March 18, 2012

Public Programs Battle Funding Gaps

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Recent slashes in publicly funded treatment centers meant that few beds were available when Lindsey Arias finally worked up the courage to seek help for her addiction.

Arias is one of thousands of Oklahomans with little or no health insurance asking for an intervention in her prescription painkiller addiction but finding few options.

“Addiction is a two-way street,” she said. “People don’t know what to do or how to get out of it. We need to get access to a program to know how to make our own choices again.”

The 34-year-old mother of three found a spot at a government-funded bed at Tulsa’s 12&12 Inc. center and has graduated into a grant-funded transitional living program.

“Who would want to be this way?” Arias said. “I saw this as my last shot to get it right. I’m halfway there. This has helped me make the right decision, regain control of my choices.”

As Oklahoma tops the nation in nonmedical use of prescription painkillers and remains high in meth and alcohol addiction, the state agency charged with addressing those problems has had to deal with severe budget cuts.

When residents without health insurance ask for help, many are forced to wait nearly six months, leading to dire results.

“When someone comes to ask for treatment, we need it at that time,” said Terri White, director of the Oklahoma Department of Mental Health and Substance Abuse Services.

“By the time there is a bed available, we often call and can’t find the person because they have moved on, the person has committed a crime and is sitting in jail or worse – losing them to an overdose or suicide.”

Since 2009, funding to the agency has been cut by 11 percent – from $326.3 million to $289.8 million.

State and federal appropriations for substance abuse programs have decreased 21 percent – from $87.6 million to $69.5 million.

This has reduced funds to at least 70 private providers by more than $3.5 million, forced the merger of a Norman substance abuse treatment center with a children’s recovery center, and closed several programs, including a co-occurring unit at the Tulsa Center for Behavior Health, an enhanced residential treatment unit at Central Oklahoma CMHC and a unit at Griffin Memorial Hospital. A total of 95 treatment beds were lost.

Cuts last year added at least 1,200 Oklahomans to the nearly 1,000 already on the waiting list for treatment.

Oklahoma’s mental health and substance abuse agency served 16,865 adults during fiscal year 2011 in substance abuse and alcohol treatment programs – including detox and transitional living. Of those, 80 percent were in outpatient care.

Patients qualifying for government services have incomes within 200 percent of the poverty line and are not eligible for Medicaid.

“Our system is to help the most vulnerable – those with no means to pay, those working but without insurance and cannot afford services,” White said. “But we are only able to serve about one-third of them.”

‘We can’t do anything’

After being offered a Lortab – prescription hydrocodone used to treat pain – by a co-worker on a construction work site, a Tulsa man started craving the energy it gave and ramped up his usage.

Justin now spends $300 a week for at least 70 opiate pills. He has a full-time job as a machinist, has custody of his elementary-aged son and has been waiting five months for a spot in a government-funded bed for detox and treatment.

“There’s a euphoric feeling with it, but now there is absolutely no euphoria,” he said. “Now, it just levels me out to function.”

Justin’s identity is being withheld because of his fears of losing custody or his job because of drug abuse.

He is not alone in his wait.

Officials say that between 600 to 900 residents a day are on the waiting list, which they say is a conservative number. On Thursday, 1,730 Oklahomans were waiting to enter a treatment program. That number includes duplicates, or individuals waiting on several lists.

About 1 in 10 on the list are adolescents.

Federal guidelines require pregnant women and intravenous drug users to get priority in government treatment beds.

“It is a terrible way to get health services,” White said. “The idea of what we are doing is pushing the consequences to other, more expensive parts of our system. Can you imagine what would happen if this was our system for treating heart disease?”

Of the 10 people who supply Justin with the prescription pills, at least seven are elderly women. The women are aunts or grandmothers of friends who sell their medications, usually covered by Medicare.

For help, he went to the nonprofit Counseling and Recovery Services of Oklahoma, 7010 S. Yale Ave. Although he works at least 40 hours a week, he has no insurance and does not qualify for Medicaid.

“What’s available to him? Nothing,” said Tom Boone, substance abuse services program director at the nonprofit.

“I wish I could solve all the problems on an outpatient level, but until we get him into detox, we can’t do anything.”

Opiate detox is considered one of the most painful – 10 times worse than the worst flu. The length of time for detox depends on the drug. For prescription painkillers, it takes about a week.

Justin said he has tried to quit on his own at least 25 times. The longest he has gone without a pill is a little more than one week, but the time lapse before pain sets in is about a day.

“It’s like every muscle cramps up, and my eyes water so bad I can’t see,” he said. “My legs feel like they weigh 300 pounds. I end up using again. Within 20 minutes of taking a pill, the pain goes away.”

Some family members know about his addiction, but he keeps it hidden from his son and everyone else. His ex-wife is also addicted to prescription painkillers.

“I know I have a problem,” he said. “I can’t go on spending this kind of money. I’ve bought pills instead of buying groceries.”

Justin checks in with the nonprofit agency periodically to see about any openings.

“I really believe one day I will quit,” Justin said. “I need the right kind of help. I want to be the best person I can be, and I’m at 50 percent of that now. I feel like I’ve been wasting time, and my son deserves better than that.”

‘A crisis so important’

Detox is the initial stage of the treatment process, and the state helped 1,970 people receive that service in fiscal year 2011.

Medical detox programs help people avoid health problems such as organ failure and ease the pain of withdrawal symptoms.

Two facilities in the state offer government-funded medical detox – 12&12 in Tulsa and The Referral Center in Oklahoma City. Between them, the state pays for about 42 detox beds.

“For most of the people we serve, detox is a huge part of the need,” White said. “But in the last four years, we’ve had basically a stand-still budget. We need to develop ambulatory detox, which is in the range between medical detox and self-detox.”

After getting someone clean of drugs and alcohol, the question is what to do next.

Outpatient treatment is most available – with 13,579 adults served for all substances in 2011, according to the state’s data.

Taxpayer-funded residential treatment served 2,685 adults Oklahomans last year, followed by 369 adults who graduated to a halfway house program, according to data from the state mental health and substance abuse agency.

Some individuals may have participated in more than one program last year.

To be admitted into detox and residential treatment, programs require the patient be an active user, giving them no incentive to stop using.

“People don’t go to any treatment unless there is a crisis so important to them they know they have to get help,” Boone said.

Boone said outpatient treatment is not always the best course for addicts who may require detox or inpatient treatment.

“With outpatient, it is not a level of care that is going to work with many people,” Boone said. “It takes about an 18-month period at different levels of treatment to get the most successful outcomes.”

A pilot program of four women at the nonprofit features a new drug that allows for an outpatient detox from opiates but requires a team of support overseeing the patient.

“We’ve got to find different ways to shore up the problem,” Boone said. “Financially, the state cannot afford to build more facilities, and we have got to find a way to overcome this opiate problem.”

‘An anemic response’

Tulsa’s nonprofit 12&12 program offers a full range of treatment, from detox to transitional living. About 35 percent of its revenue comes from the state, with the rest coming from sources such as grants, insurance contracts and contracts with groups including American Indian tribes and veteran’s organizations.

Executive Director Bryan Day said the nonprofit could serve more people in its residential treatment if it had more money. Reimbursement rates have not increased in more than a decade.

“We are prolonging an individual’s suffering by not engaging people in treatment as soon as possible,” Day said. “With the current levels of funding, we are providing an anemic response.”

Nearly 60 percent of the nonprofit’s patients have alcohol addictions. Many patients have co-occurring disorders, which means they have an addiction and mental illness. About 20 percent have opiate addictions, and about 8 percent are methamphetamine addicts, Day said.

“Treatment is no longer a one-size-fits-all approach,” Day said. “That is not acceptable. Providers like 12&12 have to collaborate at various stages in the process, including with the medical and psychiatric community.”

The nonprofit recently had more than $100,000 in state funding cuts from its transitional living program.

“The trickle-down from those cuts is happening,” Day said. “It means individuals who go into treatment and need up to four months of additional services don’t have money there for that. We hope they are ready after residential care. But if they have no family, no money, no housing and no options for continuing service care, unless we help them engage in the community, their success rate at staying clean and sober go down.”

The 12&12 center developed a program, the Sober Living Program, which is a continuation of services that requires patients to pay for room and board.

“That’s only covering those with the ability to pay,” Day said. “Many individuals utilizing state resources do not have that capacity.”

Curtis Killman also contributed to this story.