Starting Sept. 1, people with fentanyl addiction in the Portland area will have a new place to go for three to seven days while they get treatment. The nonprofit Recovery Works NW used Measure 110 funding to open a 16-bed treatment center, which will be staffed around the clock 365 days a year. Recovery Works NW has been working with doctors providing outpatient medical assisted opiate treatment for years, and aims to provide better treatment for fentanyl users with this inpatient model. Joe Bazeghi, the director of engagement with Recovery Works NW, tells us about the new center and the need for this kind of treatment in the Portland area.
This transcript was created by a computer and edited by a volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. People in Multnomah and Clackamas counties who are addicted to fentanyl will soon have a new place to go for inpatient treatment. A 16-bed center is opening in East Portland on September 1st. It’ll be the first alcohol and drug withdrawal management facility in the state that was paid for with funding from Measure 110. Recovery Works NW has offered medication assisted treatment for opioid addiction for nearly a decade, but this is gonna be the first time they’ll be operating an inpatient facility. Joe Bazeghi is the director of engagement at Recovery Works NW and he joins us now. Welcome to the show.
Joe Bazeghi: Hi, Dave. Thank you so much for having me.
Miller: Yeah, thanks for coming in. When did people at Recovery Works first start to notice that fentanyl had arrived on the scene?
Bazeghi: Well, fentanyl, as an illicitly produced substance in our street drug supply, has become an increasing problem for about four years now and it has proliferated. So we no longer really see a lot of the more traditional street opioids that we were familiar with [like] heroin or pharmaceutical pills that have made their way to the street. Nowadays, we see a lot of either fentanyl specifically or fentanyl contaminated opioids.
Miller: What has that meant for the work that you do?
Bazeghi: It has changed our work dramatically. We provide services that aid people in their choice to recover from addictions. And the majority of our clients and participants have been addressing opioid addictions. Well, tools that previously were very, very effective, that our physicians offered, that our behavioral health professionals offered, these are no longer as effective as they previously were. And that’s due to the nature of fentanyl. It’s far more potent and it has a different profile in how it interacts with the body and how it exits the body. These complicate the works.
Miller: My understanding is that this inpatient treatment center that’s opening on Friday that you’re here to talk about wasn’t Recovery Works NW’s initial plan. So what happened?
Bazeghi: That’s right. So a congruence of trends came together at roughly the same time. So our physicians were becoming more and more aware of the challenges and dangers presented by illicitly produced fentanyl. At the same time, Measure 110 was kicking into gear. So while our physicians were meeting to discuss responses to this new very, very dangerous challenging trend, we were also working to expand our outpatient programs. And in that search and in that investigation, we came across a facility that was very well suited for short stay, medically monitored withdrawal management.
So just as we were contemplating our response to Measure 110′s initial request for proposals, we found a facility that basically just met the needs that our physicians were really describing. For our traditional tools such as buprenorphine-based medicine, assisted treatment to be effective, they needed an inpatient environment where people could be under medical supervision for three to seven days, while they stabilized on these medicines that support recovery and reduce overdose.
Miller: I think to understand what those doctors were telling you, we should explain what the old model was. Not even that long ago, maybe in the first wave of the new waves, people have been dealing with addiction to versions of opiates or opioids for a long time. But in our recent memory, Oxycodone arrived and then [a heroin epidemic] after that. For people who were addicted to those versions of opiates or opioids, what was the medical model for treatment that worked?
Bazeghi: Wonderful, that’s a great question. And it was based on this most modern iteration, as you mentioned. A couple forms of opioid replacement therapies, medicines that are managed by physicians and provide relief of cravings and in some cases, even prophylaxis or protection against overdose in the case of a return to use.
So buprenorphine was approved by the Food and Drug Administration in 2001 as a drug called Suboxone. And our practice, our physicians, have concentrated on that particular tool. And it has been incredibly effective in helping people who were either dependent or addicted to legitimate painkillers such as Oxycodone or for that matter street heroin, as we previously knew it. It was like a black tar form of heroin that was produced and distributed on the West Coast and very potent stuff.
Miller: What would Suboxone/buprenorphine do to someone’s brain or body? How does it actually help?
Bazeghi: Yeah, it’s what the docs call a partial opioid agonist. So what it does is, it’s actually, itself, an opioid. But it’s a very long-acting opioid and it only targets parts of the brain that are associated with the physical mechanisms of withdrawal and sickness and all, as well craving. So it doesn’t provide euphoria such as an Oxycodone or heroin or fentanyl would. So physicians are able to manage this medication over time. It’s nontoxic and safe when managed by a physician. So with this medicine, folks could go see a doctor in an outpatient setting anywhere, see him a couple of weeks then every week or so to begin with. And then as you stabilize on it, you only need to see the doctor every month or so to get your prescription filled.
And with that, people are no longer experiencing the cravings that lead to drug-seeking behavior. And they’re able to start doing a number of things such as gain employment, repair relationships in their life, and begin to do the inward-facing work associated with uncovering the root causes of addiction and compulsive behaviors like this. And that’s myriad and complex but oftentimes involves [a history of] significant personal trauma. And work with behavioral health and mental health specialists can really speed that process or aid that process. So when folks were taking buprenorphine managed by a physician, they were no longer engaged in the chase of illicitly-produced street opioids.
Miller: So that model you’ve just described, an outpatient model, why doesn’t that in general work for fentanyl?
Bazeghi: Fentanyl is challenging on so many levels. And in many ways, it was unexpected. So we found ourselves, in this profession, almost reacting [to it]. But we’re getting to the point of response now. But fentanyl is… in a physician’s language, they talk about morphine equivalent units. And so it is 100 times more potent than morphine. So roughly, a milligram of fentanyl is equivalent to 100 milligrams of morphine. Because of this, when folks are using fentanyl to solve whatever problems they’re solving in an addictive cycle, what ends up happening is tolerance grows quicker. People end up taking significantly more substance into their body to achieve the same ends as they would with morphine, heroin, Oxycodone or otherwise. This has to do with opioid tolerance.
And as people use opioids over time… what used to do it yesterday, it doesn’t do it anymore. You need more. And that’s that idea of chasing doses or chasing the dragon, however people say. So a couple of years ago, folks would come in with serious heroin problems and they might be IV-ing several grams a day. Well, nowadays, because of the proliferation of fentanyl and how cheap and available it is, people are coming in taking just undreamed-of quantities of opioids into their system. Additionally, one other complication is how it interacts with the body. So traditional opioids are processed through the body in a way that they’re eliminated in about 72 hours. Fentanyl has this very interesting character to it where it becomes stored in the fat cells and is released unevenly and unpredictably over a much longer period of time than 72 hours.
Miller: All of which adds up to the necessity of having a doctor on hand and having somebody be an inpatient for up to a week just to get to a version of stable?
Bazeghi: Right.
Miller: Whenever people who are in recovery from opioid addiction have described withdrawal, it’s always sounded to me like a waking nightmare. That was before fentanyl. Is fentanyl withdrawal even worse?
Bazeghi: Hands down and without question, it provides more significant withdrawal symptoms and they’re less predictable, which is part of the necessity of having this space where folks can be monitored by physicians, nursing staff over time.
Miller: Well, can you give us a sense for what those physicians and nursing staff, the people who are now staffed up and gonna be starting work in just a couple of days, what they might be seeing, what people who show up might be experiencing for a couple days?
Bazeghi: Well, generally, when folks come into the environment we do everything we can to do outreach and pre-engagement so that we’re working with people before their journey starts at the withdrawal management facility. However, when people come in, they’re in chaotic and active cycles of addiction. So people are gonna come in terrified of the withdrawal process. It’s the process of becoming as physically sick as a person can really experience in many ways. I mean it affects the whole body. And so people come in really, really afraid of that process. That’s one reason why people are hesitant to engage with treatment. And it’s worth mentioning, this is the beginning of treatment. This is just the process of waning folks off of these high doses of street opioids. The facility will also treat alcohol dependency as well.
So while they’re with us, the benefit of having medical staff on hand is that all of these different symptoms range from incredible body aches and pains to gastrointestinal symptoms to ear, nose, throat stuff. It’s like a whole-body thing. It’s a waking nightmare. Physicians can offer medications that support this process and add comfort and reduce the traumatic nature of the withdrawal. As well, and we consider this to be a very important piece of the puzzle, they can help to stabilize them on medications that will support continued recovery, abstinence from street drug use, reduced cravings, and potentially the most important being the absolutely deadly nature of fentanyl, prophylaxis against overdose even in the case of return to use.
Miller: That’s actually something that we’ve talked about a lot recently, especially when some recent overdose data came from emergency room calls, or I should say 911 calls in Multnomah County. But we’ve heard that one of the most dangerous times for people, in terms of potentially fatal overdoses, is when they return to use, if they return to use, which is sadly very common. But we’ve skipped ahead to say day seven. How will people get there in the first place? One of the things you said at the beginning is that you aid people in their choice to address their addictions. How will people end up walking through your door?
Bazeghi: Recovery Works NW, in our experience and just in our philosophy, understands that treatment, when voluntarily engaged with, has better outcomes. We do work with community partners across the board, including partners and partnerships that we value with corrections and with parole and probation, all that. However, in all cases, Recovery Works is an open door where people choose to walk through in one form or another. And that can be either by our front door, literally walking into any of our outpatient clinics. We have three in operation currently with a fourth coming online soon. Or a phone call to our number, 503-906-9995, or by working with one of our many, many, many partners in the community who offer other services that support people recovering.
Miller: Methadone and now Suboxone, they’ve been around for a while and it seems like there are best practices, decades old best practices, at least for their use in medication assisted treatment. But we’re only a few years into this version of the fentanyl crisis. Is it fair to say that, on some level, you are all still figuring out what you’re doing?
Bazeghi: Yes. And this is the practice of medicine, because we don’t live in a world of stasis and change is inevitable. And so in the work that we do, we are constantly working to understand new trends, not only in the treatment world, but also what our participants are experiencing, you know, how they are interacting with substances on the street and how those substances are changing. Yes, it’s a moving target.
Miller: That actually just seems like a major challenge?
Bazeghi: Indeed. It is, absolutely. And this is a matter of life and death now because, and it always has been, but that urgency is just without question. It has increased significantly. We are experiencing a public health emergency and I appreciate this venue because I do feel like this is worthy of our community time and resources here.
Miller: Did you encounter any NIMBYism [Not in My Back Yard] from immediate neighbors when you proposed this site to be a new inpatient drug and alcohol treatment center?
Bazeghi: Yeah. The site that we found was so uniquely suited to what we’re doing. We didn’t necessitate a change in occupancy permit or anything like that because it was already a group living environment. And it was purposely and custom built for that. So it is in Southeast Portland. However, the way that the lot is built, it’s removed from the street. It already has some built architecture that helps remove it from, necessarily, the neighborhood around it. And we haven’t had any direct pushback on the use of the space. In fact, some neighboring properties are also already engaged in the recovery sector. So we’re hoping to maybe make, maybe a little hub of something happening in that part of Portland.
Miller: Can you give us a sense for how you think an average patient might be doing it and what they might need after say, five days?
Bazeghi: This is the most important question of all and you were alluding to it earlier. So, while they’re with us, it’s worth saying, they’re gonna have a… the facility is built for trauma and formed spaces. It’s wide open. There’s lots of natural light. All of the aesthetic is built towards calm. It is not a lockdown facility. So we built with the intention of humane spaces. People get three meals a day, home cooked on site, and then a lot of opportunity to connect with behavioral health resources when they’re ready. So that it’s not forced.
Miller: You said it’s not a lockdown facility. What would prevent somebody…it seems like a very rational decision, if they’re going through physical and mental and emotional agony and if they know that they can walk out the door and probably within 10 blocks or within two hours, find what they might call medicine to get well again to find some fentanyl. Why wouldn’t they just do that?
Bazeghi: Yeah. The purpose of the facility is so that our physicians can provide medications that will make that period of traumatic suffering as short and as managed as possible. So they’re gonna be able to offer medications in such a manner they wouldn’t be able to offer in an outpatient setting. And therefore, that’s going to ameliorate some of those really difficult symptoms. Anybody that has a level of commitment to a new life without a need to compulsively self administer these very dangerous contaminated drugs, there’s any window of openness, these physicians have, within their scope of practice in that environment, to offer some more tools to really support their staying there. And again, it’s a beautiful place and there’s nice food. And they might not be able to eat on day one or two. But there’s other things that we’re just wrapping around to help people feel safe.
Miller: OK. So to go back to my earlier question. Obviously, everybody is an individual. But on say, day five, what’s your expectation for what an average patient where they might be when they’re more stabilized and what they might need?
Bazeghi: Yes. And this is the most important question of all because when people are stable on a dose of medications. Of course, no one’s forced to take medication. So that’s another thing where they’ll self-select. “I would like medications to support my recovery and to keep me safe after this.” But once that process is done, they’re going to be eating. They’re gonna be obviously walking on their own. They’re going to be living without a terrible sense of pain or anxiety due to withdrawal. Stability on their medication is our hope. People will choose to go down that path when it makes sense.
At that point, then they are ready to move on from the facility. This isn’t housing, long term. This is just solving the problem of how we can get folks, with the least trauma possible, off of these high doses of street opioids. So day five could be day four in some people’s cases or maybe day seven. Whenever the medical staff has determined this person is physically capable of moving forward to the next step, they will be, by that point, already very familiar with case management and behavioral health resources on site there.
And what that means is these are gonna be people that are gonna be there to make sure they know all of their different options to continue for their treatment, whether that is with one of our partners in the community in a residential setting, 30, 60, 90 days of residential treatment. That’s a beautiful option for some. Recovery Works, ourselves, offer what we call a housed, intensive, outpatient program for adult male-identifying fentanyl users. And that’s one different option where they could be housed for four to six months without paying for it and they’ll just engage with outpatient treatment on a very significant level. Or there are many other different resources. But one thing we know for sure is everybody that needs housing should be offered access, a pathway to supported housing. This is something Measure 110 has really helped us to really facilitate. There’s so many more supported housing resources online for people that are really addressing their substance usage.
Miller: I should say this is something that we talked about, but it’s been a little while. I’d love to get your thoughts on it because when the money for Measure
110 finally started going out, there were some people who said, “Wait a minute, I thought this was gonna be for drug treatment. Why are you putting money into housing?” What’s your answer to that?
Bazeghi: Our housed IOP (housed outpatient treatment program) involves significant engagement with outpatient treatment. So that house, this is a partnership that was facilitated by Measure 110 exclusively with the local organization called Bridges To Change. And Bridges To Change provides houses and housing environments across a continuum for folks that are addressing their substance use concerns, their substance use distress.
So Measure 110 funded five categories of services: low barrier and freely accessible substance use treatment, supported housing, supported employment, peer services, and also expungement services. It’s this whole group of services that support people to, not only go to treatment, but also be able to find stability to address their wellness goals, especially around substance use disorder on a broader more holistic scale.
Miller: In just a couple of days, you’ll be able to take care of 16 people at a time at the new facility. Can you give us a sense for the level of need out there?
Bazeghi: I can tell you the need is overwhelming and we are under-resourced. And I can say this from personal experience, working with folks currently in this landscape and also with so many different community partners. So 16 beds doesn’t sound necessarily like a lot of beds. We’re treating people on average from three to seven days. Let’s call it an average of five days. This is hundreds and hundreds, over 1,200 treatments per year we’ll be able to offer from that one facility.
It also represents an increase of roughly 18% in withdrawal management capacity in the city of Portland. So in a short time, we’ll be admitting some folks into our space there and we’ll be at a total of 90 detox beds in the city of Portland. This is woefully under-resourced. So another reason that we realized we had to do this is that we have been relying on withdrawal management resources in Otis, Oregon and in Coburg, Oregon. And we’ve been having to shuttle people all around the state.
Miller: Meaning people in the Portland area have to go to Lane County or further away to get these services?
Bazeghi: Absolutely, because our primary service providers in the whole community of Portland…just from my personal perspective, [I have a] a deep, amazing amount of gratitude to the folks at the Central City Concerns Hooper facility as well. Because they’ve been doing it alone and there’s a wait list every day. Someone who is in the throes of this deadly addiction comes to a place of readiness and says, “I’m ready.” They come to us and say, “Hey, Recovery Works, we’re ready now.” So we say, “OK, great. Well, now we’re gonna drive you to a couple different places, make phone calls and we’re gonna go through a process of you being turned away several times, just keep showing up every day.” That’s a deadly equation and it’s proven so.
Miller: Joe Bazeghi, thanks very much.
Bazeghi: Thank you, Dave. Thank you very much for having me.
Miller: Joe Bazeghi is the director of engagement with Recovery Works NW. They are about to open the first inpatient drug and alcohol treatment facility in the state that is gonna be paid for with funding from Measure 110.
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