For Some Opioid Users, Homelessness Becomes Barrier To Treatment

Jul 8, 2019

State officials say a dramatic increase in treatment services for opioid use disorder has mostly eliminated waitlists for Vermonters trying to get into recovery, but some active opioid users in Brattleboro say they continue to face barriers to care.

There's a picturesque park in downtown Brattleboro, where you can sit on one of the wood benches and listen to a brook that's so close you could drop a rock in it. Most people in town refer to this place as the Whetstone Pathway, but Shawn O'Dell has a different name for it.

"I call this my living room. Because everybody's here, right?" O'Dell said last month.

By "everybody," O'Dell means people in situations like his: substance users experiencing homelessness. They congregate here in surprisingly large numbers these days.

O'Dell is 49 years old and rail thin, wearing a plaid shirt, dark green coat and an old pair of well-worn Carhartts. It's a beautiful spot, this "living room" of his, right across from a high-end food co-op — and that makes the drug scene here all the more unexpected.

"When people are going by, we're smoking weed. ... You know, some of us do crack down here," O'Dell said.

About 30 seconds after arriving at the park, I told O'Dell, I saw a man snorting some kind of powder from a small folded envelope. O'Dell said open-air opioid use is common these days.

The results can be catastrophic. O'Dell pointed to a spot of ground about 10 feet from where we were sitting: "Over there? Look over there," he said. "That's where I fell out on April 7. Overdosed, right there."

According to the Department of Health, Windham County had the highest rate of fatal opioid overdoses in Vermont last year.

Brattleboro is having a tense public discussion right now over quality-of-life issues associated with substance use, panhandling and homelessness. That's not what this story is about, however.

This story is about how O'Dell, and the people in his "living room," perceive a substance use treatment system that's supposed to help them get on a path to recovery.

I asked O'Dell whether he feels like he has ready access to treatment services: “No, no, no, you can't. There's a waiting list,” he said.

O’Dell said he'd like to get clean again.

"I'm thinking about it, really am. I had 15 months. That's a good stint. That was the best time of my life, really,” O'Dell said. "But you know how addiction is — once you relapse, it's hard to go back."

Hard to go back and hard to find a provider to help you get back, according to one woman I talked to at the Whetstone Pathway.

"I know of a lot of people who are waiting a long time to get into recovery, and because of that they stay out here," she said.

The woman did not want me to use her name — she just got approved for subsidized housing, and she said she's worried about jeopardizing her placement.

In September 2017, state officials declared that Vermont had arrived at a place where most active users can access "treatment on demand." According to this woman, that just isn’t true.

"If let's say I'm using yesterday and today I'm going to get clean, no, I can't just hop into the Retreat, you know, even though I have Medicaid,” she said referring to the Brattleboro Retreat, a so-called treatment "hub" in Windham County.

More from VPR — Hub-And-Spoke Opioid Treatment Program Has Grown In 5 Years Since Shumlin Speech [Jan. 9, 2019]

The latest state-issued census on Vermont's treatment system says there are zero people waiting for treatment in Windham County. It also says there are also zero people waiting for services at the other geographically scattered treatment hubs.

Tony Folland, the manager of clinical services at the Vermont Department of Health's Opiate Treatment Authority, said those waiting list statistics refer to people looking for medication-assisted treatment — with Suboxone, for example — at one of the state's nine treatment hubs.

According to Folland, gaining access to treatment shouldn't be as difficult as users in Brattleboro have found it to be. He said O'Dell, or anyone else in Brattleboro for that matter, could walk into the Brattleboro Retreat, or another Brattleboro treatment clinic called Habit OPCO, and ask for help right away.

"You can either call them or walk into their program," Folland said, "and they will start doing an assessment."

Folland said clinicians also provide medical support services, in addition to medication.

"They go in for medicine every day. They're assessed by a nurse every day," Folland said. "It's really around getting them on a stable dose of medication that replaces the narcotics they've been using on the street."

Folland said active users won't always be able to start on medication assisted treatment the day they seek help.

"Yes, there is a bar, there is a bar to get into [treatment], because we're going to be starting someone on a narcotic medicine," Folland said. “And we want to make sure that patient has full informed consent of what that means."

But Folland said providers stand ready to work quickly with people with opioid use disorder and that those providers appreciate the urgency the situation requires. Maybe not same-day treatment, all the time — but quick, he said. Residential detox services, Folland said, are rarely more than a two- or three-day wait.

The picture Folland paints, however, differs significantly from the one some people in Brattleboro say they're seeing.

"You're not reaching out because you don't need the help. You're reaching out because you need the help. You're at the lowest of your low, and you can't take it anymore. And to get turned away at that point, that crushes — crushes — a person's mind." — Nicholas Kane, recovering opioid user

Nicholas Kane is another Brattleboro resident experiencing homelessness. I met with him outside a coffee shop in downtown Brattleboro, along with Brenda Siegel, the local resident who also introduced me to Shawn O'Dell.

Kane is a former user who's in recovery now; he picks up his medication daily from the Brattleboro Retreat. He said Folland's account just doesn't jibe with what he sees around him.

"I know that because I've been through it myself. I know it firsthand," Kane said. "There is help, to a certain extent. But, if you don't meet that criteria that they have, you don't get any help."

For active users who decide it's time to get clean, Kane said, the hours between when they ask for help and when they get it are potentially the most critical ones of their lives.

Kane said many users he knows have to wait much longer for care than state officials suggest. And he said even a one- or two-day wait can be the difference between recovery and overdose.

"You're not reaching out because you don't need the help. You're reaching out because you need the help. You're at the lowest of your low, and you can't take it anymore," Kane said. "And to get turned away at that point, that crushes — crushes — a person's mind."

Nicholas Kane, a former user who's in recovery now, picks up his methadone daily from the Brattleboro Retreat. The Retreat is one of the state's "hubs" for opioid treatment.
Credit Howard Weiss-Tisman / VPR

So how does one reconcile the state's assessment of the treatment landscape in Brattleboro with accounts like the one from Nicholas Kane?

"You know, I think there's a complexity to this issue," said Susan Walker, the director of Turning Point of Windham County — a meeting place and resource center in Brattleboro for people in recovery. "There's layers of complexity, really, that I'm not sure people appreciate."

It's true, Walker said, that Vermont has seeded Brattleboro and other communities with numerous treatment options for opioid users. And it's also true, she said, that some of those users still struggle to access those services.

"We know there are still barriers there for some people. Yes, there is a lot of treatment on demand and there are a lot of services," Walker said. "But, the kinds of things we see sometimes are that somebody at one point left against medical advice, and now a provider is reluctant to take them again."

Walker said a user's financial means can be a factor.

"It could be a matter of insurance," Walker said, "which sometimes is a matter of just simply saying to somebody, 'Yeah, you don't have insurance, but you're eligible for Medicaid, so let's help you with that.'"

And Walker said homelessness could also impede a person's access to treatment.

"The homelessness gets in the way of people being able to access some services, because some providers want to be sure that there's a safe place for them to go to once they come out of treatment," Walker said.

"The homelessness gets in the way of people being able to access some services, because some providers want to be sure that there's a safe place for them to go to once they come out of treatment." — Susan Walker, Turning Point of Windham County

According to the Department of Health, Windham County had the highest rate of fatal opioid overdoses in Vermont last year. Tony Folland, at the State Opiate Treatment Authority, said it also has some of the lowest rates of uptake for substance use treatment.

Brenda Siegel, a treatment advocate who lobbied for several measures in the Statehouse earlier this year, said those statistics signal a serious problem.

If Vermont wants to beat its opioid problem, Siegel said, it needs to hear what Kane and O'Dell are saying.

"If we just listen to the people who are actually experiencing the problems, then we're going to find solutions to the problems," Siegel said.

Walker said a group of organizations in Brattleboro is doing precisely that sort of listening right now. Windham County won a $200,000 federal grant that's being used to assess shortcomings in the region's treatment system.

"And so part of what we've done, through focus groups and forums, is talk to a lot of people to get various perspectives on how things are working and not working in our county, and where the gaps are," Walker said.

Walker said the effort has included conversations with service providers, first responders, police, people in recovery, as well as people who are actively using opioids. Folland said the people running Vermont's treatment apparatus are eager to hear what they have to say.

"Because they are trying to figure out how to make the services more appealing and less barrier-driven," Folland said, "so they can get more people into care."