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Renovations underway at the first floor lobby of the Hoitt’s building. Photo by Ryan Lessard.




Treatment explained

The treatment process is different for everybody, depending on their needs and, unfortunately, their available resources.
If an addict seeks help with drugs still in their system, they’ll need to detox first. Some can manage to detox in a community setting with some observation and consultation. But the worst cases will likely require medical detox.
Medical detox is the process of helping addicts get over the hump of withdrawal sickness in an inpatient medical setting, sometimes with the help of drugs like Suboxone to ease the transition. Spofford said it generally lasts about 6 days.
From there, they would begin proper treatment, either on an outpatient basis — with medication assisted therapy in some cases, traditional psychotherapy and group therapy — or inpatient basis, which often includes a lot of rules, structure and therapy.
Residential treatment is divided between high-intensity inpatient treatment for 28 days and low-intensity treatment for 90 days. During low-intensity residential treatment, patients gain more freedom of movement, start to take on more responsibilities and begin the process of transitioning back into society. 
The lengths of stay in treatment programs is a general rule of thumb but the American Society of Addiction Medicine criteria recommends flexibility based on individual needs. In the past, providers and insurers were inconsistent in meeting that criteria, sometimes kicking out patients too soon, but a bill signed into law from the emergency session this year now requires providers and insurers to comply with the ASAM criteria.
After treatment, there are transitional living options with Serenity Place or sober living homes operated by Granite Recovery Centers. People can use sober living homes as a safe, drug-free place to stay while finding or working jobs and sorting out the nitty-gritty details of everyday life.
Ultimately, people end up in recovery and can use the growing community recovery scene to tap into resources or attend regular meetings to stay sober.
That’s how it’s supposed to work, anyway.
For many people who leave treatment, they end up in the same toxic environment, dysfunctional family dynamic and negative influences that expose them to substance use and relapse triggers. One of the things the RAPS program is designed to do is to keep in touch with patients and coordinate their care with providers at each step (see p. 20 for more on RAPS). Sandi Coyle at Granite Pathways said they also plan on having recovery specialists who will follow a client for one year after treatment.
 
Statewide Addiction Crisis Line
1-844-711-HELP (4357)




What keeps him up at night?
How NH’s drug czar, recovery experts and social workers are trying to build a rehab system that lasts

09/22/16
By Ryan Lessard news@hippopress.com



 Take a walk inside the old Hoitt’s Furniture building at 293 Wilson St. in Manchester and you’ll see construction workers busy renovating the first floor, as they have been for the past several weeks. It will soon be the home of HOPE for New Hampshire Recovery.

Brick walls, stone foundations and a turn-of-the-century wooden freight elevator reveal an older building than the ’70s-era redesign would have you believe it is. The exterior is covered with a beige stucco-like substance and the roof is still sporting the old company sign, where it’s been for generations. 
During a recent tour of the first floor, crews were working on the finishing touches needed before the interior walls — existing then only as metal frames — are installed. In just a couple weeks, Scott Schubert with Anagnost Companies said, this hollow, wireframe shell of an interior will be reborn as office spaces and meeting rooms. 
With the new recovery and treatment center located at the corner of Valley Street, just a short drive up from the Manchester Police Department, the police will now be bookended by a county jail to the west and the flagship recovery center to the east, both visible from their windows. 
That image serves as a fitting parallel to the shifting ways the Granite State is tackling addiction. Where once the issue of illicit drug abuse was virtually the sole domain of law enforcement, a greater emphasis on treatment and recovery has taken hold in the past few years, leading to rapid improvements and expansion of a long-neglected system.
 
Olympian task
To many, the new HOPE facility is seen as ground zero in the fight against the state’s addiction epidemic ravaging New Hampshire. So far in 2016 there have been 241 confirmed drug overdose deaths in the state, and the Medical Examiner’s office expects the year to end with another record death toll: about 480 deaths. Last year there were 439; the figure has been climbing since 2012. According to the state health department, emergency room visits for overdoses reached 666 in July, 538 in June and 462 in May. About 40 percent of those happened in Hillsborough County. 
While there’s no easy way to know how many addicts there are in the state, the rule of thumb nationwide is 10 percent of the population, which would be about 130,000 in New Hampshire, according to Tym Rourke, chairman of the Governor’s Commission on Alcohol and Drug Abuse.
Of the 2,562 inmates in the New Hampshire prison system, about 85 percent report having a history of substance abuse.
To solve this problem, the state has to face up against the influence of drug trafficking organizations, piece together a healthcare system out of a complicated mess of nonprofit and for-profit providers, insurers and state agencies, and help each struggling individual win the war against their addiction.
CEO Eric Spofford of Granite Recovery Centers said the latter is going to be the hardest part.
“Addiction’s the same thing that has the the nine-months-pregnant woman trying to [take] dope because her water breaks and she can’t go have this baby before she gets high. Addiction’s the thing where they know they might die but they do it anyway,” Spofford said. “Addiction’s the thing where people lose their children to the state and the addiction is so powerful that, despite their moral convictions and who they are truly as people deep down inside, they can’t stop.” 
And the system we build needs to be built for the long term, says Courtney Gray, the executive director of the New Hampshire Providers Association.
“It’s important to not build something that’s going to be taken down, that we continue to make sure the infrastructure is going to stay standing and it’s not a ready-to-go thing [but] an existing, solid, permanent infrastructure,” Gray said.
 
NH’s “drug czar”
That’s a lot to handle but, in New Hampshire, one man is tasked with overseeing all of it: the so-called “drug czar.” James Vara, a 38-year-old former prosecutor in the attorney general’s office, isn’t a fan of the sobriquet, but he’s got bigger problems to deal with.
“I understood going in that this position would be a difficult position. [I’m] coming into a position knowing and understanding that we are in, as a state, a public health crisis,” Vara said.
As the Governor’s Advisor on Addiction and Behavioral Health, Vara has been busy meeting with government officials, key stakeholders and families affected by the drug crisis every day since he took the job in April. But it’s those families that help to keep things in perspective for Vara.
“My sort of daily grind … pales in comparison, frankly, to what those folks are suffering,” Vara said.
Still, Vara has logged about 11,000 miles of driving to and from various meetings, listening and learning what the areas of need are and what problems need fixing. And he spent his nights and weekends writing up a comprehensive report on the progress made so far with some short-term recommendations for future improvements to the state’s response to the crisis, the first report of its kind.
“Probably a lot of that goes back to my role in prosecution where you sort of say to yourself, ‘what evidence do we have?’” Vara said.
Vara has been emphasizing data collection as a critical component to this overarching effort, not just to have a clear accounting of progress statewide, but to ensure tax dollars are spent on programs that are working, and when they are, to be able to present that data to lawmakers who hold the purse strings whenever funding needs to be revisited.
So while he’s coordinating efforts to build up the treatment and recovery infrastructure, Vara is also building a case for long-term legislative buy-in. The idea is that when the crisis abates and pressure to fund an emergency response dissipates, important treatment programs don’t get defunded. And for this system to achieve long-term sustainability it will also need to develop a diversity of revenue sources besides just state money.
“That is something that I think of every day,” Vara said.
First, he needs to coordinate the full buildout of these addiction services for today’s demands. How to create such an infrastructure is complex, even with funding. There are barriers to recruit people who would work on the front lines, make sure insurance reimbursements are fair and sufficient and to educate the public on how this whole thing is supposed to work. 
 
Treatment vs. recovery
Policy makers and experts agree that to fight the drug crisis we must focus on four things: law enforcement efforts to stem the supply of illicit drugs, addiction prevention initiatives, crisis treatment for addicts as they fight through withdrawals and learn to overcome the underlying psychological triggers, and ultimately a recovery system that helps people stay sober and reintegrate into society. 
So, how far has New Hampshire come in building up the systems needed? What holes have yet to be filled? And how will the state be sure it’s constructing a permanent infrastructure that will be in place for the next crisis?
HOPE for New Hampshire Recovery is a community recovery service, which is perhaps best understood as a sort of Sears catalogue to recovery resources, including 12-step programs, to ensure that those who have achieved sobriety keep it going for the rest of their lives. It’s led by peer coaches, which are people in recovery themselves who offer suggestions and do some of the legwork to help folks out based on what works for them. 
Dick Anagnost is the developer of the project on Wilson Street and is partnering with AutoFair CEO Andy Crews to make the roughly $5 million project happen. Crews’ wife, Melissa Crews, was the chair of the HOPE board when the project was announced back in October 2015. 
Anagnost said HOPE will have its new home ready by Oct. 19 with room to expand from Phase 2 of the first-floor space. It will be moving from about 900 square feet of space at its current location at 140 Central St. to about 7,500 square feet in the 37,000-square-foot building.
The HOPE program offers the kinds of services that come late in the fight against addiction, which are just as critical as the vanguard of addiction treatment services. 
The upper floors of the old Hoitt building will offer different services. Families in Transition will offer its Family Willows program, an intensive outpatient treatment service for women, on the second floor with 11 apartment units for mothers in recovery, and recovery housing with eight bedrooms for single women on the third floor while Mental Health Center of Greater Manchester will base its mobile crisis unit on the fourth floor. Anagnost said he expects the fourth floor will be done by December.
Having these various services in one building will be helpful, but it may be confusing to those who don’t understand the difference between treatment and recovery.
Where treatment is a rescuer picking up the fallen travelers, brushing them off, seeing to their health and providing a roadmap, recovery is a line of formerly fallen travelers standing, hand-in-hand, as a bulwark against the edge of the ever-present cliff, guiding fellow travellers and warning those who stray from the path.
But that path is far from straight and not everyone who stumbles will need the same level of care. In real terms, that means not everyone who needs treatment will need intensive, inpatient care. 
“A bed is not treatment. Assessing people at the appropriate level of care and getting them exactly what they need is competent client care,” said Serenity Place CEO Stephanie Bergeron.
Serenity Place has long been a community treatment provider and used to provide a small number of detox beds and addiction counseling but has lately ramped up an outpatient treatment service for men and repurposed its beds — of which they hope to get up to 10 — for 28-day high-intensity treatment and a transitional living program that has 14 beds for men and 14 beds for women.
Bergeron and other addiction specialists say the focus on beds can often detract from the public understanding of what treatment entails, which can vary from person to person. 
Many people do need beds, however, and there are still waiting lists for those folks. More than anything, beds have become a symbol of the state’s historically under-resourced treatment capacity for mental health and substance use disorders.
“That’s where there’s been a tremendous dearth over the last 25 years,” said Joseph Harding, the director of the state Bureau of Drug and Alcohol Services.
But in the past couple years, state and local officials and organizations have been working frantically to ramp up programs that had either fallen into disrepair from years of neglect and budget cuts or to create systems that had never previously existed in the state. 
The result is a number of unprecedented changes in just the past year — an expansion of addiction coverage through Medicaid, a statewide crisis line and half a dozen new recovery centers — which all agree is forward progress but that few would call a solution just yet. 
The first big change is funding. Money has been coming in from the state and federal governments, local charities and businesses.
“For the first time, I guess, ever, we have been given the resources that we need in order to be able to effectively address the misuse of drugs and alcohol in the state,” Harding said.
But using that money to build up the treatment and recovery services needed does not happen overnight.
 
Starting line
Vara is the first to admit the available services are still insufficient given the overwhelming need for treatment.
“Certainly, there’s waiting,” Vara said.
But he’s proud of how far the state has come so far. When one looks at where the state started just a few short years ago, it’s not hard to see why.
According to a 2011 report, only 5.6 percent of those who need treatment in the state actually get it each year on average. In real numbers, that’s about 5,600 people out of 100,000. And that’s before the opioid epidemic hit a fever pitch in 2013 and 2014. 
Economist Brian Gottlob compared that to data for every other state in the nation and found that New Hampshire ranked 49th for access to treatment. Only Texas had lower numbers. 
Eric Spofford with Granite Recovery Centers said the addiction problem has been severe and present for years.
“We’re 15 years too late,” Spofford said. “For 15 years, this opiate epidemic has spiraled out of control — [an epidemic] that no one was paying attention to, until the last couple of years.”
Opioid addiction has been prevalent in New Hampshire since OxyContin was released on the market in 1996. Heroin spread faster in recent years but Spofford said it was already here, invisible to the public. 
And it didn’t happen entirely by accident. The forces that attracted drug dealers to within our borders were simple supply and demand. High opioid prescriptions in New Hampshire and other parts of New England led to lots of people getting hooked, and when they couldn’t get any more pills they turned to heroin, which was far cheaper and more potent.
But Bergeron at Serenity Place said she was surprised to learn just how planned out some of the drug trafficking was, straight from the source, when she sat through presentations given by law enforcement showing business plans by Mexican drug kingpin Joaquin “El Chapo” Guzman of the Sinaloa Cartel targeting New Hampshire specifically because of its high rates of opioid prescriptions.
“I feel like it’s a Quentin Tarantino movie. Literally, El Chapo — business plan — New Hampshire,” Bergeron said.
She remembers when the heroin problem really started to heat up in the winter of 2013 and the sheer volume of patients coming in for help was more than they could handle.
“All of a sudden we’re all trained on how to use Narcan. … I have a sharps bucket and I’m out here picking up needles out on Manchester [Street]. It feels like it was overnight,” Bergeron said. “We were always that provider that took care of the indigent population or people who really had nowhere else to go, but then we had everyone coming to us.”
HOPE’s CEO, Cheryl Coletti-Lawson, thinks the issue of addiction came to the forefront because opioids were crossing over socioeconomic lines, affecting more families directly and even the employees of area businesses.
But Spofford thinks something else is to blame.
“It’s not the opiate epidemic that got their attention. It’s fentanyl. It’s the body count,” Spofford said, referring to the advent of the far more potent synthetic opioid that has caused the majority of drug-related deaths this year and in 2015, according to the ME’s office.
Fentanyl started appearing in state forensic lab tests in small amounts in 2012, but by 2015 fentanyl became 10 percent of all the drugs the lab was testing. It’s now about 20 percent and it has overtaken heroin at 14 percent, according to Tim Pifer at the forensic lab. That makes it the No. 2 drug tested by volume after marijuana.
And all of this was happening in a state that was ranked second to last in treatment access. 
When it came to recovery services, New Hampshire was the only New England state without a single peer recovery community center. 
Though groups like HOPE have been around for years and offered services to folks in recovery, they didn’t have any physical locations where people in recovery could walk in and seek help before last year.
 
Recovery centers
A couple of years ago the leaders of HOPE were moving forward very cautiously to start opening recovery centers. 
“Two years ago, we sat in a room with a white board, threw it up on a board and said, ‘what does it look like?’” said Coletti-Lawson. 
Lawson started as a board member, worked her way up to being chair and just a month later became the president and CEO this summer. 
In February 2015, the then-director of HOPE told reporters they had plans to open one center in Portsmouth and another in Manchester down the road, maybe a year or two later.
But things ended up moving a lot faster than expected, and as Coletti-Lawson describes it, leaders in the organization decided it was time to act quickly and not shy away from the inevitable challenges.
An aggressive fundraising effort with the help of several area businesses and charities laid the groundwork for opening not one or two centers, but six with a seventh on the way.
“Our strategic plan is not as conservative today as it was then,” Coletti-Lawson said.
HOPE ended up opening its first center in Manchester in May 2015. This year saw rapid-fire openings starting in Newport in March. After that, centers opened in Concord in May, Derry and Claremont in July, Berlin in August, and a center is due to open in Franklin in the coming weeks.
Meanwhile, Portsmouth was the site of a new recovery center called Safe Harbor, run by Granite Pathways, which opened in May. 
Other players like the White Horse Addiction Center in Ossipee and the SOS Recovery Community Organization in Rochester also started up recently.
Coletti-Lawson said she’d like to see a recovery center, HOPE or otherwise, in each of the state’s 13 public health networks in the near future. 
In the short term, she said, HOPE is finalizing plans for another two or three centers for the coming year and is willing to open a center in any community that invites it.
Meanwhile, the governor and executive council authorized a $1.5 million contract with Harbor Homes, a Nashua-based nonprofit that provides various programs to aid the homeless and veterans, to facilitate the development of new recovery programs with partnering organizations in no fewer than five of the state’s regional public health networks. 
Another $500,000 in direct grants was also made available to help with the expansion of recovery services.
 
Catching up
A lot of the progress made so far in ramping up access to treatment and expanding its capacity has happened in just the past year, some great leaps in just the past few months.
Since January, the state has approved more than $24 million in contracts to multiple providers for substance use disorder treatment and recovery, according to Vara’s recent report on the state’s crisis response.
BDAS has contracts with 15 separate treatment providers like Serenity Place. Bergeron said once all options are exhausted in attempts to get insurance reimbursements for patients, they can dip into state money from BDAS so they don’t have to turn anybody away for lack of coverage.
Perhaps the biggest game-changer has been seismic shifts in the insurance market that expanded coverage for substance use disorder.
In New Hampshire, the expanded Medicaid population (about 50,000 people) got access to SUD treatment in January and, as of July, that spread to the rest of the traditional Medicaid population — another 140,000 people.
This was not only good news for low-income people struggling with addiction; it was good news for providers that had been helping them the best they could and eating the cost, according to Courtney Gray at the New Hampshire Providers Association.
“I know for a number of providers the reimbursement has really helped in their revenue streams,” Gray said. 
And that added revenue could go a long way toward bolstering treatment capacity.
 
Making our beds
Serenity Place recently expanded into the second floor of the old Manchester police station on Chestnut Street, which is right across from Serenity’s Manchester Street location and adjacent to the Manchester Fire Department’s central station on Merrimack Street.
Serenity is using the new space for its outpatient services, administrative office space and a day program for people waiting to get into formal treatment.
One of the offices was actually once a holding cell. Bergeron said they hope to renovate and expand into the rest of the second floor soon.
Serenity is a scrappy outfit, a low-budget nonprofit that’s more charity than clinic. And there are others like it across the state, charged with taking their small neighborhood services into brave new territory. 
Other organizations, like the Farnum Center on Queen City Avenue in Manchester, have a more high-end business model. Compared to Serenity, Farnum has more beds and more medical staff and has licensed prescribers, which enables them to use medically assisted treatment with buprenorphine, known more commonly by the brand name Suboxone.
While Serenity’s setup in the police station seems a bit haphazard, surrounded by empty ramshackle hallways and above a basement with rooms stacked full of abandoned furniture, Farnum’s facility is purpose-built, clean and professional. Farnum works with a larger budget and is a program of Easter Seals.
However, Farnum only has a few beds dedicated to Medicaid recipients. Most of the clients they see have commercial insurance or pay for their stay through other means. 
This past July, Farnum’s Webster Place in Franklin opened an expansion with an additional 40 beds.
While it’s important to remember that bed capacity isn’t the only thing or even the most important thing needed to create a working treatment infrastructure, there are some statistics that show the state’s treatment bed count moving in a positive direction.
There were 215 state-funded beds in February 2015. That number is now up to 270, according to Vara. But that’s not the complete picture as not all treatment beds are subsidized with tax dollars. 
Spofford opened two new treatment centers over the past year with several new beds for inpatient treatment: New Freedom Academy in Canterbury and Green Mountain Treatment Center at the former Lakeview Neurorehabilitation Center campus in Effingham.
“Out of 75 licensed beds, we only have 59 open currently,” Spofford said.
He plans on converting another 15 beds into a new medical detox unit due to open on Oct. 1.
“There’s absolutely a shortage of residential treatment beds in the state, but medical detox there’s an even larger shortage of,” Spofford said.
His rehab facilities operate under a private, for-profit model without any money from the state or federal governments.
According to Spofford, his business model has a high staff-to-client ratio with hand-picked talent from across the country in order to provide the highest-quality treatment possible.
“We built the Yankees,” Spofford said.
But he’s quick to add that while the programs are aimed at providing a real life-changing experience for patients, it’s a far cry from the luxury rehab centers in Malibu.
Still, his dream team comes at a high cost. And that means only people with the right insurance or adequate resources can afford it. None of Spofford’s facilities accepts clients on Medicaid.
Spofford said it costs about $330 per day per bed to offer someone intensive inpatient treatment using his model. But he says Medicaid pays only about half that.
“Unless you run a state-funded, nonprofit, bare-bones budget facility, you can’t afford to take Medicaid, because they pay at $162 a day,” Spofford said. “I can’t help those people. I wish I could. It bothers me to no end that I can’t.”
And he says his model isn’t about making money but about providing high-quality care.
“I run a moderately sized company but [I’m] certainly not getting rich,” Spofford said. “There’s something to be said for quality as well, because if people aren’t being treated effectively, they’re not going to stay sober. And if they’re not going to stay sober, you’re defeating the purpose.”
Spofford’s company started with a sober living house he opened in 2008, which he said was the first of its kind in the state.
“We went from a company that had I believe 27 employees [to] in the last year we opened up two primary treatment centers, another extended care and another straight sober living house and we’re up to 150 employees,” Spofford said.
And Spofford said he didn’t start out as a businessman. 
“I started off by shootin’ too much heroin,” Spofford said.
His addiction started at a young age. As a teenager, Spofford had already experimented with marijuana and alcohol when one day he and his buddy split an OxyContin in his father’s basement. He says he was immediately born into an opiate addict.
Most of Spofford’s formative years were spent using heroin and other hard drugs almost daily and constantly running into problems with the law. In fact, it wasn’t treatment that got him on the right track. He managed to detox while trying to evade a robbery charge in Maine and discovered a recovery community that got him through the 12-step program. 
That was in 2006. Spofford is now 31 years old.
“In 2006, I never thought I’d live to see 2008,” Spofford said.
So his passion project of offering treatment and sober living services to residents could just as easily never have happened.
After being sober for more than a year, he turned himself in and the court ended up dropping the charges after he paid a $150 fine.
“Recovery has been so good to me,” Spofford said. “Never in my wildest dreams would I have thought that my life would’ve accumulated to not even one percent of what it is today.”
 
Safe Stations
When the cartels threw gasoline on an already large fire of prescription painkiller addiction in New Hampshire, we didn’t have enough firemen, fire trucks, fire stations or fire hydrants to put out the figurative fire.
In some ways, building up the treatment infrastructure in places like Manchester is not dissimilar to creating a trained, resourced and agile firefighting force from scratch, while the city burns. So it’s perhaps appropriate that one of the programs that may be turning the tide in Manchester’s addiction crisis is taking place in the fire stations, quite literally.
The Manchester Fire Department launched the Safe Station initiative, with the backing of Mayor Ted Gatsas, in May. And just a month later the mayor’s office released statistics it said pointed to the program’s success, including a reduction in overdose calls in May compared to prior months.
The program essentially opened the doors of all of the city’s fire stations to addicts who sought help. After someone presents at a station, someone would pick up the individual and get them into a treatment program.
Initially, peer support specialists from HOPE were the folks picking up addicts and connecting them with services, often setting them up initially at the Amber’s Place respite shelter located in the same building on Central Street as HOPE’s temporary city location.
Earlier this month Serenity took over that job and Amber’s Place, which opened in April, is no longer being run by HOPE. The 16-bed shelter is now run by Helping Hands, a faith-based outreach organization for the needy. It’s also no longer open 24/7. 
Under the new arrangement, the shelter will be open evenings from 3 p.m. to 9 a.m. and it will be used exclusively for the Safe Station program. During the day, folks will attend Serenity’s day program, which starts out with meetings, case management and homework for the addicts while they wait to get into a treatment program, often days later.
Bergeron said a Serenity staff member selected to be on call for Safe Station carries a cheap, prepaid cell phone — referred to jokingly as the “burner phone” — and every time someone seeks help at a fire station, a fireman dials the number to that phone.
 
Drug Court
Given the many threads that interlace drug addiction and the criminal justice system, experts say a significant part of the treatment landscape needs to become more available to addicts going through that system.
One positive step for that is a new treatment program at Hillsborough County jail called Substance Abuse Treatment Community for Offenders, or SATCO. County commissioners approved $281,000 for the program in June, which will provide an intensive drug education service to up to 40 inmates over a period of two months each.
But the biggest change in the criminal justice system has been the creation of a fully funded statewide drug court office. 
Drug courts operate by diverting offenders from incarceration in favor of treatment by suspending their prison sentence and putting qualifying individuals through a system of regular meetings with counselors, accountability from the drug court team of lawyers and judges, frequent drug tests and sanctions that kick in whenever relapses occur.
Proponents says it’s more cost-effective than incarceration and cuts down on repeat offenses.
Superior Court Chief Justice Tina Nadeau has been championing drug courts for years, but looking back just two years ago she would not have expected a massive reform like this to have happened in so short a time.
Traditionally, each county that wants a drug court will start it up in its own superior court, initially with federal grant funding, and then transition to county funding. But with legislation passed this year, millions of dollars have been set aside to prop up these drug courts using state money instead — a rare example of upshifting costs in a state that often sees the reverse.
This fall, Hillsborough County Superior Court North in Manchester is poised to be the first recipient of this money as it has never had a drug court, despite a few recent attempts to win grants. As one of the largest courts in the state, it qualifies for the largest annual grant of up to $490,000. 
The absence of a drug court in Manchester has been sorely felt as officials agree it’s the place with the most demand for such a program, given the high rates of addiction and drug trafficking that occur in the Queen City these days.
Earlier this month, the state drug court office quietly released a Request for Information to start the bidding process for a treatment provider to partner with the court. When the drug court is up and running, it could serve up to 100 people per year at the start and expand if needed.
The next place to get a drug court will likely be Merrimack Superior Court in Concord, likely by fall of 2017. And as existing drug courts in Cheshire, Grafton, Rockingham, and Strafford counties plus Nashua either run through the rest of their grant money or reach the end of their county budget cycle, they’ll gradually start turning to the state for funding, which could free up those county dollars for other local treatment initiatives. 
 
Connective tissue
As important as adding treatment capacity is, it changes little without improving access. 
To better understand just how non-existent the treatment and recovery infrastructure was in New Hampshire, one needs only to look at the lack of a centralized network that connects people in need of treatment to the few services that existed. 
People had to do a lot of research on their own, scouring the internet and making phone calls to several different places until they found a provider with an opening or an organization that accepted their insurance or was willing to help for free. 
And often times, they would just give up, discouraged by a confusing and burdensome process. 
To continue with the fire analogy, people were searching for water for lack of a hydrant. 
This year, that began to change in some significant ways.
In May, the Statewide Addiction Crisis Line was launched. The hotline (1-844-711-HELP (4357)) is run by Keystone Hall, a treatment center in Nashua, and is set up to be the primary outward-facing connector to services.
Vara says he can’t emphasize enough how critical a change that is. But the plumbing beneath the street still needs to build out.
That’s where Regional Access Point Services, or RAPS, come into play. 
The RAPS are programs designed to help addicts and families figure out what they need and how to get it in their community; case managers keep in touch at each step of the process. 
After an initial assessment is made using criteria from the American Society of Addiction Medicine, trained RAPS workers try to get the addicts into a treatment program in one of the facilities that have partnership agreements with the network. 
“If the appropriate level of care isn’t available… then they have to refer them to interim services. The interim services are meant to engage them [and] work on motivation issues,” Harding said.
An example of that is the day program at Serenity.
Two RAPS exist right now as pilot programs in the Manchester and Monadnock public health networks. 
Serenity has the contract to run the Manchester RAPS, which began earlier this year. Since then, Bergeron said she’s added about 11 employees and still needs to hire three more for the program and a few clinicians willing to work on a per diem basis.
The goal is to have a RAPS program for all 13 public health networks. To that end, the state awarded a $1.2 million contract with Granite Pathways to create a RAPS system in the remaining 11 public health networks.
Granite Pathways CEO Sandi Coyle said they have moved into a new office space in Concord and hired six people, with four positions still open.
The launch date is scheduled for Oct. 15, at which point calls to the crisis line from those regions under Granite Pathways’ purview will get directed to them. Coyle expects her team will be serving between 7,000 and 10,000 individuals.
“These are individuals and families who have previously had limited success,” Coyle said.
There won’t be any physical RAPS locations in those regions, but Coyle said case managers and recovery specialists will be mobile for any case where individuals can’t do an assessment over the internet. 
“This is a startup. It’s innovative, it’s new for New Hampshire and it’s huge,” Coyle said.
 
Sustainability
At a recent press conference held by Gov. Maggie Hassan and James Vara for the release of his report, a third man, Tym Rourke took the podium. As the chair of the Governor’s Commission on Alcohol and Drug Abuse, Rourke is a ubiquitous figure in the effort to improve treatment access. 
The fund his commission oversees has been regularly raided by legislators in previous years, but his protests always fell on deaf ears. This day, he didn’t pull any of his punches. 
Perhaps feeling a bit vindicated, Rourke reminded everyone at the event that there’s still more work that needs to be done and that it’s critical to not just resolve the present crisis but also continue treatment services well into the future.
“While we are particularly focused on opiates at this time, we must remember that, historically, New Hampshire has had very high rates of substance abuse, and very low rates of treatment access. That has been true whether the drug of choice has been opiates or not,” Rourke said.
His fear, and the fear shared by many in the addiction treatment field, is a return to the old status quo. 
Courtney Gray said it’s important to start thinking about these things now so we build a system that can withstand future economic recessions, donors closing their checkbooks and constantly changing political winds.
One way to do that is to make sure we have a trained workforce available, especially master’s-level licensed alcohol and drug abuse counselors.
“I know that in New Hampshire we have a workforce capacity issue,” Gray said. “We do not have enough M-LADACs in the state, so it’s important that we can try to drive some workforce into the state. I think that we can look at reimbursement rates to be able to do that.”
Right now, there are unanswered questions about how well private insurers are complying with new federal parity laws, which require substance use disorder payments be equitable to any other medical treatment. But Gray thinks there are likely a few areas where those reimbursements can be improved.
Another resource that can be used to improve the state’s workforce challenge, not just for substance abuse treatment but for mental health treatment overall, is the Section 1115 Medicaid waiver. The 1115 waiver will bring in $150 million ($30 million per year for five years) in federal dollars directed toward expanding and transforming the state’s mental health care system, but some of that money could be used to create competitive pay models that would attract talent from other parts of the country. 
Even federal insurance could use a tune-up, according to some.
Spofford thinks if the upper limit on Medicaid’s payout for inpatient services were doubled, his and other for-profit rehab facilities would be able to offer more care to Medicaid recipients and relieve the burden somewhat for other providers. 
But with higher federal reimbursements, providers will also be able to offer better pay in nonprofit sectors. 
The other thing that’s needed for long-term sustainability is a diversity of revenue sources. As long as providers are relying too heavily on government grants and donations, they’ll be on shaky ground. 
Gray said other sources of revenue could include contracts with area businesses and medical institutions as well as billing for services.
For treatment providers, this issue was largely solved with Medicaid coverage for SUD though they still get some pushback from commercial insurers. 
Recovery centers, however, still don’t get any money from insurance carriers.
“Up until now, all of our funding is one-time funding,” said Coletti-Lawson of HOPE for New Hampshire Recovery. “It’s individuals, it’s corporations, it’s grants we applied for.”
But this may change soon as state rules were rewritten recently to classify recovery community organizations like HOPE as providers, enabling them to bill insurance.
“We need to start thinking about a sustainable economic viability of the organization. I spend 90 percent of my day on exactly that,” Coletti-Lawson said.
Gray said the New Hampshire Providers Association launched a billing service about a year ago and there are now about 20 providers using it. The NHPA handles all the billing for them and pockets 8 percent of the claims paid in return.
And pretty soon she expects recovery organizations to take advantage of the service as well.
Ultimately, how the system gets built, improved and funded is secondary to how well it’s executed, according to Spofford.
“Treatment needs to be a powerful, life-changing experience. We’re dealing with addiction here and addiction is one of the most powerful things in the world,” Spofford said. “How do you compete with that?” 





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