Inside an elaborate late-19th century mansion in the Heritage Hill neighborhood overlooking downtown Grand Rapids, nearly a dozen men are undergoing substance use treatment. The building’s interior features extensive wood decor, a dining room for family-style dinners prepared by a chef, a basement gym and Tiffany stained glass. The rehab facility straddles commercial and residential areas but feels like a home.
Residents stay from two weeks up to 45 days at a time, receiving about six hours of therapy a day. The home, owned and overseen by Sanford Addiction Treatment Centers, known commonly as Sanford House, is modeled off a similar facility for women located less than a mile away. Rehabbing the two historic Heritage Hill homes has served as a metaphor for the treatment Sanford House uses with its patients, an increasing number of whom in recent years are battling opioid addiction.
About two miles south in Grand Rapids’ Madison Area neighborhood is a remarkably different scene of people fighting the opioid crisis. The Grand Rapids Red Project’s offices are cramped on a corner lot on the city’s southeast side. Workers were buzzing through the one-story building on a recent workday morning.
The Red Project, founded in 1998, has distributed rescue kits of the overdose-reversing drug Naloxone and administered a needle exchange program for more than a decade. It provides training across the state to companies, police departments and treatment centers — including Sanford House — on overdoses and the life-saving benefits of Naloxone. By most accounts, it’s one of the most effective and far-reaching organizations in Michigan fighting the opioid crisis. The Red Project works in seven counties in West Michigan and has trained more than 10,000 community members. In more than 1,000 cases, a Naloxone rescue kit distributed by the Red Project has saved a life.
Naloxone, an opioid antagonist, can be injected or sprayed into the nose and takes effect within minutes. During an overdose, a person’s central nervous and respiratory systems become depressed, and the drug helps restore breathing.
The Red Project attributes the availability of Naloxone as having a direct effect on the community. To that end, Kent County has the lowest opioid-related death rate among Michigan’s most populous areas, according to a 2018 statewide assessment commissioned by the state.
As the opioid crisis grew, so has Red Project’s annual budget, which increased from $70,000 six years ago to about $1.5 million currently, making it the largest program of its kind in the state. (By comparison, the annual budget is about the same amount the owners of Sanford House spent rehabbing its men’s treatment facility.)
Former Grand Rapids Mayor John Logie is credited with jump-starting The Red Project program under a series of recommendations in 1998 from the Mayor’s Task Force on Drug Policy Reform. Funded primarily through grants, its services are free to the public.
The Red Project and Sanford House both serve on the front lines of the opioid epidemic, treating a growing number of individuals grappling with what Gov. Gretchen Whitmer has called the “greatest health crisis of our lifetime,” and which President Trump has declared a public health emergency. In 2017, opioid-related deaths nationwide reached 47,600 people. The problem has evolved as restrictions on prescription painkillers gave way to illicit drug use, and then to illicit drugs being combined with pharmaceuticals, most notably fentanyl.
Sources for this MiBiz Deep Dive reporting series say one of the under-reported aspects of the crisis is how broadly opioids’ tentacles reach into society and the economy. Experts say employers can no longer afford simply to avoid the issue. The state and others are in the process of a broader awareness campaign around removing the stigma toward users as well as proven effective treatments. Perhaps as a sign of the issue’s cultural pervasiveness, even a “Sesame Street” character’s mother was recently revealed to be in treatment for addiction.
Meanwhile, people who use opioids often are portrayed in the media at their worst or as someone who has “beat” the addiction with abstinence, which advocates say is a misleading portrayal of treatment and devalues people who are actively using.
Unfortunately, more than a decade and tens of thousands of deaths came before broader public awareness and education about the issue. The way opioids were unleashed on the public and the institutional response from health systems and the government has been a uniquely American problem.
“The dialogue that’s been created due to the opioid epidemic allowed people to look into treatment — it’s not so frightening or unknown,” said Rae Green, founder and president of Sanford Addiction Treatment Centers. “It’s sadly ironic. It has cost lives to get people talking about it and to get action.”
Steve Alsum, executive director of the Red Project, called it a “shame” that more communities are just now getting behind programming and treatment long stigmatized by the public and health systems.
“Look at all the people who died in the past 10 to 15 years who could have easily been saved,” he said.
How we got here
Professionals in the treatment and prevention space tend to agree on how the crisis evolved and what steps could help solve the opioid epidemic, which in 2017 claimed the lives of 2,033 Michigan residents. That’s about double the number of traffic fatalities the same year. By comparison, Michigan had just 115 opioid-related deaths in 1999.
Alsum described three phases of the opioid epidemic.
When the Red Project started distributing Naloxone in 2008, the bulk of fatalities were from prescription opioids, he said. This continued until around 2012 when the medical community started recognizing the role of prescription opioids in those fatalities.
As access to these drugs began to be restricted, a lack of evidence-based addiction treatment — in the case of opioids, a combination of medication-assisted treatment and behavioral therapy — often led to heroin use, Alsum said. From 2012 to 2015, overdose deaths from heroin spiked.
Alsum says we’re now in the third phase as illicit drugs like heroin are laced with substances like fentanyl, an extremely potent prescription opioid.
Throughout these phases, widespread public acceptance of evidence-based treatment didn’t exist, nor did funding support for such programs, Alsum said.
“With such a highly stigmatized health issue, people don’t want to come together around it,” he said. “They want to hide it and pretend it doesn’t exist.”
Overall, Michigan ranked 11th nationwide in 2017 for opioid-related death rates, according to the Centers for Disease Control and Prevention. Between 2013 and 2017, Michigan saw about 7,000 opioid-related deaths. In 2017, the number of deaths had more than doubled compared to 2012. Most deaths occur among men between the ages of 26 to 35 and 46 to 55, according to state data.
A medical examiner report for 11 West Michigan counties from Leelanau to St. Joseph shows 193 opioid-related deaths in 2017. In Calhoun County that year, people who died ranged in age from 23 to 72.
Kent County saw 156 opioid-related deaths in 2017, up from 93 the year before. From 2013-2015, Grand Rapids had among the lowest death rates among major cities in the Lower Peninsula, while Southeast Michigan had some of the highest overdose death rates.
“We certainly face a severe crisis in Michigan, but we’re not among the top states in the nation,” said Andrea Taverna, senior adviser for opioids strategy at the Michigan Department of Health and Human Services (DHHS).
While Michigan’s prescription rates have declined in recent years, overdose deaths haven’t. This backs the data suggesting users will turn to illicit opioids if their access to prescriptions becomes restricted.
Robert Sheehan, executive director of the Community Mental Health Association of Michigan, said newer research links depression — both emotional and economic — and opioid use.
“States with the highest per capita death rates from opioids are those that are either Rust Belt states or former coal mining states,” he said. “In the social determinants of health, this is a clear one.”
Fighting stigma, increasing access
The stigma around opioids is twofold, focused on both the addiction itself and the treatment many health professionals agree is most effective. Medication-assisted treatment — or using opioids like methadone or suboxone on a schedule — is widely proven to limit acute withdrawal symptoms. Meanwhile, access to clean syringes is a proven method in not only decreasing the spread of diseases, but also in leading users to seek treatment.
“These programs have said this for 20 years, but it’s still framed as being controversial,” Alsum said. “We need to be moving forward with more innovative programming.”
Access to programming like medication-assisted treatment is even more limited in rural areas, whose residents are shown to be more susceptible to the opioid epidemic. In 2018, a Centers for Disease Control and Prevention study listed 11 Michigan counties among the top 220 most vulnerable in the U.S. to significant increases in hepatitis infection or HIV outbreak because of injected drug use. All 11 are in the northern Lower Peninsula.
During the administration of former Gov. Rick Snyder, Michigan ramped up its efforts against the opioid epidemic. In 2015, Snyder created the state’s first opioid task force. Multiple state agencies coordinate efforts, while the state Department of Health and Human Services distributes federal funding.
Taverna said discretionary federal funds for treatment services also have ramped up in recent years, including $16 million in 2017. It’s difficult to track how much the state spends annually to address the opioid crisis as it comes in at varying cycles, although Michigan has $50 million this year in federal discretionary funding to support treatment and harm reduction.
Recommendations to DHHS from a Snyder-era commission have been completed or are in progress, Taverna said. Snyder created the Prescription Drug and Opioid Abuse Commission in 2016 to “expand” the state’s efforts and “keep the momentum going,” she said. The efforts have continued to ramp up under the Whitmer administration.
The past two years have seen significant policy changes, notably updating and mandating the use of the Michigan Automated Prescription System (MAPS) in 2017, which tracks prescriptions issued to patients. The state also has pushed for more Naloxone in communities, ordering 53,000 kits to be distributed for free. Under a standing order by the state allowing it to be accessed at a pharmacy, about 13,500 Naloxone prescriptions have been filled.
The Community Mental Health Association of Michigan helps distribute a variety of state and federal funding to its member organizations across the state. Funding goes toward training, counseling and administering medication-assisted treatment. Federal block grants and Medicaid are the biggest sources of funding to the state for programs and services, said Sheehan of the Community Mental Health Association of Michigan.
The Healthy Michigan program created under the Medicaid expansion of 2014 is widely credited for expanding the availability of opioid treatment to more residents. For many years, Medicaid has funded substance use treatment.
“Increasing the population of individuals who have access to that insurance is really one of the biggest things we can do to ensure adequate treatment,” Taverna said.
In 2018, Michigan spent $145 million on total substance use treatment through Medicaid and Healthy Michigan, Taverna said. More than half of that was specifically for opioids.
“I’ve been impressed with the state’s stable and sustainable approach to this,” Sheehan said.
The barriers experts see going forward include sustained funding and access to quality treatment that combines medication with cognitive behavioral therapy. Simply stopping prescription patterns of high doses and a large number of pills will not make the crisis go away because people will still seek opioids, experts said.
“What we really need are more community-based organizations around the state with open, judgment-free relationships with folks who are actively using,” Red Project’s Alsum said.
The state, meanwhile, is making a concerted push to promote Naloxone. In the 2020-2021 fiscal year, a public campaign led by DHHS will focus on reducing the stigma that has isolated people struggling with addiction and limited health systems’ use of proven effective treatments.
“We’re hoping to really push for as broad of access as possible (to Naloxone), understanding there are stigma and other factors we’re combatting here,” Taverna said. “I think we’re working against a cultural understanding of addiction that really dates back for decades. Many still see addiction as a moral failing rather than a health care condition. It’s hard to change public opinion, especially long-standing public opinion. It’s why we’re seeing a bit of a disconnect from the people who work on this day in and day out and the broader public.”