Oregon pays steep price for neglected addiction treatment system

Jesse Cushman sat in the portable outhouse, weeping.

A few steps away, his children pleaded with their mother to see him, unaware of his hiding spot.

A barrel-chested 36-year-old mechanic, Cushman dared not step out. The recovering meth addict was under orders to stay away from his two sons and three daughters.

As he wept, Cushman resolved to get treatment.

But in doing so, he joined thousands of Oregonians in a system with its own troubles.

The state agency in charge has little clue whether treatment clinics work. Public officials have failed for decades to act on recommended reforms, showing little will to do better. An estimated 303,000 Oregonians remain untreated for alcohol or drug abuse, according to national data.

As a result, the state is in an undeclared public health emergency that affects every Oregonian, addicted or not.

At the heart is the state Addictions and Mental Health Services Division, a unit of the state's biggest agency, the Oregon Health Authority. The division regulates clinics, doles out millions for treatment and is supposed to lead the way to achieve better care.

It does none of it well, The Oregonian found, after reviewing more than 5,000 pages of government records, and 100 interviews with state and county officials, counselors, legislators, law enforcement officials, nonprofit executives and recovering addicts across Oregon.

To ensure Oregonians are getting good care, agency auditors inspect the state's 235 treatment clinics. But the agency is a paper tiger, fixated on whether the clinics' forms are in order.

Treatment clinics regularly report how many patients they get, how many are engaged in treatment and how many complete their care.  That information has been pouring into the state since 1999.

The agency never uses it.

» See the treatment providers and their success rates. 

The data indicates whether a clinic is delivering results, or just moving patients through in rote. For taxpayers and legislators, such numbers tell whether public money is well used. Treatment clinics, for instance, receive $124 a day in public money for each adult getting residential treatment.

The data is not hard to generate and is revealing. Last fall, the agency finally ran a compilation, but only at The Oregonian's insistence.

The results unveiled abysmal success rates.

For example, Clackamas County's in-house clinics reported only 36 percent completed care compared to the state average of 59 percent. Native American Rehabilitation Association of the Northwest also posted a completion rate of 36 percent. Volunteers of America, a close partner with Multnomah County on treating offenders, had a 41 percent completion rate. State officials agreed such numbers are alarming, because it means most of those clients return to the community with their addictions unresolved.

State workers compiled performance information by county four times a year, but they didn't act on that either. They don't run the report any longer.

"I wasn't paying attention to this report," acknowledged the division's administrator, Karen Wheeler, who has been with the agency 18 years. "It's not been that important."

Wheeler and her colleagues don't track another key measure of the addiction system's performance – the relapse rate.

Because addiction care is so challenging, patients frequently relapse and return over and over. A high relapse rate could mean many things, including that inadequate treatment from the start. It also is expensive.

At The Oregonian's request, the agency calculated readmissions among those who participated in residential treatment, the most intensive and costly service. The agency reported that in 2010, about one in six discharged patients returned within a year for more treatment.

The agency also doubled back last fall to recover $753,000 in overpayments to treatment clinics. The cost overruns had been overlooked for more than a year until The Oregonian asked about them.

When questioned about the agency's poor use of data, executives assessed every report the agency generated. They discovered that not one was used to improve clinic performance – or the agency's own work.

Yet a revamped system to provide information that executives need to manage the state's care only recently was functional -- a year after its launch. Yet officials said last week they still aren't producing the expected reports.

"The agency continues to work with providers to improve data quality and data submission," the Addictions and Mental Health Services Division said in a statement to The Oregonian last month.

***

The financial drain on Oregon from this ineffectual system is staggering – nearly $6 billion a year as calculated in a state-sponsored study in 2006, the last time such an analysis was done.

The $6 billion problem

What substance abuse costs Oregon in a year, based on latest calculation, done for 2006:

Lost earnings:

$2 billion – due to substance abuse

$1.2 billion – due to criminal conduct, victimization

$978 million – due to premature deaths

Healthcare:

$506 million – medical costs and insurance administration

$307 million – drug and alcohol services

Other costs:

$656 million – Criminal justice costs

$271 million – Motor vehicle crash damage

$26 million – Fire damage

$13 million – Welfare costs

Source: ECONorthwest

Addicts miss work and cause on-the-job injuries. Addicted doctors, nurses and other professionals endanger their patients.

Addicts strain the medical system, resorting to costly last-ditch care for health problems caused or worsened by their abuse. Their children often are moved to foster homes, which the state said costs taxpayers $31,000 a year per child.

Addicts resort to crime, particularly burglaries and thefts that each year turn thousands of Oregonians into victims. Their demand for drugs ensures a growing market in Oregon for Mexican cartels. And they jam the prison system, caught for crimes committed to get cash for their substance abuse.

Because of health care reform, more addicts than ever have a chance for treatment, but hurdles remain. Reform counts on the medical community to take over, but doctors have virtually no training in addiction care.

Reforms are hobbled by misperception, as well. Addicts face a public attitude that substance abuse is a moral failing. In fact, addiction dramatically rewires brain chemistry into a disease that cannot be undone by sheer will power.

Experts say that even if Oregonians scorn substance abusers, they should demand in their self-interest a better system.

A 2010 state report, one in a string of reform-minded projects, concluded that better addiction care would mean "fewer children will be abused and fewer crimes committed."

"What many don't realize is that someone with a serious addictions disorder is going to have their body fall apart in a relatively short period," said Dale Jarvis, a consultant who recently studied Oregon's addiction system. "They are going to become disabled, if they don't die first. They are going to end up costing the taxpayer an enormous amount of money treating their serious health conditions, and then they are going to die early."

***

Kelly Goss, a former thief and heroin addict, more plainly explains how Portlanders benefit from his recovery.

"People aren't losing their heirlooms. They don't have to feel violated. They're not spending money on keeping me in jail," said Goss. "And I'm paying a lot of taxes."

Once known to police as the "West Hills Burglar," Goss now owns a string of privately run drug-free homes for recovering addicts.

Oregon's system, though, remains what one treatment executive terms a "third world industry," impaired by inadequate funding, research, and support.

Gov. John Kitzhaber acknowledged in a 2013 interview that Oregon's system is "misorganized and mismanaged."

State Sen. Alan Bates, a Democratic physician from Medford and a key state budget writer, agreed.

"We have been unsuccessful. We have not done a good job because of a lack of a system," Bates said.

The Addictions and Mental Health Services Division hasn't succeeded in building that system, largely because it hasn't provided persuasive data to state leaders.

"We know what works as far as prevention and treatment. But do we fund it? Absolutely not," said Greg Stone, manager of the Portland men's residential treatment program run by Volunteers of America.

Dan Ward, executive director of the state Alcohol and Drug Policy Commission, agreed.

"The number one issue is not enough funding and not enough momentum politically to get more treatment out there," Ward said.

People enter the system through several doors.

Many are compelled to get treatment because of criminal conduct or driving arrests, and they typically end up in publicly funded programs. Others are guided to treatment by family or friends, checking into the publicly funded programs, or relying on insurance to enter private treatment centers.

Last year, 22,620 Oregonians used publicly funded care. Because of the complexity of the system, state officials couldn't calculate the cost, although the agency gets about $40 million a year in state general fund dollars.

No one tracks the number of patients using private clinics. Moda Health, one of the state's largest insurers, calculated for The Oregonian that it paid out $6 million last year to treat 1,600 for addictions.

Hooked on Failure: The series

• A months-long investigation by The Oregonian discovered troubling failures in Oregon's addiction treatment system. Substance abusers are paying the price – and so are Oregonians who continue to be their victims. The estimated annual cost to taxpayers: $6 billion.

Statewide, substance abusers don't get effective care because there isn't enough money.  Addiction counselors – nearly 3,000 certified in Oregon – carry caseloads double the national average. They run group sessions double the recommended size and spend one-fourth the time set by national standards for one-on-one counseling.

Counselors said their ability to treat addicts is further impaired by paperwork requirements.

The Addictions and Mental Health Services Division, for instance, mandates detailed notes about each group session, said Leslie Kendall, a Medford clinic counselor. They are generated solely to satisfy state inspectors.

"We're not using the notes" for counseling purposes, Kendall said.

Meanwhile, counselors in Oregon are paid little better than fast food workers because agencies are so short funded.

"You're making nine bucks an hour and people are yelling at you," said Wheeler. "Counselors are cheap, unfortunately."

***

Patients who complete treatment often leave with little more than some literature and encouragement to join an outside support group. Clinics don't get paid to make counselors available afterward, or to provide any other help.

Experts say that leaves a gaping hole in Oregon's system.

"I don't have time to go chasing after people," said Sue Haines, a counselor. "I don't have time to be calling up people and encouraging them."

Recovering heroin addict Siggy Torfason, 36, has been in and out of Portland-area clinics for years. A short stint in a residential treatment center isn't enough, she said.

"How is 28 days going to make a huge difference? You just don't get to use for 28 days," she said.  "Life change is needed. You don't learn it in a month in a treatment center."

Experts say attention after formal treatment – called after care or continuing care – dramatically improves results.

A company called Hazelden, part of the Hazelden Betty Ford Foundation, operates treatment centers across the country, including in Newberg and Beaverton.  The company realized there was more to treatment than a stint in a clinic.

"We got stuck in treating this like an acute illness – 'Here's your 28 days of care.' The insurance companies were saying, 'Why didn't you fix them?'" said Janelle Wesloh, Hazelden's executive director for recovery management.

The company now builds in 18 months of continuing care once a patient completes the initial program, working with a "recovery coach." Hazelden's research found that time span to be optimal.

Wesloh said the constant contact means that if there is a relapse, "we can intervene quickly so the damage is not so great."

Oregon applies this principle to licensed health professionals.

In 2009, the state reorganized the way it spares the licenses of physicians, nurses, dentists and pharmacists who abuse drugs or alcohol. They are required to undergo treatment. Once that's completed, the licensee must call in daily, turn in urine samples and talk weekly with an adviser. The monitoring, paid for by the individual, lasts five years. The state counts 241 enrolled currently.

But addiction counselors say nothing comparable is available to the far larger pool of addicts treated in publicly funded systems. Counselors have no doubt they could cut down on relapses – and the costs of more rounds of treatment – with such continuing care.

"Imagine you're on a diet and your weight is being monitored daily by a nutritionist," said Wanda Urban, an addiction counselor and community college teacher. "If you know you're going to be weighed by someone each day, you're more likely not to cheat."

Pam Martin, director in charge of the state Addictions and Mental Health Services Division, told The Oregonian she was unaware aftercare was an issue.

***

Another flaw in Oregon's system is the lack of safe housing. Treatment providers, counselors, and addicts themselves say the best chance of getting an addict to abstain means a place to live free of the wrong influences.

"You don't want them going back to an uncle's house, who's drinking a beer every day in front of them," said Silas Halloran-Steiner, director of the Yamhill County Department of Health and Human Services.

Central City Concern, a Portland nonprofit serving the homeless, pioneered subsidized housing for addicts who have been through treatment. Such housing is crucial to success. An intense study of 87 clients showed that just four returned to substance abuse after treatment.

Public attitude remains a roadblock to dramatically changing Oregon's addiction system.

Tim Hartnett, executive director of CODA Inc. in Portland, said public policy for too long has been built on a "stunningly wrongheaded" practice of considering abstinence as the only measure of success. "We don't do it with any other disease."

Dennis McCarty, a professor and researcher in addictions at Oregon Health & Science University, agreed.

"For too long, we've blamed the patient," McCarty said. "We have to put more responsibility on the program. ... We don't stop treating diabetics because they keep eating sugar."

Sarah Dunagan, a recovering heroin addict in Medford, said Oregon needs more care for more people and longer treatment.

"We are sick," Dunagan said. "We do have a disease. If I had cancer, would you take my doctor away?"

-- Les Zaitz