Losing her: After detox in Southwest Florida, a precipice with few safety nets
Weatherley, a fentanyl addict who is homeless, wants to go to detox. Andrew West and Patricia Borns/The News-Press, Fort Myers News-Press
“Why couldn’t I catch you?”
Willie Weatherley will ask that question long after the heartbreak of her loss subsides.
She will wonder why she survived her opioid addiction while her sister Jessica did not.
When last seen by The News-Press in December, Jessica Weatherley had made it into detox after a frustrated first attempt.
Lacking money or insurance, the young Fort Myers mother next went to a sober home on Florida’s east coast where, far from the influence of using friends, Willie hoped she might stay on the recovery path.
But with her tolerance gone and emotions exposed, Weatherley’s relapse came fast and hard.
A week before Christmas, a phone call from Palm Beach County informed the family that she had been found in a back room of a convenience store, deceased.
And so for the thousands who detoxed in Southwest Florida and the hundreds who lost their lives to opioids in 2018, we also ask: why can’t we catch them? What could make the road to recovery better for the Weatherleys of our world?
After detox, a clear and present danger
The National Institute on Drug Abuse reports that opioid users who detox without follow-up treatment relapse almost as much as users who don’t detox at all.
They’re more likely to have overdosed and died within a year than patients who don’t detox, according to a 2003 study.
A physician assistant with Lee Health, Catherine Murtagh-Schaffer, put it bluntly, “The problem with detox is we know it doesn’t work without medical support.”
And that support, unlike for other chronic conditions such as asthma or diabetes, is all over the map.
“Everything is so case by case it’s scary,” said Tom Brady, a Naples substance abuse therapist.
This is not to say that Charlotte Behavioral Health where Weatherley detoxed, or any similar facility, releases a newly withdrawn patient with a handshake and goodbye.
“Treatment starts from the moment they enter the facility,” Charlotte's Director of Recovery Services Nicole Liberto said.
Although privacy laws protect the specifics of Weatherley's case, a clinician, nurse or nurse practitioner and a physician’s assistant or MD would have examined her physical and emotional state to assess her needs.
She would have been offered counseling, group therapy, wellness classes, even yoga and aroma therapy to engage her in the recovery process.
At the end of four to seven detox days, a case worker would have helped her make a plan to maintain her sobriety. She would have received a free Narcan kit – a naloxone nasal spray to block and reverse the effects of opioids should she relapse – and a schedule for her first follow-up appointments within seven days.
“There are supports if they avail themselves," Liberto said, "but they frequently don’t. We have people we know very well because they repeatedly want to detox but decide they don’t want to continue.”
Who is responsible to say let’s fix their problem?
Almost with one voice, medical and behavioral professionals across Southwest Florida say it's up to the patient; there's only so much they can do.
“We give them resources and point them in the right direction, but the opioid patients who come through our ER are not coming for help,” Lehigh Regional Medical Center CEO Gary Bell said. “They’re coming because they’re afraid to die. I’ve seen some bolt out the door with the IV lines still in their arms after a Narcan reversal.”
A revolving door
Was Weatherley one of those patients who opted out of a follow-up plan?
She had often said about getting clean, “It’s just that I’m not ready right now, I still have a lot of issues to work out.”
Would it have been better for someone with so few support systems not to detox?
Most treatment professionals say no.
Getting to recovery: When an opioid addict was ready, the detox beds in Southwest Florida were not
"Opioid abuse is suicide by installments," Brady said. "Regardless of their circumstances, detox is always a good thing to give them a chance to make some changes."
If a user’s life is in danger, a family member or police could petition the court under the Marchman Act to admit them to an addiction receiving facility for a few days.
Otherwise, as the saying goes in the treatment profession according to Brady, ‘If you don’t want this program, don’t worry. You won’t get it.’”
Only Jeremiah Gardner of Hazelden Betty Ford suggested otherwise.
"It is wholly inadequate, even dangerous, to receive only detox," said the spokesman who's mother died of an overdose and is in long-term recovery himself.
Fragmented and flawed
And so they come, relapse, and try again, with supports that are often inadequate to help them stay sober, providers admit.
"Seven days (of detox) is not enough to keep someone in recovery," David Lawrence Center's Chief Operating Officer Nancy Dauphinais acknowledged. "People can have intense post-acute withdrawal symptoms in the first 30 days. They have to restore a lot of weight, to get to a productive sleep-wake cycle. It’s very hard to manage in an outpatient setting."
Drowsiness from medications and the physical and emotional depletion of their using lives make it even harder for detoxing patients to engage in treatment in the first days.
With a call to the sheriff's office, an opioid user could start on Seboxone or Vivitrol while at Charlotte Behavioral – medications that ease the withdrawal process and make it safer – then continue as an outpatient for free or low cost, Liberto said.
But those like Weatherley, who want Charlotte outpatient services, can't get them if they identify themselves as homeless in Lee.
Another challenge: if an indigent person is discharged with a few days of medications and a prescription, "They are going right back to their habit if they don't have the money for a refill," Brady said.
And if an underlying mental health problem is involved – "extraordinarily common," says Central Florida Behavioral Health Network's Larry Allen – sober homes, Bible groups and 12-step meetings don't have the skills to handle it.
State Attorney Dave Aronberg, who is fighting patient brokering and kickbacks in Palm Beach County, sums up the current state of our treatment industry as "a decentralized form of rehabilitation with a disconnected group of sober homes and treatment centers of varying quality."
Brick by brick, in funding fits and starts, it is changing:
- Longer engagements The short-term – usually 28-day – residential treatment model that's prevailed for decades is giving way to longer interventions on an outpatient basis, Aronberg said. For example, a step-down from intensive treatment to a counselor and peer support for 12 months or more.
- Support them at the intercept Sober residences should accommodate medications, Gardner and others urge. Central Florida Behavioral Health Network, which funds services for the region, is focusing on what Allen calls "the intercepts" – expanding treatment in jails and prisons, emergency rooms and child welfare – wherever mental health and substance abuse are underlying issues.
- Medical parity Moralistic approaches to substance abuse are bending to evidence-based practices like medication-assisted therapy that can be shown to work. Facilities that don't offer it are no longer funded by the network, Allen said.
- Care coordination An intervention that could have helped Weatherley, this program follows a person out of detox with phone calls, bus passes, even home visits and supported housing to make sure they stick with their case plan.
It's similar to what hospitals do when patients with chronic diseases like congestive heart failure are released to make sure they're not readmitted, and it works – in one year (2016-17), detox patients who were repeat visitors had 63 percent fewer inpatient days and almost 40 percent fewer readmissions.
Only a handful of high-need users get this level of attention, however, because "there is never enough money," the network's Alan Davidson said.
"It starts with expanding insurance access," Gardner said. "Florida didn't expand Medicaid, so there are people who fall through the cracks that we need to find support for."
Do no harm
A former drug counselor, Julia Negron didn’t mean to start a movement when she relocated from Los Angeles to Sarasota, but the founder of the Suncoast Harm Reduction Project kept running into parents who’d lost their kids to opioid overdoses.
The ex-wife of a former Three Dog Night vocalist, Negron beat heroin but lost her mother to it and has watched her son cycle in and out of rehab and prison for 20 years.
"We have far too many abstinence-only treatment centers. It’s a dangerous cycle that we put people through over and over again," she said.
In 2015, Suncoast scored successes lobbying Florida legislators to expand access to Narcan and make it available through pharmacies with a doctor's standing order.
Three years later, overdoses in Lee County are trending down by around 15 percent; in part, Lehigh Regional's Bell believes, because of Narcan.
Southwest Florida’s Ramona Miller gives opioid users the overdose antidote Narcan for free. "The best person to help an addict is an addict," she says. Patricia Borns, email@example.com
This year Negron is advocating a bipartisan bill filed this year, the Infectious Disease Elimination Act (HB 171), that would give cities and counties the option to offer needle exchanges so IV drug users can swap used needles for sterile ones, protecting them from HIV, hepatitis and other blood-borne diseases.
Currently Florida's only such program is in Miami-Dade County.
Like her counterpart in Lee County, Ramona Miller, Negron and her Suncoast volunteers give out Narcan for free on the street and teach people to use it.
Miller, who runs a small nonprofit A Voice In the Wilderness, used to give Narcan to Weatherley and an occasional meal. The warm socks and cup of noodles approach helped her get to detox when she felt ready.
"In treatment they say, 'Wait for people to reach a crisis level.' This way, you engage them along the way. People can't recover if they're dead," Negron said.
Through it all, providers insist detox and treatment are worth it.
"The number of overdose deaths is catastrophic, and you cannot overstate the impact of substance-abuse disorders to families and communities," Allen said.
"However, it is important for everyone to know that treatment works, and that it is not uncommon for an individual to have multiple treatment attempts before entering recovery."
Follow this reporter on Twitter @PatriciaBorns.
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