It was during a fit of desperation in early 2014 that Sean Nicholson stepped into the emergency room at Frederick Memorial Hospital and told the desk staff what they needed to hear.
“Which is that I wanted to harm myself, or harm others,” Nicholson said. “Because I knew that they would medically detox me once I was admitted through the psych ward, and then they would ship me out and help facilitate me getting to an inpatient facility.”
Nicholson, 34, of Middletown, is a former heroin user who now works with the Up and Out Foundation of Frederick County, guiding current addicts through the recovery process. He was about to speak to around 40 patients at the Crossroads Center of Frederick when he was asked if he knew of other people who have gamed the system like that, using the hospital as a stepping stone to rehabilitation.
“I’m getting ready to speak to people in outpatient treatment, and I’d say that probably 50 percent of them have went through a psych ward,” Nicholson said. “It’s sad, but true. If you’re in that state of desperation, the quickest way to get in is to make that move.”
As the opioid epidemic continues, a greater number of people are getting desperate. From 2007 to 2014, Frederick County had 95 heroin-related deaths and 85 related to prescription opioids, the second-highest numbers in western Maryland, according to data from the state Department of Health and Mental Hygiene.
Statewide, rising rates of opioid addiction have prompted Gov. Larry Hogan to declare a state of emergency and for county agencies to scramble to find possible solutions. In 2015, Maryland reported 1,259 overdose deaths, 86 percent of which were heroin or opioid-related.
In Frederick County, responses to the crisis are varied. Most law enforcement officers have carried naloxone — an overdose-reversal drug more commonly known as Narcan — since the end of 2014. Addicts who enter the judicial system can opt to participate in Drug Treatment Court, while the Frederick County Health Department advertises a slew of programs. There’s the Take Back My Life campaign — aimed at expanding awareness of the risks that come with opioid abuse — and prescription drug take-back events several times a year. The department also employs peer recovery specialists and even formed an entire coalition that meets to brainstorm possible responses.
But even as experts develop new solutions, some Frederick County residents slip through the cracks. From Nicholson’s perspective, the problem stems not just from a shortage of comprehensive recovery programs, but from the tangled bureaucratic path to rehab. When addicts reach out to the hospital for treatment, it’s often a last resort, he said. These are residents who usually don’t have insurance, or a safe place to stay while they go through withdrawal.
“Honestly, it’s a logistical nightmare for a lot of people because a lot of them just don’t know how,” he said. “You have these families that have realized and identified that their son or daughter has an issue, but they don’t have the answers there in front of them to say, well this is who I call or this is what I do.”
Looking for answers
Karen Mackey, a real estate agent from Urbana, has first-hand experience navigating the treatment system. Her youngest son, Ryan, died from a heroin overdose last Fourth of July after a family barbecue, at the age of 23. Her older sons — Scott, 31, and Kevin, 28 — also struggle with addiction and have spent time in both residential and outpatient treatment.
Mackey, 60, has become well-versed in inpatient recovery centers, from Mountain Manor in Emmitsburg to various high-price facilities in Baltimore and Florida. She’s been frustrated by some of Kevin’s experiences in residential rehab, the quality of which, both say, is largely dependent on a patient’s insurance or ability to pay hefty entrance fees.
But to an even greater extent, Mackey has grown frustrated with Frederick County’s ability to respond to residents in the throes of addiction. In early April, she was terrified when Kevin overdosed three times in one weekend, just a week after his return from a residential treatment program in Florida.
The first time, she said, emergency responders revived Kevin with Narcan and left soon after he refused to be treated at the hospital. The second time, Kevin again refused treatment, but police at the scene arrested his older brother, Scott, after discovering an outstanding bench warrant for his arrest from Baltimore County.
The third overdose, Mackey said, pushed her over the edge. That Saturday, she kept an eye on Kevin by asking him to drive her to the houses she was showing. The two had lunch together and returned home around 4 p.m., when Mackey asked him to shampoo the downstairs carpet. She stayed upstairs to call a friend, but soon had a feeling that something wasn’t right.
“So, I acted on on my intuition and came down to check on him, and there he was, on the bed, overdosed, eyes rolled back,” Mackey said. “Needles, blood dripping down his arm. I had one Narcan left, so I worked on him first, but then I came up and got my phone.”
When first responders arrived, the bleeding had stopped, and Mackey couldn’t find a heartbeat. She pleaded with them to take him to the hospital before he could be revived and refuse treatment. Beyond that, Mackey wanted police to file an emergency petition, a legal measure that allows for a patient to be transported to the hospital — even without consent — and evaluated by a medical professional. It can only be granted to patients with demonstrable signs of a mental disorder who present a threat to themselves or others. Kevin qualified, Mackey said, because he was suicidal — earlier that morning she said he told her, “I’d rather be dead than be an addict.”
“Well, the officers told me, ‘We can’t do that because it violates his Fourth Amendment rights,’” Mackey continued. “They said he didn’t qualify. But that’s what he needed. He needed to be treated like someone who wants to kill themselves because he did. He said, ‘I want to be dead.’”
Worse still, Mackey said, was the response she received from FMH. Though a neighbor who worked at the hospital said she would try to get the attending physician to grant an emergency petition, Kevin was released from care around 7 a.m. the next day. An employee from the crisis center left her a voicemail explaining the decision. “It’s pretty clear that his drug abuse is unfortunately a poor decision, but we can’t involuntarily commit him for that, and he’s not willing to be voluntarily admitted,” the person on the voicemail said.
When Kevin got home, he had also been given several informational pamphlets. One advertised a 24-hour helpline from the American Addiction Centers, with an area code in Virginia. Another was from Genesis House, a private residential treatment program in Florida. The last focused on Safe Harbor at Mountain Manor, a residential treatment program for pregnant or postpartum women and their children.
“Well, first of all, Kevin is a man” Mackey said, her voice shaking. “And when it comes to the ‘poor choice’ statement, well, it’s one thing to hear that from a police officer. But this is the crisis center at a hospital.”
Representatives from Frederick Memorial Hospital said they couldn’t comment on specific cases. But the rise in opioid addiction has also affected medical professionals, said Mike McLane, the assistant vice president for behavioral health at FMH.
During overdose cases, doctors and nurses are increasingly confronted with emotional family members who are frustrated by their loved ones’ unwillingness to seek treatment, and by staff members who can’t force the patient to stay, added Jason Barth, the hospital’s coordinator for crisis management services. In Maryland, as in most of the country, substance abuse treatment is completely voluntary, unless a patient has been court ordered to complete a program.
Even in cases of an emergency petition, nearly all patients admitted for drug or alcohol intoxication were released from the emergency room soon after the effects of the drugs wore off, according to one study from 1990. Though clinicians can advise further treatment, it’s virtually impossible to force treatment on an unwilling patient, McLane said.
“All too often, we see these people get up and walk out the door,” he added. “They’re medically safe, but oftentimes, they want no part of rehab at this time. They choose to leave. And it’s their right to leave.”
Another issue, Barth added, is that patients often confuse detoxification — a medical term that refers explicitly to removing drugs or alcohol from the bloodstream — with rehabilitation, or treating the underlying causes of addiction. The misunderstanding leads many to say that FMH does not provide detox services, when in fact, the hospital does.
“We never release patients before they’re medically stable,” Barth said. “But I emphasize medically stable. Not every substance requires a medically supervised detox process. Opioids don’t. Cocaine doesn’t. And that’s shocking to some people.”
But for residents with firsthand experience in addiction, cravings and withdrawal often continue for weeks after opiates leave the bloodstream, and true detoxification takes on a deeper meaning. After an overdose, or when an addict first decides to seek help, is a critical time, Nicholson said. Most people need more than a night’s stay in a hospital room. They need a safe place to stay, free from access to drugs, before being referred to other recovery services.
“Because, say you don’t get treatment and the next day comes and your buddy comes over and says, ‘Dude, I just got my income tax check,’ or whatever it is,” Nicholson said. “Then you’re right back in the mix. And every time you reach out for help and you don’t take it, it just gets worse and worse and that burden is just heavier and heavier.”
In response to that need, Frederick County is currently researching the feasibility of establishing a 24-hour detox center somewhere in the community, a treatment center that could accommodate individuals in crisis and provide inpatient care during the initial withdrawal period before connecting them with other services. The facility is currently a key priority in the county’s local health improvement process, said Andrea Walker, the director of Behavioral Health Services for the Frederick County Health Department.
Cynthia Terl, the director of community outreach for Wells House treatment center in Hagerstown (and a group leader for the project), said the county hopes to open the center within the next few years. But barriers to the facility remain, especially when it comes to cost.
According to rough estimates provided by Wells House, a non-hospital detox center would require at least 10 beds to treat an average of 700 patients a year, given an average stay of four to five days. The facility would require a designated medical director, on-call physicians or nurses, and licensed counselors to treat the patients, plus at least two employees for non-medical services such as cleaning or meal prep. The total cost, according to those estimates, would be at least $730,000 a year. A 15-bed facility could run up to $1.5 million a year.
Even if the county received funding for the project, there would still be a shortage of treatment programs for patients after the detoxification process, Terl said. For many, inpatient care is inaccessibly expensive — the average residential program costs roughly $1,000 a day, and even those with insurance coverage can face high deductibles.
For more affordable programs, patients often encounter long waiting lists or find beds in facilities far across the state. While a three to four month stay at Wells House costs the average patient about $1,000, Terl said, the program always has a waiting list of at least 100 people from Maryland and neighboring states. While addiction continues to rise, she said, treatment services aren’t following suit.
“I could have 500 beds and we’d keep them full all the time,” she added.