Shawn Vestal: Referral for addiction treatment is the first step in a long, complicated journey (2023)

James Tillett didn't stop using drugs when he went to prison for three months.

Nor did he give up the first time he was hospitalized for an IV-related infection. Tillett, who was homeless and used "every drug I could get my hands on," was sneaked substances by friends while he was in recovery.

His change came only after a second near-death crisis landed him in hospital in early 2021 - suffering from endocarditis, pneumonia and other problems stemming from an infection caused by licking the tip of a needle to catch a drip before injecting. He was in Sacred Heart's cardiology unit for two and a half months at a time when COVID protocols prevented visitors.

During his stay, the nurse asked him, 'If you survive, would you be ready for treatment?'"

Tillett survived and entered a 30-day inpatient program, followed by continued outpatient treatment and peer support programs. He has been sober ever since and works as a peer counselor. Most recently, he served on a state advisory committee that made recommendations to the legislature on drug policy.

Tillett's path was not unique. Relapse is common for people who are trying to get sober, and especially for those who have no place to sleep. Some 85% relapse within a year of treatment, according to the National Institute on Drug Abuse. About two-thirds return to drug use within weeks of starting the program.

"Some people may need a dozen times," Tillett said.

That's one of the complicated truths underlying Washington's new chapter on drug possession. State lawmakers, after failing to pass the "Blake fix" at the end of the regular session, passed a new law last week that toughened penalties for drug possession and use, and paired them with a series of proposals and funding for treatment-oriented diversion.

The package won praise for balancing the interests of prison and treatment, but was criticized by those who wanted even harsher penalties — and those who said the new law criminalized addiction and did too little to address needed care.

Senate Majority Leader Andy Billig described it as a "treatment-oriented bill" with a criminal justice component.

"Addiction is a health disorder, so it makes sense to take a health approach," he said.

But he acknowledged what is widely understood within the recovery community—even with increased funding, our capacity to provide that treatment falls far short of need.

Treatment programs are difficult to get into, and staff shortages plague the behavioral health field. The availability of the most effective evidence-based programs, which rely on medication and harm reduction strategies, is even less.

"If you want to get into an addiction treatment program now, you're waiting at least two weeks," said Justin Johnson, director of the Spokane County Department of Community Services, which provides a range of behavioral health services including court-ordered treatment.

That challenge is compounded by a network of insurers and providers—each operating with contracts that limit and define what is covered and who gets treatment—that create a seemingly impenetrable bureaucratic thicket. Each individual who relies on Medicaid to pay for treatment faces a complex challenge made up of different rules, payment schedules, and partnerships between insurers and providers.

"The No. 1 question we get is how do you even manage this?" Johnson said. "It is a much more complicated question than saying that there is a certain number of beds. It's a really, really weird and complex system.”

'Begging for help'

Four years ago, long before the Supreme Court's Blake decision struck down Washington's drug possession laws, Hallie Burchinal was working with homeless people on the streets of Spokane.

Burchinal was trying to "direct them toward services"—to find detoxification and treatment options to begin the recovery process. Among the people living on the street, she became known as a person who understands and they turn to her for help.

"I had to fight really hard to get them into any treatment facility," Burchinal said.

Availability was scarce. On top of that, she was surprised to find that one of the main obstacles was the attitude among the providers themselves—those who had seen people fail in treatment and were skeptical that they really wanted to change.

"People were begging me for help, and I was dealing with a system that was saying, 'They don't want help,'" Burchinal said.

This prompted Burchinal to start her own nonprofit organization, Compassionate Addiction Treatment, in 2019 to provide peer counseling and treatment. Burchinal has just opened a new 16-bed sobriety center – a detox facility of sorts – to help with the final stages of Camp Hope's cleanup.

Like many who work in the field, Burchinal believes that pushing for tougher penalties could frustrate some people's efforts to stop using drugs - particularly those who openly use drugs in public places, many of whom are homeless and face a range of problems including mental disease.

The intent to force treatment is unlikely to work, they say, and prison then becomes the standard -- a standard that stigmatizes people and puts obstacles in the way of recovery.

"It's really a revolving door with homelessness, substance abuse and the prison system, and prison is very expensive," she said.

The opioid crisis, now fueled by the powerful, deadly synthetic fentanyl, has increased overdose deaths across the country, and public use of the drug — whether smoked or smoked — has contributed to a sense of public urgency stemming from concerns about crime and homelessness.

City and county leaders across Washington, as well as law enforcement leaders, have called for tougher criminal penalties for drug use to protect the public and encourage drug users to seek treatment. But researchers say incarceration has proven ineffective as a response to drug addiction over the past 30 years, even as research establishing addiction as a treatable brain disorder has grown.

Between 1980 and 2015, the number of people in federal prison for drug offenses increased more than tenfold, from 25,000 in 1980 to more than 300,000, according to a Pew report. During this period, self-reported drug use continued to rise, and recidivism - that revolving door - did not abate.

"As the federal prison population grew, spending increased by 595 percent between 1980 and 2013 without achieving a compelling return on public safety," Pew concluded, adding, "The rate of federal drug offenders leaving prison and placed under community supervision, but commit new crimes or violate the terms of their release has been about a third over three decades.”

At the national level, the picture is similar. Among states with very different approaches to drug sentencing, Pew found no significant differences in levels of drug use, arrests or drug overdoses, regardless of how severe the sentences were.

Fifteen years ago, the National Institutes of Health published a review of research on incarceration and drug addiction. It found that an estimated half of all people incarcerated in the country met the criteria for drug addiction and called for a shift in policy from prison to treatment.

It did not determine the effect of harsher prison sentences on recidivism. In addition, he noted that drugs are commonly used in prisons and jails, and that the threat of relapse after release is very high – and that once released, people face a range of challenges that contribute to relapse, from relapse environment to the lack of a stable apartment or employment.

The "molecular and neurobiological adaptations" experienced by those with SUD don't just disappear while someone is incarcerated, the NIH found, and "compulsive drug-seeking" returns strongly even long after abstinence.

"This may explain why many drug-addicted individuals quickly return to drug use after long periods of abstinence during incarceration and underscores the need for continued treatment after release," the NIH reported.

As Burchinal said, "If prisons worked, we wouldn't have anyone struggling with substance abuse disorders."

'Big pinch point'

Repeated studies show that drug treatment is less expensive and more effective in reducing drug use and drug-related crime. For one example, the Washington State Public Policy Institute estimates that every dollar spent on community-based addiction treatment results in $18 in future crime-related costs.

A 2017 state analysis estimated that every dollar spent on treatment services within the criminal justice system saved between $5 and $13 overall and reduced recidivism by as much as 9%.

So, what is the realistic availability of such treatment? It is difficult to gather a single, simple picture of the capacity of our community. There are several different private and not-for-profit providers that offer outpatient counseling services; the availability of long-term care is limited and has decreased in recent years.

Detox beds, especially for medical detox for the most severe addicts, are very limited. Burchinal said that "if all the stars align," there is a bed available in a time of need. Often the stars don't align, she said.

"Last week we drove someone across the state to access medical detox," she said.

Spokane County opened the Mental Health Crisis Stabilization Center in 2021, the first facility of its kind in the state. Officers who encounter people they might otherwise arrest for low-level crimes can refer them to the center, which has rehab beds, medical services, counseling and medical staff, and other services.

It was celebrated when it opened as a step towards recognizing and dealing with the untreated disorders that are at the heart of so much recidivism.

However, the gap between needs and capacities remains large. A county survey conducted over three months in 2020 – before the center opened – found that 37% of those booked into the jail met criteria for mental health or substance abuse treatment.

That amounts to about 2,000 people. The institution has 47 beds. Not everyone needs an inpatient detox period to get treatment, and even those who do will transition to outpatient services at some point, but the numbers are telling.

The Spokane Regional Health District operates an outpatient methadone program for opioid addiction. About 1,100 people are involved, and 500 to 600 of them come for medicine every day.

Misty Challinor, director of treatment services at SRHD, said fentanyl has dramatically changed the landscape of recovery. Synthetic opioids have quickly become prevalent and are often split into other substances so people don't even know they're taking it.

"It becomes much more difficult to work with the monster because it is much more powerful than any other substance," she said.

She said that because of this, there is a need for more capacity in the methadone program, but that labor shortages make it difficult to hire enough staff even when funds are available.

This has been a major challenge facing the entire field of behavioral health and is one obstacle to turning legislative proposals into reality on the ground.

Jeff Thomas, executive director of Frontier Behavioral Health, said high vacancy rates and turnover of field workers make it difficult to expand services. A November survey of community behavioral health providers in Washington found that the average staff vacancy rate was 29% and the average turnover rate during the year was 32%.

Frontier is not currently contracted to provide substance abuse treatment, but it does provide services adjacent to — and often intertwined with — that need, including helping the homeless and partnering with local police agencies to respond to people in crisis.

As the number of people seeking treatment for some form of behavioral health problem has grown, and as Medicaid has expanded and more investments have been made in public health, the workforce has not kept pace, he said.

Thus, government investments in new programs and employment do not automatically produce services on the ground. For example, the recently passed state budget included a 15% increase in funding to encourage the hiring of behavioral health professionals — an important and necessary investment, but one that doesn't immediately create staff, he said.

"It's great that there's more investment and it's great that there's less stigma for people accessing these services," Thomas said. "It just creates a big pinch point."

The limited treatment area has frustrated the final stages of clearing Camp Hope, which was down to about 30 people by the end of last month. It's difficult to get the most severe cases into treatment - part of the reason for CAT's new sobriety center.

Julie Garcia, who runs the camp, said she agrees with the ban on open drug use.

But she said that while the goal of responding to treatment referrals sounds good — and everyone on all sides says they want to encourage it — there just isn't enough capacity on the other side of that encouragement.

When he sees lawmakers debating diverting detainees to treatment, he thinks, “Cool. Where did they go?"

Without a concrete answer, failure becomes a prison or criminal sentence that might encourage some people to seek help—but will become a barrier for many others, making it difficult to get an apartment, find a job, and otherwise stabilize their lives enough to get sober.

"We need another model"

Caleb Banta-Green, a research professor at the University of Washington School of Medicine's Institute on Addiction, Drugs and Alcohol, who is among the nation's leading experts on addiction and recovery, began his work in the field 28 years ago in the methadone program.

At that time, the emphasis was on setting strict rules and screening out those who don't follow the rules or stop using drugs immediately. The prevailing public view – still widely held – was that using drugs was a bad choice and quitting smoking was a good choice, and that people should simply make the right choice.

Decades of research have clarified that addiction is a disorder of brain chemistry and has a strong genetic component. It is a medical condition that can be cured, but not a simple, direct cure.

Today, Banta-Green advocates a different approach—one that focuses on addressing the needs of each individual, tries to address contributing factors such as lack of housing or medical care, and recognizes the reality of relapse and works to keep people connected to recovery. , instead of denying treatment for breaking the rules.

"The chances of recovery are better if you keep people in care, even if they continue to use substances," he said.

The need for such care far outstrips availability. Two-thirds of Washington counties do not have an opioid treatment program that can provide withdrawal medication. The vast majority of people addicted to opioids – whether living on the streets or in a mansion – do not receive treatment.

"The treatment system works well for some people," he said. "The traditional health care system works well for some people. But our treatment gap is over 80%. We need another model."

A harm reduction approach that keeps people alive, understands the reality of relapse, uses appropriate medications and helps solve other problems in people's lives is the most effective approach, he said.

"The evidence for mandatory treatment is poor," he said, "and the health impacts of prison are very poor."

Banta-Green has served on legislative advisory boards and the governor's office. A major recommendation he and his colleagues on the Substance Use and Recovery Services Committee made ahead of the last legislative session was the creation of health involvement centers to provide emergency services for substance use disorders and other needs such as general medical care, housing and employment.

The Services Board has recommended funding for one such hub for every 200,000 people in the state. It was dropped from the bill that fell at the end of the regular session; the package adopted at the special session included the financing of two such pilot projects.

Evidence shows that harm reduction strategies, such as safe needle programs, work to move people toward recovery, he said. But it faces political opposition that grows out of entrenched social attitudes toward drug use that stigmatize the user and underestimate the long road to recovery. He calls the philosophical divide rooted in the prison-versus-treatment debate "the ultimate wedge issue."

Some people can "drive it away" into sobriety, he said. Most simply cannot.

'You gotta want it'

A recurring theme among people working in addiction treatment is the corrosive effects of stigmatizing people with addiction and mental health issues.

Stigma follows people throughout their lives and makes it difficult to find housing, work, and avoid the stresses and cues that cause relapse.

"If people thought of addiction as a set of symptoms rather than a character flaw, then we would have a better understanding of the recovery process," Burchinal said.

Tillett, 36, said when he was convicted and sentenced to prison — for drug distribution and related charges, not simple possession — it didn't result in him getting treatment. However, it got him thinking about the possibility.

That planted the seed.

For him and others he has counseled, he said the movement toward recovery often occurs in such phases. His prison sentence and hospitalizations were part of the stop-and-start process common to drug addicts. The fact that one does not succeed immediately is typical, but it does not mean that success is not possible.

The key is individual commitment, he said. And this was not created by legal threats or offers of help or even large interventions such as months in prison.

Tillett is not opposed to introducing criminal sanctions for drug possession and public drug use, although he said such laws may be more effective at simply keeping drug use out of sight rather than actually changing behavior.

He said that when he took the drug, he would not use it in the open, simply because he knew it was illegal. Instead, he would find hidden places to use it - for example in the toilets of local businesses.

"You have to want it," he said. “That's the hardest thing about this. (Offering treatment) is a great concept, but the individual has to want it.”

Editor's note: This story has been updated to include the name of UW professor Caleb Banta-Green.

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