Credit: Darrow Montgomery

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“This is a true crisis, but it’s being treated as anything but.” With these opening remarks, Councilmember Vince Gray set the stage for a day of outrage and frustration at Monday’s nine-hour Council oversight hearing to investigate failures in the District’s response to the opioid crisis. This winter has brought a steady stream of scandals and turmoil to the Department of Behavioral Health—the agency in charge of substance abuse treatment in D.C.—in a city where the number of deaths from opioid overdoses tripled between 2014 and 2017.

In an effort to publicly unearth what went wrong and to guide the way forward, Councilmembers Gray and Charles Allen, chairs of the committees on Health and the Judiciary & Public Safety, respectively, held a roundtable to investigate.  

More than nine hours of expert testimony brought some substantive insight into the successes, failures, and future of the Department of Behavioral Health, but perhaps above all, it made clear just how opaque the city’s response to the opioid crisis remains, even to the people responsible for administering it.

At the end of November, DBH director Dr. Tanya Roysterdeparted as Mayor Muriel Bowser announced that Dr. LaQuandra Nesbitt would serve as the Interim Director of DBH while continuing in her role as the Director of the Department of Health. Days later, the Washington Post released a scathing article in which several community health organizations said that the District’s response to the opioid crisis was “woefully inadequate,” with allegations of mismanaged grant money and failures to provide local service providers with support. The Substance Abuse and Mental Health Services Administration, the federal agency that provides much of DBH’s funding, subsequently launched an audit of the department.

But at least some of what has been reported as grant mismanagement may actually have just been misunderstanding. For instance, Medical Home Development Group (MHDG) was reported in the Post as contracting for $1.4 million in grant money but not receiving a single referral for medically assisted addiction treatment. The provider even started leasing an office to intake the patients that never came. During the hearing, Nesbittclaimed that when she looked into this, she found that the grant money was not mispent and indeed went to some sort of care at MHDG—staff there were just misled, in informal talks, that DBH would be using them to provide addiction treatment. The real problem, she claimed, was that in a “breakdown in communication,” someone in the Department had made promises to the provider that they never kept.

In perhaps the biggest revelation of the hearing, she said that this was a pattern, the result of an improper, devil-may-care approach to grant management at DBH that can leave partners out to dry. “We don’t have a structured grant management process. We appear to have a process of verbally contracting or negotiating things outside of a structured grant managements process that gives vendors and potential grantees … the hope that they are going to be able to do something that never materializes.”

This fuzzy process meant that it was hard for Nesbitt, let alone outsiders, to tell what happened. As Gray pressed on the various grant management problems reported by community health providers, Nesbitt had to throw up her hands. “It is virtually impossible for me to wrap my arms around everything that [a provider] says they were promised and did not get.”

This was the theme of the day: deep anxiety that the District is failing in its response to this devastating crisis, coupled with continual frustration at an inability to tell what the District already is or will be doing. Soon after the Postarticle came out, the Bowser administration released a plan to reduce the number of opioid-related overdoses 50 percent by 2020, which includes 63 strategies to get there, from the creation of 24-hour intake and crisis intervention sites to the distribution of naloxone wherever there are defibrillators. One of the primary purposes of the hearing Monday was to discuss and debate this plan. However, councilmembers and expert witnesses alike agreed that when it comes to the details that would make the debate constructive, the plan is “sparse.” Gray reiterated almost hourly over the course of the day, “It’s not really a plan. It’s more of an outline.”

Allen thought this was unacceptable, given that the plan has been in the works since October 2017. Speaking derisively about some action items in the plan that say that in the next six months, the District will “explore strategies” to do this or that, Allen said that after all this time, “I don’t want to talk about things like strategizing to begin to consider a plan.”

About 50 subject matter experts—from hospitals, advocacy groups, harm reduction programs, and major treatment providers—testified about what they thought DBH was doing wrong and the serious gaps they saw in the city’s opioid response. Bad regulations and lack of funding are preventing their attempts to distribute life-saving medications. There are not enough peer recovery specialists to get people through the process. Many, many best practices are reportedly not being followed.

But when Nesbitt and Chief Medical Examiner Roger Mitchelltook their seats to testify on behalf of the District government, the tone changed. They gave no apologetics. It was soon clear that there was a discord between the outside perception of the District’s response, and the D.C. agencies’ own understanding of what they’re doing. Mitchell said that they are still getting the final numbers, but it looks like the number of opioid deaths decreased almost 30 percent in 2018 from the year prior (although still is over two hundred). “There is more to be done,” he said, but “what the District is doing seems to be working.”

Echoing some of the expert witnesses, however, Allen and Gray pushed back on the idea that this decrease was necessarily evidence of the District’s success. “Did we do something different in 2018,” Allen asked, or “is it that this profile of individuals with substance use disorders—that we just have less of them, because they’ve been dying over the last several years, and so that’s why we’re seeing mortality go down?” Mitchell did not dismiss this horrific possibility. “The answer directly is: I don’t know,” he said. “But I would like to think that that it’s the efforts of the people that packed this room earlier. The efforts of my colleagues here.” 

When Allen tried to press Nesbitt on some of the specific problems the expert witnesses raised with DBH processes, she understandably was not ready with the esoteric details. “I can’t speak to that. I’ve been [at DBH] seven weeks. I’m peeling an onion,” she said. Allen pressed, saying that some of her staff there should know, as the esoteric details can be consequential. “We’re peeling an onion,” restated Allen. “I’m worried what we’re going to find.”       

This lack of culpability was Gray’s frustration with the hearing from the outset. He said Police Chief Peter Newsham didn’t accept his invitation to the hearing, and Nesbitt had just taken over DBH, but at the same time, he implored, “someone should be accountable for 700 deaths.” He requested that for each of the 63 strategies in the Mayor’s plan, someone be made responsible for that action item, so that if more initiatives fell through, at least this time individuals could answer for them.       

Allen opened the hearing by saying, “I want to come away from this hearing with a concrete, actionable next step that we can start implementing today, and next week.” But the only clear next step to come out of nine hours was that in six weeks, the executive branch will re-release its plan with more details about how they will execute the strategies. Nesbitt claimed that the city is already doing a lot to work toward many of the goals, and “we just need to document them.”

The only matter that no one at the hearing contested was the urgency of getting all of this right. “If we don’t break this cycle, we are not going to make any progress,” testified Dave Milzmanof the D.C. Emergency Medical Services Advisory Committee. In the District, “there are anywhere from 1400 to 1700 chronic users. We know that in the next year, we could lose probably 20 percent of those patients.”