What does addiction treatment look like for low-income patients?

This story originally appeared in the New Haven Register.  

By: Esteban L. Hernandez – New Haven Register

NEW HAVEN >> The man approached Humberto Jimenez in broad daylight, nudging a .45 caliber gun into his lower back.

He ordered Jimenez to follow him. Jimenez complied.

Jimenez recently recalled the incident while sitting in an office at the Multicultural Ambulatory Addictions Services on East Street. The man shot Jimenez eight times — four times in each leg.

“He must have been afraid to kill me,” Jimenez said in Spanish. “Maybe he wanted to incapacitate me.”

It worked. Jimenez, 55, spent five weeks in the hospital after the shooting on Sept. 17 near the Farnam Court housing projects. He’s still recovering. He occasionally uses a cane to get around, moving slowly, lifting a heavy right leg that is usually masked by a long sock to keep the large scar there hidden.

Jimenez said he isn’t sure why he was shot, though someone had clearly sent the man to assault him. It could have been his past catching up to him. He used to sell heroin and spent time in jail.

In-and-out of jobs, feeling lonely and depressed, Jimenez started using heroin in 2000, 20 bags a day at the height of his addiction.

“I felt alone,” Jimenez said. “Like nobody cared about (me). I was looking for an escape.”

Sixteen years later, Jimenez is in recovery. A Cuba native who’s lived in Connecticut for 27 years, he’s been receiving treatment from MAAS for about a month. He receives the pill form of Suboxone, one of several medications available to treat opioid addiction.

He was referred to MAAS from another clinic. He’s described his introduction to MAAS using a Cuban idiom in Spanish: “me viene como anillo al dedo.” It arrived like a ring on a finger. A perfect fit.

Jimenez is unemployed, and since he’s still recovering from the shooting, he said he’s been unable to work. Yet over and over, he expressed gratitude for the health center, which provides treatments such as Suboxone and methadone to low-income individuals. He goes to the clinic daily.

“I’m just talking about me,” Jimenez said. “I feel like they saved my life, honestly. They saved my life.”

TOUGH TO GET

But access to addiction treatment is low across all socioeconomic backgrounds.

The Center for Behavioral Health Statistics and Quality’s National Survey on Drug Use estimated that in 2013 and 2014, 7.9 million Americans 12 and older needed treatment for illicit drug use. Just 20 percent who meet criteria for illicit drug use disorders were receiving treatment.

Last month, the Fair Haven Community Health Center launched a more formal collaborative effort with MAAS to provide more wrap-around addiction treatment services for patients. MAAS is operated by the Chemical Abuse Service Agency, which has five other sites in Connecticut.

Dr. Doug Olson, vice president for clinical affairs at FHCHC on Grand Avenue, said he hears stories like Jimenez’s every day.

The patient is from a Latin American country and left their family behind after immigrating here. They developed post-traumatic stress disorder in the process. They now live in a one-bedroom house with multiple occupants. Work is limited, and with it, hopes for assisting the family left behind.

The patient develops depression. They have no access to treat any of their illnesses.

“So they self-treat,” Olson said. “Drugs and alcohol is a way that a lot of people do it.”

Olson said this story is common among his patients. He operates in one of the city’s most predominately Latino communities, and Olson, who is white and fluent in Spanish, estimates 70 percent of his patients speak Spanish. At least 30 percent speak only Spanish. He said while the story is common among Latino patients, he points out not everyone who has experienced trauma ends up using substances.

At least 95 percent of the center’s estimated 16,000 annual patients are well below the federal poverty level. This means most of these individuals earn about $13,000 a year. Most live in New Haven.

Many patients treated by the two health centers have additional worries about employment, job security or transportation on top of their addiction, which makes seeking or receiving treatment difficult.

Olson said the organizations have been pillars of the community, working collaboratively to take care of the same population for several years. Over the past year, there’s been more of a need on MAAS to deliver primary care, while delivering addiction treatment to Fair Haven’s patients who need it.

The two organizations have always worked closely; they’re separated by about half a mile.

Robin Adefuin, program director at MASA, said this means the two share many of the same clients.

“There are certain populations that are underserved, which, a lot of them, like the Latino, African-American populations that really are in this area, that’s kind of our catchment area,” Adefuin said.

A majority of patients receive Medicare or Medicaid, including dual-eligible patients, and uninsured patients, Olson said.

They also treat patients who are uninsurable.

“They will, under our current laws, never have access to health insurance,” Olson said. “That doesn’t mean that they’re immune to addiction.”

While medical professionals in Connecticut and nationwide are still developing best practices for how totreating substance use disorders, Olson said providing treatment usually has the same outcome no matter what the race or socioeconomic status.

“That means the treatment works, and the problem is that there’s not access to treatment,” Olson said.

FEDERAL FUNDING HELPED DEVELOP THE PARTNERSHIP

FHCHC received $352,083 in March from the U.S. Department of Health and Human Services to expand its substance use disorder services, which was part of $94 million in Affordable Care Act funding to 271 health centers across 45 states, according to an agency release. The money targeted clinics serving underserved populations. Six other medical agencies in Connecticut received funding totaling $2.5 million, including Cornell Scott-Hill Health in New Haven, which received $406,250. The White House proposed funding $1.1 billion in federal money to address opioid addiction. Connecticut would be eligible for $9 million over two years, according to the White House.

IMPROVING RELATIONSHIPS, IMPROVING TREATMENT

The money received in March will support staffing and staff training at FHCHC. This helps bring addiction experts from Yale University to train staff on best practices and standards of care, Olson said.

“It just made sense for us, being here in Fair Haven, as Fair Haven and as MAAS, to make our relationship more formal and collaborate even more deeply to serve this patient population,” Olson said.

The partnership usually goes like this: MAAS provides patients with intensive outpatient treatment before referring them to FHCHC for primary care. Patients seeking addiction treatment services for opioids can receive medically assisted treatment such as methadone and buprenorphine (which Suboxone contains) at MAAS, and after their intake, they’re referred to FHCHC as their condition stabilizes. MAAS also has a psychiatric clinic on Saturdays, Adefuin said.

FHCHC now has a nurse stationed at MAAS, so as patients receive treatment, they can begin the transition to the other clinic. Olson illustrated the process by picturing a line of patients receiving methadone treatment, with his clinic offering a hand at the end of the line. “At the end of the methadone line, where they throw their cup out, there’s a room where they can get their primary care,” Olson said, referring to the FHCHC nurse. “Their entire life is not about standing on that line, to get that cup of methadone.”

Prior to the formal collaboration, Olson said most patients would get sent to other places in the community. But the partnership offers patients two organizations already familiar with one another’s work and treating patients from the same ethnic background. Olson said by receiving a patient from MAAS, a spot for someone seeking or in need of more intensive addiction treatment can be opened. Conversely, Olson’s clinic can identify new patients it can refer immediately to MAAS.

The FHCHC nurse was placed at MAAS’ office after Olson’s staff realized even suggesting to patients that they seek treatment a few blocks away could create a hindrance.

Kristin Bonilla, associate director at MAAS, said there’s several reasons this hesitation affects most patients.

“Particularly in the Latino community,” Bonilla said, “people trust people. They connect with people, not buildings. And there’s a lot of fear. Sometimes there’s language barriers.”

Bonilla, who is white, is also frustrated with how the opioid epidemic has been portrayed in mass media, which appears to pay more attention to the effects of the epidemic on white suburbia. The path to addiction is much different for low-income residents than the common path for most people with opioid addiction take, which usually begins with an addiction to prescription painkillers.

As Olson noted, many of their patient’s self-medication through addiction could be traced back to using a substance to treat past traumatic experiences.

“This isn’t new in the black and Latino communities,” Bonilla said. “This is real in our communities. It has been real in the black and brown community.”

Bonilla said heroin — which was involved in the fatal overdose of 416 people last year in Connecticut — has been prevalent in the Latino and black communities for years.

Dr. Evelyn Cumberbatch, behavioral health director and psychiatrist at FHCHC, said many patients have an added element that leads to addiction: a prevalence of violence in their lives.

“It continues to shock me, when I see new people, the level of violence in their lives,” Cumberbatch said. “Middle-aged women who’ve lost one or two children to street violence, where there’ve been multiple deaths in a family because they’ve been shot or stabbed.”

FHCHC has about 200 employees, with a large minority staff. Olson said he tries to staff the center with bilingual employees. It’s a requirement for support staff at FHCHC. MAAS also has a predominantly bilingual staff.

“The employee pool is not such that we can always get that, and that’s just a reflection of our national provider pool in our country,” Olson said.

Resources are still needed, with both Olson and Bonilla adding that their respective health centers could always use more personnel and space for services.

COST OF TREATMENT

One way the two health centers assist their patients is providing low-cost prescription options.

Federal funding through the 340B pricing program is instrumental in helping FHCHC assist patients. The program requires drug manufactures to provide outpatients drugs to eligible health care centers at reduced prices, according to HHS’s website. This gives Olson’s office the ability to prescribe medicine to uninsured patients and, in cases like Jimenez’s, to patients who are also unemployed.

Olson said an uninsured patient buying medication like buprenorphine could pay $600 a month out of pocket. With the help of 340B, a patient will end up paying $20 to $30 a month.

Buprenorphine is a medication that helps people with opioid addiction wean off the drug by mimicking the effects of narcotics without its euphoric effects, similar to methadone but not quite as strong. The FDA recently approved a new form of dispensing the medication, marketed as Probuphine and developed by Braeburn Pharmaceuticals.

It’s another tool in the battle against the opioid epidemic, which the CDC estimated claims the lives of78 people daily in the U.S. In Connecticut, 729 people died of accidental drug overdoses last year. The state Medical Examiner’s Office is projecting that number will jump to 832 by the end of 2016, though he also said overdose deaths may be levelling off overall.

 

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