Roadwork on the path to recovery

Roadwork on the path to recovery

This article is part of an ongoing New Bedford Light series examining the far-reaching impacts of addiction.

Those hours at a shelter in December were crucial for Demeterious Melbourne. The now-recovering addict living in a sober house in New Bedford’s North End was waiting to begin once more an effort to start fresh in a lifetime of addiction, living on the streets, recovery attempts, jail time.

That night, he stayed the course at the shelter in Worcester. It could easily have gone another way, he said, taking him off track and back to the life he’d led for more than 20 years. Instead, he went right from the shelter to clinical treatment, then to a New Bedford halfway house. Last month he moved to the sober house. 

Melbourne’s progress is one version of how treatment advocates say recovery systems are supposed to work — and how they need to work more often. 

This story is about what some in the addiction treatment world call a “continuum of care,” while others say “levels of care.” The term refers to treatment and recovery programs and the practitioners, organizations, government entities that provide them.

An effort is now unfolding in the South Coast recovery world to get practitioners talking about this system of care and how to improve it. 

This shows a course of treatment that applies for some people in recovery, but not all. Recovery advocates are also pursuing ways to expand the range of treatment options to include alternative medicine and meditation.

Sources: High Point and Steppingstone

When the planets align, treatment goes well. The addicted person gets the help they need when they need it, stays on track, and, through months to a year or more, emerges in a better place. And stays there. 

Addiction, in medicine, is considered a chronic disease that is not curable, but is treatable. 

The Substance Abuse and Mental Health Services Administration, a federal agency, recently posted that 7 in 10 adults who have ever had a substance use problem considered themselves to be recovering or in recovery. The same agency reported in 2020 that about 90% of people who needed addiction treatment were not getting it. 

Many treatment practitioners in this area and elsewhere sought help themselves, and got it. They have found the happy convergence of available resources and their own readiness to make a new life. No South Coast practitioner interviewed for this story who is in recovery said they made it on the first try.

Some cannot say why that last time was the one that worked, why they felt their commitment click in at a certain moment. Some attribute it to a certain life event. Some see the work of God.

That includes Melbourne, a tall, slim man who is 40 years old. He spent a few hours in that shelter in Worcester, waiting for a spot to open up in a nearby clinic. He planned to try again to get free of a crack cocaine habit running about $200 a day. He was running every day, hustling here and there, panhandling.

The shelter time in Worcester was short. Just the sort of moment, though, where things can go awry. Depends on whom you meet. Depends on what they’re carrying. Depends on how deep, at that moment, runs your commitment to your own recovery.

Practitioners have a saying for the addicted person about recovery: you have to want it more than I do.

Melbourne looks back on that moment in the shelter and says: sure, at another time in his life, that moment could have been added to the times he started down the path and stumbled.

It seems every person in recovery can tell about several times they started on course and veered off. Something happens. 

Sometimes the detour is personal. You’ve completed a first phase of treatment, think you’re all set and go no further, cutting recovery short. Some familiar face from your drug life reappears. You stop going to the meetings, thinking you don’t need them anymore. A loved one falls ill or dies. You lose your job. You reach for what in the past has helped carry you through.

But sometimes, you hit a problem with the system. The clinic doesn’t have room the day you need it. The insurance coverage falls short. 

Ideally, an addicted person moves through a sequence of treatment steps, a “continuum.” 

The term carries the reassuring connotation of a smooth, consistent process. Practitioners, though, say it’s difficult to predict what combination of care — clinical, outpatient therapy and medication maintenance — will work for any given person. 

It’s not clear how many people are in treatment in this area at any given time. The state Department of Public Health, which tracks licensed treatment programs, reported that in the year ending in July 2023, nearly 4,000 people were admitted or enrolled in these programs, split about evenly between New Bedford and Fall River.

Relapse is common in addiction treatment. Nationally, the rate of relapse is usually put at 40% to 60% — comparable to other chronic conditions, such as high blood pressure and asthma. 

The stakes are high, especially as the drug supply has become more hazardous because of fentanyl, a synthetic opioid, and xylazine, a sedative commonly used in veterinary medicine. Among some 2,570 drug overdose deaths in Massachusetts in 2022, the most recent year for which reliable figures are available, lie stories of people who relapsed, who fell through gaps in the “continuum.”

A New Bedford Light analysis of death certificates last year showed that at least 92 people died of accidental overdose in New Bedford in 2022, more than double the state rate.

Melbourne has survived living in the streets of New York City, upstate New York, and Worcester. After some 20 years of crack cocaine, he has avoided a fatal overdose, and fathered a daughter who lives in Massachusetts with her mother, giving him a reason to want to build a different life. He’s been drug-free for stretches of months before, but he said this is different. 

Demeterious Melbourne just moved from a halfway house to a sober house in the North End, is working for two retail stores, and feels confident that this time, his recovery from a cocaine addiction will hold. “Not only has God kept me alive, but He preserved me,” said Melbourne, who is 40 years old. “I feel like there’s a plan.” Credit: Arthur Hirsch / The New Bedford Light

“I feel like everything in life has been preparing me for this now,” he said, sitting on a couch at R.I.S.E. Recovery Support Center on Belleville Avenue, where he’s done volunteer work. “Not only has God kept me alive, but he preserved me. I feel like there’s a plan.”

‘The system is the community’

Carl Alves has seen the local network that provides treatment and housing grow since he started running Positive Action Against Chemical Addiction, PAACA, in 1992. And yet there’s more to be done, questions to be asked.

What needs more attention in the so-called “continuum of care”? How are people in recovery slipping off course? What different approaches could be considered? Are treatment providers in close enough communication with each other?

The overall picture of treatment outcomes in the South Coast area is not clear. 

David Daniels, program director at R.I.S.E. Recovery, which is affiliated with PAACA, said he knows of no agency or organization here that tracks people from starting treatment to quitting or staying in recovery. 

Noel Sierra, Southeast regional coordinator for the Massachusetts Organization for Addiction Recovery, also said he knows of no detailed information on treatment outcomes for this area.

Alves sees recovery as a “community process” — practitioners and others gathering around the addicted person and helping them through the stages of treatment and recovery. 

In a conventional course of treatment, the person addicted to alcohol or opioids starts with detoxification or “managed withdrawal,” then moves to “clinical stabilization services,” then perhaps to “transitional support services,” then to a halfway house. These are all clinical settings, licensed by the state, with less structured daily schedules each step of the way. 

The next step could be some form of managed housing with no in-house clinical component, such as a sober house. After that, perhaps a “graduate house,” usually for people who are working or in school — possibly as the person continues to pursue outpatient behavioral therapy and medication, such as methadone or suboxone. 

That’s a relatively simple version. Complications soon arise. 

Step one, detox, is only for people addicted to alcohol or opioids. There is no such procedure for the person addicted to stimulants such as cocaine or methamphetamine. That person might start at the second step, clinical stabilization, depending on the program. 

Also, advocates in the field debate what constitutes “success” in addiction recovery. Is it complete sobriety? Is it functioning well with limited use? How many addicted people can do that?

Earlier this year, Alves launched an effort to spur conversation among South Coast treatment practitioners about the work. He has sent out surveys and engaged a researcher to do interviews and analysis. He may eventually call for recovery practitioners to gather for discussion. 

Carl Alves sees recovery as a “community process” — practitioners and others gathering around the addicted person and helping them through the stages of treatment and recovery.  Credit: Joanna McQuillan Weeks / The New Bedford Light

“The problem is where people get disconnected,” said Alves. He was referring both to people in treatment becoming isolated, which can derail their recovery, and practitioners being out of touch with each other. 

Alves’s researcher, Thomas Flanagan, a neurobiologist, has written extensively on collaborative communication and problem solving. Flanagan said he’s casting a wide net for perspectives. The categories of about 50 perspectives include first responders, nursing, neurology, spirituality, neurology-psychology. It also includes a few that one might not anticipate: storyteller, arts, yoga. 

In addiction treatment, Flanagan said, “the system is the community … The community has to tell us what we don’t know.”

Alves has released a few samples of responses to eight survey questions. Responders offered thoughts on what’s working in behavioral health care and where the work falls short.

About emerging developments in the field, one person wrote: “Public awareness is shifting to recognize that ‘toughing it out’ just doesn’t work … There is a growing recognition of gaps in the continuum of care for individual patients.”

Another response noted that “behavioral health care and general health care are becoming better-integrated.”

About strengths in the field, one person wrote that the New Bedford area “has many providers and a lot of options for care … There appear to be ongoing efforts to find new and alternative approaches that are not contingent on traditional patient management.”

On a question about weaknesses in the field, another responder saw confusion about the options: “patients don’t know where to go — who to speak to. Doctors’ offices don’t seem to be making helpful referrals. Too many choices (over choice; for varied demographics and age) to navigate … Too much reliance on word-of-mouth to try and find care …”

In one view, there are “too few clinicians, too long training cycles, low pay incentives. Turnover of staff, including burn out. Lack of teams for counselors to support counselors. Accessibility and insurance challenges also work against us. … Excessively long waiting lists (months). Lack of housing. Horrible lack of access.”

Out of all these voices, Flanagan said, the hope is to find fresh approaches to stubborn challenges. 

“We’re in discovery work,” he said. “How long does it take to discover a new medicine?”

Resources and complications

The woman in her late 30s from Cape Cod had finished 14 days of detoxification at a clinic in Worcester. She was ready for the so-called “warm handoff,” a smooth move from one treatment step to the next. It didn’t happen. 

Micaela Manzone, southeastern Massachusetts community services representative for Adcare, told the story at the Green Bean coffee shop in downtown New Bedford as her phone kept ringing with calls she had to take. She works for the addiction treatment provider out of her car, in coffee shops, at home, in the thick of the care network. 

The story did not occur in the South Coast area, but it could, and illustrates a point about the complications of sustaining a seamless “continuum.”

In January, Manzone was trying to move the woman from Cape Cod to the most likely next step, clinical stabilization services, or CSS. She was on waiting lists at several places. Manzone said they got her insurance to cover three more days at Adcare, but then the clock ran out. 

The woman had to be released, with nowhere to go but home to her mother on Cape Cod, with no clinical element or structure. Nonetheless, she was released at 10 a.m. 

Three hours later, a CSS place called to offer a spot. Too late. This CSS provider would not take a person from the community, only directly from detox. 

To continue treatment, the woman would have to re-qualify for detox, or diversionary withdrawal management, and start again. Months later, she relapsed, Manzone said. She began anew, and has been on course since. At last word, she was living at a sober house on the Cape, Manzone said. 

This was a question of timing, and policies that might be reconsidered, Alves said. He said he can understand why a clinical stabilization provider would want to ensure their patients are drug-free, but the detox requirement can present a barrier. 

Deirdre Calvert, who heads the Massachusetts Bureau of Substance Addiction Services, said she sees barriers to treatment across the state: lack of access to medications, lack of treatment centers, lack of transportation, and poor integration of addiction treatment into all clinical settings.

She noted a higher level of federal regulation for methadone in particular, including where it can be dispensed, and dosing limits. 

Calvert said other obstacles to treatment include stigmas about seeking help, and what she considers wrong or outmoded thinking about addiction and the lives of addicted people. 

“What other disease in the world do you have to leave your family, have your cell phone taken away” to get treatment? “These programs were made for alcoholic white men in the 1950s,” she said. As a woman with three children who is in recovery herself, she said, she would likely have her children taken from her if she were found to have relapsed. 

“This is the only disease where we expect perfection. If you are not totally willing to be absolutely free of substances, then we can’t help you,” Calvert said. The diabetes patient who relapses, she noted, is treated with more compassion than a person in recovery. 

Daniels, of R.I.S.E. Recovery, said there’s a potential barrier to care in the fact that detoxification only treats people addicted to alcohol or opioids, not stimulants such as cocaine and methamphetamine. Finding the first door to treatment closed, the person addicted to cocaine may not pursue an alternative. 

High Point, with operations in New Bedford, Plymouth and Brockton, is the only provider in the South Coast offering all steps in a conventional course of treatment. Chief Executive Officer Daniel Mumbauer said there’s enough money from the state Department of Public Health to cover patients without insurance at all levels of treatment. 

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But there’s only so much room under the High Point umbrella. According to state licensing records, the organization has 86 detoxification slots, 108 slots for clinical stabilization, 32 for transitional support and 53 in two halfway houses. So patients can still be shut out of treatment for lack of room. In that case, Mumbauer said, the company provides a recovery coach to keep tabs on the patient until they’re placed. 

Laura Goode, in her second year running Ignite Recovery in Fall River and Attleboro — providing recovery coaching, some clinical services and help in navigating the treatment system — said she has also provided recovery coaches to cover these gaps. 

According to the state, about 1,900 people were admitted to all licensed programs in New Bedford from June 2022 to July 2023. That’s individual people, not multiple admissions for the same person. 

In all, the state in April counted 93 licensed programs in the southeastern region, running north to Marshfield and Sharon, west to the Rhode Island line, southeast to the Cape and Islands. That’s the second-highest of the six state regions next to the area west of Boston. The state counted 1,249 beds in licensed inpatient and residential programs, the most of the six state regions.

There are no figures on the cost of treatment in the South Coast region, but the current annual budget for the state Bureau of Substance Addiction Services is $232 million. Add to that the total MassHealth is projected to spend through June on services by clinicians providing substance abuse treatment exclusively, just over $537 million. The total is $769 million, not including MassHealth spending for substance abuse care by clinicians who also treat other medical conditions.

Melissa Kachapis, clinical director of behavioral health services for Steppingstone, which provides housing and addiction treatment, said the main weakness she sees in the continuum of care is the lack of managed housing for people leaving halfway houses. Steppingstone runs four halfway houses accommodating 88 men and women in New Bedford and Fall River. 

After leaving — after an average stay of 80 days — she said, too many go out completely on their own. Often it’s too soon, she said. Too soon to handle the pressures of everyday life and recovery, making relapse more likely.

“It’s nice to have that opportunity to practice the balance between recovery and life, the stresses that come with life,” Kachapis said. For that, managed housing, such as a sober house, is the right next step, but there doesn’t seem to be enough of it. 

Goode, of Ignite Recovery, said she sees a gap of short-term housing for people waiting to get into treatment. She and her employees have occasionally paid for a patient’s motel room.

Sober housing is not covered by insurance, but government and private grants are available for it — if you know how to apply and have the tools, or help, to do it. 

Demeterious Melbourne, who was staying at a halfway house run by High Point, got help from a recovery coach there in securing a grant from the Herren Project. That paid for the first seven weeks of his stay at a sober house, where the rate is $160 a week.

The rising cost of sober housing is becoming a greater obstacle to recovery, said Sierra, of MOAR. 

“I would call it the sober living cash cow,” Sierra said, referring to the emergence of sober homes as a business. “People have seen they can make money by putting four people in one room and calling” it a sober house, he said, noting some places are getting $200 a week. 

It can also be costly to root out the essential emotional cause of addiction. 

“Something caused you to get caught up in addiction,” Sierra said. “You’re not dealing with the inner you. I think it takes a lot of poking and prodding,” he said. That means therapy over time, which means money, and another potential barrier. That is, if the recovering person is receptive to talking to a therapist, which many aren’t, Sierra said. 

Albie Cullen, adult services director at PAACA, said the longer the time in treatment the better, and he acknowledges that insurance can sometimes impose limits. Still, he said in Massachusetts, with the MassHealth insurance system, with government and private grants, there’s money if you know how to go after it. 

The number of slots available in clinical settings at any given time can be an obstacle, he said, but once you’re in, the money is not as big an issue. 

Indeed, Calvert, head of the state’s Bureau of Substance Addiction Services, said her agency is the “payer of last resort,” meaning it covers treatments and services for people who are “uninsured or whose insurer denies coverage for medically necessary treatment.”

Cullen said “clinicians will go above and beyond to keep people in treatment. If somebody wants to stay, they’ll find a way.”

That can be a big “if,” Cullen said. As he sees it, a chief obstacle is the addicted person’s commitment to their own recovery. 

“The primary barrier is behavior,” Cullen said. Even an abundance of resources won’t help if the addicted person is not “ready,” as they say, to start a very different life, he said. 

‘Terminally hip and fatally cool’

Demeterious Melbourne reckons it’s possible he tried recovery 20 times. He cannot recall every one. Treatments in Springfield, Boston and Westfield, Massachusetts, among other places. Auspicious beginnings, but that was all.

As he sees it now, he wasn’t facing the real trouble. He thought he didn’t have a drug problem. The drug was a solution. He stopped his visitor on the word “disease,” got up from the couch where he was sitting at R.I.S.E. Recovery in the North End, grabbed a pen and wrote in a notebook: “Dis-ease.” 

He had a “dis-ease,” he said, a lack of ease with himself. 

Adopted at age 3, haunted by a sense of abandonment, he said he always needed to be the funniest guy, the one everyone would look to for a laugh, for the life of the room. Why? 

At first, as a teenager, the alcohol made it better, then marijuana, cocaine, crack, crystal meth. 

He was sober for long enough stretches to start pursuing his aspiration to work as a hairstylist, studying at schools in Manhattan and in Quincy. The effort has never progressed as far as he’s hoped, at least not yet. 

Melbourne said he’s still hoping to realize that ambition. Maybe a small shop. A couple chairs and, off to the side, a table set aside for chess, one of his long-standing pursuits. 

He said he feels certain that this time will be different. That day in December in Worcester, something turned, he said. 

He stopped in at Community Healthlink in Worcester, which had to first refer him to a shelter for a night to wait for a spot in clinical support services. He could not qualify for a conventional detoxification, as his addiction was cocaine, not opioids — the potential barrier that Daniels at R.I.S.E. talked about.

He got a spot in Brockton, a 30-day program run by Adult & Teen Challenge, a Christian spirituality-based organization. 

Adult & Teen Challenge, established in the 1970s, is well regarded in Massachusetts, Alves said. 

“It’s not for everybody,” because of the religious framework, Alves said, but they’ve had a lot of success, he said. Daniels and Sierra have both pursued a Christian-based recovery. 

From the 30-day clinical treatment, Melbourne went to Harmony House, a halfway house in the North End run by High Point. After three months, he has moved to a sober house. He said he’s working two jobs now: full-time stock work at WalMart, added hours at Burlington. 

It’s early yet. He’s been to this point before. He’s reaching six months sober, the first of several milestones that practitioners consider significant. The longer you make it, they say, the more likely you’ll stay on track.

Daniels has been there, and Sierra and Manzone, Cullen and Goode. All are years into their recovery. All say they slipped more than once, then came to their moment of resolution, and found the resources in the community to make their recovery stick.

Manzone said she’s grateful for having the support of her family. Goode said she’s grateful for the intervention of Boston Police detectives, who caught up with her for warrants, and sent her to an involuntary commitment to treatment. 

Melbourne declined to say if he had a traditional religious upbringing, but he said he feels the hand of God guiding him, as he tries to push the bounds of his own history. 

“I think, honestly, it was a God moment” that day in Worcester.

Before this, he said, he was not “ready” to give up his attitude — his thinking he had all the answers. His phrase for it: “I was terminally hip and fatally cool.” He needed to “be in the mode” he said, rolling his body from side to side. 

“Now I’m like this,” he said, putting up both hands in a gesture that said a few things: I surrender… I don’t know… You tell me…

Email reporter Arthur Hirsch at [email protected].

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