Since October 2018, New Hampshires governor and Executive Council have approved contracts for more than $64.5 million in federal money to create the Doorway system of referral and treatment for opioid addiction.
The state was awarded $45.6 million for 2019 and 2020 in State Opioid Response funding from the federal Substance Abuse and Mental Health Services Administration, and almost $12 million in additional funding for year one. Another $6.9 million came from federal sources not linked to the opioid response grant, as the state continues to struggle with one of the highest per-capita rates of opioid addiction and fatal overdoses nationwide.
In its final installment of a year-long examination of the project, the Granite State News Collaborative set out to determine where that money has gone and what it has accomplished. Reviews are mixed.
There is widespread agreement the investment created a group of regional portals for those seeking treatment, but has done little to expand the availability of treatment, particularly in the northern part of the state, and particularly in regard to residential treatment.
Manchester officials criticized Gov. Chris Sununu and the Doorway for failing to significantly expand treatment services, which they say made the city, where such services exist, a “dumping ground” for other hubs. Mayor Joyce Craig expressed concern echoed by the citys Board of Aldermen that without a meaningful evaluation of how the opioid response grant was leveraged in 2019, year two will end without a significant return on the federal governments $64.5 million investment.
The Doorways in Manchester and Nashua are run by Granite Pathways, which recently had its state contract to operate a residential youth treatment center revoked, while its Doorway contracts are under review, according to the Department of Health and Human Services.
Thats not to say the effort has not had some impact. Narcan is more readily available throughout the state, as is medication assisted therapy (MAT).
But overdose emergency calls remain at historically high levels, and the state is unlikely to see a significant reduction in opioid-related deaths in 2019 compared to 2018, when 471 people died of drug overdoses, and 490 in 2017.
The Office of Chief Medical Examiner puts the death total from drugs for 2019 at 240 as of the middle of October, mostly from opiates, with 72 cases “pending toxicology reports.” They almost always come back positive, which puts the more likely number at 312, with the rest of the year to be accounted for.
“Of course we have a very long way to go. We are only 10 months into a new infrastructure system,” Sununu said in a phone interview. “I dont think we are going to see the number (of fatalities) lower by that much. One thing Ive learned is the majority of pending toxicology reports will be positive. Were making progress, but dont expect us to cut our number in half.”
Deaths averted since the launch of the Doorway are largely attributed to one of its most successful outcomes the widespread availability of the overdose reversal drug Narcan. Funding directed to the hubs includes money for Narcan administration.
“The state used to distribute Narcan directly, but now with hub and spoke, the hubs are responsible for distribution to all area partners, and that Narcan is at no cost,” said Jarrett Stern, vice president for administration at Littleton Hospital, which operates its hub at a freestanding location off Main Street.
Anecdotal evidence has convinced Stern and others that Narcan is only part of the story. “The Doorways have been open for 10 months now,” he said, “and in Littleton, we have 300 people in our program. As far as Im concerned, thats 300 people whose risk has gone down significantly. Why the total number of overdoses is still at or approaching levels of the past I wish I had a better answer.”
Increased availability of MAT with drugs like Suboxone is cited as another success story by DHHS Commissioner Jeffrey Meyers.
“We had very few funds before for MAT, other than some small appropriations from the general fund,” he said. “Now theres tens of millions of dollars paying for MAT. Thats a relief to thousands of individuals.”
New Hampshire was 48th among the states in terms of MAT providers per capita, with as few as 10 to 12 providers statewide. With additional funding and a push for more training, the number now has grown to 70, with more in the pipeline.
The state invested heavily in MAT, with more than $5.5 million in contracts approved for MAT administration or training for the two-year period.
Not all hubs equal
The largest portion of spending on the Doorway program, almost $24 million, went to standing up the nine hubs.
In the Littleton and Androscoggin regions the availability of healthcare providers or counselors to serve as spokes is so limited the North Country hubs offer both Narcan and MAT.
“Were the hub and the spoke,” said Christine Fortin. “As a hub, we have the assessments and case management support staff the other hubs have, but we also have a therapist here full time, and a MAT provider four days a week.”
The Doorways are affiliated with local hospitals, except in Nashua and Manchester. The vision for the program was to have hospitals lead the charge in every region, but the two hospitals in Nashua and two in Manchester all declined, without saying why.
With four of the largest hospitals unwilling to play a lead role in one of the most ambitious public health initiatives in New Hampshire history, the state turned to Granite Pathways. The New Hampshire subsidiary of the national federal contracting firm Fedcap has been jumping in where others fear to tread on behalf of DHHS since 2016. Thats when Fedcap took over Granite Pathways, then a faltering peer support organization, as part of an effort to expand its footprint in New England.
In September 2016, the state awarded Granite Pathways a $1.2 million no-bid contract that was needed, according to state officials, to speed up the opening of what were then called regional diagnostic centers “to assist individuals with substance abuse disorder.”
Granite Pathways, operating out of the states two population centers, drew the largest chunk of Doorway funding directed to a single organization. In addition to its $5 million share of the $16 million initially allocated to the eight hub operators, Granite Pathways later was approved for an additional $90,000 as the “only organization in NH that provides residential treatment for youth diagnosed with opioid use disorder,” and another $1 million for “targeted prevention programming for DCYF involved families.”
More recently, Granite Pathways was approved for a $195,234 contract to provide “workforce readiness and vocational training programs for individuals with opioid use disorder.” But in late November it lost its contract to provide residential treatment for youth diagnosed with opioid use disorder after reports of drug use and overdoses among patients.
“A 30-day review on all contracts the state has with Granite Pathways is underway and additional actions may be necessary based on that review,” according to DHHS spokesman Jake Leon.
Granite Pathways and Dartmouth-Hitchcock, by far the largest recipients of opioid response funds at more than $6 million each, were the only two hub operators that declined to be interviewed for this report, referring questions to DHHS.
Granite Pathways State Director Patricia Reed in a written statement confirmed many of the observations made by the smaller hub operators.
“Individuals come to the Doorway at their worst and receive initial services in a supportive and non-judgmental environment,” she wrote. “At the same time, implementation of the Doorway system has revealed other system gaps that must be addressed to truly solve this public health crisis.
“As expressed by one Doorway director We do a great job assessing people and figuring out what they need and then we wait largely due to wait lists for residential treatment or safe respite beds.”
According to all hub operators, wait times for residential treatment, about two weeks or more, have not improved in the program’s first year, despite more than $16 million in contracts for residential treatment.
The Doorway has drawn more people to seek treatment, without a significant increase in certain treatment options.
“If I am going to positively reinforce an individuals behavior, there has to be something more than the first step,” said Peter Fifield, hub coordinator for the Seacoast out of Dover. “There has to be the second, third and fourth. The state is open to hearing this and we now have to build more spokes.”
There has been progress in expanding treatment options, but mostly in the south and central parts of the state. More than $6 million was poured into recovery services, including a $1.4 million contract with Harbor Homes, based in Nashua, to serve pregnant women and parents with young children in recovery. Harbor Homes was already providing these services in Tilton, Portsmouth and Dover under a previous $515,198 contract, and is using the additional funds to expand to three other locations. But the demand for services is growing faster than expansion can accommodate.
“Theres been improvement from years past,” Fifield said. “We are making strides forward and are at capacity that could have met historic needs, but not new needs.”
Access times at issue
The Doorways promise of 24/7 access to referral and assessment rolled out with an official “Anyone, Anytime can ask for treatment” campaign was misinterpreted as a promise of around-the-clock access to treatment.
“I dont think they promised treatment; they promised a place you can go for referral for treatment, and I dont even know if thats realistic,” said Keith Howard, executive director of Hope for New Hampshire Recovery, a peer-based recovery and support organization that operates in Manchester and Berlin.
Howard and his team work with people in addiction crisis every day and the feedback they get on the Doorway has been less than encouraging.
“The experience folks have had has not lived up to the hype or the promise,” he said, referring to the Manchester Doorway in particular. “People who are working there have nothing but good intentions, but there are systemic problems in terms of getting folks into treatment right away. There is no place to send them, and if there is, theres a long waiting period.”
The problem with addiction, says Howard, is that once the crisis forcing someone to seek help abates, “Most of us in addiction think we really dont have to quit after all,” amplifying the need for immediate intervention.
Sarah Gagnon, vice president of clinical operations at Riverbend Community Health Center, believes expectations may exceed what is realistically possible with 24/7 access.
In addition to its $1.5 million share of the $16.6 million hub-setup fund, Dartmouth-Hitchcock got another $2.5 million after it reached an agreement with the other hubs to provide 211 clinical coverage off-hours, on holidays and on weekends.
“Anyone dialing 211 after hours, Dartmouth-Hitchcock will answer. So someone is still able to speak to a clinician at any time,” Gagnon said. “Weve talked a lot about what it would mean to go 24/7 (at all hubs), but the fact remains, if someone calls or walks into a doorway, even with 24/7 coverage, there are no facilities taking admissions at 2 a.m.”
Despite the funding and regular media reports on the initiative, many of those directly or indirectly touched by the addiction crisis claim to be unaware of the Doorway.
The state increased an existing $3.4 million contract with JSI Research & Training by $1.4 million to include restarting the Anyone/Anytime public advertising campaign, which was rebranded as the Doorway once the system launched.
A $200,000 contract was awarded to Portland Webworks (winner of three bids submitted) to develop, design, implement, host and manage a consolidated website for the initiative.
While the fire station-based Safe Station programs in Nashua and Manchester continue to serve large numbers of people in addiction crisis, the Doorway has been the go-to option for friends and family, according to Gagnon.
“Word of mouth is definitely a big thing and people are calling to get resources for people they care about. Up to half of our calls are friends and family,” she said.
The state predicted the Doorway would serve 5,000 clients per year, a prediction surpassed Oct. 31, the most recent report on the Doorway website.
The report states 5,910 individuals were seen in person or assisted by phone. As of Oct. 31, hubs conducted 2,645 clinical evaluations and provided 4,091 individuals with treatment referrals. What happens after those referrals is not well-documented, although the Doorway program is required by federal law to report on the status of its clients at intake, six months and discharge at least for the clients it can keep track of.
Future of funding
In the project’s second year, the state will focus on adding more beds for respite and residential treatment and services to keep individuals whove detoxed from relapsing. Those include transitional housing, ongoing therapy and the recovery-friendly workplace.
The Executive Council approved only $613,096 in contracts for transitional housing in the first year of the program.
Expanding treatment options will require more providers, which has proven to be the highest hurdle.
“The biggest barrier we have is workforce,” Sununu said. “It isnt that we dont have the money or that it isnt going to the right places. Its hiring the people we need.”
Healthcare providers in the addiction field are hard to come by, and much of their work is paid for through Medicaid. New Hampshire, with some of the lowest Medicaid reimbursement rates in the nation, has been at a disadvantage with neighboring states when it comes to recruiting providers from a dwindling pool.
Last year, the state increased Medicaid payments for medical detox services and will increase Medicaid payment rates across the board by 3.1% in fiscal years 2020 and 2021.
“Is that going to solve every gap in every corner of the state? No. But its moving in the right direction,” Meyers said. “Weve added money now three years in a row.”
Meyers will soon leave DHHS and hand the project off to his successor, but hes confident the state will continue to receive federal funds.
“I dont think its a question of whether were going to get more funds,” he said. “I think its a question of what we are going to get and how much flexibility well get to use the funds in New Hampshire.”
Next Sunday, we will conclude our two-part series with a look at Safe Station and whether it has potential to be a statewide solution. We will also hear from folks in recovery about what it is like to use these systems.
This story was produced by The Granite State News Collaborative as part of its Granite Solutions reporting project. For more information visit www.collaborativenh.org. Follow us on Twitter @NewsGranite and like us on facebook @collaborativenh.