The State We’re In: Doorways still seeing pre-pandemic volume of patients

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COVID-19 has presented new challenges for people seeking substance use disorder treatment and mental health services. In the next episode of THE STATE WE’RE IN by NH PBS, we will explore new practices to keep practitioners and people seeking treatment and recovery connected. Watch the video above, which features:

Carol Furlong who oversees SUD services at Elliot Hospital.

Ken Norton Executive Director – NAMI NH

Jay Couture (she) CEO/Executive Director Seacoast Mental Health Center

Moderator Melanie Plenda of Granite State News Collaborative.

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Care providers around the state are worried about the ongoing substance abuse and misuse crisis combined with what will likely be long-term fallout from the COVID-19 pandemic. 

“The pandemic also puts us at risk of a significant amount of toxic stress in our residents and that increases the likelihood they may develop mental health and substance abuse problems,” said Tym Rourke, director of New Hampshire Tomorrow at the NH Charitable Foundation and member of the Governor’s Commission.

Addiction is a disease of disconnection, while treatment and recovery are about rebuilding connection and community.  As people deal with the trauma of job loss and financial loss, it can affect the success of people who are early in recovery, he said.

Healthcare workers at the state’s nine Doorways , the hubs of the state’s $64.5 million treatment network, are still seeing pre-pandemic levels of patient volume, while having to enact social distancing guidelines and additional medical protocols and institute telehealth services.  

“I just hope this doesn’t get put on the back burner because of this (COVID-19),” said Christine Fortin, who oversees the Doorway in Berlin, said of the effort to increase the state’s network of prevention, treatment and recovery for substance abuse disorders. 

Patrick Tufts, chair of the Governor’s Commission, said New Hampshire has had historically high alcohol addiction rates and that has not changed during the pandemic. He cited calls to 211 NH, the statewide service referral hotline, regarding substance abuse remaining in the top three. The top two referrals calls are related to COVID-19 and financial concerns, said Tufts.

“Addiction continues to be a pretty pressing issue,” said Patrick Tufts, “We are concerned that may be a bit of a boomerang effect in the coming months where more people need access to addiction services.”

“One of our concerns is that alcohol has always been the number one abused drug in New Hampshire, and it continues to be,” he said. “We put a lot of emphasis on opioids, and rightly so, but alcohol continues to be abused at very high rates.”

Liquor stores are among those businesses allowed to remain open, and restaurants can sell alcohol for takeout.

“When the opioid crisis started back in 2008, not coincidentally, it was indeed driven by over-prescribing and misuse, but it got its root in the middle of that last great recession,” Rourke said. “In my world of private philanthropy, there is a lot of concern that this (pandemic) is actually gasoline on the fire on behavioral health. People are looking for ways to mitigate what is assumed will be a new wave of people in that situation.”

Indeed, Tufts said the Commission had plans to inject an $12 million into expanded treatment, recovery and prevention efforts.

“We were set to make unprecedented investment in expanding recovery and treatment options,” he said. “Multi-millions of dollars for expanded services, but we do anticipate some delays in those services to come online because of everything we are dealing with now.”

New Hampshire law mandates that 5 percent of state liquor profits go into the alcohol fund, which is used for prevention, treatment and recovery programs. The Governor’s Commission coordinates and funds those initiatives, which are separate from the federal State Opioid Response grants the state received to create the hub-and-spoke system.

Patient volume remains steady

In the meantime, patient calls to the Doorways around the state have remained consistent. In March, 655 individuals contacted the state’s Doorways, and of those, 316 were for opiate/opioid issues. In all, 9,587 individuals were served between February 2019 through March 2020, according to the state.

Fortin and others say the state’s hub-and-spoke system of treatment and recovery is working, combined with the availability of and use of Narcan to treat overdoses and Safe Stations, designated fire stations where those in need can get an initial assessment for treatment referral.

Overall, drug-related deaths are down from 2019, including those caused by opioids.The number of confirmed drug-related deaths as of April 10 is 41, with 34 of those caused by opiates/opioids, according to the state’s Office of Chief Medical Examiner.

In Concord, the Doorway staff does six to 10 intakes per week, which is similar to the volume they had prior to the pandemic.

 The center, like other health care facilities, has instituted a number of changes to comply with health and safety guidelines, including providing a separate space for telehealth visits with a clinician or caseworker, said Shanna Large, director of substance use disorders at Riverbend Community Mental Health Center.

“I would note that the clients that are coming in to the Doorway are those with higher needs,” said Large, who oversees the Doorway in Concord. 

 “They are able to see a face and speak to them directly,” Large said, adding the Doorway is able to get those clients into treatment, but in some cases, it may take longer.

In the Upper Valley, the Doorway at Lebanon follows Dartmouth-Hitchcock Medical Center’s protocol for screening and precautions. Everyone, including staff, has a temperature check prior to entering the clinic and has to wear a mask, said Luke Archibald, MD, director of Addiction Services at Dartmouth-Hitchcock.

Overall, Archibald says the patient volume coming through the Doorway seems to be consistent but is waiting for more data to make an objective comparison. 

 “The majority of our visits are being conducted by telehealth or telephone. However, we continue to accommodate urgent walk-ins, and some visits for established patients are considered necessary to occur in person,” Archibald said. 

Programs offering medication-assisted treatment for opioid use disorder are available via telehealth. 

“One of our most difficult challenges is weighing the risks of social contact by asking people to come for in person evaluation and a drug test versus a telehealth or telephone visit, where it is possible that we are not capturing the whole picture of what is happening in people’s lives,” Archibald said. 

Peter Fifield, who manages the Dover Doorway at Wentworth-Douglass Hospital, agreed and said the lack of face-to-face connection is not what people with substance use disorders need.

“You do lose a lot without the visual,” he said. “You learn a lot when you are face-to-face, but virtual is the best case if it’s not in person.”

Fifield said they have modified the workflow to reduce contact and in-person visit, but it’s hard on the vulnerable population they see. Many of those who come through the Doorway don’t always have reliable access to a phone or shelter. 

“So we are still taking walk-ins, but we do try to do as much care coordination over the phone as we can,” said Fifield, who is a mental health and alcohol and drug counselor. “But it can be a crazy mess to try to manage this over the phone.”

While being able to provide telehealth services and counseling has been critical during this time, it isn’t the same as an in-person visit. 

 “What has been challenging is the effect social distancing practices have had on group therapy,” said Christine Fortin, specialty practice manager for Weeks Medical Center, which operates the Doorway in Berlin. “A lot of people say it (virtual group therapy) it’s not as engaging as being in person. But if you don’t have transportation, it is a good alternative. But not everyone can talk openly about their situation while they are at home.”

Like the other Doorways, patient volume at the Doorway at Cheshire Medical Center has continued at pre-pandemic levels. Typically, the Doorway sees 70 to 110 patients a month, and that has not changed, said Nelson Hayden is the director/clinician of the Keene Doorway. 

“Opioid and alcohol are still the top substance abuse issues we see,” Hayden said, noting there has been some increase in patients with methamphetamine use disorder. 

Granite Pathways, who have operated the Doorways in Manchester and Nashua, lost those contracts after a state review prompted by overdose deaths and other issues at a teen facility late last year, according to news reports and information from the state. Representatives of Granite Pathways declined to comment.

Catholic Medical Center in Manchester and Southern New Hampshire Medical Center in Nashua will take over Doorway services later this month.

In Laconia, the location of the Doorway had to move from inside Lakes Region General Hospital to Hillside Medical Park because of the pandemic to better accommodate on-site patient evaluations.

“We still want people to call first before they come in,” said Corey Gately, director of the Doorway and Substance Use Services at LRGHealthcare, noting the Doorway is providing on-site plus remote visits and counseling.

Gately, who also runs the hospital’s recovery clinic, saw an additional 28 people in the MAT program just in April. Many of those patients are referrals from the Doorway. In terms of patient volume, she said there has been a steady increase in calls to the Doorway since the beginning of the year.

“In October, November and December, we had total referrals (through the Doorway) of 125 – that’s an average of 2 a day,” Gately said. “We’ve had 88 referral calls just in April. In March, we had 107 calls and 28 clinical evaluations.”

What accounts for the increase? Gately said it is likely that people are more aware of the Doorway system since it launched more than a year ago, and people are willing to reach out for help.

“As weeks and months rollout, this population will need a lot of help,” she said, echoing the concerns of Tufts and Rourke.

Rourke said the NH Charitable Foundation has moved $300,000 in recent weeks to support telehealth equipment purchases and pre-paid mobile phones for clients. Despite all of the challenges treatment and recovery, providers are facing, the ability to use telehealth services will likely continue. 

“Once the genie is out of the bottle is hard to put back in,” he said. “There have been for a long time conversations about it and pilot projects expanding its use.”

Rourke said it’s likely the rules that allowed these services will become permanent. In addition, although Rourke and others say in-person connection is vital to treatment and recovery of addiction, the ability to have this tool is critical. 

“I wish it started under a different situation, but hopefully telehealth continues after this crisis,” he said. 

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