The St. Louis heroin epidemic: barriers to treatment
(Part 3 of 3)
In November 2013 Kari Karidis was in her office at Collinsville High School when a local hospital called to tell her that her son Chaz was in cardiac arrest. When she arrived at the emergency room she was told her son had died. All she could do was go into his room and say goodbye.
“He still had the tube — the breathing tube in,” Karidis recalled, sitting in that same office earlier this year. “I just sat there. I don’t know how long. I just remember thinking I can’t look at this but I can’t leave.”
The Metro East educator learned her son was addicted to heroin six months before he died of an overdose. She put Chaz in rehab right away, but he struggled to stay clean. He eventually landed in Madison County’s drug court — a legal recourse for addicts who have committed non-violent crimes.
According to Karidis, the court recommended residential rehab, but there wasn’t a bed available so he was assigned intensive outpatient therapy instead. A few weeks later, Chaz left the outpatient center after his day’s meetings were over and ended up dead.
“I would never go so far as to say anybody’s decision directly caused (his death). But I think, yes, it contributed to it because he wasn’t in a place to exert self-control or exert the willpower because his brain was not healed, Karidis said.
“I was new to this whole process so I didn’t know what to ask and I also didn’t know how to fight for my child and what was best for him. I thought that the system was developed to do that.”
Insufficient residential care
The rise in heroin addiction in St. Louis has brought a corresponding increase in need for treatment. But obstacles can sometimes prevent St. Louisans from getting the help they need to overcome their addiction.
St. Louis Public Radio surveyed area drug treatment centers to find out what type of care they provided. The survey found that outpatient therapy is much more prevalent than residential care.
Options are especially limited for people who don’t have insurance or the means to pay. There’s a six-week-long waiting list for a bed at one of the few state-funded detox centers in St. Louis — Bridgeway Behavioral Health.
Bridgeway director Mike Morrison gave St. Louis Public Radio a tour of its detox floor on Vandeventer Avenue in St. Louis, pointing out the nurse’s center where a registered nurse is on call at all times. According to Morrison, Bridgeway is the only place in Eastern Missouri that offers state-funded medical detox.
“On certain days of the week, that waiting room out there will be full of people that just walk in saying we need help. And it’s really hard to deal with because they desperately want help and we often times just can’t give it to them,” said Morrison.
Bridgeway averages a waiting list a hundred people long. Morrison said it’s heartbreaking because when it comes to a heroin addiction they know people could die while they wait for one of their 16 detox beds.
“We try to keep engaged with them and keep them around until we can get them into treatment. But when they walk out of this door they walk out with their drug addiction and they’re going to go find some drugs,” Morrison said.
An opiate addiction creates strong cravings and excruciating withdrawal, which makes it difficult to stop using without help.
One reason Bridgeway’s residential detox waiting list is so long is because the provider helps people with Medicaid and private insurance as well as those who don’t have any way to pay. Medicaid also limits the number of treatment beds to 16 per facility.
But Morrison said he has to accept Medicaid and private insurance to make his funding stretch further.
It’s a philosophy he shares with Missouri Department of Mental Health Director Mark Stringer, whose agency provides state funding to Bridgeway.
“If (treatment centers) didn’t serve Medicaid at all they’d still be serving people who were on Medicaid and then we wouldn’t be getting the federal share of the reimbursement. We’d be paying for it with all state funds. And so that is financially irresponsible and would ultimately make treatment access worse in Missouri,” said Stringer when asked whether he had considered removing Medicaid funding from some centers so they could increase the number of beds.
I can't live in anger. I'm saddened my child had to go through it, but I have to take all my anger and frustration and say this is what didn't work for us. How can we make it work for someone else? - Kari Karidis
Stringer also said he’s hopeful that a pilot program exploring increasing the number of beds allowed in Medicaid facilities will eventually be adopted nationwide.
At the same time, Stringer doesn’t dispute that Missouri needs more residential drug treatment.
“Frankly there aren’t enough inpatient beds available. We’ve obviously had state budget cuts, insurance companies have clamped down pretty hard on inpatient care so I think we need to have a goal of establishing that balance. It’s just going to be difficult to get there,” Stringer said.
According to Stringer, the need for drug treatment in Missouri is twice the state’s capacity. He believes the best way to pay for expanding treatment is Medicaid expansion.
Missouri legislators have declined to expand Medicaid for the past three years. But when asked what the Department of Mental Health can do without expanding Medicaid given the reality of a Republican-led general assembly that have made their opposition to expansion, Stringer said Medicaid expansion remains the state’s best hope.
“Every year we make the case. Our elected officials are certainly aware of the magnitude of the problem. They’ve actually been pretty good to the Department of Mental Health,” said Stringer, pointing to slight increases in the DMH budget allocations. “Meanwhile our providers are getting more sophisticated in terms of individually tailoring services so people don’t get anymore or any less than what they need in order to get into recovery … although I say that with some hesitance because the demand is so staggering, particularly in St. Louis, that it’s just really hard for people to get into treatment.”
At least one treatment provider in St. Louis will soon be able to help more people. The Salvation Army is building a new facility for their state-funded center.
At the construction site on Washington Avenue just a few blocks from its old treatment center, social services director Kim Beck explained that the new building will have three floors, with the first floor set aside for a health clinic and community events, the second dedicated to outpatient drug treatment and the third for residential care.
“We’re going to have a facility that could in any one hour serve 200 people,” said Beck. “We’re going to probably triple the number we’ve been able to (help) in the current facility.”
But because the center will soon accept Medicaid, the number of inpatient beds will remain the same: 16.
To Beck, the focus on outpatient care is a plus because it helps people adapt to the real world.
“The approach that we have shifted to in addiction treatment is not sending someone away necessarily for 30 days to a false environment where they can get clean for 30 days and then putting them right back where they came from,” but instead “helping them to stabilize and then putting them in their environment and teaching them how to live a recovery lifestyle,” Beck said.
By increasing outpatient capacity, the Salvation Army is following the trend of other major drug treatment providers in the region, including Bridgeway Behavioral Health and for-profit Assisted Recovery Centers of America.
The ideal heroin addiction treatment
Experts interviewed for this story agreed outpatient care can work, as long as they have a good support network and are strongly motivated. They also agreed medication and counseling are important parts of the mix, both to address underlying mental health concerns that may have motivated addicts to start using drugs and to help addicts learn tools to cope with cravings.
According to Dr. Laura Bierut, a Washington University School of Medicine professor who specializes in addiction research, the ideal heroin treatment combines counseling with medication.
“People respond to behavioral therapy, changing the environment, counseling—those aspects (are) very important. There’s also great evidence that people respond to medications,” Beirut said, adding that longer treatment has been found to be more effective.
Bierut also said the decision to use outpatient or inpatient treatment depends on the severity of the addiction.
According to Dan Duncan of the St. Louis area National Council on Alcoholism and Drug Abuse, however, the extra cost of inpatient therapy can sometimes influence the decision.
“If they’re not too far progressed into their addiction and / or they’re very motivated, they may be a good candidate for outpatient, especially if there’s a medication-assisted component. But if that’s not the case then by and large you’re not going to look at successful treatment,” said Duncan.
In 2002 the U.S. Federal Drug Administration approved a drug called Subutex to treat opiate addiction. It is designed to help reduce the symptoms of withdrawal during detox. Sometimes doctors prescribe Suboxone instead, which also contains a drug called Naltrexone that helps with cravings.
In 2010 the F.D.A. approved an injectable form of Naltrexone called Vivitrol, which blocks addicts from feeling the effects of opiates for 30 days.
According to Duncan, those two drugs can help outpatient therapy be more successful. But it's important to note that no drug is a cure-all. It's possible to overdose and die from heroin while on the Vivitrol shot and while taking methadone or Suboxone.
As a mom who lost her son to heroin, Kari Karidis sees better access to medication as another tool in saving lives. Her son Chaz was prescribed Suboxone after he left inpatient rehab, but because he was over 18 he managed his own health care and she doesn’t know whether he used it. He was not prescribed any medication after going through Madison County’s drug court.
“I would love to see Vivitrol or Suboxone –and I’m sure Vivitrol would be easier to control or mandate through drug court –but I would love to see that for every patient who is in outpatient treatment or who is recommended for inpatient but they don’t have room for,” Karidis said.
Karidis also would have liked her son to learn new ways of thinking to retrain the brain to fight the addiction. After her son’s death the Metro East educator joined the Madison County heroin task force to help fix what she calls a “system made with the best of intentions.”
“I can’t live in anger,” Karidis said. “I’m saddened my child had to go through it, but I have to take all my anger and frustration and say this is what didn’t work for us. How can we make it work for someone else?”
Katelyn Petrin and Marshall Griffin contributed to this report.
Follow Camille Phillips on Twitter: @cmpcamille.