A 21-year-old woman recently entered a Central New Jersey hospital emergency department seeking admission to an inpatient treatment program for her heroin addiction, recalled Bruce Bonanno, the emergency doctor who treated her.
She was successful only because “She said the magic words, ‘If I don’t get in I want to kill myself,’ ” Bonanno said. The state has a shortage of inpatient treatment beds and prioritizes those patients who are a threat to themselves and others.
Roseanne Scotti, state director of the Drug Policy Alliance, recalled one resident who died from an overdose while on a waiting list for treatment, and another whose overdose death followed shortly after being released from a treatment program (the patient said he knew the release was too soon).
With the rise of heroin addiction and the requirement of the ACA to treat mental-health services on par with other health services, an already inadequate system is being overloaded by a number of stressors. They range from the lack of inpatient beds, availability of outpatient services, inconsistent modes of addiction treatment (or lack of agreement whether to use methadone or other substances to tame heroin addiction), and a general a lack of funds and inability to coordinate care between the general healthcare system and addiction services.
And those who treat and advocate for New Jerseyans who are addicted to narcotics know all too well the human costs of a system that’s overburdened not just with a shortage of funding but with a stigma that can make it impossible to even find a neighborhood willing to allow those who are recovering from drug use to live within its boundaries.
That helps explain why they are advocating for a wide range of policy solutions to address barriers to accessing treatment, starting with improvements in the collection of data that will better detail the scope and nature of the addiction treatment shortfall. They say improvements are needed in access to both inpatient and outpatient treatment, as well as the medications like methadone that have bad reputations among the general public and some segments of the treatment-provider community but a long track record of helping to save lives.
In addition, these advocates and providers want better coordination between different service providers, so that residents can seamlessly move from treatment to post-treatment housing, thus helping them reestablish their lives.
Differing Views About Use of Medications
Alan Oberman, CEO of Atlantic City-based John Brooks Recovery Center, said that
medications like methadone, which is generally given at a clinic, and Suboxone, which is prescribed in doctor’s offices, should be better integrated into addiction treatment. However, these medications meet philosophical opposition from providers rooted in 12-step programs, which avoid any drugs that can alter patient moods.
“I stopped judging how people improve their life,” Oberman said. “It disgusts me to see someone stick their nose in the air when somebody is just clawing at getting out and trying to improve their life.”
The center operates both intensive outpatient programs that use medications like methadone to treat patients, as well as a 119-bed inpatient treatment facility.
But the center recently witnessed the challenges that result from addiction stigma when it tried to move some of its services from its 100-year-old Atlantic City building to a Pleasantville shopping center. Pleasantville residents pressured the zoning board to block the move by determining that having methadone users at the center posed a public-safety problem. The center is appealing the decision.
“This is sort of along the NIMBY (not in my backyard) idea, how zoning laws are used and sometimes I would say manipulated to make it much more difficult for treatment centers to expand and therefore improve access to treatment,” Oberman said, adding that a delay in the approval has threatened funding for a new inpatient facility.
Oberman noted another challenge that has resulted from the state’s expansion of drug court — a program that allows nonviolent drug users charged with crimes to receive treatment instead of jail time. Drug-court participants occupy roughly 70 of the center’s 119 inpatient beds, leaving fewer spaces for nonoffenders.
Advocates said inpatient treatment wait-lists can be anywhere from two weeks to three months, depending on the patient’s insurance status and treatment needs. Oberman estimated that it would cost $50 million to $70 million to address the statewide shortage of inpatient beds, but suggested that many patients would benefit from less expensive medication-assisted outpatient treatment.
Oberman added that Atlantic County’s flailing economy is aggravating the problem.
“There used to be a point where you could say to somebody, ‘If you get sober, you’re going to get a better job,’ ” Oberman said. “Many of our clients never had a job and aren’t going to get one when they get sober.”
Assemblyman Herb Conaway Jr. (D-Burlington), a doctor, agreed that medications are effective in preventing overdoses, adding that it’s wrong to deny treatment to those who have relapses, since relapses are a normal part of addiction. Conaway recently held a hearing on the access issue. The Legislature is discussing a 21-bill package designed to address the use of heroin and prescription opioids.
Tonya Ahern of Parent to Parent Inc., an organization that helps residents and their families find drug treatment, said insurance deductibles — amounts that must be paid before insurance kicks in — were too high in New Jersey, which contributed to her sending her son to Florida for treatment after he had eight overdoses. She added that insurance doesn’t pay for doctors to provide care to patients who receive Suboxone, although it does pay for the medication itself.
Difficulties in Finding Inpatient Care
Ahern expressed frustration that drug users must repeatedly call treatment centers to see if they have an available bed.
“How do we do this to people? There’s no other disease where we would do this to somebody,” she said.
The healthcare system too often leaves the treatment of patients whose primary condition is their addictions to mental-health specialists, said Jim Romer, director of psychiatric services for Monmouth Medical Center.
“We can detox them, but that’s not the place where the drug abuser is going to get the optimal treatment,” Romer said of hospitals.
He quoted a staff member as saying of a patient seeking inpatient drug treatment: “I would have an easier time getting him into Yale than I would into drug treatment today. Romer added that he understood why some treatment professionals would advise their clients to go to the emergency room and “tell people you want to kill yourself, and stick to your story… Essentially, what we’re telling them to do is to begin their treatment on a false premise, and honesty is so important at that point.”
Debra L. Wentz, CEO of the New Jersey Association of Mental Health and Addiction Agencies, said there is insufficient capacity across the “full continuum of care” from treatment to post-treatment housing. She said more funding is needed for treatment programs, like a sterile-syringe access program; for Medicaid, which funds many residents’ drug treatment but is burdened by some of lowest reimbursements in the country in a high-cost state; and for salaries to attract and retain treatment-center staffs.
She said federal requirements to provide insurance for mental-health and addiction services at the same level as other healthcare services, combined with an expansion to treatment from drug court and the Affordable Care Act, is stressing a system with an already-high level of unmet demand.
Wentz said some limits on care from insurers are arbitrary and called for state Department of Banking and Insurance to dedicate staff members in its ombudsman’s office to enforce insurance requirements.
“You get what you pay for — there’s no magic answer and there’s no easy, low-hanging fruit to replace the cost of care,” Wentz said. “You can’t do it for physical healthcare and you certainly can’t do it for substance treatment.”
Scotti said the state won’t know the full extent of the problem with a lack of access to drug treatment until it measures the need for treatment, which will be a necessary step to prioritize funding and other resources.
“This is a multifaceted problem — it needs a multifaceted answer,” said Scotti, who added that Suboxone is greatly underused in New Jersey and urged the state to target increased Medicaid funding to reimburse for the medication.
Scotti expressed frustration that she’s never reached a human being when she calls the state’s community resource hot line, 211, which is supposed to connect residents with addiction specialists.
“Could we at least figure out how we adequately staff the addiction hot line, so that when people need help they can at least get a real person who can give them some direction, some way to go?” she said.