Dr. Jeffrey Aalberg remembered a case from about six months ago. A child, 14 or 15 years old, was coming into the Day One Residential Treatment Center in New Gloucester.
“She was using a lot of opioids and admitted to this,” Aalberg, Day One’s medical director, said, “so we knew that and we were prepared.”
They quickly brought her to a hospital emergency room, where she stayed for the next three days, suffering from withdrawal and nearly constant vomiting while they moved her onto suboxone, which reduces cravings for opioids. Then they were able to transfer her back to the residential home.
“That was a positive outcome,” Aalberg said, “but the emergency rooms don’t want to do that. They’re not built for three-night stays.”
And in this case, Aalberg and his colleagues at the South Portland-based nonprofit that specializes in substance-use-disorder counseling were ready and prepared.
A more common occurrence happened more recently. A young woman came in on a Friday, seemingly OK, and began to get settled in the home. At dinner time, however, she passed out, face down in her food.
“It’s a Friday night,” Aalberg recounted. “We have a weekend crew on. They’re not medical. What do you do? What’s going on? What is she coming off of?”
Fortunately, they were able to get her to a hospital where she “pulled through,” he said, but that was a function more of luck, and “nobody really knew what the extent of that situation might have been.”
Both cases are typical of what those working in the substance use disorder and child services communities are saying is an increasing problem: Kids, sometimes not yet 10 years old, coming into the system addicted to multiple, sometimes unknown substances, with no good facilities available to help them detox safely in what can be a life-threatening situation.
“It’s polysubstance,” Aalberg said, “usually two, maybe more, predominantly cannabis use, but more and more heavy, heavy alcohol use, meth, as well as a smattering of opioids and fentanyl, and benzos. Some you feel terrible coming off, others are life-threatening. Alcohol and Xanax are deadly in withdrawal; opioids you feel terrible, but you won’t die.”
The problem is raising enough concern that a task force of sorts has come together to address it, bringing together Day One with many of its adult-focused counterparts in the substance-use disorder community, along with the state Department of Health and Human Services and legislators who’d like to help.
One of those legislators is state Rep. Victoria Morales, D-South Portland, the chair of the Young People’s Caucus. She has suggested a bill – LR 1420, “An Act to Address the Complexity of Substance Use Disorder in Youth” – that would do three essential things, she said.
First, it would have DHHS contract with a hospital (or more than one) to provide immediate access to beds for adolescents for the purpose of medically supervised withdrawal services on an as-needed basis. Then, it would task a group of stakeholders with creating a more permanent solution within the MaineCare system. And, finally, it would create a methodology and billing ability in MaineCare that would allow for intensive outpatient services for children and adolescents.
This last part is crucial, said Malory Shaughnessy, executive director of the Alliance for Addiction and Mental Health Services and Maine Behavioral Health Foundation. Intensive outpatient services, or IOP in the business, is a specific level of treatment that’s reimbursed at a specific level by MaineCare.
“It’s three days a week, three hours per session,” Shaughnessy explained. “Then outpatient is just once a week.”
Even in the adult community, three days a week and three hours per session is a high bar to meet, and if the patient doesn’t show for one of the sessions, the providers don’t get paid, which makes them reluctant to offer the service at all.
“Then they say, ‘hey, this can be used for youth!’,” Shaughnessy lamented, “but it doesn’t work.” With school, lack of mobility, and many other factors, she said, most kids don’t fit the classic IOP model, which essentially means there’s no way for providers to get paid to help them in that way.
So it’s in-patient treatment or not much at all.
Long Creek dilemma
One irony that many observers point to involves the Long Creek Youth Development Center in South Portland, Maine’s only incarceration facility for children. There’s widespread agreement at this point that Long Creek should be closed, but that presents several problems around detoxing kids.
“Historically,” said Greg Bowers, executive director at Day One, “the majority of our referrals would be coming out of Long Creek.”
Kids in crisis would often enter the corrections system, land at Long Creek, which has access to medical professionals and a relatively safe environment for detox, then find their way to Day One’s residential facilities or be treated while remaining at Long Creek, Bowers said, where Day One has counselors available.
“Now that Long Creek is getting smaller, we’re getting more coming from the community, from schools where kids are on the fringe of expulsion, or we’re seeing them come directly to us from hospitals, emergency departments, psychiatric hospitals, and occasionally directly from families with nowhere else to go,” he said.
“We support deinstitutionalization of kids,” Bowers continued. “We support treating kids in the community. However, there has to be enough treatment in the community to care for them safely, and that includes detox as just one example. It’s great these kids are back in the community, but it’s like Jello. You push it one way and it’s going to come out somewhere else.”
Even Colin O’Neill, associate commissioner of the Maine Department of Corrections who oversees Long Creek, doesn’t want to see kids wind up there. He’s in favor of finding a way to eliminate the need for Long Creek entirely.
“Just in the last 20 months,” O’Neill said, “we’ve reduced the amount of kids in here by 52 percent. But if we’re going to continue that reduction even further, you have to get in the weeds further of what you’re using it for.
“If you look at substance use, typically, this is what happens,” he continued. “Kids will have committed a crime, but also substance use is very much a primary component, and the criminal activity is secondary.”
So they keep them out of Long Creek, but they may have conditions they have to follow in order to stay out of incarceration, which include avoiding substance use and engaging in treatment.
“Relapse is part of recovery,” O’Neill said, “but when there is a relapse and there’s not a treatment response to that, that’s where we get into a problem where we’re using Long Creek for stabilization, maybe detox, if they can’t get into a hospital setting, and we know there’s a dearth of any kind of detox. That’s where there’s a problem.”
Bowers also noted that one thing Long Creek does provide is an incentive to keep kids in programming because it would force them to choose: “You either go to treatment or you can go to Long Creek,” he said. “Without incarceration, there are fewer incentives for them to want to undertake treatment – and they’re treatment averse in the first place.”
But if not Long Creek, then where?
If Morales’ bill becomes law it would be a good first step, but it really only solves the problem of that initial crisis. Residential programs like Day One are voluntary. What happens if a kid doesn’t want to be there?
“We don’t have a dedicated psychiatric unit for kids with locked doors,” Shaughnessy said. “There needs to be some of those. There are some kids who’ve done some egregious things, and putting them in jail won’t help them, but they do need psychiatric care with safeguards. … They can be acting out or violent and just hyper-aware and sensitive and (places like Day One) don’t have the facilities to handle that, and they don’t have the medication to provide comfort care.”
It might seem like a different way of describing the same facility, but O’Neill said it’s really about a change in philosophy: Psychiatric care is focused on the safety of the individual, while corrections is focused on the safety of the public. That’s a big difference in the way facilities are administered.
O’Neill also made the point that in Maine the kind of agreement Morales’ bill would create doesn’t necessarily address the fact that a kid one month might be in Fort Kent, and the next in Kittery.
“A lot of these programs go from feast to famine,” O’Neill said. “Sometimes there’s a waiting list, and sometimes it’s, ‘where are all the kids?’ We need to develop programming so that it can sustain during the ebb and flow of treatment needs.
“That’s not just a money issue, it’s an issue of how you integrate that into local community partnerships, connecting with providers who are already doing the work and helping develop capacity so that when the need is there, they can pivot and do that, and if it’s not there, they can do something else,” he said. “… It won’t be a specific detox center for kids. It’ll be capacity in hospitals so that when the need arises, there can be a mobilized effort to provide the care necessary.”
For Morales, who has made closing Long Creek a mission, this really feels like one of the last puzzle pieces missing.
“The only barrier to getting this done is cost,” she said, “but when we talk about budgets, we talk about the limited two-year cycle.”
It’s a lot more money to spend down the road, the lawmaker added, “if you think about what we actually spend on young people when they don’t get treatment.”
Sam Pfeifle is a frequent contributor to the Phoenix. He was a member of the SMART Family Services board of directors and became a member of the Day One board when the agencies merged recently. He can be reached at firstname.lastname@example.org.