The Uphill Battle
Obstacles abound in the pathways to stable lives
For substance users eager to leave their addiction behind, getting into recovery is easy. But, getting back their life is a whole another matter.
When Jamie Carnell was packing her bags to leave the residential recovery treatment center, she didn’t have any place to go.
She had been at the center in Portsmouth, Ohio, in 2021, recovering from heroin addiction for less than a month. Then she was being released without an address in hand.
“I told them, if I left there, and if I didn't have anywhere to go, I knew I would end up getting high,” Carnell recalled.
It’s not unusual for someone in recovery to suffer slip-ups while learning to navigate their new lives. One of the biggest challenges for those recovering is detaching from the environment that led to addiction in the first place. Without the resources to help them stand on their own – such as insurance coverage or access to ethical recovery centers – they become vulnerable to relapse.
Jamie Carnell, a resident at Summit Recovery Center, waits to take part in a group counseling session.
Photo by Bharbi Hazarika
Health-insurance limits can curtail recovery
Some experts say that patients in recovery centers are highly dependent on their insurance coverage. To ensure sustained recovery, oftentimes counselors have to downplay the short-term progress of their clients so that they can keep their insurance coverage to continued longer-term treatments.
At the treatment center, Carnell went through treatment protocol and was placed at a higher level of care. “Levels of care,” developed by The American Society of Addiction Medicine, are classifications of treatment offered by most addiction treatment facilities. The ASAM levels of care broadly lays out five categories of treatment that vary in intensity, from least to most intensive – and from least to most expensive.
Like most other patients in recovery, Carnell depended on her insurance to pay for her treatment. Insurance providers rely on the reports submitted by case managers and counselors to assess if the patient is improving and determine when to terminate their services. When Carnell began the treatment, she felt her prescribed “level of care” dropped frequently, even though she wasn’t getting better.
Because Carnell had completed all her treatment requirements before time, she was awarded with an “early completion” certificate, with the expectation to go from all-day treatment six days per week straight to finding a job and paying the bills.
The women at Summit Recovery center sit in a circle to participate in group therapy. Many bring stories from their past to discuss and reaffirm to one another that they are not alone.
Photo by Bharbi Hazarika
Carnell moved to Summit Recovery center in Logan, Ohio, which offers intensive outpatient substance abuse counseling and recovery housing for women who have completed a prior treatment program.
Travis Bookwalter, co-founder of Summit Recovery center and himself a recovering substance user, said the most difficult part of rehabilitation is realizing that recovery doesn’t have an end point.
“That life is no longer there," Bookwalter said. "The problem is that they put you in there and then they may set you up to get clean. And then say, ‘See ya!' But how are you gonna live clean?”
That is precisely the question that Carnell was trying to answer, and which led her to Summit Recovery. But now she said her recovery at the previous residential treatment center felt like ticking off boxes on her insurance provider's checklist.
“Everything I had on my list to do, basically got checked off, even though I wasn’t anywhere near completion,” Carnell recalled. “The way the insurance saw it is that I didn't have anything else to work on anymore, so there was absolutely no reason for me to still be there.”
State officials may skew oversight of insurance coverage away from the best interests of the patients. When asked to talk about those issues, Ohio Medicaid's chief communications officer, Lisa Lawless, issued the following written statement, which does not mention the recipients of care: “The Ohio Department of Medicaid works to prevent fraud and assure the integrity of our program through a variety of techniques and processes; from enrolling proper providers, prior authorization of certain services, data analytics, post-payment reviews and audits, and collaboration with law enforcement and other partners, including our managed care organizations, sister state agencies, and the Auditor of State.”
Those with insurance may find it difficult to maintain the coverage if they improved quickly at first but, later, suffer downturns. For the uninsured, accessing treatment for opioid use disorder is much harder.
According to a 2019 analysis report by Kaiser Family Foundation, across the country, nearly one-fifth of nonelderly adults with opioid-use disorder were uninsured between 2016 and 2017, and almost 75% of those needing treatment did not receive any. Most of those people were young males with very little income, making that demographic particularly at risk.
Not enough transitional facilities
The path from “pushing needles” to building a stable life has always had its obstacles. Bookwalter and his wife, Ashley, work with people who have completed recovery treatment plans. The Bookwalters have housed and guided many former addicts to getting jobs and building sober lives.
A coffee station at the Summit Recovery Center. The white board behind explains the center's mission: "Find your path."
Photo by Bharbi Hazarika
Transitional and sober-living homes are key components in recovery, Ashley Bookwalter said. For many with acute addiction, transitional housing facilities are the next step after graduating from a regimented life in a treatment center. In transitional homes, members still must participate in counseling sessions, but their routines are less intense than they would be at a treatment facility. Sober-living houses are another option: they are substance-free accommodations that do not require the residents to attend counseling as they would in transitional housing.
In 2014, Ohio Mental Health and Addiction Services formed Ohio Recovery Housing, after recognizing the need for an agency that could help develop substance-free residences for individuals recovering from addiction.
“Recovery housing is about more than residential stability and the benefits of safe, affordable housing;” Lori Criss, director of OMAS, wrote in a 2021 report. “It emphasizes the importance of connecting to a community of people in recovery that help navigate the challenges and celebrate the successes of a life in recovery."
Despite the importance of recovery housing like sober-living and transitional facilities, Ashley Bookwalter said there is a shortage of such facilities statewide compared to the ubiquitous treatment centers. “When you start looking, especially (in places) like southern Ohio, on the border of Kentucky and West Virginia, looking for treatment centers is like going to Vegas for casinos," she said. They're everywhere.” The same is not true for transitional and recovery housing facilities.
There are 726 substance use treatment facilities in Ohio, according to Ohio Mental Health and Addiction Services. By comparison, there are 582 recovery housing facilities, out of which only 268 are certified. The disparity is even more stark in the 32 counties in Appalachian Ohio, where there are 118 treatment centers but only 28 transitional housing, halfway house, or sober homes, according to the Substance Abuse and Mental Health Addiction Services treatment locator webpage. That may look like a small disparity, but while treatment facilities usually house patients for up to two to five months, recovering patients usually live at sober and transitional living homes for upwards of six months, according to the residents at Summit Recovery center.
Substance use treatment and transitional and sober living facilities in Ohio
The graphic shows the availability of substance use treatment facilities and transitional and sober living homes in Ohio. Use the slider in the middle of the graphic to compare.
Infographic by Bharbi Hazarika.
Source: Substance Use and Mental Health Addiction Services
The reason for the imbalance is that recovery treatment centers provide a wide variety of services that generate more profit compared to transitional or sober-living places, Ashley Bookwalter said.
“I feel like there's a lot of business investors who prey on a very vulnerable population, because there is a significant amount of money to be made,” she said. “Especially when you get into MAT," she said, using the acronym for medically assisted treatment.
Fueled by the rising cases of drug overdose, the addiction treatment market grew to a $42 billion industry in 2020, according to MarketResearch.com. An analysis by the Hazelden Betty Ford Foundation, an addiction center and advocacy group, found that a mix of unethical marketing and business practices, including “patient brokering” -- paying for patients and patient leads – and an absence of strong universal standards for quality treatment pounds the vulnerable patient population dealing with substance use disorder. The report argued that the opioid crisis has hauled with it expanded insurance coverage, attracting sometimes unscrupulous private investment and a rush of new providers “motivated by profit over people.”
The same report warned against excessive consumer billing, where providers press clients to overuse services such as drug testing, so that the centers can bill them and yield more profit.
Most of the women at Summit Recovery home echoed those sentiments, with one saying she had to postpone her dental appointment after being coerced to attend a counseling session. When she pushed back, her treatment provider asked, “You didn’t care about your teeth before, why do you care now?”
For the most part, treatment routes are broken into four types, from lowest to highest intensity of care: outpatient (referred to as "OP"), intensive outpatient programs (or "IOP"), partial hospitalization programs (or "PHP") and residential care, which often includes detox and medically assisted treatment (or "MAT") programs.
Expenses for different types of treatments per week
Infographic by Bharbi Hazarika
Source: Ohio Department of Medicaid; Ashley Bookwalter, co-founder of Summit
An analysis of the different types of treatments for opioid addiction and breakdowns of the expenses.The average rates are compiled with information from current recovery center workers, including Ashley Bookwalter, and is based on information from three treatment facilities. Those numbers may increase or decrease depending on the number of people on staff at a treatment facility.
Treatment centers providing medical detox charge the most, costing insurance up to $2,750 a week per person, according to the Ohio Department of Medicaid. At the lower end, outpatient care costs about $350 per week, according to Ashley Bookwalter. Those numbers increase depending on the number of medical and mental health providers on staff, Ashley Bookwalter said.
Carnell doubts if the providers at the previous treatment center – where she was a patient – had any ill motives. But she recalls that the entire process of recovery there flew by in a flash. So, when it came time for her to leave the recovery center, a 30-day extension was out of question. “My insurance already decided that they didn't want to pay for me being there anymore,” she said.
One drug court realizes the need for aftercare
The gas station on Carroll Street in New Lexington has a sign inside that reads, “no public restroom.” The cashier explained that he would frequently find needles and blood on the bathroom floor, prompting him to finally put up the sign.
A sign on the wall of a hallway inside a gas station in New Lexington, Ohio, reads: "No public restroom." The store manager closed it off to the public after finding evidence of substance use in their restrooms.
Photo by Bharbi Hazarika
Half a mile away, Main Street is dotted with small businesses and government agencies. A block away from Perry Behavioral Health Services, an addiction treatment center, sits the city’s municipal court, where Judge Dean Wilson started the Perry County New Direction Drug Court in 2017.
Wilson's initiative was not started on a whim. He first visited drug courts across the state, sitting in on several sessions, taking notes about how they operate. When he finally started the Perry County drug court, he adopted many of those approaches that he observed to create a system that worked for the community. Above all, he was adamant to implement one measure – the judge's involvement in their recovery.
Wilson – who is in his 60s – rarely wears his black robe during drug court. He thinks the judge’s robe can be intimidating to the defendants, with whom he is trying to build a rapport. Each Wednesday, during the status review hearings in which participants of the drug court share their progress, Wilson is quick to banter with the attendees and gives every one his attention and encouragement.
“He is always the last person to leave the court,” Brad Agriesti, a probation officer at the Perry County drug court, said of the judge.
Some 200 people have already "graduated" from the Perry County drug court. At any given point, the drug court has no more than 30 participants, even though it could pack in as many as 60. Wilson believes in keeping the numbers low to maintain individualized care.
“Yeah, it looks great on statistics, when you're reporting to somebody,” Wilson said. “But you lose that individualized care that you need to have for the participants.”
In Perry County, drug-related offenses make up most of the charges that are brought to court. Before the introduction of the new drug court, the county was spending more than 16% of its total budget on jail expenses. That number has been reduced to roughly 8% since implementation of the drug court.
Wilson attributes the low recidivism rates to the drug court’s integration into the lives of the defendants who have participated in the program. Defendants charged with misdemeanor drug charges may be eligible to participate in the drug court after they complete a mental health and substance abuse analysis, Agriesti said. The tests are conducted by the court’s treatment team, which includes five behavioral and mental health agencies.
Perry County's New Direction Drug Court sits along Main Street in New Lexington, Ohio.
Photo by Bharbi Hazarika
Once defendants are deemed eligible, they are allowed to enter the four-phase rehabilitation program. Each phase lasts two months. In the first two phases, participants go through intensive care and counseling, when they aren’t allowed to work and must spend most of their time attending group counselling sessions, therapy and checking in with the court. In the last two phases, the intensity of counseling is dialed down, and the participants are encouraged to join the workforce. The court has relationships with local factories and businesses that are willing help participants secure jobs.
Unlike most other drug courts in Ohio, the Perry County drug court implements an additional fifth, or "step-down," phase. Wilson adopted the latest phase when two participants relapsed after graduating from the program. He said that the problem lies in the fact that most of the participants go from a regimented life where they must report to the court weekly, if not daily, and then suddenly they are on their own. He likened the status quo treatment offered to substance use offenders in drug courts across the state to Ohio’s foster care program.
“It's just like foster kids. What happens with those kids is that when they are in the system, they've got somebody taking care of them from the time they're six years old until they're 18,” he said. “And all of a sudden, when they reach 18, the system's done; you're on your own; good luck!”
The fifth phase was built to curb relapses and help participants of the court to transition back into the community, Wilson said. The phase begins after the defendants have graduated, during which time they are required to report back to the court monthly for 90 days to ensure that they are sustaining recovery. They are also required to commit to drug tests once every week, and any failure to report or relapse guarantees sanctions on the patient.
“Depending on the seriousness of the drug, we decide what kinds of sanctions should be imposed,” Agriesti said. “If the participant does, for example, hardcore heroin, they will probably have to go to jail.”
For less severe drug positive cases, like marijuana, the sanctions, too, are less intense. Agriesti said, for milder drugs, the sanction may simply require the participant to test for drugs two or three times a week instead of once. The goal is to make sure the court preps them to lead functional lives, he added.
When the drug court was being recertified in March 2021, Wilson mentioned the fifth phase to the state Supreme Court official who reviewed Perry County's program, but he refused to give the official further details. He said he feared that the Supreme Court would place restrictions on what he sees as a necessary phase that hasn’t yet been mandated.
Wilson said the reason the state’s Supreme Court hasn't created a phase five plan, in part, may lie in the fact that they expect a “cookie-cutter” result from each defendant’s participation, after which they are retired from the program. Although the fifth phase is working well for Perry County drug court, with a success rate of 82%, Wilson acknowledges that such a phase may not work for drug courts in other communities or big cities.
“A judge from another county came to our court to ask about our drug court and how we run it,” Wilson said. “I told him that the drug court will only work if he bases it upon what works for his community.”
Wilson knows most people who come through the doors of the courtroom, or he knows the families of the defendants.
“It’s more of a personal thing with me,” he added. “And I try to make them feel that way. I think that's the reason we have the success rate we do.”
Building a community around recovery
In December 2021, in a bowling alley right off the Main Street in New Lexington, drug court participants gathered with their families. Agriesti, the parole officer, greeted each defendant like a neighbor, welcoming many with a pat on the back. Mothers arrived with kids; brothers arrived with siblings. Judge Wilson shook hands, chatting with the defendants and escorting each of them to the buffet table across the room.
Wilson and the drug court team often organize such gatherings to forge a community for the defendants.
Angela Simon, one of the participants of the drug court, sat with paper plates full of food as she watched her three kids bowling. She is in her second phase of the drug court and excited to continue her journey of sobriety.
“This place has changed my life,” Simon said, looking at her children. “I'm finally starting to get the life back of the person I used to be before all the drugs.”
Back at Summit Recovery, six women sat in a circle, announcing how long they have been in the transitional home.
One woman said, “two months.” Another said, “one day.”
When Carnell’s turn arrives, she beams and says, “almost a year.” Although she is no longer required to attend most of the group sessions, she chooses to continue with the activity.
The women at Summit Recovery Center sit on the floor, chatting about life outside of addiction.
Photo by Bharbi Hazarika
Travis and Ashley Bookwalter, through Summit Recovery, have built a community for the women who not only share a home but also share their lives. Most of the women are either enrolled in school or working and have more upbeat things to talk about than addiction and the hopelessness it causes.
Long after the end of the group session, Carnell sticks around. She and two other women chat and giggle in the corner.
When Carnell first arrived at Summit Recovery, she didn’t expect that she would have so many people to lean on. Now, she is happy to be a confidant for others.
“If I'm able to take something I went through," Carnell said, "or some experiences that happened to me – good or bad – and then give somebody comfort, or some sort of security from it, then, it wasn't for nothing.”