Tag Archives: heroin

Inpatient Detox Not So Much In The Ithaca Drug Plan

Another story on the Ithaca drug policy. This was all reported in two days after the plan rolled out, but the story ran another week later. The not-for-profit heads quoted below were a bit offput by the plan’s rollout: the short of their complaint was “We’re working on more solutions … but we don’t go around announcing projects until the funding is worked out.” Photo is of the Dick Van Dyke Center in Seneca County, which, from what I hear, has no connection to the actor Dick Van Dyke. 

A lack of places to go for people to get off addictive substances is a common complaint around Ithaca. Tompkins County has neither an inpatient detox facility nor a crisis walk-in detox. The perception, at least, is that one must be court-mandated or fail out of an outpatient program like those at the Alcohol & Drug Council (ADC) or Cayuga Addiction Recovery Services (CARS) to get a spot in an inpatient detox – the closest of which are in Syracuse, Binghamton, Elmira, and the state-run Dick Van Dyke facility in Seneca County.

Take this quote from someone in the “business” focus group convened to give input to the new Ithaca drug policy for an example of this frustration: “Most people addicted to heroin are going to be on Medicaid. In order to get into in-patient, you have to fail out of outpatient … They need to have three or four dirty drugs screens before they can qualify to get into inpatient, which is where they needed to be initially, which can take 3-4 months.” Or read our June 2014 feature on the heroin epidemic “No Question It’s Gotten Worse” on ithaca.com, which features the frustrations of several people in recovery.

“Insurance is probably our biggest struggle with the inpatient (facility),” said Monika Taylor, director of chemical dependency services at Crouse Hospital, Syracuse, which hosts a 40-bed unit. “There’s supposed to be parity with behavioral health and primary health, but I don’t know if that’s fully happening quite yet.”

Once a patient does get into treatment, sometimes the insurance company might only end up covering a few days of treatment, Taylor said.

“You hardly ever see 28 days (of treatment) anymore,” said Rich Bennett, director of the Ithaca Rescue Mission. “You have to ask if it’s worth it to go into treatment for a week, and then whatever jobs and relationships are there might go away.”

Nevertheless, when someone walks into the Rescue Mission and says “I can’t take it anymore, get me into treatment,” Bennett said they do their best to get someone help because their attitude might “drastically change in three days.”

ADC has been in talks “for a while” with New York’s Office of Alcoholism and Substance Abuse Services (OASAS) to bring an inpatient detox to Ithaca, according to executive director Angela Sullivan. For now, ADC offers what they call “intensive outpatient” programming, which includes three three-hour meetings a week along with medically-assisted treatment for most of its clients trying to get off opiates – a number which has increased from about 5 percent of people calling them their primary drug in 2011 to about a third of the approximately 500 people ADC served last year.

As a state-certified provider of addiction services, ADC does have to reveal a positive drug test to probation or social services, whoever the referring partner might be.

“We do not automatically discharge someone for a positive test,” Russell said. “That is an old school myth that I don’t even think was true 10 years ago. When someone tests positive there’s always a conversation.”

Bill Rusen, CEO of CARS, found the lack of detox options in the Ithaca Plan to be its most objectionable omission.

“Imagine (Cayuga Medical Center) without an ER,” Rusen said. “When CMC was being built, they might have said we’re going to have shamans in there, it’s going to be fantastic. We’re going to have aromatherapy, an ICU, cancer care, cardiac care, but we’re not putting an emergency room in. If you’re having a heart attack you’re really not too interested if the shaman shows up. In this unfair, fallen universe we live in where there’s not enough time, energy, or resources for everything I think the first choice has to be a detox.”

CMC did host a detox until 2009, but “it’s a loser” financially, Rusen said. “You have to have a nurse and a medical person on duty all the time, even if they never saw a patient that day. Even insurance which pays better than Medicaid doesn’t pay enough to cover the costs.”

Rusen said he’s had a proposal “sitting around for about two years” to cover a walk-in outpatient detox, which would cost about $150,000 a year to cover staffing.

Though there’s no inpatient detox for Ithaca in the new plan, one of the recommendations is a 24-hour crisis center, which would serve as a place for law enforcement to bring intoxicated people without going to the CMC ER, a place with short-term temporary beds for people waiting an inpatient bed, and a safe “chill out” spot for people to go rather than being inebriated in public.

At the moment of crisis, the idea for the 24-hour center is to replace trips to the CMC ER, which cost the hospital, Bangs Ambulance, and Ithaca police $413,526.91 in 2015, according to the plan – one of the very few hard numbers included in the report, and one that CMC has made clear is not sustainable.

There is money available for this kind of diversion right now, according to Rusen and Russell, in the form of the Delivery System Reform Incentive Payment (DSRIP). The idea of DSRIP is to reduce avoidable hospital trips by people on Medicaid 25 percent in the next five years, with up to $6.42 billion available statewide.

“I assume this center is going to piggyback on (DSRIP) a little bit,” Rusen said.

The Medical Treatment Options for Opiate Addicts

Here’s the original story I wrote on medically-assisted treatment recommendations in Ithaca’s much-written-about drug policy; it was cut down a bit on the end for print, since Vivitrol wasn’t mentioned in the mundanely-named “Ithaca Plan.”  I thought it worth fleshing out what exactly the issues with these treatments are right now, since no one else was doing it, and especially since in a lot of places recommending something like a methadone clinic would raise hell all on its own (hello, Williamsport!). This story ran as part of our March 2 cover package, a week after the plan’s official release. Photo is mine, of Nicole Pagano, who has an honest-to-goodness soda counter in her pharmacy. 

Beyond the potential “supervised injection facility” for heroin addicts not yet taking steps to recovery, there are many more recommendations in the new city drug policy for new and increased services to help those who want to get and stay off dope. A large part of building the comprehensive “recovery-oriented treatment continuum” the plan proposes is getting people access to what’s called “medically-assisted treatment” – that is, drug treatment that help dull cravings for the dangerous street stuff.

Mayor Svante Myrick said last week that one of the plan’s “low hanging fruit” could be convincing more physicians to prescribe Suboxone – the brand name for a combination of buprenorphine, an opioid, and naloxone, which deters use by injection. Under federal regulations, a doctor can only prescribe the drug to 100 patients at a time.

“If the mayor has a special relationship with the president and he would like to sign an executive order to lift the cap, that would help,” said Dr. John Bezirganian, one of four doctors in Tompkins County currently certified to prescribe Suboxone.

Bezirganian has a private psychiatry practice and is medical director for county mental health and the Alcohol and Drug Council (ADC). Since he started prescribing Suboxone about 15 years ago, he’s treated 520 people with the drug – about 20 of his initial patients are still with him today.

In earlier days, if someone came to him off the street and asked for Suboxone, he told them to go to the ADC, and then he could generally promise to get them onto the drug once they graduated from treatment. Because of the limit on prescriptions, now he has to make choices about his patients.

“To some extent I’m playing God a little bit, but I have to pick the best available people,” Bezirganian said. “If I have to make a choice of a single mother who’s sober and working against someone dabbling in other drugs. A young single guy might say that’s not fair. And it’s not fair. But that’s the way it goes.”

The original limit was 30 Suboxone patients per practice, “but they raised it to 100 because no one was signing up,” Bezirganian said.

A special Drug Enforcement Agency number must be issued for a Suboxone provider. There is a seven-hour course to get certified on the drug, some of which is mere “hoop-jumping training,” Bezirganian said. More so than the training itself, he thinks that more doctors don’t participate because of the effect they think prescribing Suboxone might have on their private practice.

“I think many primary care doctors would be fine if they have five people they like and can do it for them, but they don’t want 30, 50, 100 people coming in the door saying ‘Hi, I want Suboxone,’” Bezirganian said. He gets four or five calls a week, and keeps a few spots open in case someone in special circumstances, like pregnancy, needs the drug.

“If I had the spigot open it’d be limitless,” Bezirganian said. “If all doctors could prescribe it, I don’t know how big it would be.”

Nicole Pagano of the Green Street Pharmacy said she has developed a “good working relationship” with ADC and Cayuga Addiction Recovery Services (CARS) since she opened her shop in 2010.

“I can spend hours and hours and hours on the phone to figure out insurance,” Pagano said. “We try to work out insurance ahead of time. Sometimes we can use coupons for the medication to help someone cover the cost for the first few days … If we can’t treat someone today, they might be lost tomorrow.”

Pagano strives to foster a “judgment-free zone” at GSP; she said many people going on Suboxone are in a situation where they’re afraid of losing their children.

“With no other disease do you have the pharmacist look at you like, ‘Oh, another one of those,’” Pagano said. “Everyone who comes in here is dealing with something … One day of heroin use is more dangerous than a lifetime of Suboxone.”

People in recovery dealing with the aide of methadone right now have to leave Tompkins County to get their treatment. The Ithaca Plan recommends adding a methadone clinic here or even, as Myrick has floated, a mobile unit to distribute the drug.

Monika Taylor, director of chemical dependency at Crouse Hospital, Syracuse, said that there are currently seven patients commuting from Tompkins County on a daily basis to the Crouse methadone clinic. Her clinic can serve up to 650 people at any one time under state regulations, with a waitlist about nine to 12 months long and about 350 people deep right now. The program admitted 265 people in 2015, its most in a year since opening in 1975, and is serving about 550 people at the moment.

The only issues that can move someone up the wait list are either pregnancy or being HIV positive.

“It’s challenging for people to understand we can have a wait list with capacity,” Taylor said. “The problem is when you admit someone into treatment a lot goes into that – methadone is a controlled substance and it requires pretty close monitoring. For the first three weeks or so there’s daily assessment of somebody in that induction phase to get to that therapeutic dose where they’re neither sedated nor going through withdrawal.”

Most people in treatment of opioid addiction do receive some kind of medically-assisted treatment, according to Angela Sullivan, executive director, of ADC. About 33 percent of ADC’s approximately 500 patients last year were admitted for opiates as their primary drug – up from about 5 percent in her first year, 2011. Of that 33 percent, about 27 percent of their total patients received some form of medical assistance.

Heroin-assisted treatment is also mentioned in the plan as something to be explored – providing addicts who don’t respond to Suboxone or methadone with synthetic heroin is a “last resort,” though, according to Peter Schafer of the New York Academy of Health.

One medical treatment unmentioned in the plan is Vivitrol, the brand-name for naltrexone, an opiate blocker that also treats alcohol dependency, which can be prescribed by any doctor and requires a monthly injection.

Alkermes, Vivitrol’s parent company, is “going to every county and pushing it in jails,” Bezirganian said. Because of serious interactions with opiate use, “they tell you only to prescribe it to people who are highly motivated, like an anesthesiologist with a drug problem or people on state parole,” the doctor said.

In an ideal world, Bezirganian said that Suboxone would be widely available for people no matter what other recovery steps they’re taking.

“Some people aren’t that interested in the whole recovery thing, going to groups, which is part and parcel of coming to an agency,” Bezirganian said. “For people coming in using lots of heroin, you could start them on a good dose and lower it over time. You can let people detox themselves.”

Police Not So Pleased With Shooting Heroin, Legally

Here’s the law enforcement angle story about the “Ithaca Plan,” the drug policy rolled out by Mayor Svante Myrick in late February 2016. This story ran as part of our March 2 cover package, a week after the plan’s official release. Image is that week’s cover illustration, representing the “four-pillar” plan, by Marshall Hopkins. The sheriff’s quotes were contributed by my colleague Jaime Cone, who also did a fantastic interview for the issue with the fantastically named Herebeorht Howland-Bolton.  My portion, with IPD Chief Barber, was completed in-person at Island Fitness, a gleaming palace of ellipticals and weights on the Ithaca waterfront; the chief saw me walking outside along the Inlet while working out and he gave me a call. We’d been playing phone tag, and he was leaving for vacation the next day. Score one more in favor of aimless walks. 

The supervised injection facility for heroin users proposed as part of Ithaca’s new municipal drug policy garnered lots of media attention, but not much in the way of praise from local law enforcement leaders.

Tompkins County Sheriff Kenneth Lansing said his department was not consulted in the development of the drug plan.

“We all know that people that are doing things they shouldn’t be doing are paranoid, and I’m just not sure how safe they’re going to feel going to a facility that’s going to allow them to do this,” Lansing said about the injection facility. “There are hurdles with the legality to look at. Nothing against the mayor; I think he’s doing a hell of a job, no doubt about it, and the plan has some great ideas. I just can’t accept [the injection facility], and I can’t support it.”

Ithaca police Chief John Barber said that as “an officer of the law, I have to uphold the law.”

“I applaud Mayor Myrick for coming up with a plan that’s not business as usual,” Barber said. “I don’t agree with all aspects, but [the plan] could do a lot of good and ultimately save lives.”

Even if the injection facility comes to be at all, it’s certainly not happening immediately. The facility does have the backing of Gwen Wilkinson, the Tompkins County district attorney, but as Myrick said at the Feb. 24 press conference the city has “no interest putting time and resources into something that will be shut down a couple days later.” Getting the power to open such a facility will likely take a legal change or at least the governor’s support, the mayor said.

One major recommendation in the “Ithaca Plan” does not face any legal hurdles: starting a“law enforcement assisted diversion” (LEAD) program. The LEAD concept was pioneered in Seattle in 2011.

The “diversion” in LEAD means that police can use their discretion to “reroute people into the intake process, rather than court,” Barber said. One of the findings in the Ithaca Plan is that drug courts “are not a sufficient solution” because of the strict requirements like total abstinence from substances.

The gist of the LEAD idea is to get people struggling with addiction some help, rather than adding to their complications by further entangling them in the criminal justice system or taking them back to the emergency room for one more night that doesn’t solve any of their underlying problems.

“We can’t, and neither can the hospitals, take these frequent fliers—the people who are constantly taking up the professional facilities,” Lansing said. “The hospital doesn’t have the time or the staff to deal with that, and other than putting them in a cell by themselves there’s not much that we at the jail can do. It’s a very difficult thing, withdrawal.”

In July 2015 Albany became the first New York city to approve the concept, and it has since received at least one grant of $70,000 from a private foundation to hire a staffer.

The memorandum of understanding passed by Albany’s Common Council to start their LEAD program calls for a protocol-making committee made up of representatives from law enforcement and relevant county and city departments, like mental health. Non-profit service providers and the Drug Policy Alliance, a New York City nonprofit that played a large role in writing the Ithaca Plan, serve at will on the committee in an advisory role.

In July 2015 Barber attended meetings on the LEAD concept hosted by the White House. He said at the Feb. 24 press conference that he came back “renewed” after seeing how a plan could be “put together for a specific person, and then it’s working.”

Barber couldn’t provide numbers offhand, but said that people with drug problems are responsible for well over half of property crimes in Ithaca.

“People who are addicted are stealing to support their habit,” Barber said. “There are a small number of people in the community who are in and out on a regular basis, and the way we approach it now is not working.”

“Police officers are in the field every day building a rapport with people,” Barber continued. “[LEAD] is really another form of community policing.” •