Hub and spoke approach helps battle opioid addiction in New Hampshire

Editor’s Note: This story was produced by The Granite State News Collaborative as part of its Granite Solutions reporting project. For more information, visit www.collaborativenh.org. Next week’s story will focus on the issue of Medicaid reimbursements and what is being done to address the issue.

NASHUA – Julian Bush says he’s running out of room on his body to garland tattoos, as he points to the “Reckless” ink laced around his neck.

“It’s another addiction,” the 34-year-old said, tugging his cap tighter around his forehead.

But Bush delineates the crowded body art from the addictions he’s suffered most of his life. He started smoking pot when he was 7. By age 11, he was drinking with his friends. By high school, he was on to hard drugs: cocaine and amphetamines. During sophomore year, he left school and took odd jobs in the construction industry, where he saw other workers abusing substances. “I thought it was normal,” he says.

And while Bush says he grew up in an addict home, he doesn’t blame his environment or his parents for letting heroin seduce him. Looking back, he was self-medicating. “I never felt like I fit in,” says Bush. “I was always an outsider.”

No one wants to get hooked on heroin, or any other opioid. Researchers explain that opioids barrage the brain with dopamine, a naturally occurring chemical messenger that plants a sense of feel-good calmness in the body. Inhale, ingest or smoke the drugs once, and the opiates rewire the brain’s circuitry, signaling the addict to restore the body to its tranquil state with more drugs.

For Bush, this ultimately meant needing a package of dope to get up and shower – to live.

Most people who abuse substances have a co-occurring mental health disorder, said Melbourne Moran, a clinical social worker who directs Integrated Care and Population Health at Harbor Homes, a Nashua nonprofit agency providing social services to low-income, homeless, and disabled individuals. It’s where Bush receives his primary health care.

Today, Bush is living at Gatehouse, a private drug treatment center in Nashua, where he’ll reside for another four months. He had checked into rehab a handful of times before, but never for more than a month before falling helpless to the clench of heroin. The drug no longer elated him, but it allowed him to function, while tampering with his moral compass so he’d do anything to buy some smack: lie to his family, steal or get into a brawl.

Sometimes his toxic plight landed him in jail, which he describes as “people in a room that have the same problem” with no hope of a solution.

If he didn’t end up in prison again, he’d die. Bush says he overdosed six times – at least that he can remember.

Last summer, he asked his father to take him to the fire station on Amherst Street in Nashua, where the city runs a Safe Station program to assist anyone seeking treatment for addiction. He was one of 2,665 individuals who sought help from the Safe Station since its inauguration on Nov. 17, 2016, according to a report from American Medical Response (AMR), the agency Nashua contracts with to provide emergency medical services and transportation.

Within five minutes a representative from AMR took Bush’s vital signs. Within 10 minutes an on-call Harbor Home staff member – the mobile crisis team – transported him to the Peggy and David Gilmour Medical Respite Center on High Street in Nashua to receive medical detox.

“It was way harder to get clean without the Safe Station program,” said Bush, who relapsed once, the day before Thanksgiving. But unlike in the past, he continued to attend Alcoholics Anonymous (AA) and Narcotics Anonymous meetings, and said he is more open to getting help.

The Safe Stations average 3.3 visits a day, said Nashua Fire Chief Brian Rhodes. In 2018, the program responded to 315 overdoses in Nashua, with 34 resulting in death. That was a 22 percent drop from 2017, when the city of Nashua reported 45 fatalities from opioid overdoses.

Jessica Parnell is executive director of Revive Recovery, a peer-based recovery organization in Nashua, one of 10 in the state where many people who’ve benefited from the Safe Stations program can go for meetings and family support groups, as well as classes on spirituality and yoga. The fire stations provide a place “you can always go on a dime,” Parnell said.

But despite the effectiveness of the Safe Stations, the program is $200,000 in the red, according to Peter Kelleher, CEO of Partnership for Successful Living, the umbrella organization under which Harbor Homes is a member. Kelleher said the 24/7 Safe Station operation – including transportation from the fire stations, evaluations and assessments, and withdrawal management – costs $1.3 million. The city of Nashua contributes $50,000. To offset fiscal woes, the Safe Station program seeks private donations, garnering $100,000 this year, about 30 percent more than in 2018.

This year, the Safe Station program also received a $175,000 state grant for respite shelter services, but Kelleher said the money is running out and he doesn’t expect it to be renewed because the state is shifting resources to the hubs as part of a statewide grant funded Hub and Spoke system.

Nashua’s public health director Bobbi Bagley, is cautiously optimistic that Greater Nashua can continue to see a decline in opioid deaths with the introduction of a regional hub-and-spoke system of care that’s modeled after Vermont’s treatment infrastructure. The new system launched on Jan. 1.

The rollout is made possible by a $45.8 million federal grant to the state Department of Health and Human Services, to help fight the opioid crisis. The federal money is available over a two-year period, with $22.98 million to be spent in the first year.

The plan offers nine regional doorways or “hubs” for any person seeking treatment for opioid addiction. The goal is that no one should have to travel more than an hour to get help from a hub.

Most of the hubs will be run in conjunction with hospitals. Dartmouth-Hitchcock Medical Center in Lebanon; the Concord Hospital; Androscoggin Valley Hospital in Berlin; Wentworth-Douglass Hospital in Dover; Cheshire Medical Center in Keene; Lakes Region General Hospital in Laconia; Littleton Regional Healthcare in Littleton.

In Nashua, the hospitals are not participating. Instead, the nonprofit Granite Pathways, which has a presence in Manchester but is little known in Nashua, is taking the reign as hub coordinator.

RAPs into Hubs

Tym Rourke, a member and former chair of the Governor’s Commission on Substance Abuse, said the biggest change from the Hub and Spoke system is the hub.

While some treatment providers are receiving new funding for things like parental support programs and increased medication-assisted-treatment capacity, some are not, but they are all considered the “spokes” in the system.

“The spokes are the system we have now,” Rourke said.

In some areas, the hub isn’t an entirely new concept. In Manchester and Nashua, they already had well-established Regional Access Points (RAPs), which served as initial points of contact for people seeking treatment. They also have the Safe Station programs, which have served as a brick and mortar doorway for treatment.

In other parts of the state, some RAPs consisted of a phone service that referred people to local providers, Rourke said. “The hubs are intended to … replace those Regional Access Points or enhance them,” he said.

In Manchester, Granite Pathways has been the established point of contact, providing services like screening, treatment referral, case management, recovery support and family support. Under the new regime, they will continue to do much of the same. But Rourke said the most significant change is in centralizing the clinical assessments which were previously done by providers (the spokes).

“There are multiple pathways to recovery and addiction is a complex condition, so getting someone a proper screening and assessment as quickly as possible in a hub that can also provide care coordination gives patients the best chance for rapid access to the various treatment and recovery options they need,” Rourke said.

The idea is to make the process more efficient in terms of the time it takes to get addicts into treatment and reducing instances of patients getting juggled around from one provider to another.

Granite Pathways

In most cases throughout the state, designated hubs will be hospitals, except for Granite Pathways in Nashua. Their office at 12 Amherst St., also known as The Doorway, is open from 8 a.m. to 11 p.m. Granite Pathways is providing two recovery-support workers at the Amherst Street location and two case managers at Revive Recovery in downtown Nashua. Pending state approval, the equivalent of 2.5 clinicians from Harbor Homes will also work for Granite Pathways. Harbor Homes’ Moran says the mobile crisis unit will still respond to emergency calls from the fire stations.

Kim Haney, director of The Doorway at Granite Pathways in Manchester and Nashua, spoke at a public forum in Nashua on Jan. 14. She said she wants make it easy for people looking for basic services so they don’t have to navigate different points of contact. “We’re going to collaborate with providers to create an integrated system of care.”

Yet Haney also conceded that the logistics of this new infrastructure are still being worked out.

State Rep. Patricia Klee, who is also a Nashua alderman, questions how the Hub-and-Spoke model will be an improvement on the Safe Stations program.

Safe Stations is a program that assists anyone with a substance use disorder, including addictions from opiates, methamphetamines or alcohol. The majority of people who walk into a fire station come in late at night, said Klee, who emphasizes that Safe Stations are 24/7, while The Doorway is only staffed until 11 p.m.

“Why import something from another state when you have something here that’s working?” she asks.

The success of Safe Stations is in the numbers: In January, Nashua’s Safe Station responded to 13 overdoses, with no fatalities. That has not happened since December 2015, according to Christopher Stawasz, regional director for AMR.

But while opioid deaths are down, Revive’s Parnell is seeing a spike in other substance abuses, especially the less expensive methamphetamines, which are made with over-the-counter ingredients in secret labs.

“All the other drugs are still a problem, have always been a problem, and will always be a problem,” she said.

Haney says that while The Doorway will not turn anyone away, the Hub-and-Spoke money is specifically targeted to recovery from opioids.

Moran says the Hub-and-Spoke model is a boon for more rural areas with limited resources – or none at all. And he credits Granite Pathways for recognizing the role fire stations play in bringing people into The Doorway office at Harbor Homes.

In October, the regional division of the Health Resources & Services Administration (HRSA) organized a conference to promote the city’s Safe Stations program. The federal agency hopes to replicate components of Nashua’s program in other parts of the country, according to the HRSA.gov web site.

“The federal government has had more buy-in to the Safe Stations program than our state government has,” he adds.

Thirty-four-year-old Justin Carter remembers going to the fire station on Nashua’s Lake Street in the final days of 2017 and being transported to a hospital emergency room for the abscess in his arm. From there, he went to the Harbor Homes’ Maple Street Shelter, where he spoke with a licensed drug and alcohol counselor on the phone.

Carter, whose burly stature and gentle gray-green eyes camouflage a history of mental anguish, says, “I was doing a ridiculous amount of drugs. I needed to be medically detoxed.”

His memory fogs the timeline, but a few days went by before he was admitted to Hampstead Hospital, a private psychiatric facility, for seven days.

“I went down to Lawrence (to buy drugs) right before I went there, and on my way there, I done three grams in like 20 minutes. I was high for two days.”

His withdrawal from heroin at Hampstead precipitated vomiting and intense pain. He thought he’d never have to do it again. But nearly three weeks later he relapsed – more than once. Later, he was charged with domestic violence.

“The way I got my first month of clean, sober time is sitting in Valley Street (jail).” That’s where he thought about, in the process of a 22-hour lockdown, how to manage adversities without using drugs.

Would the continuous monitoring of a Doorways case manager have quickened Carter’s path to recovery? Would the hub-and-spoke template have reduced his recidivism?

Carter can’t say for sure. All he knows is that he was prepared to change.

His last of four stints in the Valley Street correctional facility in Manchester was on May 24, 2017. He thought about his 3-1/2-year-old son and girlfriend. He went to AA meetings.

He acknowledges that an addict might miss the high of doing drugs: “But you don’t miss the life.”

He’s now 20 months into his recovery and volunteers at Revive to help others with their journey.

But whether people enter the system through the Safe Stations portal or a Hub-and-Spoke doorway, some believe it may not matter much if there is no place to put them.

Ken Lewis, director of HEARTS Peer Support Center of Greater Nashua, said getting people into residential treatment beds is the biggest roadblock. He says responders have only 10 to 15 minutes before addicts who ask for help may change their minds.

“The problem is,” says Lewis, “are there going to be beds available?”

“They can put all the counselors and therapists in the room, but if you have nowhere to place (patients) – what is it? It’s just a song and a dance,” said Lewis.

In the meantime, the Nashua Safe Stations are still open for people who are ready to walk through that doorway, though for how long remains to be seen.

GSNC correspondent Ryan Lessard and Project Manager Melanie Plenda contributed to this report.