Mental Health Association of Portland

From the Portland Tribune, June 28, 2012

Substance abuse and crime are like fast food and heart disease — everybody knows they’re connected, and experts think they know how dealing with one could help solve the other. But over time, nothing much changes.

Consider Portland, where drug use is high and treatment options, even for the uninsured, are more available than in most cities.

That might help explain a bit of good news/bad news data from a federal report on nationwide drug use.

The Arrestee Drug Abuse and Monitoring report (also known as ADAM II) shows that people arrested in Portland have the highest rate of previous drug or alcohol treatment. In 2010, 41 percent of arrestees in Portland reported having been through inpatient treatment. Thirty-eight percent reported having gone through outpatient treatment.

Indianapolis, by comparison, had 11 percent and 23 percent of people arrested having been through inpatient and outpatient treatment, respectively. Minneapolis? Thirty-three percent and 26 percent. Sacramento? Twenty percent and 13 percent.

The good news appears to be that we are providing more drug and alcohol treatment to the type of people who commit crimes. The bad news? Many of those people who received drug treatment continue to get arrested.

A 1999 study found that nationally, about 95 percent of state inmates with histories of drug abuse had returned to drug use within three years of their release from custody. Many undoubtedly received some form of treatment while in prison.

“People need multiple treatment episodes, and it can take several treatment experiences before someone really can achieve long-term abstinence,” says Steven Belenko, a Temple University criminal justice professor, an expert in the field of addiction treatment in correctional settings.

People here get high. According to federal 2008 data, Oregon trails only New York, South Dakota and Colorado for the per capita number of residents admitted to substance abuse treatment programs.
Sacramento is worse.

Considering the well-established connection between addiction and crime, the bigger mystery could be why Oregon and Portland don’t have higher crime rates. Oregon ranks as the 17th safest state in the country, and Portland as the ninth safest large city.

Eric Martin, who studies addiction data as the policy and legislative liaison for the Addiction Counselor Certification Board of Oregon, says that the key to understanding the high rate of previous treatment among Portland arrestees is in the ADAM II data, which reported drug test results for arrestees in 10 cities. More than seven of 10 people arrested in Portland had at least one drug in their system when they were booked at the county jail. Three of 10 tested positive for more than one drug.

That puts Portland in the middle of the mid-sized cities studied in ADAM II. Sacramento’s arrestees were worse.

But digging deeper, Martin notes that Portland has the highest rate of the 10 cities surveyed for opiate use — mostly heroin. People who take heroin are more likely to have had prior drug treatment than people who smoke marijuana or use most other drugs, Martin says. Also, he says, heroin users generally have the highest drop-out rate in treatment.

So, Martin suggests, Portland has more than its share of heroin users, who at some point, voluntarily or by court order, start — but don’t finish — addiction treatment. Eventually, many of them get arrested, or re-arrested, pushing Portland’s rate of arrestees with prior treatment to the top.

Ineffective treatment

Martin is convinced that the ADAM II data is not an indictment of drug treatment in the Portland area. In fact, he and others believe that Oregon’s treatment programs for the uninsured, and for those on probation and parole, are better than what is offered in most states.

“Part of it could just be the epidemiology of the drug epidemic that we’re having in the city,” he says.

Much of the treatment that would show up in the ADAM II data was likely delivered to people previously arrested, especially for drug crimes. People arrested here for drug crimes tend to be given sentences of probation, with required drug treatment.

But probation officers are often burdened with heavy case loads, and reluctant to send a probationer or parolee to jail just for missing or failing a drug test. The majority of Multnomah County drug crime probationers are placed on what is called case bank probation, with no real oversight by a probation officer. They are told to attend outpatient treatment, and if re-arrested they would be showing up as having had previous treatment, but few in the local criminal justice system believe they are getting what they need to beat their addictions.

“The effectiveness of getting those persons actually into, through and completed with their court mandated treatment is not necessarily that great,” says Multnomah County Deputy District Attorney Ryan Lufkin.

More people are ordered to treatment here than in states that more frequently send people to prison for drug offenses, according to Lufkin. But, he adds, a 2010 federal report ranked Oregon 47th among U.S. states for funding substance abuse treatment. That study showed that 55 percent of Oregonians ordered to treatment completed their treatment, compared to 45 percent nationally.

Lufkin believes that in Multnomah County the criminal justice system sends more people into treatment, but that they re-offend more frequently. That might be because the treatment is ineffective, or sets too low a bar for graduation.

Or, Lufkin says, it might be a result of Oregon’s unwillingness to send people to prison for serious drug offenses. If re-offending drug offenders here had stronger consequences and more supervision, he says, there would be fewer getting arrested again.
Finding a place to live

Funding for probation and parole addiction treatment has dropped precipitously, according to an Oregon Department of Corrections report that shows state money to Multnomah County declined from $11.5 million in the 2007-09 biennium to $8.1 million in the 2009-11 biennium to $4.1 million in the current biennium.

Funding for treatment to people in prison has dropped from $11.7 million two years ago to $9.8 million in the current biennium.

According to a Department of Corrections report, three of four people in Oregon prisons have a drug or alcohol problem. With fewer dollars to work with, community justice officials are putting more probationers and parolees into outpatient programs each year. That might seem a less effective treatment, but Sarah Goforth, who oversees mental health and addiction services for nonprofit Central City Concern, says whether probationers get inpatient or outpatient treatment doesn’t matter all that much.

What matters, Goforth says, is where people live after treatment. If they don’t have a sober environment to come back to after treatment, or after prison, they rarely stay clean.

“What we’ve known for years is that residential treatment can serve as a warehouse for people,” Goforth says. “You go in and get treatment, but unless you have a clean and sober environment to put people in, they just cycle through.”

Goforth estimates that only 10 percent to 20 percent of those who go through inpatient addiction programs manage to stay clean and sober.

Some of those who don’t stay clean will end up committing crimes, and they’ll show up in the ADAM II data that says more arrested Portlanders have a history of drug and alcohol treatment.

According to data from Central City Concern, the county’s largest provider of supportive housing, in the past two years funding for recovery housing has dropped while the demand has been going up.

Karen Wheeler, until recently addiction program administrator for the state of Oregon, agrees with Goforth on the need for recovery housing. Wheeler says people getting out of jail often can’t afford rent and don’t have jobs. Getting those people into housing in a community of people committed to sobriety is critical, she says.

“If you don’t have a place to live, you’re going to use, bottom line,” says Wheeler.

• Arrestees with previous drug or alcohol treatment (outpatient)
Portland 38%
Minneapolis 26%
Indianapolis 23%
Sacramento 13%
New York 23%
Atlanta 8%

• Arrestees with previous drug or alcohol treatment (inpatient)
Portland 41%
Minneapolis 33%
Sacramento 20%
Indianapolis 11%
New York 23%
Atlanta 12%

Source: ADAM II data

From the Portland Tribune, May 9, 2012 – by Peter Korn. Second of Two Parts

Painkiller cuts send some patients to street drugs

A year ago, Dr. Gary Oxman, Multnomah County’s public health officer, saw evidence that demanded what he calls a moral decision.

He had watched as each year the number of Multnomah County residents dying from prescription painkiller overdoses had grown.

Dr. Gary Oxman, Multnomah County public health officer, faced a tough choice a year ago -- overdose deaths due to prescription painkiller abuse were rising, but so were deaths from heroin overdoses.

Physicians with whom Oxman consulted, who had moved to Portland after practicing elsewhere, told him that doctors here tend to prescribe more pain medication than doctors in other cities.

Last May, Oxman’s county health department dramatically changed its policies. Nine pages of guidelines were developed requiring that physicians, before prescribing painkillers, comprehensively assess the patient not only physically and mentally, but also from an addiction standpoint.

The result? Some patients at county clinics have been told they can’t get prescriptions anymore. Others have had their doses reduced.

Compared to a year ago, about half as many of the county’s primary care patients are on prescription painkillers.

But another disturbing trend has captured the attention of public health officials. The number of deaths in Multnomah County due to heroin overdoses has increased dramatically in the past year (see “Welcome to Heroin City,” May 3). And a number of people in the local health care community have told the Tribune that part of that rise may be an unintended consequence of the new guidelines.

Pain sufferers and addicts, they say, cut off from their prescriptions, have begun looking for alternative sources of relief and have found it in the cheap heroin flooding Portland’s streets.

None of the physicians or addiction treatment specialists the Tribune interviewed disagreed with the county’s new policy. Someone had to draw a line somewhere and begin halting the cycle that creates new addicts in Oregon, they say.

The county’s new policy — followed by most other local clinics that provide health care to the poor and uninsured — is an important first step.

Sarah Goforth, who oversees mental health and addiction services for nonprofit Central City Concern, says the county made a hard choice, but the right one.

“We have people getting cut off from their pain pills and turning to illicit drug use,” Goforth says. “It’s tricky. (The county) is letting us all know this is going to stop. We own that this is out of control and we don’t want to be a part of it anymore.”

Not like other addicts

Northwest Portland resident Pam Boyd can visualize a future as a heroin addict, and it frightens her.

Boyd, 56, was a substance abuser for years. She used Vicodin to excess, she drank and smoked pot. Depression and a variety of ailments allowed her to rationalize her habits. But she had her limit.

Recovering heroin addict Pam Boyd does a forgiveness meditation at the Old Town Clinic's Renew class as part of her rehabilitation.

“As long as I didn’t do heroin I figured I was OK,” Boyd says. “I figured I wasn’t as bad as all the other addicts.”

In 2000, she was hit by a car, suffered a series of severe injuries, and, she says, couldn’t find a doctor willing to prescribe enough of the pain medication she so desperately wanted. One night, she was at a party when she heard people making noise behind a bathroom door.

“I stuck my arm in and said, ‘I don’t know what you’re doing in there, but give me some of it,’ ” she recalls.

Somebody stuck a needle into her arm. That was her first heroin injection. Eventually, she developed a major heroin habit.

Boyd has been clean of illicit drugs for four years. But injuries from her first accident and a second one, when she was hit by a car on Southeast 82nd Avenue, have left her in constant pain. When she gets up in the morning, the first thing she does — has to do, she insists — is take OxyContin and lie still for 20 minutes before the pain subsides enough to allow her to get out of bed and begin the day.

She takes painkillers throughout the day.

Boyd’s physician, Dr. Rachel Solotaroff, says Boyd’s prescriptions exceed the recommended ceiling of 120 milligrams total morphine per day. Her plan is to taper the doses so Boyd gets under that ceiling, but she won’t do it in a vacuum.

The Old Town Clinic, where Boyd receives care, has developed a program called RENEW for patients who need alternative therapies. Boyd has taken relaxation and meditation classes there. She’s tried acupuncture at the clinic as well as nutrition classes, and next week she is scheduled for physical therapy and an aromatherapy class.

One-on-one, Solotaroff, with patients such as Boyd, is re-enacting the hard choice that Oxman has dealt with on a countywide level. But it’s not easy.

Boyd says all the alternative therapies provide only temporary pain relief. If she were to be cut off from her prescriptions — Solotaroff says that won’t happen — returning to heroin would loom as a real possibility.

A floating life

Solotaroff, Central City Concern’s medical director, isn’t a big fan of prescription painkillers, even for patients suffering chronic pain. The drugs, she says, dull the sensation but don’t generally help patients learn to deal with their pain.

“Opiates don’t help you set goals to improve your activity or occupation or socializing,” she says.

Boyd exemplifies that half of the equation, according to Solotaroff.

“If we were just doing pain medication with her, she might just sit at home all day,” Solotaroff says. “It’s an isolated and not fulfilling life, kind of floating. What Pam is doing, which is remarkable, is trying to work with us to get opiate doses lower and understand it’s only going to take away 10 or 20 percent of the pain.”

Boyd says most of the people she knows will “go back to the street” if denied their pain prescriptions. That means heroin for their pain, as well as shoplifting and prostitution to make enough money to buy the heroin.

When Multnomah County issued its new clinic guidelines, Solotaroff says, it essentially changed the way all clinics in the county operated.

“Everybody was heading in that direction, but when the county made its changes it forced the other community clinics to do the same thing or all the county’s patients were going to migrate to your clinic. You’d be the candy man,” she says.

Solotaroff says at the Old Town Clinic most of her patients, when assessed using new guidelines, are considered at high risk for addiction. She says an unintended consequence of the new rules has an increasing number of patients going from one doctor to another or switching clinics or even visiting hospital emergency departments in an attempt to gain access to new prescriptions.

Some of her patients have told her that since their prescriptions have been reduced they have begun buying drugs on the street.

Solotaroff says the county was right to lead the way with its new guidelines, but she’d like to see other changes that could help head off some of the consequences.

A moral imperative

The Old Town Clinic runs a program from its new building in Old Town, which has space to offer a variety of alternative therapies. The goal, Solotaroff says, should be that every time a physician tells a patient his or her pain medications are going to be cut off or reduced, the patient has immediate access to resources such as a physical therapist and an addiction specialist.

The latter can advise a patient on the dangers of going to the black market for pain meds or heroin, and possibly check in with the patient once a week. The former can offer pain relief alternatives.

That won’t be easy, Solotaroff says, and money is only one of the reasons. Most primary care physicians are not trained in addiction, and are unprepared for dealing with patients who might be gaming the system in search of extra painkillers they can use or black market.

“The primary care and medical community is very separate from the behavioral health and addictions community,” she says. “I don’t think they talk to each other very much. They don’t sit as the same table.”

Oxman says Multnomah County primary care clinics have social workers who can work with patients being weaned off painkillers. But, he says, a comprehensive pain package with a host of alternative pain therapies — what Solotaroff is able to offer — isn’t something the county can provide now. He wishes it could, and he recognizes the potential short-term cost of cutting down on painkiller prescriptions without the alternatives.

“Should we have waited until we had all that stuff in place to change our prescribing practices?” Oxman asks. “I felt there was this moral imperative. We were in a position of knowing our own patients were dying and it would be years before we had adequate capacity.”

Others are searching for alternatives. Volunteers of America’s clinics treat a large number of county residents on probation and parole. Greg Stone, director of the VOA’s inpatient men’s residential drug treatment center in Northeast Portland, says the new 18- to 25-year-old heroin addicts are harder to keep in treatment.

“They can’t tolerate the physical and emotional distress, and they’re not sufficiently motivated to be able to hang in there,” he says.

As a result, Multnomah County has provided money for a pilot project that will allow some of those new heroin addicts to be treated with methadone, an option that almost all recovered heroin addicts abhor, Stone says.

Typically, Stone says, recovered addicts see methadone as substituting one addiction for another, but rarely a path to sobriety.

“We have a crisis right now, so maybe it’s worth giving it a shot,” Stone says.

An ‘evil thing’ takes over life

Chris Pin smoked heroin for three days and knew he was addicted.

Chris Pin used heroin daily for six years, but waited until the day before he entered detox to first shoot himself up with the drug.

Pin grew up in a middle-class home in the Johnson Creek area, partying with alcohol and pot and occasionally cocaine and all the while able to hold down a job as a cable installer.

Pin first tried heroin on a Sunday afternoon. His older brother and some friends called it “a Sunday smack down.”

Pin smoked heroin, got sick, puked and settled into the relaxed state the dope provided. A couple months later, he paid $100 for the phone number of a heroin supplier. He smoked for three days and was hooked.

“I remember vividly a sickening feeling, and my mind was turning me toward heroin,” Pin says, adding that his mind was telling him he could no longer make it through a day without heroin.

Oddly, the first time Pin gave himself an injection of heroin was the day before his mother drove him to Hooper Detox so he could attempt to get clean. Now clean and sober, he recognized the contradiction in his thought process:

“I’m going to be getting clean tomorrow, I might as well try it one time, today,” Pin says.

Pin spent six years as a heroin addict. His favorite place to score was among the day laborers near East Burnside Street and Grand Avenue. He’d wade in asking for “chiva,” and eventually find a supplier.

Pin recalls talking to a Mexican dealer while in jail, and hearing the man say he was going to get deported but he’d just use the opportunity to get more drugs in Mexico and come straight back.

Pin traveled all over the West and tried to buy heroin in cities ranging from Las Vegas to San Francisco and Phoenix, but never found it as easy as in Portland. He knew people who lived in Seattle and would come to Portland for their dope.

Pin, who now has a job as a machinist, says he is still dealing with the time he spent as a heroin addict, because once or twice a year he hears about an old friend dying of an overdose.

“It’s just the most evil thing to me. I don’t know how I ever thought it was fun,” Pin says.

Needle points to new level

Jimmy (not his real name) swore he’d never put a needle in his arm. A steady user of black market prescription painkillers — OxyContin was his favorite — Jimmy was accustomed to paying close to a dollar a milligram for his fix.

A heroin smoker, Jimmy vowed he would never stick a needle in his arm, until someone offered him a free injection. Now, he injects himself daily as the only way to ward off becoming dope sick.

He was a University of Oregon student using recreationally until the night he had only $30 on him, not enough for the Oxy high to which he’d become accustomed. A friend offered him a free smoke of heroin and explained the drug’s advantage — its cost.

“I didn’t know how cheap heroin was,” Jimmy says, adding that he set a limit.

“I vowed at that time that I would never shoot. Once you bring a needle into it, that’s a whole new level.”

But it’s a level most young users find themselves reaching eventually, say addiction specialists.

Now the only way Jimmy can get the rush he desires is from injecting heroin, which he does every morning and sometimes before bedtime.

Jimmy has left school. Until a year and half ago, he was able to work as a Web designer. Now he spends his days as a low-level drug dealer, a lifestyle interrupted by two and a half weeks in jail after one bust.

Drug’s heavy (and low) price

Mike Longatino wasn’t an addict when he arrived in Portland in 1995 at the Greyhound bus station. But, he says, the drug found him quickly enough.

A coin beside his bed marks two years of sobriety for Mike Longatino, who has embraced a life free of heroin at a sober living house in Portland.

“I got off at the bus station and hadn’t walked more than three or four blocks and I was asked if I wanted to purchase cocaine and heroin two or three times,” he says.

He hadn’t even liked heroin the couple of times he’d tried it at parties. But Longatino, 38, says he learned that a small bag of heroin and cocaine — what addicts call a speedball — could be bought for anywhere from $7 to $30. And price, he says, did matter, especially after he reached the point where he would try to shoot up as much as he could in a day.

Longatino began stealing from stores to support his habit. He then turned to burglary and panhandling. Some days, he’d earn $20 begging on the street, and occasionally as much as $200.

It all went for dope.

Longatino says he kicked heroin in jail, thanks to “a cocktail” of drugs offered there that helped him withdraw.

His last jail sentence included a visit to the Volunteers of America inpatient treatment center in Northeast Portland, and after his nine-month stay, with VOA’s help, he moved into the nonprofit Oxford House in Northeast Portland, a facility for recovering addicts.

Longatino knows how lucky he is. Heroin, he says, is almost impossible to permanently leave behind.

“All the people I’ve been through treatment with at the VOA, I can count on one hand the ones who have stayed clean,” Longatino says. “And it’s a really good program.”

From OPB.org, April 27, 2011

LISTEN – The Numbers Have Dropped But Meth Still Takes Its Toll

Police were pleased to see arrests for meth possession drop after the state cracked down on pseudoephedrine – a key ingredient in home-made meth. But the anti-meth policy hasn’t completely insulated Oregon from meth abuse.

The graph of Oregon’s methamphetamine arrests draws a downward slide, starting around March of 2007.

That month, 956 people were arrested for either making, selling, or just having meth. The numbers drop lower, and lower, bottoming out in December 2009, at 542.

All this as the state was tightening access to a key ingredient to illegal meth, pseudoephedrine. It now only sells with a doctor’s prescription.

Joe: “I don’t believe that the legislation toward pseudoephedrine was the end-all, but it definitely assisted us in different avenues of the impact of methamphetamine in our communities.”

You’re hearing a man we’ll call Joe. He’s an employee of the Marion County Sheriff’s Department and works on undercover drug cases.

He asked us not to use his real name, to protect his safety. Standing across the street from a green house in Salem where his department made its latest large bust, he says there’s some good news.

Joe: “What we don’t see is a lot of the kids suffering in the houses where it’s being manufactured.”

Joe and his colleagues no longer routinely find so-called mom-and-pop labs. But he’s still busy. He and colleagues seized five pounds of meth in the green house earlier this month.

And according to statewide figures, meth arrests started to rise again after 2009. There were just under 700 arrests in February of this year. That’s 100 more arrests than in February of 2010.

Police say dealers are selling more meth from California and Mexico.

While the mom-and-pop labs are largely a thing of the past, the state still struggles to get Mom and Pop themselves off meth. Especially Mom.

Sarah Goforth: “At our residential pregnant women and children’s treatment center, it’s still the primary drug and it’s amazing.”

Sarah Goforth is Director of Recovery and Mental Health Services at Central City Concern in Portland. She says the admission diagnoses at even one Central City facility would suggest the meth supply chain is going strong.

Sarah Goforth “At one point a year or two ago, it was really kind of evening out: heroin, alcohol, marijuana and meth. And I thought OK, we’re finally seeing a downward trend. Today if I called over there, it’s probably 75 percent meth, and they’re women”

It’s difficult to track who’s using meth in Oregon with precision. Treatment centers can’t afford to place everyone who wants help in residential or outpatient programs. So no reliable record exists of people who wanted help.

In 2010, the last year for which the Department of Human Services published records, meth was the third most common drug reported as the reason for seeking addiction treatment.

Alcohol and marijuana were first and second, respectively.

Goforth has a theory about why meth addiction has stayed strong, even amid the ups and downs of the economy.

Sarah Goforth: “I’m always leery when I do these interviews because I know there are scientists who would refute this, but I just know from my many years of doing this work. Here you are, you’re a young mom, you start using meth, and you can get stuff done, you can clean the house and ‘Oooo, look at this I’m losing weight!’ And you begin to depend on that level of energy.”

Goforth says meth is a way for women who use it to get by, until the day when it doesn’t work, and the user needs more. She calls meth one of the tougher addictions to break.

One former meth user in recovery can attest to that.

Amber Parke: “It’s not just the meth. It’s the gambling, it’s the crime, it’s the criminality, and all that.”

Amber Parke is a mom and a masters’ student at Portland State. She holds down a job at Portland Community College, where she was a decorated undergraduate.

Many of her classmates didn’t know she’d overcome years of drugs, including meth. She started around 13, even using meth with her mother sometimes.

While her life descended into a fog of petty crimes to fund her addiction, Parke says she ultimately turned things around through 12-step meetings.

Amber Parke: “I remember some of those people sitting in the meetings, and some of the stuff that they talked about that I thought they were all lying about – about how their lives had gotten so much better. It wasn’t really one thing they’d said, it was more the impression of, like, I knew it had worked for somebody. I decided I was going to get clean.”

The kind of recovery Parke is talking about hinges on treatment. And with the state looking at budget cuts this year, it’s not clear how much money there will be to fund state treatment programs.