Why It Can Be So Difficult To Get Treated For Substance Use Disorder

Portland, Ore. – Tents continue to line every part of Portland, and Oregon still ranks last in drug treatment. Yet, our news partner KGW has reported on any given night, more than 250 shelter beds remain empty. Substance abuse is seen as the largest reason as to why, with many shelters putting up barriers for those that use. But how can you begin to treat someone if they don’t have a roof over their head? And wouldn’t it make sense for shelter providers to communicate with those that provide treatment for addiction? What does the process of getting someone clean and off the street even look like? Well, like most things in the homeless crisis, it’s complicated.

“I would say, broadly, there is not a really coordinated, clear way for people to enter substance use disorder treatment,” said Alison Noice the executive director of CODA, one of Oregon’s largest not-for-profit substance use treatment programs.  “The self-referral pathway for addictions treatment, in my experience, is not the most robust one.”

It typically takes some sort of intervention to get someone help. The ones that do get treatment are often referred through some sort of social program or a medical professional.

“We have historically relied on referral sources that have an element of mandate to them. People with criminal activity or substance use disorder get funneled into specialty court. Or people because of child welfare involvement are mandated into treatment. Or people who have been hospitalized for serious illness,” Noice continued.

And those referrals aren’t typically coming from shelters, where organizations see first hand who is suffering

“It’s hard, because there are those restrictions. Shelter beds want to provide a safe environment, they don’t want active substance use going on. But it’s sort of counterintuitive because most people suffering from houselessness, not all, but most, are suffering from some sort of addiction or substance use disorder,” said Angela Teuscher the Patient Care Manager for Fora Health. “It’s sort of backwards how we have the system established. Ideally if someone had a roof over their head it would be easier for a case manager to call (Fora) and say ‘hey can you keep an eye out for them.’ We will definitely keep an eye out for people referred over.”

Both of them say their organizations also heavily rely on word of mouth. Which is good, but not exactly consistent.

“Often the people who come to us, know us because we’ve been here forever. Or maybe we’ve treated them once before,” Noice said. “Because CODA’s work is largely with the Medicaid population, and most of our work is with people who really have pervasive substance use disorders, were a known quantity. But those are really imperfect and disconnected ways to enter treatment.”

Fora Health is even more so built around people showing up on their own.

“It’s based on a first-come-first-serve system. We have quite a line. Most days we’re having to turn people away,” said Teuscher. “We don’t allow people to camp out on our campus, but there’s been some people that have stayed really close, we’re right across from Adventist Health. We’ve had people camp out for a couple nights trying to get into services.”

The problem with this is that, the desire to want to get help can be short-lived from someone dealing with severe addiction.

“People get discouraged with wait lists when you don’t have enough space. When you hear ‘you qualify, we’d love to bring you into a residential program… we’ll see you in three months.’ For someone who is suffering from substance abuse, you might as well have told them they can get help in five years,” Teuscher said. “It’s really easy to give up when you’re in that moment, and you have that fire lit underneath you and you want it right then. And then there’s a couple of doors that get shut, or a process doesn’t go smoothly. Then it’s real easy to get discouraged and just say ‘well why bother change if I can’t get change.”

Both agree it’s not fair to say a person doesn’t want to get help. No one decides they want to spend their days hooked on drugs and alcohol.

“The motivation to change behaviors that are wrapped up in addiction is a really complex, and often fleeting experience. People who are deeply embedded in a substance use disorder are not making a choice to use drugs versus go to treatment. They’re compelled to just maintain some level stability, and that stability is about staying a certain level of impaired,” adds Noice, who is trying to fight against the narrative that it is simple to accomplish sobriety. “Anybody that’s so wrapped up in that cycle of: drug use, cravings, withdrawal, preoccupation, there’s a part of that person that says ‘this isn’t working I wish I could do something different.’ But the pull, physiologically, neurologically, and then just simply fear and stigma keep people away from treatment.”

Plus, this work requires a lot of patience.

“As the treatment industry, I think our work is to get better at saying ‘I’m not going to tell you what your recovery needs to look like, you tell me. Is it just using less? Is it not using one substance, but keep using another?’ We have make our entry point way more oriented toward what is the best way to start for that person,” says Noice who also adds that the person who has become homeless because of high rents or after losing their job requires a way different strategy than the one who has been on the streets for years due to drug use.

Frustratingly, whether because of bureaucracy or lack of funding,  neither of these organizations that are providing drug treatment are doing direct outreach on the streets to try to reach the chronically homeless that we see everywhere we go.

“Honestly because of the way the system is built, we don’t get paid to do outreach. We don’t get paid to do anything until the person has literally come here and answered all the questions and done all the things that the regulations say you have to do to become a patient of ours,” said Noice. “Our model struggles to support outreach.”

That said, Teuscher says more organizations in Portland are starting to adopt that practice. What it comes down to for her, is likely what we already know. We need more resources to help solve this problem.

“Part of the reason we’ve gotten to this point is because there is a lack of services. Our organization is one of the largest residential in the state of Oregon, but however, with our 70 beds that’s kind of a sad statement when we’re the largest,” said Teuscher. “Our waitlist is five months long to get into residential treatment. That to me is unacceptable. No one should have to wait five months to address something they want to address now.”