They pulled up to the liquor store and hopped out of the van in matching white polo shirts, the letters “DBH” stitched over each of their chests: Department of Behavioral Health. They were looking for someone, and they had been looking for him for a while. A few days earlier a man had overdosed on heroin, but someone had called an ambulance and it arrived in time to save his life. Usually, that would be the end of it as far as the District was concerned. But these workers were here to make sure the man did not fall through the cracks. The addresses they’d had on file for him were on the other side of town, but when he was nowhere to be found, they asked around and managed to get in touch with his sister. She pointed them here.
They walked into the liquor store and called out his name; the man answered. One of the workers walked up to him and spoke softly: “We came here to help you. Your sister told us you’d be here, and your sister is so happy that we’re here.” After the man bought his liquor, they sat down outside the store and talked. It was soon clear that an intensive detox was the best option for him. He agreed, and said he was ready to go that very minute—as soon as he finished his half-pint. He went into the alley behind the store, chugged it, and returned. “Let’s go,” he said. They all got in the van, went to grab his clothes, and then drove off to treatment.
This was how the Heroin Screening, Brief Intervention, and Referral to Treatment (Heroin SBIRT) pilot program operated. In the summer of 2015, as the opioid crisis was beginning to take hold of D.C., the city began an innovative program to offer treatment to those most at risk. Whenever Emergency Medical Services responded to a suspected opioid overdose, rather than resuscitating the person and forgetting about them, the first responders would pass the person’s name and information over to DBH. Within a week, DBH would send outreach workers to find that person and offer to clear whatever obstacles they could—anything that was keeping the person from getting treatment.
Two years later, in May 2017, Mayor Muriel Bowser took the stage at the Regional Opioid and Substance Abuse Summit, which she co-hosted with the governors of Maryland and Virginia so that hundreds of policy makers could share strategies for combating the opioid crisis. In her keynote, she took the opportunity to describe three of the District’s initiatives. One focused on law enforcement. Another distributed Naloxone—the lifesaving medicine that can reverse overdoses—around the city. The third was the Heroin SBIRT. “Between May and August of 2015,” she said, “the District’s Department of Fire and Emergency Services partnered with the Department of Behavioral Health to offer immediate access to treatment to individuals who experienced opioid overdose.”
As she spoke, the Heroin SBIRT program had been shuttered for almost two years. City agencies have yet to restart or replace it.
Several of the Department’s top substance abuse officials from that time still want to know why. One former member of DBH leadership tells City Paper, “I met a lot of our clients, and to find out they’re dead now … It didn’t have to be that way. We could’ve done something.”
***
The opioid crisis was not yet dominating national headlines in 2014, but District officials had noticed that the number of overdoses was on the rise. The city formed a “Heroin Working Group,” bringing all of D.C.’s public health and public safety agencies together to strategize and to coordinate their response.
In 2015, 114 people died from opioid overdoses in D.C., up almost 40 percent from the year before. Most of the people who use heroin in D.C. are what city officials describe as a “fixed population.” Whereas the image of the opioid crisis nationally is white kids on OxyContin, the heroin users in the District are primarily black, middle-aged, longtime D.C. residents who have been using heroin for decades. According to District data, 59 percent of D.C. opioid users have been using heroin for over 25 years, and 88 percent have been using it for over a decade. It is not uncommon for a person overdosing on heroin to have overdosed and been resuscitated before. For instance, during the 65 days of the Heroin SBIRT program, emergency medical services responded to 97 different people overdosing on opioids. Seven of those 97 people overdosed twice during that period, and officials found that those 97 had generated over one thousand calls to the city’s Fire and EMS (FEMS) in the previous eight years, averaging over 10 ambulance calls a person.
FEMS knew who the people suffering most deeply from opioid addiction were—the city just needed to connect them to treatment. So they started the SBIRT program as a two-month-long pilot.
Every day or two, FEMS officials would send DBH a list of the people who had overdosed. Four days a week, a team of DBH outreach workers would take the list and drive around the city to find them. One of the outreach workers involved in the program—who asked to go by Jordan to protect their identity—describes the process to City Paper.
Sometimes finding the people they were looking for was easy, but sometimes the DBH workers had to leverage people across the community to track them down. The men who hang out at Jurassic Park—a well known spot near Congress Heights to buy and use heroin—would tell them where to look for someone. Homeless shelter employees would call them when someone finally came in.
Final statistics on the SBIRT program indicate that, more often than not, DBH found the people it was looking for. Then, Jordan says, they would give the person a hug and ask them if they wanted help. “If someone comes and says, ‘I got a ride. I’m here to help you,’” says Jordan, “What a joy. What a joy to a dying man.” If they were too hungry to think straight, the workers would buy them food from McDonald’s. They would answer questions, talk to the person about their options for treatment, and even offer to take them directly to treatment, right then and there.
Of the people the outreach workers managed to get in touch with over those 65 days, over half made concrete plans to enter treatment, and 20 percent agreed to be immediately driven straight there.
So often, it was not lack of desire that was keeping people from getting help. Those dealing with the most dangerous forms of opioid addiction often face a long list of barriers to treatment. Jordan says, “Some knew [where to go for treatment], but some people didn’t know. Some people knew, but they didn’t have a valid form of ID” to prove they were a District resident, and couldn’t assemble the money to get a new ID.
Maria Paige, an addiction specialist at the community health nonprofit Mary’s Center, says, “You just can’t say that people don’t want to be sober. Because everybody wants a good life.” Paige says the structures keeping people out of treatment range from worries about whether seeking treatment will get them in trouble with their employers or probation officers to inability to pay for transportation to get to DBH’s only intake center, which is in Northeast.
But perhaps the largest barrier to people getting themselves into treatment is the nature of heroin addiction itself. The amount of time between an addict’s last dose and the onset of intensely painful withdrawal symptoms is just a matter of hours. As Paige puts it, when someone is severely addicted and says they need help, “we have to do it right away. Because within an hour or two, that’s not going to happen. We have people who have been using heroin for 10, 30 years, and that’s the window of opportunity.”
Dr. Dan Smith, who leads the addiction treatment programs at Mary’s Center, says, “It’s tempting sometimes to want to treat the most stable patients: the people who come to all their appointments on time, get there early, have jobs, all that sort of thing. But the reality is that the people who need treatment most, especially if we’re going to make an impact on the number of overdose deaths, are the people who are not those things … Those are the people we really need to access.”
The idea behind SBIRT was to stay in touch with those most in need and try to make it as easy as possible for them to access treatment when they were ready for it. In Jordan’s lengthy career, they say they have “never had that much power to help people,” as they did during the SBIRT pilot. Jordan, like many of the peer outreach workers, is a D.C. native who first encountered the city’s addiction treatment services as a client rather than as a provider, and has been in recovery and working to treat addiction in the city for over 20 years. In all that time, Jordan adds, “I have never seen nobody coming to get you except the police—until this.”
The outreach workers did not always arrive at a time when their client felt able to seek help. Jordan says people would often say, “I’m not ready right now. Come back tomorrow.”
And so the workers would follow up.
Jordan describes one person who had been a long time, heavy heroin user. The outreach workers followed up with him two or three times after their initial contact. One time, he had a court date and could not miss it by going into treatment. Another time, he was in withdrawal and did not feel up to it. But eventually, his family called and said he was ready. The team drove straight there, and took him to the Psychiatric Institute of Washington to enter detox. Jordan ran into him six months later and he was still clean.
Then, as the program continued, something unexpected happened. People began to recognize the workers’ van and word spread that they were there to help. Jordan says that people would waive them down or call them, asking if they could take care of their grandson or their sister. These people got the same treatment as the ones on EMS’ list. Program evaluation documents indicate that in the first month of SBIRT, eight people who were not on the overdose list got into the program this way. In the second and final month, about 50 people did.
In August 2015, the pilot ended. Emails obtained by City Paper through the Freedom of Information Act show that at that point, DBH officials began work on implementing a permanent version of the program, and later started preparing to apply for a federal grant that would have provided funding to restart an expanded version of the SBIRT program (the original pilot had been done with existing Department resources).
But by January 2016, the mood had changed. Emails indicate that DBH’s deputy director had recently told one staff member that DBH would not be reimplementing the SBIRT program or applying for the grant after all. That month, Department of Health Director Dr. LaQuandra Nesbitt requested an update on the status of restarting the program. The staff member was not sure how to respond, and so she wrote to the deputy director and Dr. Tanya Royster, director of DBH until last November, to confirm that “SBIRT is not a priority right now.” They responded that the staffer was correct.
The city has not reimplemented any similar program since—with one small exception. In 2017, as the number of synthetic cannabinoid overdoses continued to mount in the District and the Department faced pressure to act, they ran a second SBIRT pilot similar to the heroin one but for synthetic cannabinoids such as K2 instead. This pilot, however, lasted only a week. D.C. officials presented the concepts of both SBIRT pilots at the Regional Opioid and Substance Abuse Summit later that year.
Between May 2017 and September 2018, D.C. ambulances responded to an average of more than five opioid overdoses every day.
Since the Heroin SBIRT pilot, there has been no program focused on directly connecting high-risk drug users to treatment. And when someone overdoses in D.C. today, nobody from the city is responsible for following up to help them. (A point of terminology: D.C. has programs that use the SBIRT evaluation method, a standard practice for identifying substance use disorder and determining treatment options. The Heroin SBIRT pilot also used the SBIRT evaluation method, but otherwise, these programs are unrelated.)
Royster tells City Paper that “the primary reason the SBIRT pilot was not continued was that FEMS did not have the staff to continue to provide the data (names and address of overdose victims).”
Retired Deputy Fire Chief Rafael Sa’adah tells a different story. Sa’adah led the FEMS portion of the Heroin SBIRT pilot, and says that he was willing to keep sending the data over, but “sensed that DBH did not want to engage in any ongoing partnerships where FEMS would be inside their shop,” so he set up an automated version where DBH could receive the list without needing FEMS to compile it. But, he says, “Dr. Royster essentially ghosted me and would never follow-through on implementing the SBIRT as an ongoing program.”
A spokesperson for FEMS says that while “the Heroin SBIRT pilot program was instrumental in paving a path forward in our efforts to reach, touch and connect with those seeking help with their substance disorder disease” and influenced D.C.’s new plan to reduse opiod use, released in December and dubbed LIVE.LONG.DC, he suggests that “the initial pilot program did not afford us with the opportunity to connect with as many people as we had hoped.”
Nesbitt, who is now acting director of DBH as well as the director of the Department of Health, was heavily involved with the Heroin Working Group in 2015, and acted as a spokesperson for DBH regarding the SBIRT program. When asked why the program was discontinued, she did not answer directly, but said, “the results of the Heroin SBIRT pilot program [were] used to craft new strategies that we expect to bring more people into treatment.”
But officials who were at DBH and FEMS at the time suggest that there were other reasons for the program’s demise, pointing to what they see as deep-rooted problems in the District’s response to the opioid crisis.
***
In September 2016, Royster joined top officials from across the District government in a meeting to discuss an opioid crisis that was rapidly worsening. 231 people died from opioid overdoses in 2016, more than twice as many as the year before.
When Royster’s turn to speak came, she talked about how the group of people using opiates in D.C. was substantially different than in a lot of other cities, consisting primarily of long time heroin users. She described them as “a recalcitrant population.” “We do have capacity to treat them if we can get them into treatment,” she said, “but they have turned down treatment many, many, many times over those 30 years.”
City Paper interviewed five high-level substance abuse officials who were at DBH at the time of the SBIRT pilot, all of whom wished to remain anonymous to protect themselves from retaliation. They tell City Paper that this outlook corresponded with a lack of appreciation, under Royster, for the factors that may keep a person away from addiction treatment. Her attitude toward the challenge of getting people into treatment is not exceptional in D.C. government, and some say it may indicate a deeper structural problem at DBH.
DBH is only five years old, created when D.C. merged the Department of Mental Health with the Addiction Prevention and Recovery Administration. This was part of a national trend to combine mental health and substance use disorder treatment, since there is often substantial overlap. In D.C., as in many other jurisdictions, the addiction treatment arm was the much smaller of the two.
The five substance abuse officials City Paper interviewed describe the environment during the SBIRT pilot as hostile, with serious tensions between the two components as mental health rose to dominance. Two of them said, in separate interviews, that “it was less of a merger and more of a takeover.” But all admit that the power dynamic was inevitable, given their respective sizes.
All five also said that there were instances where mental health leadership overruled substance abuse leadership in ways that they felt neglected the differences between addiction and mental health treatment. As one says, “they tried to hammer a round peg into a square hole—tried to make everything mental health-like. Certainly, there are many intersections; many people in addiction are also dealing with depression and anxiety. Some have SPMIs [serious and persistent mental illnesses], but that’s far from the majority.”
And substance abuse outreach may have been one of those instances. One official explained, “With mental health, people reach out. They call hotlines. Substance use comes with stigma, so they’re less likely to reach out—they’re afraid they’ll be arrested. Some are on probation. Some have jobs and don’t know who they’ll run into. So that’s why you do outreach. You go to people and understand their circumstances and figure out what they need to get into care. Outreach really plummeted [during Royster’s tenure]. People in mental health didn’t understand the value of it.”
Royster says she worked “very hard to have one DBH not a mental health side and a SUD [substance use disorder] side.”
There are also more mundane reasons SBIRT ended. Three of the DBH officials City Paper spoke with and retired Deputy Fire Chief Sa’adah say they think it ended due to personal conflicts and what one described as “deep-seated resentment of working with other agencies at DBH.” Another former member of DBH leadership let out a long sigh as she recounted the tension around the program: “You know how people get when they get threatened. It’s not about you. People are dying.”
In the near future, the District will have an exciting, new program to connect people who have overdosed with treatment. For much of the past year, the Department of Health and the Department of Behavioral Health have been gearing up for a pilot that will connect overdosees with treatment in the emergency room, and if the person declines treatment in the ER, they will send peer outreach workers to follow up a day or two after the person is discharged. Michael Kharfen of the Department of Health says that he hopes the pilot will begin offering treatment in April or May. Unlike the Heroin SBIRT, the program only takes in those who come to the emergency room, which Kharfen says is an obstacle they are working to solve, because currently as many as half of people who EMS treats for overdoses decline to be transported to the hospital.
The past may prove instructive.
Sa’adah says the bickering that killed the SBIRT program gets at a larger problem with how the District handles collaboration. “The interagency and interdisciplinary approach [was] absolutely the most effective way to address our ongoing overdose crises in D.C.,” he says. “However, what was lacking in [the SBIRT pilots and the Heroin Working Group] was the ongoing involvement of the deputy mayors of the relevant clusters.” He thinks that when communication broke down between the agencies involved, city leaders “should have stepped in and forced cooperation between the agency directors.”
“That never happened,” he says, “so a promising approach to saving lives was thwarted by petty turf wars.”