Dominique Skae returned to the Outer Banks to find the help she needed.
Dominique Skae returned to the Outer Banks to find the help she needed. Photo credit: Taylor Sisk

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<p>Dare County tackles a shortage of substance abuse and mental health services.

By Taylor Sisk

“Opiates took this place by storm,” Dominique Skae said of her home county of Dare. “If you said you didn’t have a family member affected by it, you’d be lying.”

That storm swept her along – prescription pills and then heroin – rocking her world at gale force.

Dominique Skae returned to the Outer Banks to find the help she needed. Photo credit: Taylor Sisk

Skae, 39, grew up in the town of Hatteras, on Hatteras Island, the southernmost area of a county that runs 100-plus vertical miles. She became addicted in the early ’90s, an era, pre-Internet and satellite TV, when isolation in a community such as Hatteras was for real.

Hatteras was a fine place to grow up, Skae said. You had the ocean, and an influx of vacationers in the warm months. But winters were a whole other thing. “There’s not a lot for kids to do, other than after a basketball game at school you’d go to a party.”

Drugs were a ready escape.

That storm still wreaks havoc. Deaths from unintentional opioid pain medication overdose have increased sharply across the state over the past decade and a half, and from 2010 through 2013 Dare County had one of the state’s highest death rates, along with high rates of emergency room visits.

Public health officials will tell you this is a tragedy of epidemic proportions.

The worst years for Dare were 2003 and 2004. As Skae was sinking deeper into addiction, 16 people died from overdose poisoning. Help for those with substance abuse and mental health issues was in very short supply.

But along about that time, a “community uprising” occurred, according to Michelle Decker, supervisor of New Horizons/PORT Human Services, a nonprofit that now provides mental health and substance abuse services and supports in Nags Head.

Recognizing that substance abuse and mental illness are very often intertwined, the community put strategies and resources in place to tackle both, and from multiple fronts.

The county commission allocated a half-million dollars a year for three years to provide treatment services. New Horizons was launched and subsequently incorporated into PORT Human Services, expanding its services, the first facility of its kind on the Outer Banks.

Therapists and prevention advocates reached out to local doctors to encourage them to make better use of the state’s controlled substances reporting system. The school system became more actively engaged in prevention and treatment initiatives.

In 2013, the Dare County Department of Public Health was a finalist for a national Kate B. Reynolds’ Charitable Trust Innovations in Rural Health Award for its comprehensive work in substance abuse.

Hope springs eternal

Dare is not unlike many largely rural North Carolina counties, and it’s dramatically different. It’s similar in that under- and unemployment are relatively high. (The county had the second-highest unemployment rate in the state last year, at 13.8 percent.) Public transportation is limited, and the outer reaches are remote.

What separates Dare from most is that it’s in a resort region, presenting some unique challenges.

Dare has been among the counties in the state with the highest rates of death and emergency department visits due to heroin overdose. Data courtesy of the Department of Health and Human Services, Division of Public Health, Injury and Violence Prevention Branch.

“From a mental health and substance abuse standpoint, it’s going to bring about challenges when your population is normally approximately 33,000 and it goes up to 250,000 from May to September every year,” Roxana Ballinger, the department of public health’s director of education and outreach services, pointed out.

“You’re going to have things that don’t normally happen happen.”

“When people are down here for their one week of vacation,” said Amber Bodner, director of the Dare Coalition Against Substance Abuse, or Dare CASA, “they behave very differently than they do when they go back to Pennsylvania.

“We always say they check their brains at the bridge.”

Spring arrives in Dare County, and “it’s a hopeful time,” Decker said. “Everybody gets really super busy.” The tourists pack in. And while the economic boon is welcomed, the party-time atmosphere unsettles.

Other factors associated with tourism contribute to the instability. Kathy Burrus, a child and family therapist, noted that because service-industry work is seldom your typical 9 to 5, child care can be a challenge. Lots of kids are left home unsupervised in the afternoons and evenings.

Summer rages; then, along about Labor Day, the guests pack up, and the reality of winter sets in.

“Lots of stress and strife, depression, and panic,” Decker said. For many, “sheer panic: ‘How am I going to make ends meet?’”

‘It’s a community’

Skae’s single mom waitressed or cleaned houses, whatever she could find to provide a home for her two daughters.

“She tried to be a good parent and instill good values in us,” but she grappled with drugs and excessive alcohol. “I had to grow up very quickly,” Skae said.

The summer after she graduated high school, Skae settled into restaurant work while unwittingly charting her escape from the island.

First, cocaine.

“It starts out as recreational, just having a good time. And before you realize it, it’s a problem.”

Prescription drugs followed, then heroin. Treatment options were miles and hours away.

Skae became heavily addicted. She moved to Portsmouth, Va. to be closer to her source, found money however she could and served time as a consequence of it all.

Meanwhile, Dare County had been confronting its issues. When Skae returned to Hatteras in 2009, determined to turn things around, she found help. The county’s community health needs assessments had been indicating to local officials that access to behavioral health services was a primary concern. Kids from prominent families were overdosing, regularly making the evening news. Syringes were littering the streets.

The health department took the lead in bringing the community together for discussions, and the launch of New Horizons filled a tremendous void. In addition to therapy, it now offers a substance abuse intensive outpatient program, a full-time physician assistant who can prescribe psychiatric medications and telepsychiatry services. (The health department also offers telepsychiatry.)

Among the school system’s initiatives is the Peer Power Program, in which high school students help younger kids develop healthy lifestyle habits.

Then there’s the matter of interdiction, and local government invested heavily in that as well. Heroin use remains a primary concern. But local law enforcement has recognized the need to be actively engaged with the county’s other resources.

“You’re never going to arrest your way out of the issues that we have here,” said Kevin Duprey, a captain with the sheriff’s department’s criminal investigations division.

“Our strongest advocate since our inception has been law enforcement,” Dare CASA’s Bodner said.

“It’s a community” is Duprey’s view. “We all live here. We can’t overlook the helping of people.”

‘In our infancy’

Gaps remain.

There is no psychiatrist in Dare County, and several health care professionals cite child psychiatric services as the greatest need.

The Dare Coalition Against Substance Abuse’s Amber Bodner says the county has come a long way in 10 years. Photo credit: Taylor Sisk

“If kids don’t get good mental health care, they’re self-medicating,” Bodner said, “then it’s a substance abuse issue on top of the mental health issue.”

Neither is there a detox facility. PORT offers detox in Greenville, Ahoskie and Washington. But as with most communities in North Carolina, there’s a shortage of slots. And even if one can be found, each of those towns is a two-hour drive away, which, Decker emphasized, “is a long trip if you’re in withdrawal.”

Kelly Roberts, a clinical social worker in Manteo, said another major issue is a shortage of behavioral health service providers who accept Medicaid. (PORT does accept Medicaid and operates on a sliding-fee scale.)

But those in the field agree there’s much more hope today for people in need, and they’re optimistic things will continue to improve.

“We’re really in our infancy,” Decker said. “Things that are new and exciting in the Outer Banks are probably things that have been going on elsewhere for a long time.”

A long way

Skae can’t say for certain what brought her to the turning point, only that, “I was so tired of being hopeless and depressed and nothing, that I decided I wasn’t going to do that anymore.”

She saw a therapist for a while at New Horizons’ satellite office in Buxton, on Hatteras Island, got busy with work and life, relapsed, then pulled it together again. She learned of PORT’s Suboxone program in Nags Head, and, to her surprise, was enrolled immediately.

Therapy with Suboxone – an opiate that doesn’t cause a user to get “high,” reduces the craving for other drugs and helps ease withdrawal – has been gaining wide use in treatment programs. Studies show that Suboxone use is more effective at helping people get and stay off addictive opiates than cold-turkey methods.

It helped Skae get to the next step.

When Michelle Decker arrived in Dare County in 2005, she was shocked by the shortage of substance abuse services. Photo credit: Taylor Sisk

“Suboxone is the carrot,” Decker said, “but they need to participate in the outpatient program too.”

Through the first critical months, Skae attended every group session she could, hanging around all day.

“That’s how much I wanted to get my life back.” She now crosses the bridge from her new home in Elizabeth City for a group session every other week and a visit with her counselor once a month.

“Recovery is possible,” is her message to her community.

“This community is really very supportive of people getting treatment,” Decker said. “It seems like everybody is affected.”

“We’ve come a long way in 10 years,” Bodner added. “We try to throw every possible thing that we can at it because it is so complicated.”

Local prescribers’ use of the North Carolina controlled substance reporting system has gone from less than 15 percent in 2009 to 42 percent in May of last year. The sheriff’s department now provides a drop-off for unused prescription drugs. Last year, PORT provided services to more than 2,000 Dare County residents in need. And testimonials such as Skae’s speak volumes to those in the trenches.

“If we weren’t seeing these successes,” Bodner said, “it would be hard to go on.”

[box style=”2″]This story was made possible by a grant from the Winston-Salem Foundation to examine issues in rural health in North Carolina. [/box]

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