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April 3, 2023

Mothers Face Broken Addiction Treatment System

This story was produced via a USC Annenberg Center for Health Journalism Data Fellowship.

Kayla Quinones began having contractions a few hours after midnight. Her baby, Jacarri, was on the way.

Quinones, 33, was homeless at the time and staying with a friend in upstate New York, and when she began to feel the undulating pains, spaced about 8 minutes apart, she called for help. Those pains, her friend told her, were contractions. They needed to get to a hospital.

Before staying with her friend, Quinones spent 6 years living on the streets of Sullivan County, about 2 hours north of New York City. She had been using heroin for 7 years, and cocaine for the last 4. She was homeless for the majority of her pregnancy. And using for all of it.

Doctors rushed Quinones to the delivery room, and the birth went smoothly. Jacarri was born healthy, but had developed neonatal abstinence syndrome. At the time of his birth, Jacarri had methadone and cocaine in his system, so doctors transferred him to the neonatal intensive care unit at a nearby hospital. The hospital where Quinones delivered him did not have one.

After Jacarri’s birth, Quinones was more motivated to get help for addiction than ever before. Jacarri’s father, Quinones’ longtime partner, died when Quinones was 4 months pregnant, and she was now learning that she’d lost custody of her baby. Jacarri would be going to stay with Quinones’ mother in Queens and would stay there until Quinones could get into a treatment program. She was again living on the street, searching for a program that would take her in.

It wasn’t the first time she had looked for help. She had been enrolled in a methadone program during her pregnancy, but continued to use heroin.

Now looking for a more comprehensive treatment program, Quinones ran into a new problem. Because she hadn’t received a postpartum check-up — which typically occurs between 4 and 6 weeks after delivery — many treatment centers wouldn’t take her, she said.

“They were denying me left and right,” Quinones told MedPage Today. “I was still running the streets, and miserable because they took my kid away. And I was worried that I wasn’t going to get into a program.”

In an underfunded, siloed mental healthcare system, pregnant and postpartum people with addiction face endless barriers to treatment. While patients typically come into contact with the medical system more frequently during pregnancy, those with addiction struggle to get adequate care, as insufficient numbers of behavioral health providers, logistical hurdles, and distrust of the medical system deter people from accessing treatment, according to providers, patients, and advocates.

“There is a presence of substance use that often gets overlooked and undertreated in pregnancy,” said Leah Habersham, MD, an addiction medicine specialist and ob/gyn at Mount Sinai Health System in New York.

Medication-assisted treatment (MAT), such as buprenorphine (Suboxone) and methadone, are the gold-standard treatment for pregnant patients with substance use disorder. These therapies manage cravings and prevent patients from going into withdrawal, which can result in preterm delivery or fetal growth issues.

But not all patients can access MAT, data show. Nationally, only half of pregnant patients with opioid-related substance use who received care at an addiction treatment center received methadone treatment in 2020, according to an analysis performed by MedPage Today.

Those who seek treatment in New York, where Quinones lives, receive it at a rate higher than the national average. In 2020, there were 635 episodes of treatment involving opioid use in pregnancy at New York addiction treatment centers. Of those treatment episodes, 75{35112b74ca1a6bc4decb6697edde3f9edcc1b44915f2ccb9995df8df6b4364bc} received MAT at discharge.

The data, which come from the Substance Abuse and Mental Health Services Administration’s (SAMHSA) treatment episodes database, is a compilation of addiction treatment center data reported by state agencies. Many of the treatment centers that report to SAMHSA receive state funds or federal block grants to provide drug or alcohol treatment services, the agency says.

Of the 6,200 times pregnant patients received opioid-related treatment nationwide in 2020, all received care at addiction treatment centers, such as methadone clinics or specialty behavioral health centers. However, providers say this is an underestimate of patients that receive care.

Many patients access treatment for substance use disorder outside of specialty care facilities, including from a family medicine provider, addiction specialist, or ob/gyn practitioner who prescribes buprenorphine — treatment that is not recorded in public databases.

Not knowing how many patients do or do not get treatment poses a host of issues, according to patients, providers, and advocates. Without an accurate count, it’s difficult to properly allocate resources to treat substance use disorder among the population of pregnant patients, they say.

“We don’t know how many people receive comprehensive services,” said Mishka Terplan, MD, MPH, a board-certified ob/gyn and addiction medicine specialist based in Maryland. “And that’s really kind of unknowable.”

Kayla Quinones, who lives with her son Jacarri at Greenhope Services for Women in East Harlem, New York, looked for treatment centers for a month before enrolling in the residential treatment program at Greenhope. Before having her baby, judgment and stigma from medical providers prevented her from seeking care, she says. Photo by Liam Quigley.

A Growing Problem

More than 1 million people have died of an overdose since the opioid epidemic began in the late 1990s. The crisis intensified during the COVID-19 pandemic, as isolation and interruptions to medical care led to skyrocketing overdose deaths.

Nationwide, there were an estimated 108,000 overdose deaths in 2021 — an all-time high, CDC data show. The majority of those deaths involved fentanyl, a synthetic opioid that’s 50 times more potent than heroin.

Opioid use disorder trends among pregnant patients are directly connected to patterns in the general population, Terplan said.

In total, 6,000 women had a maternal opioid-related diagnosis at delivery in 2017, the most recent year for which data are available, according to a study in JAMA. Self-reported data from the CDC suggest that 6.6{35112b74ca1a6bc4decb6697edde3f9edcc1b44915f2ccb9995df8df6b4364bc} of women used prescription opioids during pregnancy. One in five women who used prescription opioids reported misuse, the study showed.

“We all know that opioid use disorder is a rising problem, and it’s hitting the pregnant population as well,” said Wendy Wilcox, MD, chief women’s health services officer at NYC Health + Hospitals, New York City’s public hospital system.

The vast number of opioid-related deaths has left policymakers scrambling to solve a worsening addiction problem. Last October, the Biden administration released a plan to improve access to substance use disorder treatment for pregnant and postpartum people specifically.

The plan aimed to correct issues that were preventing patients from accessing MAT and looked to improve public reporting of access data.

Currently, there are no public databases that clearly show how many patients — pregnant or not — get medical treatment for substance use disorder. (Click here for more on the challenges of reporting data around substance use in pregnancy.)

Late last year, the federal government also deregulated buprenorphine to improve treatment access. Providers previously needed an X waiver — a special Drug Enforcement Administration (DEA) certification — to prescribe buprenorphine, which required an 8-hour training and restricted the number of patients a clinician could treat.

After years of rolling back restrictions, the federal government eliminated the X waiver entirely in December. The nixing of the rule allows any provider with a DEA license to administer buprenorphine, pending a one-time training.

Most ob/gyns are licensed by the DEA to prescribe controlled substances. But addiction medicine experts worry that though federal regulations on treatments for substance use disorder have begun to ease, there will remain a gap between the number of primary care providers and ob/gyns willing to prescribe buprenorphine and the number of patients who need it.

Should Ob/Gyns Provide More Addiction Care?

Medical organizations, including the American College of Obstetricians and Gynecologists (ACOG) and the American Society of Addiction Medicine (ASAM), have firmly said that they believe MAT is the gold-standard treatment for pregnant patients addicted to opioids.

Though there are three drug treatments available to all patients with opioid use disorder, methadone and buprenorphine are the most commonly prescribed treatments for pregnant patients. The opioid antagonist naltrexone (Vivitrol) is also safe to use in pregnancy, but is recommended less often because it requires patients to stop using opioids for about 2 weeks prior to initiating treatment.

Despite the recognition that MAT is widely believed to be the optimal treatment for opioid-addicted patients, providers who are not trained in addiction medicine still don’t feel comfortable administering it, said Daniel Rosa, MD, medical director of the Acacia Network, a human services organization in the Bronx that provides addiction treatment services.

“The problem has always been the buy-in from ob/gyns and primary care providers,” Rosa said. “It still falls on the very few people who happen to be board-certified in addiction medicine.”

Methadone can only be dispensed through a SAMHSA-authorized opioid treatment program. But now, most ob/gyns and nurse midwives can prescribe buprenorphine, as long as they have a DEA license.

Before buprenorphine was deregulated, ob/gyns did not get certified to prescribe it in large numbers. Less than 2{35112b74ca1a6bc4decb6697edde3f9edcc1b44915f2ccb9995df8df6b4364bc} of ob/gyns who treat patients on Medicaid had an X waiver as recently as 2019, according to a study in JAMA Network Open.

“That to me, is evidence that the workforce has failed,” Terplan said.

Addiction medicine is typically viewed as separate from reproductive healthcare, Terplan explained.

“Ob/gyns provide episodic care, and addiction is a chronic condition,” Terplan said. “That’s a clinical mismatch.”

Even then, asking ob/gyns to initiate care for patients with opioid use disorder puts the onus on the doctors to treat the highest acuity patients in a different specialty, Terplan added.

Take treating a patient with diabetes, Terplan said. “The first time you take care of somebody with diabetes is not the person who’s in a diabetic coma with a gangrenous foot in the emergency room. It’s somebody in the outpatient setting who’s on insulin, who brings their sugars, and you look at the sugars and you slightly adjust the insulin dose,” he said.

“Basically, we’ve been asking people for the last 20 years to take up a new domain of health and start with the sickest patient. And, there’s some DEA surveillance for the prescribing practices,” Terplan said. “I don’t think it’s a categorical surprise that uptake has not been what it could be.”

Until there is more training around the prescription of buprenorphine, experts are skeptical that the elimination of the X waiver alone will lead more ob/gyns and primary care providers to treat pregnant patients with opioid use disorder.

“I don’t think it’s going to be that … a ton more primary care doctors or ob/gyns are going to start prescribing,” said Amy Van Milligan, MD, an internist and pediatrician who provides MAT in Cincinnati.

Elimination of the X waiver takes away the mandatory 8-hour requirement, Van Milligan added, “but it’s not going to make people magically comfortable with substance use disorder.”

Why Treatment ‘Just Doesn’t Work’ for Pregnant People

Just as some ob/gyns and primary care providers may have difficulty treating pregnant patients with opioid use disorder, providers comfortable with treating patients with substance abuse may not feel comfortable treating pregnant patients. It all amounts to a siloed system that some say makes it difficult to connect patients with the various types of care they need.

“There’s still some confusion out there amongst MAT providers about how to care for pregnant people,” said Jaine Fairbairn, a wellness coordinator at the neonatal abstinence program at Margaretville Hospital in New York. “And trying to find an ob/gyn who is versed on the actual prescribing of MAT is very difficult.”

But once pregnant patients get linked to prenatal care and find an addiction treatment specialist, then the hard work begins: obtaining care.

Fairbairn works with around 10 pregnant patients at any given time. In addition to advocating for her clients in the exam room, Fairbairn connects her patients with resources like diapers or baby food, answers questions about what to expect at each stage of the baby’s development, and helps patients coordinate transportation to medical appointments, she said.

In Delaware County, where Fairbairn works, the sheer logistics of getting to and from doctor’s visits is one of the biggest challenges that patients face. The county is the size of the state of Rhode Island, but is home to around 45,000 people, she said.

“Here in the rural universe, methadone is almost impossible to maintain,” Fairbairn said. “These places are all an hour, an hour and a half, two hours from wherever you are.”

Medicaid transportation is available, but unreliable, Fairbairn added.

“Once a patient has been burned a couple of times, they just refuse,” she said.

Child care and other family responsibilities also pose barriers. “Addiction treatment isn’t easy if you have other kids at home,” Van Milligan said.

During pregnancy, patients are already overwhelmed with the number of appointments they need to make with their ob/gyn alone, she said. Factoring in a different provider that administers MAT, coordinating transportation, and figuring out who is going to watch the kids at home — it becomes nearly impossible for some patients to get treatment, she added.

“It’s not that they don’t want it, it just doesn’t work,” Van Milligan said.

In addition to the barriers to treatment posed by coordinating care, many pregnant patients with addiction may avoid treatment — both for prenatal and addiction care — because they don’t trust medical providers.

Quinones first went to an ob/gyn when she was about 8 weeks into her pregnancy.

“I was nervous at first, walking in and knowing that I was going to have to tell him that I was an IV user,” she said. On top of that, she used cocaine, had hepatitis C, and hadn’t been to a gynecologist in 5 years.

“The doctor basically told me I was a junkie and I had to stop using, otherwise I wasn’t going to be a good parent and my kid was going to come out just like me,” Quinones said. At one point during the appointment, her physician told her it was still early, and asked if she was certain she wanted to keep her baby, she told MedPage Today.

Quinones walked out of the healthcare facility before even putting on a hospital gown. She didn’t try to get prenatal care for the remainder of her pregnancy.

“I was disappointed, but already kind of knew that that was going to happen,” Quinones said. “Because I’ve been through it so many different times.”

While the stigma of addiction is enough to keep patients out of the doctor’s office, they also run the risk of losing custody of their child or children. (Click here for more on the relationship between access to treatment and the child welfare system.)

Fear of the medical system and child protective services (CPS) prevents patients from telling their providers the truth about their substance use, Habersham said. Fear and stigma not only impact a patient’s ability to get timely care — it affects the public health system’s ability to assess how many people may struggle with addiction in pregnancy.

Recently, Habersham saw a pregnant patient at Mount Sinai’s female-only methadone clinic in New York City. The patient became addicted to prescription opioids, and then heroin, and was now seeking addiction treatment before going to the ob/gyn for prenatal care.

Habersham encouraged the patient to come to a clinic she started at Mount Sinai last year called the Bridge Program, which provides integrated addiction and reproductive healthcare. She told the patient that she could get her an ultrasound and labs so that they could begin to assess her pregnancy and initiate prenatal care. But on the day of her appointment, the patient was a no-show.

“She ended up not coming,” Habersham said. Habersham reached out to the patient’s social worker, who told her that the patient was fearful that her children at home would be taken away from her.

“I think that as we change the narrative, as we decrease the stigma, and as we start linking patients with treatment instead of linking them with CPS, that we are going to see the true numbers,” Habersham said. “I don’t think that in the current climate, that we’re going to reach that point.”

Greenhope Services for Women in East Harlem, New York, which is an affiliate of the Acacia Network, provides residential recovery services to women and their children. Children up to age 5 are eligible to stay with their mothers in treatment. Photo by Liam Quigley.

The Push for Comprehensive Care

Habersham wishes there were more centers in New York for patients to receive a range of services at once — prenatal care, behavioral health counseling, addiction treatment, and more.

In 2016, David Garry, DO, a maternal-fetal medicine specialist at Stony Brook Medicine in New York, started the Maternal Opioid Management Support (MOMS) program. The outpatient clinic provides buprenorphine treatment, behavioral health counseling, social services, and prenatal care.

“I think medication alone is not the answer, and I think that counseling alone is not the answer,” Garry said. While medications can address the biochemical mechanisms in the brain that cause drug cravings, counseling helps patients work through mental trauma, he said.

Comprehensive care sites like the MOMS program exist throughout New York State, “but it’s tricky to get them paid for,” Terplan said.

Prenatal care is bundled, so it’s often reimbursed to providers as one lump sum per pregnancy. When an individual provider gets a bundled payment for prenatal services, it can be seen as double-dipping when they charge fee-for-service payments for addiction care on top of that, Terplan added.

“It makes this integrated care by the same provider really difficult to realize,” he said.

Some providers, like Garry, have gotten around that barrier. His program’s ability to provide prenatal and addiction treatment in one place is not only cost-effective for patients, but it also reduces the stigma of accessing addiction care.

“They are just like any other patient in the office,” he said.

Garry said that his clinic tries to follow up with patients 1 to 2 weeks after birth — the postpartum period is a time when many patients may fall back into drug use. More intervention during this period could reduce preventable deaths, he added.

Almost a month after Jacarri was born, Quinones found a treatment center that would take her in, despite the fact that she had not received a postpartum check-up. She became enrolled at Greenhope Services for Women, a residential, female-only addiction treatment center in East Harlem.

Greenhope, a part of the Acacia Network, allows children up to age 5 years to stay with their parents in treatment. A month after Quinones arrived at Greenhope, a judge granted her custody of her baby. Jacarri, now age 7 months, lives with Quinones full-time.

Quinones has access to primary, pediatric, and addiction care through Greenhope’s network of providers. She leaves the facility’s campus for methadone treatment, and is steadily decreasing her dose of the treatment until she can wean off of it entirely.

The death of Jacarri’s father, her fears for the future of her child, her unstable living situation — it all served as a pull into addiction, while simultaneously motivating her recovery.

“Every reason why I was using was pretty much a great choice for it,” she said. “But at the same time, everybody was also dying. I didn’t want Jacarri to grow up without his mom.”

But all the contradictions of addiction and every barrier to treatment were trumped by Jacarri, the boy who unknowingly provided the final push his mother needed to get care.

“He literally saved my life,” she said.

February 16, 2023

The moral injury of working in a broken mental health care system.

Welcome to State of Head, a segment from Slate and Arizona State College committed to exploring mental wellbeing. Abide by us on Twitter.

“What do you necessarily mean there is no way to get me my medication?”

A younger school pupil looked at me throughout the Zoom online video psychiatry appointment, visibly angry, and a little saddened.

“There’s a lack of ADHD medicine, and I’m not even sure when it will end.” I allow out an audible sigh, “It’s annoying, I know.”

“So, then, what do we do?” The affected person seems to be right at me, hoping that I can by some means support him navigate around the barrier. But I cannot.

“There are a several, all very not-good, solutions,” I instructed him. “You can connect with a bunch of pharmacies and then explain to me which area has it in stock and in what doses. I can then deliver in prescriptions for what you require. You can also wait around right up until anywhere you ordinarily choose it up gets remedies again in inventory, but I know you require it to function, primarily in college, so waiting around could be out of the question. Or, we can also communicate about switching prescription drugs quickly.”

Switching is far from a straightforward modify or even a useful one. This patient, like lots of of those people I see, experienced to test numerous remedies prior to getting an reasonably priced just one that is effective for him devoid of far too lots of facet consequences (like insomnia, deficiency of appetite, and further anxiousness). Even if he decides to give switching a consider, there is no warranty that the new drug will even be in inventory. The lack has started to trickle into other drugs, moving from Adderall to Ritalin and Concerta, and his new a single could be following.

Listening to my sequence of unhelpful selections, my individual seems to be defeated. I come to feel responsible for it. “I’m so sorry,” I say, for the fourth or fifth time today alone.

I did not have a phrase for what I was encountering until finally the pandemic introduced it out into my lexicon: ethical harm. Right before I went into this subject, no one informed me that the helplessness that will come with doing work in psychological well being is truly regular ethical injury.

The phrase itself originated in the context of the armed service and war in buy to capture an experience of veterans that is distinct from PTSD. At its most fundamental definition, ethical injury occurs when people are uncovered to demanding circumstances and possibly perpetuate, are unsuccessful to reduce, or witness activities that contradict their have values and ethical beliefs. The personal injury element is the distress we sense afterward in any or all regions of our life—psychologically, behaviorally, socially, and spiritually.

In the army, triggering situations incorporate situations when officers have to make decisions that have an effect on the survival of others, or other individuals in which a person failed to complete a duty throughout a traumatic celebration. Throughout the early pandemic, we discussed moral injury in health treatment in reference to resource allocation issues like masks or ventilators, or viewing significantly far more than the (now tricky) predicted quantity of suffering and demise. Most not too long ago, we have mentioned it as a most likely end result of the Dobbs ruling for OB-GYNs. However number of researchers have looked at the prevalence of moral injury in health care, in a review evaluating military services veterans deployed to battle following 9/11 and health treatment staff for the duration of the pandemic, the all round prevalence prices of opportunity ethical damage were equivalent.

There was a person big difference, nonetheless: The health care personnel described better charges of moral damage from many others instead than on their own. This implies that they ended up additional probable to concur with statements like “I am troubled by having witnessed others’ immoral acts” than “I am troubled by getting acted in strategies that violated my personal morals and values.” An illustration could possibly be realizing sufferers should have family associates present when they are dying in the healthcare facility, but not getting ready to due to the fact of COVID-connected medical center restrictions. This plan might operate counter to their individual beliefs of how an individual ought to die, but they feel powerless to change it. The distinction concerning others and self may perhaps be relevant to the idea that health care workers get the job done in a broken system, and may well truly feel far more betrayed by others because of it: society, authorities, or healthcare facility leaders, for instance.

As an outpatient psychiatrist, I’m constantly apologizing for something exterior of my handle. If it is not an ADHD medication lack, it’s insurance policies denying other necessary prescriptions. Or a patient currently being unable to come across a therapist. They may change employment (or, even worse, get fired), and the coverage modifications or new fees suggest they just cannot see me anymore. As a end result, they now have to uncover a new psychiatrist in the center of a pandemic and amid a compounded lack of mental well being providers. Chronically unwell to my belly and wounded, I desire them luck.

It is not just outpatient, though. When I was in residency we were being warned that our initially two several years, made up of largely inpatient psychiatry, would be even even worse, and they were proper. We had people who stored coming back to the medical center mainly because we did not have social help to get them to appointments or to help them find the money for their prescription drugs. There were being also the sufferers waiting around days, even weeks, in the crisis home, just to get into the inpatient device, for the reason that we did not have ample beds to assistance all of the men and women who necessary it. I keep in mind currently being explained to by my attendings that I just essential to get to my 3rd 12 months of instruction, wherever I’d be primarily outpatient, to see that persons do get superior. That part is accurate: It’s 1 of the brilliant places of my job and the motive I selected it. But they forgot to convey to us that even if people increase, the procedure doesn’t.

It could help to think about moral personal injury in drugs as the variation among telling an individual “We did all we could” and “We did all we could in a broken system with out all the vital assets.” We are all unwilling reps of the process. I get yelled at or cried to regularly, and as an empath, I take up it all. I know at the core, my patients’ reactions in my visits are not about me, but that does not make it harm any fewer. In some cases apologizing is all I can do, to truly feel like I’m carrying out anything. Or it’s possible it is my way of reminding them that I’m nevertheless a excellent man or woman, attempting to be a superior doctor.

My response, however, is a usual a single. Moral damage often sales opportunities us to blame ourselves and sense responsible, to really feel offended or disgusted, and even ashamed. These unfavorable views about ourselves and many others do not immediately suggest we have psychological wellness results, but we may possibly start out to observe tension reactions like improvements in our sleep, overworking, turning to alcohol to cope, and social isolation. When moral injury by itself is not a psychological wellbeing analysis, it is a chance variable for creating melancholy, PTSD, suicidal ideas, and burnout. As medical professionals, our costs of despair and burnout are presently better than in other very similar groups, and this is just yet another result in compounding it. In truth, in 1 study of health and fitness treatment employees in excess of COVID, bigger ethical injuries scores have been linked to worsened severity of signs or symptoms, such as suicidal ideas.

Over and above the risk to the mental wellness of the particular person wellness care worker, there is a potential for ethical injury to trigger men and women to depart the subject completely. Getting rid of staff members will only strain a method with minimal accessibility to commence with, notably for mental overall health gurus. In simple fact, in accordance to the Wellness Sources and Solutions Administration, by 2030 the demand for psychiatrists will increase by 6 p.c, outpacing the provide and top to a scarcity of nearly 18,000 psychiatrists. This selection doesn’t even get into account the unmet have to have thanks to limitations to getting psychological health and fitness care, or the rise in mental wellness worries around COVID-19 that have compounded the pressure and demand from customers on psychological health and fitness experts. Accessibility is already a problem, but when the existing workforce leaves owing to moral injury, clients remaining with out care are ultimately the types who will undergo.

Naming what I’ve been encountering as moral injuries is practical and is actually a very first move in coping. In these moments, lots of of us—including the bulk of my well being care–worker clients and me—are quick to converse down to ourselves and self-blame. It is vital alternatively that we pause, accept our emotions and struggling, and practice self-compassion. To do this, we will need to find out to switch our adverse thoughts with the methods we talk to somebody else we care about—a mate, loved ones member, or even the more youthful model of ourselves. Our positions are difficult ample with out us adding to them by tearing ourselves down.

At the very same time, one of the couple of answers offered to us as individuals is sharing our ordeals with ethical injuries. Drugs is not a area of vulnerability, and as a result, we frequently truly feel by yourself in our experiences and feelings. Real self-care for ethical personal injury consists of creating alternatives with the assistance or advice of other people, when probable, and wanting for support in the conversations that result in distress (or later on). Collectively, in both structured strategies or informally just after troubling gatherings arise, we can system our activities and hear distinctive strategies to consider about or make which means from what we witnessed. We never need to have to experience in silence.

Even creating all of this out has helped me.

Point out of Mind
is a partnership of
Slate
and
Arizona State University
that offers a useful appear at our psychological wellness system—and how to make it
superior.

January 10, 2023

Peer mentors are key to Oregon’s Measure 110 success, but they are working in a broken system

On a sunny September evening in 2021, Nathaniel Sean Stringer joined family and colleagues for a recovery celebration at a park in the eastern Oregon town of Ontario. To enthusiastic applause, he received an award for his service to those struggling with addiction.

Just weeks later, Stringer overdosed on fentanyl and died inside a grocery store. He was 35.

His death shows how fragile recovery from addiction can be — and his story highlights a major pressure point in Oregon’s expanding addiction care system at a pivotal time.

Before he died, Stringer exemplified a growing statewide trend. He worked for the Malheur County Health Department as a peer mentor. “Peers” are people in recovery from addiction who engage with people who use drugs, offering mentorship and resources while demonstrating by example that recovery is possible. There are nearly 1,900 peers who specialize in addiction in Oregon, typically earning about $18 to $24 an hour.

The peer model is an evidence-based approach that is increasingly used around the country.

Now, using money generated through Oregon’s 2020 drug decriminalization law, Measure 110, a state-appointed council is pouring money into hiring many more peers as part of a shift toward treating addiction as a health care issue. Increasingly, peers across Oregon are connecting with people in need through street outreach and working in addiction care, mental health or homeless services, hospitals and jails.

Origins Faith Community is a nonprofit day shelter for people experiencing homelessness in Ontario, Ore. On Oct. 13, 2022, Anthony Caliendo walks through the dining room before the day’s lunch is served.

*Kyle Green for The Lund Report*

But without adequate funding for detox facilities for withdrawal management, residential treatment and recovery housing, people inside the system say the state’s burgeoning peer workforce amounts to a pipeline that often leads nowhere.

A recent analysis from Oregon Health & Science University showed that Oregon’s addiction care system is half the size it should be to meet demand.

Stringer was hired before Measure 110 was implemented and those close to him believe factors outside his job drove his relapse. What’s clear, however, is that while people in the peer mentor role are tasked with motivating people to seek treatment, they — like Stringer did — frequently grasp for resources that don’t exist when their clients are ready to quit using. The situation puts tremendous stress on the very people on which the system’s current expansion relies.

“I absolutely believe in peers, I believe that they are the best people to engage people who are using drugs into treatment,” said Sarah Poe, director of the Malheur County Health Department, where Stringer worked. But peers don’t themselves provide treatment and without more services to connect people to, she said, “It’s really hard work for peers to show up and keep trying to push this boulder up a hill — when the hill keeps getting more steep.”

‘He was those people’s hope’

Stringer grew up in Nyssa, a small rural community where both his parents were educators and his grandfather raised sheep. Nyssa sits west of the Idaho border, south of Ontario. In an area known for its crops and cattle, the dusty landscape is dotted with small, well-weathered homes. Malheur County has Oregon’s lowest median income.

Starting with oxycodone as a teenager and then heroin as a college student, Stringer wrestled with addiction for 15 years, going in and out of treatment. His mother, Sherry Stringer, said that one time he vomited before getting into her car after graduating early from an inpatient program. He told her it was because he was afraid of what might come next.

And yet counselors at every treatment center her son went to told her that he was so good at helping others in the program.

“I remember thinking so many times,” she said, “why can’t he help himself?”

Eventually, he did. In 2019, Stringer was a proud father and three years into his recovery as he neared completion of an intensive drug court diversion program. He single-handedly opened a nonprofit syringe exchange to help prevent the spread of disease through intravenous drug use, a need he knew was great. That’s when he connected with health staff at Malheur County for advice on the medical aspects of running an exchange.

County staff were so impressed with Stringer, they later asked if he’d like to work in their new peer support program. He jumped at the opportunity.

In many ways, the job was a perfect fit. His family and friends described him as charismatic, known for his levity. He was empathetic, non-judgmental and defended the underdog. His uncle remembers him in his youth sticking up for a soccer teammate bullied for not being able to afford a uniform.

Stringer was skilled at connecting with clients. Having once contracted Hepatitis C from injecting drugs, he followed up with county clinic patients who had just tested positive, knowing they likely got it the same way. He let them know he had stopped using and could help them do the same.

A video of him accepting the award at the recovery event shows Stringer telling the crowd he loved “every single day” of his job at the county. “The outreach we do is just so important. I get to feel like we are making a difference on the ground, which is what it’s all about.”

But the traits that made him good at his job also added to his stress. His family said it weighed heavily on him when he couldn’t connect his clients to the treatment they needed.

“He was frustrated that there weren’t enough resources,” his uncle, Matt Stringer, said. In the absence of treatment beds, he remembers his nephew considered letting clients stay at his home so they could stop using.

Nathaniel Stringer’s uncle, Matt Stringer, sits on his back porch in Ontario, Ore., on Oct. 13, 2022. A retired music marketing executive, Stringer returned to Malheur County from New York to care for his mother when she was ill.

*Emily Green/The Lund Report*

The results of a 2020 statewide survey of Oregon peers indicate the pressure felt by Stringer is mirrored across the state. Participants listed the lack of services for clients as a major challenge, “specifically treatment and housing.”

“When you have two or three or four clients that are needing support right now and you’re driving them around to each detox center, making phone calls, calling your personal contacts and then nothing is happening — it’s defeating,” Amanda Esquivel, who has worked as a peer recovery mentor in Portland for the past two years, told The Lund Report in September. “I did that this morning … right now, that individual is waiting at home to get into detox.”

In the weeks leading up to Stringer’s death, his uncle noticed subtle signs that his nephew might not be OK. Pandemic stress and feelings of helplessness around situations with friends and family that were out of his control were climaxing. But he insisted he was fine, colleagues said.

Peers interviewed for this story said it can be hard for people whose jobs are intertwined with their recovery to ask for help when they need it. And peers may fear losing their jobs if they relapse.

Morgan Godvin, a person in recovery who sits on the council implementing Oregon’s drug decriminalization law, is open about this dilemma. If she relapsed, she would “probably hide it,” she said on Twitter. “It would be so profoundly disappointing to everyone who has invested their time and resources in me. I fought really hard to stop being a bitter disappointment. I can’t go back there.”

On Oct. 17, 2021, Stringer went to an Albertson’s grocery store not far from Ontario, over the Idaho state line. He walked into the bathroom and consumed a substance containing a fatal amount of fentanyl, his family said.

His family and friends believe it was a momentary lapse.

A picture of Nathaniel Sean Stringer hangs on a wall inside the Malheur County Health Department outside the room where his office used to be on Oct. 13, 2022.

*Emily Green/The Lund Report*

Stringer left behind a wife of one year, a 3-year-old son and a 12-year-old stepson. His death sent waves of shock and grief through eastern Oregon’s recovery community, which included many people he had helped and who looked up to him.

“That’s what broke my heart,” his uncle told The Lund Report. “He was those people’s hope — and then that happens to him?”

Where has all the Measure 110 funding gone?

Today, a picture of Stringer hangs on a wall in the Malheur County Health Department, outside the door to where his office used to be.

With just 29 staff, the agency is a small operation, located inside a modest one-story office building on the southwest side of Ontario. A rainbow-colored mural spreads across the wall where guests check in at a reception window.

Sarah Poe leads the department. A person in recovery herself, you can hear her passion for her peer support team and their clients as she talks about the high hopes she had for the improvements Measure 110 money could bring to her county — and how those hopes quickly faded.

Measure 110 was sold to voters on the promise of expanding access to drug treatment in a state that ranks highest for its rate of illicit drug use and dead last for its access to treatment, according to federal data.

Following the measure’s passage, however, its proponents have said Measure 110 spending should not focus on residential treatment, arguing that it can be paid for by the Medicaid-funded Oregon Health Plan.

This change has come as a blow to providers who thought much of the measure’s $300 million would go to expanding treatment infrastructure, then watched as the council that oversees Measure 110 spending rejected applications for stabilization centers, residential treatment and detox facilities.

Even with recent increases in reimbursements, Medicaid doesn’t come close to covering the full cost of treatment. That’s why Heather Jefferis, executive director of the Oregon Council For Behavioral Health, calls addiction care in Oregon “the most extreme example of how historic underfunding creates tragic outcomes.”

Providers also need money to purchase or erect the buildings that will house needed services, to begin with. The Legislature’s recent investments in behavioral health care have largely gone to mental health, not addiction treatment. And, there’s no plan for investing in the level of detox beds, residential treatment or housing for people in outpatient treatment that would be required to meet demand.

The frustration is evident statewide and especially in Malheur County.

“We got all this money that came into our community and you know what it gave us? More peers, more syringe exchanges, more Narcan,” Poe said, referring to an opioid overdose-reversing drug. These services are critical, she said but on their own, “they’re not a full solution. And we really, really, really needed a detox facility.”

Origins Faith Community is the only place in Ontario, Ore., where people living in poverty can get a free meal. On Oct. 13, 2022, homemade meatloaf and stuffing were on the menu.

*Emily Green/The Lund Report*

Poe wondered aloud why the state isn’t taking steps to ensure each region has the basic building blocks of a functioning treatment system in place: a detox center for withdrawal management, an overdose prevention coordinator, sufficient residential treatment, recovery housing and other baseline necessities.

In Malheur County, Poe said she’s watching as health department peers hand out more and more Narcan so that people using heroin and opioids can reverse potentially-fatal overdoses.

“Narcan is just there to keep someone alive to then get them into the treatment that they need,” Poe said. “But then we need to have the treatment piece there.”

Lack of support, resources for peer mentors

Janie Gullickson fought through methamphetamine addiction before becoming the director of the state’s most prominent peer-run organization, the Mental Health & Addiction Association of Oregon. Her enthusiasm is infectious when she speaks about the strength and resiliency of the peers she represents. As one of Measure 110′s chief petitioners, she believes in the law and its role in “expanding addiction recovery services across the continuum.”

Working out of her nonprofit’s headquarters in Northeast Portland, Gullickson oversees training, supervision and support for peers around Oregon — including in state-supported programs like Stringer’s in Malheur County.

Gullickson told The Lund Report that the recovery community in Oregon has seen an increase in relapses and overdoses during the pandemic, including among peers like Stringer.

In the wake of Stringer’s death, the health authority began requiring more structure to supervisory support for peers in state-funded peer programs, though a state spokesperson denied any connection between the two.

And for county-based peer programs that wanted outside help, the state also provided supervision and support by contracting with Gullickson’s organization.

“Some had great, experienced peer supervisors and were already doing peer programs. But it was those ones that felt very isolated and didn’t have that infrastructure that we focused on,” Gullickson said. They also worked with Malheur County, where the peer supervisor had been Stringer and his replacement was a member of his team, she said.

According to a statewide assessment, Gullickson’s nonprofit helped conduct in 2020, fewer than half of peers reported receiving supervision once a week or more. Some participants attributed high turnover to a lack of support, trauma and burnout.

But Gullickson said it’s important not to “other” peers by suggesting they need more supervision than other workers and suggested stigma may play a larger role than supervision in relapse.

(Left to right) Tyler Woods, Tiffanie Stabler and Steven Wolf talk in the alley behind Origins Faith Community. They work for Malheur County and hand out naloxone, hygiene kits and other supplies during the day shelter’s free meals.

*Kyle Green for The Lund Report*

“What we’ve seen sometimes is people won’t say, ‘Hey, I need help right now’ in the way that we would think people in recovery would be able to do. But when they get in this profession, often then it’s like, ‘Oh, I’ve got to prove myself.’”

Before 2020, the state required that peers have at least two years of recovery behind them before taking the 40- or 80-hour certification courses. To meet the demand for peers and behavioral health counselors, authorities lowered the requirement to one year.

Adding to the stress of their job, many peers also say that the residential programs currently used in Oregon need to offer longer stays and different approaches to increase their effectiveness.

Kevin Fitts, a peer and director of the Oregon Mental Health Consumers Association, told a crowd during the recent opening of Multnomah County’s Behavioral Health Resource Center that while the focus now is addressing the extreme shortages in behavioral health, the question that’s being neglected is whether the current model for treatment is succeeding.

“Are we having beneficial outcomes for the consumer of the services? Got me!” Fitts said. “We have a system in crisis. … What is important is getting the services that these people need out on the street. Well, are these services meeting the needs? Are people moving forward?”

Measure 110 delivers fraction of hoped for funds

On a Thursday morning in September, the smell of homemade meatloaf filled the air inside a mid-century brick church on the northwest side of Ontario.

Steven Wolf greeted patrons as they walked up to the back door. Wolf is a peer mentor, a job that Stringer recruited him into. The two graduated from drug court together before becoming peers.

Like most mornings, Anthony Caliendo, 52, was the first to show up. He’s experienced homelessness since July. He told The Lund Report he’s not interested in drug treatment. But Wolf said he helped Caliendo rely more on cannabis and less on meth — a harm reduction method employed by some peers.

Caliendo said Wolf is easy to talk to because he comes from a similar background. “He’s been hungry and spent his money on dope instead of food,” he said.

Anthony Caliend, 52, is experiencing homelessness in Ontario, Ore. He’s seen here sitting in the chapel at Origins Faith Community, where he receives free meals and peer services, on Oct. 13, 2022.

*Kyle Green for The Lund Report*

With no local year-round homeless shelter in the area, the church is the only place in Ontario where people can get a free meal. No longer operating as a house of worship, the building serves as a drop-in center run by a small nonprofit called Origins Faith Community, which is not religiously affiliated.

Staff at Origins saw Measure 110 as the opportunity they had been waiting for. They launched a peer program with Measure 110 funds and hired Wolf as its first peer.

But as the state program unfolded, it became clear that the robust local system Origins and other local providers had planned was not going to be possible.

Origins originally asked the Measure 110 council for $3.1 million. But the state wouldn’t fund the requested transportation services, the new drop-in center and the purchase of a 20-unit apartment building adjacent to the church.

Altruistic Recovery, an outpatient behavioral health clinic across town, requested $13 million to create a detox and residential treatment facility but was also denied.

Of the $265 million in funds distributed through Measure 110 this year, $1.8 million went to Malheur County.

That money, locals lament, will fund only seven beds — slated for an apartment complex that a local nonprofit plans to purchase as housing for people living with co-occurring HIV and substance use disorder.

Origins, meanwhile, got $616,000 — less than 20{35112b74ca1a6bc4decb6697edde3f9edcc1b44915f2ccb9995df8df6b4364bc} of what it hoped for.

Counselor Dana Rush, who left Origins following cuts made in November, said she thought that Measure 110 was going to be different.

“That’s why we were so excited about it — that finally, we could really meet people where they were,” she said, her voice breaking as tears filled her eyes. “And then to watch all of the stuff unfold and go, ‘Oh my gosh, we’re not going to be able to do that. OK, give us just what you can so we can just get started. And maybe we can build what we can. And we’ll do what we can. And we’ll keep doing what we can until — dang it — we’re just gonna keep doing what we can do.’”

The Lund Report produced this story with support from the Association of Health Care Journalists and The Commonwealth Fund. Emily Green can be reached at emily@thelundreport.org.