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By Taylor Knopf
In his 20 years at Healing Transitions, Chris Budnick has never turned away someone seeking help.
But in late March after three false-positive tests for COVID-19 at the residential addiction recovery program in Raleigh, the program director made the tough call to stop all new admissions to the campuses and overnight detox.
Soon after, a 71-year-old man came to the door hoping for a bed to sober up. Turned away, he fell asleep on the side of the road and Healing Transitions staff covered him with blankets.
That incident stuck with Budnick, as he and other Wake County partners worked to quickly set up a remote detox center.
Programs for people who use drugs or are in recovery, like Healing Transitions, have been quick to adapt to the changing needs of their clients. However, some providers are cash-starved and waiting for federal and state funding relief.
Meanwhile, the pandemic has created the perfect storm of stressors, putting those who use drugs or are in early addiction recovery at risk for the COVID-19 virus and overdose.
Homelessness and drug use frequently overlap. With program closures and social distancing in effect, people living on the streets are not only more exposed to virus spread, but they lack basic necessities.
Isolation is a common trigger for people to use substances, which is why a lot of recovery programs are built on peer support. That person-to-person contact conflicts with current public health advice for people to keep their distance to stop the spread of the virus.
Stress and anxiety, which are at high levels due to the widespread illness, job losses, isolation and decreased opportunities for recreational activities, can also also be triggers for substance use.
Finally, people in recovery who have given up substances have a lower tolerance for the quantity they may have used in the past. In particular, people who use opioids are at higher risk for overdose if they return to use.
“What we know from past natural disasters is that overdose rates do go up,” said Becca Lilly with NC Harm Reduction Coalition. “We learned from those experiences to give everyone (the opioid overdose reversal drug) Narcan. People do ask for it. But now, everyone gets it. Even if they say they don’t need it, we ask them to take it.”
Quick to adapt
NCHRC workers were quick to adapt to social distancing because many of their needle exchanges are already mobile. Lilly is based in Wilmington, where she said past hurricanes had prepared the organization to have an emergency plan in place.
Harm reduction staff who work the mobile exchanges have met people where they live or gather to deliver supplies and pick up used needles, all while keeping a distance. At the one fixed site exchange in Wilmington, workers are offering curbside pickup of supplies. And the support groups and check-ins have moved online or over the phone.
Because people are isolated and still using drugs, harm reduction workers are encouraging folks to call (800) 484-3731. Someone from the Never Use Alone initiative stays on the line with the person using drugs to make sure they are OK. If there is no response after they use, EMS is called.
The pandemic has created a unique challenge for residential programs where social distancing is nearly impossible. Congregate living settings are prime breeding grounds for the virus, apparent in outbreaks at prisons and nursing homes throughout the country.
At the guidance of local health officials, Budnick made the difficult decision to close the on-campus detox center on March 25.
“We don’t turn anyone away seeking services,” he said. “This is the first time in decades we’ve had to say ‘no’ to someone.”
Remote detox center
By April 6, the temporary remote detox was up and running at a site next to WakeMed Hospital. The hospital provides the meals and the county donated cots.
In the first four weeks, the detox received 91 people, for a total of 134 admissions, with referrals from former participants, as well as Garner, Raleigh and Cary police departments and EMS. Healing Transitions staff responded to one on-site opioid overdose and saved the man’s life using naloxone.
State data shows that overdose-related emergency room visits increased in March and April over the previous months.
Of the admissions to the detox center, 60 percent of men were using more than one substance when they were admitted. Alcohol was involved in more than half the admissions, cocaine was involved in 47 percent, and heroin in 27 percent. Meanwhile, the majority of women were only using one substance, primarily alcohol or heroin.
While the opioid crisis has been at the forefront of the drug conversation in recent years, stimulant use has also been on the rise.
The remote detox uses RelyMD telehealth visits when needed to evaluate patients showing severe signs of substance withdrawal. Doctors cannot prescribe controlled substances through telehealth, but they’ve been able to prescribe drugs such as gabapentin for alcohol withdrawal, which staff can pick up from the local pharmacy.
Alcohol withdrawal symptoms must be monitored closely, as severe conditions can result in serious organ damage or death. At least two admissions to the remote detox center were transferred to the hospital for treatment of severe alcohol withdrawal, including elevated heartbeat.
“Part of the goal with the running off-site detox is to continue to serve the individual with the need, but also to try to serve first responders and to try to serve the emergency departments and hospitals to avoid people ending up there,” Budnick said.
People can stay at the detox center until their withdrawal symptoms are stabilized and they find a place to go. Since Healing Transitions cannot take new participants due to the pandemic, finding housing for people just out of detox has been more challenging.
Oxford Houses, homes for people in recovery, are still accepting people right now. Healing Transitions staff member Amy Brucia lived in an Oxford House for two and a half years and still maintains a lot of her connections to houses in the area. She’s helped several people leaving detox to navigate the application process and join one of the more than 50 Oxford Houses in Wake County.
Brucia is also on the Oxford House alumni board and the organization has adapted to the needs of people during the pandemic. For example, typically Oxford Houses have a 14-day rule that says you cannot live in the house for two weeks if you have a return to substance use. That has been lifted in many cases during the pandemic, she said.
Healthy hotels and stimulus checks
Wake County, as well as other counties across the state, has set up designated “healthy hotels” and “symptom hotels” to get people out of congregate settings or off the streets during the coronavirus pandemic.
Healing Transitions offered older residents and those with underlying health conditions the option of living in “healthy hotels.” So far, 18 participants have taken the offer. Some leaving the remote detox center have also qualified for the hotels.
But hotel living presents unique challenges for those who use drugs and those trying to stay sober. There’s a lot of time alone and now with the stimulus checks, people have extra cash on hand. Budnick said there’s an expression around tax season every year: your rapid tax refund is your “rapid relapse check.”
“I’m a person in recovery, and I know that if I was in addiction while all of this was going on, and I had a lump sum of money go into my account, I can’t imagine that would be the best,” Brucia said.
Money, isolation and being somewhere or with someone associated with getting high can all be triggers for using drugs again, Budnick said.
“Someone can be in a hotel right now for their own safety, and at the same time be dealing with the memories of getting high in hotels,” he said.
Peer support specialists from Healing Transitions have been checking in to support people in recovery living in the healthy hotels both in person and by phone.
Around the state
Some addiction treatment service providers around the state are cash-starved because they’ve been forced to alter or cancel certain services during the pandemic closures.
Addiction Professionals of North Carolina (APNC) surveyed 70 addiction treatment organizations — both inpatient and outpatient — and found that 57 percent had to close at least one program.
More than 40 percent reported to APNC that they can only survive financially for a month or less under current conditions. Nearly 30 percent have laid off or cut staff, and an additional 40 percent are deciding whether to cut people right now.
APNC found that most community-based programs are operating at half their weekly revenue and their emergency funds are almost gone.
There have been certain flexibilities and rule changes to accommodate behavioral health providers during this time, but it’s a lot to keep up with the different schedules and rules from the different payer sources, said APNC Executive Director Sarah Potter. And some have already maxed out their credit just to keep the doors open through this public health crisis.
There’s some money for behavioral health in the HEROES Act, which was passed by the U.S. House last week and is now waiting for the U.S. Senate to act. Though that won’t be enough to address the needs of the whole country, Potter said it will help. But it cannot come soon enough.
She and other recovery advocates are asking the North Carolina General Assembly leaders for help in the meantime.
“We really don’t have the runway to wait for all those things, and so we’re calling on leadership to earmark emergency funding now,” she said.