Opioids in Alexandria Part 2: City treatment program faces staffing, funding constraints

Alexandria is not immune to the nationwide opioid epidemic, as overdoses and arrests have grown exponentially here in the past two years, while treatment options have dwindled due to staffing shortages. This multi-part series examines various facets of the crisis, from statistics to stories of Alexandrians affected by the opioid scourge.

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By Alexa Epitropoulos | aepitropoulos@alextimes.com

As Alexandria’s opioid crisis continues to grow, the city’s treatment program – one of four run by local governments in Virginia – faces constraints in staffing and
funding.

This lack of funding helped create a particularly challenging 2015 for the opioid program. The number of people receiving help peaked at 130 patients that December, while simultaneously a number of key employees left, including longtime program physician Dr. Kurt Brandt.

Read Part 1: Opioid crisis has city officials working over time

As employees departed, the program instituted a freeze on new patients in the beginning of 2016. The freeze barred enrollment of new patients with the exception of pregnant women. As a result, there were only 25 new entrants to the program between January and December of 2016, a stark drop from the 67 new patients the program admitted in 2015. The freeze resulted in a decrease in the total number of patients treated in 2016 and 2017, from a high of 191 treated in FY2015, 188 treated in FY2016 and 170 treated so far in FY2017, a period that concludes at the end of June.

So far, there have been 24 new patients admitted to-date this calendar year, which, if the program holds its admission rate, would amount to about 58 new patients over the year.
These limitations on treatment options coincided with a surge in need for services. Heroin arrests have basically doubled each of the past two years, going from eight in 2015 to 15 last year and are on pace for 30 in 2017.

Though the freeze in the first half of 2016 came down to lacking the necessary staff, Susan Tatum, director of the opioid treatment program, said funding and staffing are deeply interconnected.

“Staffing is funding,” Tatum said. “When you have vacancies, you have to fill them and that takes time – and money.”

The program has a small staff, with a doctor, a pharmacist, a case manager, three clinically licensed therapists, two licensed practical nurses, one registered nurse and a part time nurse practitioner.

Tatum said just one extended absence can have far-reaching impacts, especially in a treatment program that runs seven days a week, 365 days a year.

“We’ve received a huge influx and, at the same time, we had a couple of staff changes – a longtime physician who had run the program retired, a nurse retired, a few therapists retired,” said Liz Wixson, director for the city’s clinical and emergency services, which oversees the opioid treatment program. “It takes some time to replace those people.”

Indeed, recruitment is one of the major challenges that the opioid treatment program faces. Finding staff that not only have the qualifications, but the experience with opioid treatment, is particularly difficult. Before 2015, the program had relatively low turnover, meaning that the program didn’t have established recruitment pipelines for acquiring new talent when faced with several staff vacancies.

“There’s beginning to be a better infrastructure in place for physicians,” Tatum said. “At the time, there just weren’t many people who were trained to provide the service.” Even when fully staffed, however, the opioid treatment program is one extended absence away from not being able to provide the same level of services.

“We’ve always been at a level of funding where we had just enough staff and if something happens, it’s a proverbial stick in the bicycle spokes,” Tatum said.

Any staff absence or funding decrease will be deeply felt by the nearly 200 patients who depend on the opioid treatment program in some way every year – either for outpatient services, like therapy, case management, medication-assisted treatment or, for the most severe cases, inpatient withdrawal management services, which has the capacity to house 35 patients at a time. Those participating in the opioid treatment program usually receive medication-assisted treatment, but each plan is based on the individual’s needs.

Tatum doesn’t see the demand for the program going away anytime soon. The city is poised to have a record amount of overdoses resulting in ER visits this year, with the health department projecting 123 overdoses by the end of 2017, up from 105 in 2016 and 88 in 2015.

“I don’t see it leveling off,” Tatum said. “I think the problem still exists. We’re similar to other communities in the country. I think we’ll still see continued need.”

As the city sees a surge in the number of individuals requesting help for opioid addictions,

Source: Office of Management & Budget
Graphic by Evan Berkowitz

it’s beginning to take proactive measures, including increasing its piece of the funding pie, which rose from $520,637 in 2016 to $770,556 in 2017. The uptick in the city’s contribution, as well as a Virginia grant that provided an additional $142,000, resulted in the opioid treatment program increasing from a stagnant $988,000 between 2011 and 2016 to $1,376,694 in FY2017. The opioid treatment program’s funding levels for FY2018 haven’t been released yet.

There is some ability to move additional funding within the city’s Department of Community & Health Services around, if necessary, unless it is marked as restricted, according to OMB Communications Officer Jennifer Cohen-Cordero. Any increase to the opioid treatment program’s budget would have to be approved by the Alexandria Office of Management & Budget.

Source: Alexandria Office of Management & Budget
Graphic by Evan Berkowitz

The program is heavily reliant on the city, as Alexandria’s government provides 56 percent of its funding. Another 18 percent comes from the commonwealth, 14 percent is regionally funded, 9 percent of its budget comes from the federal government and 3 percent from either insurance or client pay.

Despite the increase in funding, capacity remains limited, with the opioid treatment program capping out at between 95 and 105 patients per day currently and 125 to 135 clients per day when fully staffed. There isn’t a waiting list to get into the program at the moment, but that can change rapidly depending on demand.

“We always feel like we’re running fine and that everything is going smoothly. When something happens, though, we need a little time to regroup,” Tatum said. “Unfortunately, what that does – the bottom line is that it impacts client services. Those who would like to be new clients.”

Tatum said the individuals who turn to city-sponsored opioid programs, in most cases, are those who can’t go anywhere else. In addition, there are limited private treatment programs that have specialties in opioid abuse within Alexandria city limits, with Crossroads, located on South Van Dorn Street, being one of few alternative options.

“Public resources exist for folks who don’t have other options, in a lot of cases,” Tatum said.

As 2017 reaches its midway point, new staff members are settling in at the treatment program. A doctor, Dr. Uzma Mian, who was hired in April 2016, is on board, as well as several new nurses, who were hired due to the increase in funding. When a final additional hire, a therapist, begins work, the program will be fully staffed.

Tatum and Wixson don’t expect it to remain quiet for long – and both hope to have the right resources in place when demand again surges.

“We want to be able to do the best job that we can to serve folks and give them the treatment they need,” Tatum said.

Read Part 3: Inova Alexandria discusses life on the front lines of the opioid crisis

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