President for Population Health at Cheshire Medical Center. The MAT program has been in place since early 2021. “That’s helped the patients a lot because we’re not putting people in cars for a long time, ” he said.
Archibald also sees a need for greater supplies of Naloxone, or Narcan, the overdose reversal drug. According to state data, 4,676 Naloxone kits were distributed in the first three months of this year, compared with 214 kits handed out during the first quarter of 2019, when the state began tracking Doorway activity.
Kristin Makara of the Nashua Doorway said Narcan has made a big difference. “We go out every day for the most part during the week to try to connect with people within the community and offer them Narcan. We give them information and resources,” she said. “We also go out and train whoever wants training on how to use Narcan, whether it’s a business, a school. We offer it to the library and other treatment programs.”
According to AMR reports, Narcan use appears to have made real inroads. In June, about 31% of AMR arrivals were preceded by a member of the public administering Narcan.
Chris Stawasz of AMR, meanwhile, continues to sound the alarm about the addiction crisis: “I think it’s important we keep it in the forefront because if we don’t people will continue to die. And that’s just not right.”
And Nicholas Bickford has some advice for anyone struggling with addiction: “No matter how many times you’ve relapsed, or no matter how bad it can get, you can always stop. One day at a time, just don’t give up. Hang on until the miracle happens. Even if it’s white knuckle, just hang on, and it gets easier every day.“
These articles are being shared by partners in The Granite State News Collaborative. For more information visit collaborativenh.org.
Waiting for Care: Addiction Providers Grapple With Persistent Delays and Gaps
(A federal audit released in June by the Office of Inspector General of the U.S. Dept. of Health and Human Services found the state of New Hampshire had improperly claimed at least $7.9 million in Federal Medicaid reimbursement for Opioid Treatment Program (OTP) services during the period covering July 1, 2016 through June 30, 2019.
Among the shortfalls described in the audit: In 93 out of 100 OTP services, patients did not receive the required number of hours of counseling for methadone maintenance; methadone is among several medications approved for Medication Assisted Treatment to help addicted people kick opioids. The audit also found the state did not adequately monitor providers to ensure that they complied with federal and state requirements.
In response, the state agreed to refund $7.9 million and pointed to recent efforts to correct the problems, including training on adequately documenting counseling services, and addressing workforce challenges it described as “not unique” to New Hampshire.)