Heroin Use and Recovery in Delaware the Current Approach

Welcome to the third installment on Delaware's battles with heroin addiction. In this Hub we will be exploring a little history about the drug and its impact on the State.

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This is the fourth installment of the series on Heroin Abuse and Recovery in Delaware: From a Father's Perspective. This segment will focus on the how we define the "self" and the interplay heroin has.

Part One An Introduction to Heroin Use in Delaware

Part Two History of Heroin and Delaware

Part Three Heroin Use and Recovery in Delaware the Current Approach

Part Four Heroin Addiction and the Self

Part Five Heroin Recovery A Systemic Approach


Figure 1

Small state with a big problem
Small state with a big problem

Heroin Use and Recovery in Delaware: From a Father’s Perspective Part 3

In his 2014, State of the State address, Governor Markell proclaimed, “We all know people with addictions who, with the right intervention, could live fulfilling lives. It’s time for us to put into practice what we already know: addiction is a disease. It can and must be treated.” His comments are supported by a recent CDC statement; “Better access to substance abuse treatment. Effective, accessible substance abuse treatment programs could reduce overdose among people struggling with dependence and addiction. States should increase access to these important programs.” (CDC) The problem is effective intervention does not exist in Delaware. State sponsored programs are for those who have been court ordered to participate or are receiving state benefits such as Medicaid. For those with insurance the bed spaces and types of treatment programs are severally limited.

For this report, treatment programs will be broken down into two major categories, In-Residence and Outpatient programs. All the data for the following comparison tables (Tables 1-6) is based on a search was completed on January 18, 2015, of the following Websites: http://www.helpisherede.com; http://www.aetna.com; and https://provdir.highmarkbcbsde.com/. Each table breaks down a program by county and the type of insurance they accept. We will start out by looking at resident programs, which can be further broken down in to two categories of detoxification and rehabilitation facilities.

A distinction has to be made between detoxification and rehabilitation facilities because the terms are often used interchangeably. A detoxification center does just that; it helps cleans the body of the drug. According to the Kirkwood Detoxification Center’s (New Castle County) website, the average stay is about 5 days. Dover Behavioral Health (Kent County) states that the average stay is about 7 days, but “Patient must be in current withdrawal.” That qualifier emphasizes they are a detoxification facility and not a rehabilitation center. Detoxification alone has a limited chance of breaking the addiction cycle, because it is only addressing one aspect of the disability, there is not enough time spent in the facility to address the psychological dependency. According to the State’s Help is Here, website there are only four detoxification (Table 1) facilities in the state with one located in Kent or Sussex counties. To be admitted to one of these centers the user has to physically go to the facility and wait until a bed space becomes available. It is not unusual for potential patients to be turned away due to a lack of space.

Table 1

Detoxification Centers
New Castle
Sussex
Kent
Help is Here
3
0
1
High Mark
3
0
1
Aetna
3
0
1
 
 
 
 
 
 
 
 
 
 
 
 
It should be noted that the Help is Here DE site also lists Kent Sussex Counseling Services as a detoxification center serving Kent and Sussex counties. However, it is counseling service that provides transportation to a detoxification facility.

A rehabilitation center can also be a detoxification center. Where the person enters into the facility and placed into a detoxification program, once they have progressed passed the immediate need, and then they can begin the process of rehabilitation. According to the National Institutes of Health (NIH), residential programs last up to a year.

Residential treatment programs can also be very effective, especially for those with more severe problems. For example, therapeutic communities (TCs) are highly structured programs in which patients remain at a residence, typically for 6 to 12 months. TCs differ from other treatment approaches principally in their use of the community—treatment staff and those in recovery—as a key agent of change to influence patient attitudes, perceptions, and behaviors associated with drug use. (NIH)

The extended time frame is needed to help re-socialize the individual to drug free lifestyle. Most of the rehabilitation centers talk about a 30 day stays in their facility, well short of the recommended minimum of 180 days. There appears to be a disparity between the theory and application which may be driven by cost. An average stay at a facility is $700.00 to 900.00 a night, so the difference is $135,000.00. Table 2 has identified only two facilities, both of them are located in New Castle County and either one takes health insurance offered to State Employees.

Table 2

In Residence Rehab
New Castle
Sussex
Kent
Help is Here
2
0
0
High Mark
0
0
0
Aetna
0
0
0
Public Assistance
2
0
0

A subset of the In Residence programs is Recovery Living Facilities. The major difference is the clients during the day are not tied to the facility. They go to work, school, or whatever activity are involved with and return to the house at night. This provides them with a clean, sober, and safe place to build upon their sobriety. The Help is Here site identifies 79 (Table 3) of these houses throughout the state. The houses depend on public funding, donations, and charging of fees to meet their financial need.

Table 3

Recovery Living
New Castle
Sussex
Kent
Help is Here
53
20
6
High Mark
0
0
0
Aetna
0
0
0
Public Assistance
53
20
6

Generally speaking, an outpatient recovery program has a very board application, but normally is implying some sort of structured daily program. When it comes to opiate recovery, “Opioid treatment programs (OTPs) are regulated by the Substance Abuse and Mental Health Services Administration and are permitted to dispense the medications methadone and buprenorphine to treat addiction to opioids (e.g., heroin and prescription pain relievers such as oxycodone or hydrocodone).” The National Survey of Substance Treatment Services (N-SSATS) report goes on to say;

“The risk of relapse can be reduced during detoxification and treatment when medication-assisted therapies are used to control the withdrawal symptoms. The Food and Drug Administration (FDA) has approved three medications for the effective treatment of opioid addiction: methadone, buprenorphine (Suboxone® and Subutex®), and naltrexone. Methadone, in use since 1964 for opioid dependence, may be dispensed only in federally approved opioid treatment programs (OTPs). Treatment protocols require that a client take the medication at the clinic where it is dispensed daily; take-home dosages are allowed only for clients who have been in treatment for a specified period of time and if other conditions are met. However, physicians who obtain specialized training may prescribe buprenorphine. Thus, it is possible for buprenorphine-trained physicians to operate out of private practices and through substance abuse treatment facilities or programs. Research shows that buprenorphine may be best matched to people with mild to moderate opiate dependence, while methadone can be used for patients at all levels of opiate dependence.” (The N-SSATS Report)

The Help is Here site references roughly 55 outpatient programs in the state, with only 20 clearly identified as being able to use medication to help the patient step down from the drug. However, if you are an employee of the State and utilize HighMark Blue Cross/Blue Shield insurance option the closest facility is in Springfield, Virginia, which is about 100 miles away from Dover, Delaware. Without clinics that use medication, “Users also experience severe craving for the drug during withdrawal, one which can precipitate continued abuse and/or relapse.” (Larsen 241) Ms. Diane Jones, a mother of a recovering addict, highlighted this point in a 2013 letter to the health Care Commission. Upon her daughter's release from a facility that was utilizing Suboxone®, the family had a challenge finding a medical practice to continue the treatments. “The ones we spoke to did not choose to accept her father’s State of Delaware Blue Cross insurance plan. Medicad seems to be preferred method of payment for substance abuse providers.” (Jones) This mother was pointing out that in Kent County if you are a recovering addict and you have state employee insurance there are no options for outpatient medication assisted programs. The choices are self-pay which will cost up to $400.00 per dose, or illegally buy the drug off the street from the same types of dealers who are selling the heroin. However, if you have no insurance coverage and are on public assistance, 20 clinics will take you as a client. (Table 4)

Table 4

Med Assisted
New Castle
Sussex
Kent
Help is Here
7
11
2
High Mark
1
4
0
Aetna
3
2
0

There is no agreement between addiction professionals about the use of pharmaceuticals to treat or break the habit. Remember that many of the problem drugs of today were once heralded as miracle drugs. As an alternative Out-Patient Non Medication facilities are clinically staffed services that work with the user to break the physiological dependency of heroin. In Delaware there 35 such facilities (Table 5) with the majority of them in New Castle County.

Table 5

Non-Med Assisted
New Castle
Sussex
Kent
Help is Here
19
9
7
High Mark
3
1
2
Aetna
4
0
2
Public Assistance
19
9
7

Support Groups are nonprofit, voluntary gathering of people in mutual support of each other recovery. Many are based on principles contained in the 12 step of Alcohol Anonymous. As Table 6 shows the majority of these groups, (87%) are in New Castle County. As a side note, according to urban legend, one of the easiest ways to find heroin in a city you are unfamiliar with, is find a local Narcotics Anonymous meeting and someone will be there to hook you up. I have witnessed clients of a detoxification center arranging with other patients to get high as soon as they leave the facility.

Table 6

Support Groups
New Castle
Sussex
Kent
Help is Here
196
12
18

No report on heroin usage would be complete without a discussion about law enforcement and the judicial system, which has to deal with the residual aspects of the problem. The use of heroin is against the law and those participating in this activity stand a chance of incarceration for the use of the drug and crimes in support of their addiction. In 2013, drug use convictions has helped the United States has become the most incarnated country in the world.

At the end of 2012, nearly 7 million adults were involved in the criminal justice system—either on probation, parole, or incarcerated in jail or prison. The United States has the largest per capita prison population in the world, a costly statistic in terms of both money and societal impact. In too many cases, individuals with substance use disorders are sent to jail or prison when drug treatment—or alternatives such as drug courts—can achieve better outcomes at reduced costs. The long-lasting and far reaching consequences of criminal justice involvement are an impediment to employment, housing, and education, all necessary for a strong recovery and successful reentry into the community. (National Drug Control Strategy 25)

I am not advocating for a free pass for heroin users if they commit or participate in other criminal activity. They have to be held accountable for their actions. However, the public attitude about drug user is changing, where many states used to have mandatory sentences for non-violent possession violations, are now beginning to rethink those policies. The following is from a PEW Research Center.

More than six-in-ten (63%) say that state governments moving away from mandatory prison terms for non-violent drug crimes is a good thing, while just 32% say these policy changes are a bad thing. This is a substantial shift from 2001 when the public was evenly divided (47% good thing vs. 45% bad thing).

Across nearly all demographic groups majorities say that the move away from mandatory prison terms is a good thing, and in most cases these percentages have increased by double digits since 2001. Majorities of both men (64%) and women (62%) view these policy changes as a good thing – up 13 points among men and 20 points among women. In 2001, women were less supportive than men of sentencing revisions. Half of women said it was a bad thing compared with 40% of men. (Pew)

States are recognizing that diversion programs for non-violent offenders makes practical sense. The cost of serving time in prison far outweighs the cost of a diversion program. The individual has the opportunity to remain in the community while going through the recovery process. According to the Delaware State Courts’ web site, “A recent study showed that those who successfully completed Track I treatment were less likely to be re-arrested within 18 months following release. Statistics also show that this program has been successful in reducing the number of drug-addicted babies born to previously addicted mothers who have completed the program.” (Delaware State Courts)

If a person finds him/herself serving a long term incarceration (at least a year) in one Delaware’s state run prison, who happens to have a substance abuse issue, the Department of Corrections (DOC) has a comprehensive program to assist inmates. “Delaware's internationally-acclaimed, 3-step substance abuse treatment program (KEY, Crest, Aftercare) is proven to be successful in rehabilitating drug offenders. Treatment follows the offender from incarceration to work release to the community. Delaware was the 1st state in the nation to fully implement such an aggressive offender substance abuse program.” (DOC) The reasoning behind the program is the recognition that about, “80% of the State's offender population has issues related to substance abuse.” (DOC) Addressing the issue of substance abuse within the inmate population helps to reduce the number of repeat offenders the systems sees. Even with this program, the inmate faces two social stigmas upon their release, that of an addict and convict.

While the opinion of how to judicially deal with the addict vary, a major hurtle that has to be crossed is the stereotype of the heroin user. As a 2014 John Hopkins’, study states:

People are significantly more likely to have negative attitudes toward those suffering from drug addiction than those with mental illness, and don’t support insurance, housing, and employment policies that benefit those dependent on drugs, new Johns Hopkins Bloomberg School of Public Health research suggests. (John Hopkins)

The nature of the disease when it is full-blown engagement with the addict, the credibility, trustworthiness or dependability of the user is questionable. The need for the release of the drug takes over the thought process. Even with recovery there doubt about the accountability of the emancipated user. Part of the skepticism is due to the high rate of relapse and many former addicts will need a lifetime of support and monitoring to maintain their sobriety. Everyone is an individual so how the drug interacts with them and length of time for them to get clean varies.

Figure 2

Show how drug addiction relapses compare to other serious health conditions.
Show how drug addiction relapses compare to other serious health conditions.

Part of the issue society has with addicts is the fact they had made a choice which contributed to their life situation. There are many more choices that have to be made by the individual such as, are they going to get clean, are they going stay clean, are they going to get help if they do fall. The reality is that a number of people who try to break free of the addiction have a relapse. Some go through the process several times, while others are never successful in their efforts. According to a NIH, chart (Figure 6) 40% to 60% of patient relapse, not unlike patients on programs for other serious medical conditions. These statistics are easy to overlook when you combine the fear of relapse with the decades of demonization of the user, making the securing of public support for the recovering addict a challenge.

Next Chapter

Here ends part three of the series. In the next Hub, Addiction and the Self, highlights the relationship between the drug and person.

Should everyone have access to rehabilitation services?

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References

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Figures:


Figure 2: http://www.drugabuse.gov/publications/addiction-science/relapse/relapse-rates-drug-addiction-are-similar-to-those-other-well-characterized-chronic-ill

Tables:

Table 1: Detoxification Centers by County and Health Insurance:

Delaware Division of Public Health. Delaware Health and Social Services. Help is Here Delaware. http://www.helpisherede.com. (Accessed January 18, 2015)

Aetna. http://www.aetna.com. (Accessed January 18, 2015)

High Mark Blue Cross/ Blue Shield. https://provdir.highmarkbcbsde.com. (Accessed January 18, 2015)

Table 2: In Residence Rehabilitation Centers by County and Health Insurance.

Delaware Division of Public Health. Delaware Health and Social Services. Help is Here Delaware. http://www.helpisherede.com. (Accessed January 18, 2015)

Aetna. http://www.aetna.com. (Accessed January 18, 2015)

High Mark Blue Cross/ Blue Shield. https://provdir.highmarkbcbsde.com. (Accessed January 18, 2015)

Table 3: Recovery Living Facilities by County and Health Insurance:

Delaware Division of Public Health. Delaware Health and Social Services. Help is Here Delaware. http://www.helpisherede.com. (Accessed January 18, 2015)

Aetna. http://www.aetna.com. (Accessed January 18, 2015)

High Mark Blue Cross/ Blue Shield. https://provdir.highmarkbcbsde.com. (Accessed January 18, 2015)

Table 4: Medication Assisted Out-Patient Programs by County and Health Insurance:

Delaware Division of Public Health. Delaware Health and Social Services. Help is Here Delaware. http://www.helpisherede.com. (Accessed January 18, 2015)

Aetna. http://www.aetna.com. (Accessed January 18, 2015)

High Mark Blue Cross/ Blue Shield. https://provdir.highmarkbcbsde.com. (Accessed January 18, 2015)

Table 5: Non-Medication Assisted Out-Patient Programs by County and Health Insurance:

Delaware Division of Public Health. Delaware Health and Social Services. Help is Here Delaware. http://www.helpisherede.com. (Accessed January 18, 2015)

Aetna. http://www.aetna.com. (Accessed January 18, 2015)

High Mark Blue Cross/ Blue Shield. https://provdir.highmarkbcbsde.com. (Accessed January 18, 2015)

Table 6: Support Groups by County in Delaware

Delaware Division of Public Health. Delaware Health and Social Services. Help is Here Delaware. http://www.helpisherede.com. (Accessed January 18, 2015)


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Comments 4 comments

lions44 profile image

lions44 14 months ago from Auburn, WA

I've always favored a "lockup treatment center" approach. Very sad situation. Kind of shocked that Delaware has such a problem. It's everywhere, but I would have said a state with major cities. Good article.


Mark Monroe profile image

Mark Monroe 14 months ago from Dover De Author

Lions44 thank you for taking the time to read and comment on my Hub


Larry Rankin profile image

Larry Rankin 14 months ago from Oklahoma

Wonderful process analysis.


Mark Monroe profile image

Mark Monroe 14 months ago from Dover De Author

Larry

thank you

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