A hallway leads to patient bedrooms for the medically managed withdrawal program at Bridgeway, where patients can detox from drugs and alcohol, on Thursday, Jan. 28. (Amanda Loman/Salem Reporter)
Oregon is poised to dramatically expand an addiction treatment system that already consumes millions of dollars each year with no clear results.
Oregonians passed Measure 110 last fall to take drug users out of jails and put them into clinics. That could move thousands of people into a system already clogged and lacking evidence it’s effective, an investigation by Salem Reporter found.
For years, Oregon has had among the highest rates of substance abuse in the country. Federal estimates indicate more than 332,000 Oregonians are substance abusers, based on surveys about drug and alcohol consumption.
Alcohol abuse accounts for the bulk of that, but Oregon ranks first among states in painkiller abuse and second in methamphetamine use.
State government spends about $236 million per year to prevent or treat substance abuse. About 63% of that is for addiction-related care through the Oregon Health Plan.
Last year, that meant some type of drug treatment for about 48,000 Oregonians. It doesn’t include the total spent by individuals or private insurers.
Yet treatment providers, state policymakers and the ballot measure’s supporters agree too many Oregonians currently battle addiction on their own and too often die before they receive the treatment they need.
Local treatment providers and state policymakers say there’s little data gauging whether the programs work. There is virtually no tracking to see if the Oregonians who get treatment reduce or stop their drug use, improve their health or achieve other goals.
“It’s really a black mark on Oregon,” said John Fitzgerald, a licensed counselor and addiction specialist. He authored a 2019 state Criminal Justice Commission report for the Legislature about the state’s treatment system.
Of state spending on addictions, just 3% goes to preventing alcohol and drug abuse.
“Oregon has one of the worst prevention systems in the country measured by dollars spent,” said Mike Marshall, executive director of Oregon Recovers, which advocates for improving addiction treatment.
The cost to Oregon of substance abuse is staggering, with billions spent to deal with the effects of addiction such as children neglected or abused by their parents and law enforcement, court and jail costs for crimes triggered by drug use.
A state report last year put the annual cost at $6.3 billion dollars – equal to 16% of all state spending, or about $1,482 per Oregonian per year.
Helping people cut down or stop their drug use would cut those costs. It would mean fewer children placed into foster care because their parents can’t care for them, fewer people treated in the emergency room for overdoses and fewer people killed in car crashes caused by impaired driving.
Three in five Oregon voters in November approved Measure 110 to make Oregon the first state to reduce penalties for the possession of small amounts of drugs and offer more people a way out of their addictions.
The new law designated a portion of Oregon marijuana tax revenues be spent on building a more robust treatment system. That share would be about $91 million a year based on a state forecast. The intent is to treat addiction as a health matter rather than a criminal concern, investing in grants to expand treatment and referral centers.
It would take the roughly 4,000 Oregonians each year arrested for possessing a controlled substance and refer them to a hotline and eventually an assessment center. They would face treatment instead of a criminal charge. Those who opt not to get assessed would face a $100 fine.
Although supporters of the measure want dollars released now, legislative leaders say they need time to craft an overhaul and expansion of the state’s current treatment system. That means Oregonians newly referred to treatment starting this week will flow into an already overburdened system.
“The biggest success, I think, of 110 is decriminalization,” said Reginald Richardson, director of the state Alcohol and Drug Policy Commission. “But in terms of creating a system where people can get more treatment, which is what was advertised, that’s absolutely not what’s going to be happening.”
Richardson and local treatment providers say any improvement in the treatment system depends on how legislators implement Measure 110.
Tera Hurst, executive director of Oregon Health Justice Recovery Alliance, which advocated for Measure 110, said Oregon hasn’t seen what it looks like to have an adequately funded system to address substance abuse. She said many of the system’s flaws stem from a lack of money and addressing that problem is the first step in fixing the system.
Hurst, who’s in recovery, said there is some unfounded fear that the measure will in fact reduce addiction services.
“I get frustrated because there’s a lot of this talk: ‘This isn’t going to change everything,’” she said. “Build it and be patient. Nobody is saying this is going to change everything overnight. Systems don’t change overnight.”
She said there are providers in the state who are having to lay off half their peer mentors or close recovery houses because of economic impacts due to Covid, so additional funding is an immediate need.
Hurst said there’s ample evidence the current system of court-mandated treatment and criminal charges doesn't work, yet some fear what will happen if there’s change.
“We know one system, it doesn’t work. But people like to feel like it works, because what does it mean if it doesn’t?” Hurst said.
Tim Murphy, executive director of Bridgeway Recovery Services in Salem, supported decriminalizing drugs but opposed the measure because it lacked specifics around treatment. He said, however, that turning legislators toward overhauling the state’s system where there has been little political will to do so in the past is positive.
“I’m really optimistic and hopeful,” Murphy said.
How Oregon Got Here
When he worked at Bridgeway’s detox facility in Salem, Josh Lair got used to telling people to wait.
Clients, shaking with chills or feeling feverish, would tell him they wanted to stop using heroin or methamphetamine.
Lair knows what that’s like.
He’s been sober for a decade after years of meth and alcohol abuse and spent three years at Bridgeway as a recovery mentor, helping others get treatment.
When someone walks into detox ready to change their life, he said it’s important they get help right away. Many live with family or friends who also are addicted to drugs or alcohol, so residential treatment, where they can get a clean break from their lifestyle, is best.
But Lair said every day, he’d call treatment facilities around Oregon only to find there was no space available anywhere for a needy client.
“I had to tell people, ‘Hey, we’ve called every single treatment facility and you’re on the waitlist,’” he said.
That wait was often months, he said, and it was common to see people back in detox.
“They’re still battling and struggling with addiction,” Lair said. “They’re not able to be successful with stopping their use on their own. They need to gain the skills.”
A decade ago, addiction treatment in Oregon and most of the U.S. was harder to find and less often covered by insurance.
Nicole Corbin, addiction treatment, recovery and prevention services manager at the Oregon Health Authority, said treatment services were scarce, particularly for people with public health insurance like Medicaid.
Addiction was largely seen by society as a moral failing rather than a health issue and was disconnected from the rest of the state’s health care system, she said.
Often, “it happened in jail or it didn’t happen at all,” Corbin said.
That changed in 2014, when the state expanded Medicaid and health insurers were required to pay for treatment of mental health and substance abuse.
Suddenly, nearly all low-income Oregonians could get health insurance that until then they had gone without. By 2018, Oregon’s Medicaid enrollment had grown by 59%, adding 400,000 people, a large share of them adults.
Still, stigma about drug addiction shaped how treatment was provided. State reports say addiction care remains poorly integrated with other parts of the health care system, particularly mental health treatment.
“While health care reform in Oregon has made earnest gains in the physical health sector, behavioral health services for substance misuse, (substance use disorders), and mental health have languished due to an inconsistent, fractured, and reactive funding environment that inhibits the development of a continuum of care,” according to the strategic plan issued last year by the state Alcohol and Drug Policy Commission.
The most readily available service now is outpatient care, where a patient sees a counselor and attends group sessions.
Bridgeway Recovery Services treats more people struggling with addiction than any other organization in the Salem area, and operates the only local detox and residential treatment center.
Murphy said Bridgeway’s residential programs are suspended during Covid, but the detox center remains open, serving about 20 people each day.
There, people who have used drugs or alcohol in the past 72 hours can get both medical help and counseling as they manage symptoms of withdrawal. It’s the most expensive and labor-intensive treatment option, with Medicaid paying about $810 a day.
The goal is for clients to leave detox after about a week with a plan for treatment, Murphy said.
During that time, counselors and mentors try to determine why people are abusing in the first place.
“It's not the heroin you're using. It’s ‘Why are you using heroin?’ It's not the alcohol you're consuming. We can help you stop using alcohol but if we don't actually get to the root cause of why you are drinking at that level, you're going to find other ways to medicate that suffering,” Murphy said.
He said about one in 10 clients come from the criminal justice system. The rest reach out to Bridgeway on their own.
Murphy said Bridgeway has a good relationship with the county’s parole and probation department with mentors from his agency visiting prison to find out the needs of people getting released.
“They meet that person on the day of release and bring them into the community, coordinate care with a parole officer, with housing,” he said. “There’s a lot that’s going on between behavioral health and corrections that’s really positive.”
But Murphy said there’s a growing understanding that people don’t get better in jail if they have a mental health issue or chemical dependency. He said people are more likely to succeed in recovery when they are willing to go into treatment, rather than going to avoid prison.
“The better option is to give people treatment of their own volition,” he said.
Murphy said he doesn’t yet know how that will change under the expanded system, but anticipates fewer people coming in for treatment initially because they’ll no longer be sent through the judges mandating treatment. He said he doesn’t know if the shift will lead to more people coming in over time.
Marion County is the other major local provider, treating about 1,360 people in 2020 through its public clinics, according to clinical supervisor Teri Morgan.
The county provides outpatient care, where people meet with counselors individually and in groups, and medication-assisted treatment for people addicted to heroin or other opiates. That program gives participants a controlled dose of methadone or buprenorphine, opioids that alleviate withdrawal symptoms for people physically dependent on the drugs, allowing them to work through their addiction in counseling at the same time.
Those programs typically have space available, Morgan said. If the county determines someone needs more extensive care, they are referred to Bridgeway or another provider.
But getting into that more expansive care can take weeks, and many programs have closed their doors or cut down on beds during the pandemic.
“Residential beds are super limited, especially during Covid, and waitlists are super lengthy,” Morgan said.
Another complicating factor is that even now, treatment centers face staffing shortages.
Addiction counselors on average earn less per hour than their counterparts in mental health, state reports have found.
That remains a barrier to expanding treatment.
“We’re competing with Starbucks and right now Starbucks is winning,” Richardson said. He means the comparison literally. He said he’s aware that some rural addiction treatment centers struggle to retain employees after the coffee chain opened a nearby store, where the pay and benefits are comparable or better.
“We have people who are working in the addiction field who still get food stamps,” Richardson said.
Lack Of Data
Two years ago, a state commission assessed the state’s treatment system – the one now braced for dramatic expansion. The findings weren’t good.
“No reliable outcomes data exist ... on the effectiveness of treatment, or how well the services worked to reduce clinical symptoms and enhance quality of life,” the state Criminal Justice Commission reported.
And, the report found, it was hard to document that treating addictions helped reduce crimes that had to be handled by police, jails and courts.
Without “systems to track expenditures and measure treatment outcomes, the statewide plan will be challenged in knowing which intervention pathways will lead to the desired goals,” the report said.
State Sen. Floyd Prozanski, D-Eugene, who chairs the Senate Judiciary Committee, said he’d like better information so the state can identify models that work.
He said the 2019 report was the first step toward making improvements.
“A lot of the stuff we want to get information on we just don’t have the means to know where we stand because the data just isn't there,” he said.
Richardson said there isn’t agreement among treatment providers or people in recovery about what are the measures of successful substance abuse treatment. Programs have different goals.
Narcotics Anonymous, for instance, emphasizes abstinence from alcohol or drug use. Richardson said that there’s a growing focus on reducing, not eliminating, harm as a goal, such as getting people to use less often or in lower amounts.
Bridgeway tracks how long clients stay in its programs and if they’ve returned multiple times. Murphy said there’s no way to track if a client relapsed and received treatment elsewhere.
Bridgeway recently started more deliberate tracking of patients who volunteer after treatment. Useful results are expected in about a year.
Last year, the Alcohol and Drug Policy Commission issued a five-year plan to fix gaps in the state treatment, prevention and data collection.
The plan recommended recruiting community organizers to work on reducing drug use, particularly among young people, training more health care providers on helping their patients reduce drug use and identifying which Oregonians are not receiving care now.
But there is no money to advance, Richardson said.
“There has not been the will of leadership in our state to do that,” he said.
He said the lack of progress stems from many factors: Oregon’s two-year budget cycle, which makes longer-term planning a challenge, and a treatment system spread between several government agencies.
“Ultimately there’s no one in charge. We don’t have a czar and they have the final word,” Richardson said.
Marshall with Oregon Recovers said the state needs more robust recovery plans.
He cited a federal report that found keeping someone in recovery for five years reduces their chance of relapsing to 15%.
“There’s no other chronic health condition where you can make that level of investment and see that return,” Marshall said.
Prozanski said he wants to consider treatment systems that work both in Oregon and other states, reform Oregon’s system, and then hold providers accountable for results.
He said Oregon needs “to ensure people aren’t just in a revolving door and continue to commit criminal offenses based on an addiction.”
The Legislature, he said, has to decide how to allocate the new funding for those results. He cautioned that will take longer than the measure’s Feb. 1 formal start date.
“Everything isn’t going to be able to happen with a flip of a switch,” he said.
Hurst equated the coming infusion of cash for substance abuse programs with careful feeding of a starving person.
“People are saying things like: ‘Well we need to have a strategic integrated plan.’ You can’t write a plan when you’re starving. Let’s feed the system a little bit as we’re getting up and running,” she said.
This story was originally published by Salem Reporter.