Did APT Help?

A woman arrested for shoplifting told the cops she travels to New Haven from Waterbury each day to get methadone. And she feels she’s not getting the help she needs to wean herself off it.

Her story sounded familiar.

So a top cop, with the woman’s permission, began recording what she had to say.

“When I signed up for the clinic,” the woman told him, ​“I thought that it would be more than just getting your methadone and leaving.”

The conversation took place last week. Assistant Police Chief Otoniel Reyes had arrived at the Yale Bookstore on Broadway to help with the arrest of two people, a man and a woman, on shoplifting charges. Reyes struck up a conversation with the woman. He found her story interesting for several reasons. He used to work as a substance abuse counselor before becoming a cop. Now, as assistant chief overseeing patrol, he’s tackling the increase of people, many from out of town, using drugs and often overdosing on the Green. In that quest, he has found himself frustrated by the policies of the clinic the woman attends, run by the APT Foundation.

With the woman’s permission, and a promise to keep her identity private, Reyes shared the audio recording of their discussion in the interest of highlighting those concerns. He said her story matched those of many out-of-town substance abusers his officers encounter in and around the Green.

And he felt it gets to the heart of New Haven’s current debate over how best to address a drug crisis that has exploded into public view.

“It was alarming,” Reyes said of the discussion. He argued that it points out how APT’s unique policies — allowing clients to obtain methadone even if they test positive for using some other drugs — have made the city a magnet for people struggling with addiction from all over the state, without necessarily helping them get better. Other public officials, including Mayor Toni Harp, have raised similar concerns about APT as the drug crisis has spawned a public safety and health crisis on the New Haven Green. (Click here and here to read about some of that debate.)

Asked about the episode, APT CEO Lynn Madden expressed regret for the story about the woman’s experiences, but defended APT’s overall policies, which differ from those of other clinics and which she said the public often misunderstands.

“Think You’re Ready?”

The arrest at the Yale Bookstore occurred Aug. 30. In the beginning of the recording Reyes states that the woman wanted to ​“go on record to talk about some of the issues we’re dealing with here in New Haven from her perspective. We want her voice to be heard. She’s someone that wants to get help. She’s someone that’s trying to fight her addiction.”

A transcript of the subsequent conversation follows. (Click on the above audio file to listen to it.)

Asst. Chief Reyes: Where are you from?

Arrestee: Waterbury.

Why are you here in New Haven today?

I come to New Haven to go to the APT Foundation

How often do you come?

Monday through Saturday?

Can’t you get services in Waterbury? Why don’t you go to Waterbury?

Initially, I did go to Waterbury. But Waterbury is stricter in terms of their tox screens. If you’re positive for anything outside methadone, they detox you. You’re no longer able to [get methadone]. Whereas APT doesn’t.

They do use screens. But regardless of what you’re positive for, they really barely have a conversation with you. ​“You’re positive? OK. Bye, bye.” You can still get doses. No kind of disciplinary …

Or restrictions?

Or restrictions.

I imagine that if you’re coming here, you feel like you’re getting adequate help from the APT Foundation here in New Haven?

No, I don’t feel that way. In fact, I am not getting adequate help. As a result of that, I made appointments with a psychiatrist and a doctor. You’re not even assigned a counselor at APT Foundation. You used to be assigned a counselor for each client. Now if you go in, and for some reason you have to meet with a counselor, you just kind of wait for whoever is available. There’s no one-on-one sessions.

So when was the last time that you spoke with someone to talk about the progress of your addiction and how you’re doing?

I initiated a conversation last week to let them know I was making an appointment outside of APT Foundation because I wasn’t getting the services I needed there.

How long have you been coming here to New Haven to get services from the APT Foundation?

Oh, for a long time. I signed back up in November. Prior to that, I was on a year, then off. On for a year, then off…

Has that helped you in your addiction?

I think it has, because I’m not using heroin anymore. I’m not on the streets having to buy heroin and be in that situation. So in that regard, yes.

But when I signed up for the clinic I thought that it would be more than just getting your methadone and leaving.

Are you using any other substances now?

Right now? No. I feel I need to be on something for, like, anxiety.

They’re not providing you that?

No.

They’re not providing you any counseling, any case management, to see what your progress is, to help you wean off that particular drug …?

If you try to wean off a drug, let’s say you want to detox, they try to convince you not to.

What do you mean?

Like, let’s say I go in and say, ​“I’d like to start detoxing.” They will say, ​“Do you think you’re ready? Have you been on it long enough?”

How long have you been on it?

Since November.

But they’re really not monitoring you in any way to determine if you’re ready for it?

Yeah.

What happened here today? Why did you come into contact with us?

The person I was with was stealing out of the Yale Bookstore. I separated from him.

Where is he from?

I think he’s from New Haven. I’m not sure.

Do you know if he goes to the APT Foundation?

I don’t think he’s on methadone. I happened to run into him on the Green. He knows my husband …

Well thank you. I appreciate your candor and your receptiveness. I wish you well with your addiction.

Thank you.

Hopefully you get on the path and you get the services you need.

I’m trying to.

How Best To Help?

The arrested woman, who was born in 1974, was charged with sixth-degree larceny, a misdemeanor. Her arraignment is scheduled for Friday. She also faces larceny and failure to appear charges in pending cases in Waterbury, according to the state judicial website.

“We have heard this time and time again from our officers who come into contact with these individuals every single day and are told the same thing,” Reyes said in a subsequent interview about the conversation and why he wants New Haveners to hear it.

Reyes said the police have been working with others in government and with community organizations on a plan to respond to the disorder on the Green — with daily overdoses involving the use of both opiates and, in the case of more than 100 over a couple of days last month, a synthetic cannabinoid called K2. With an increased police presence, Reyes hopes his cops can arrest more dealers who ​“prey on these people.”

But he doesn’t want to focus on arresting the users themselves, he said. Rather he wants, with service providers, to identify who they are and what problems have sent them to the streets, then steer them to help.

“We don’t want to criminalize homelessness,” Reyes said. ​“We don’t want to criminalize drug addiction.”

To succeed, the effort needs community organizations to help solve rather than worsen the problem, he said. He questioned whether — as in cases like that of the arrested shoplifter — APT Foundation is keeping people on methadone longer than they need to be, attracting a regional crowd to the city that becomes a prime market for dealers, and even standing in the way of self-sufficiency.

“You have individuals like this individual that is in a certain place in her sobriety where she feels she would benefit more form psychotherapy, which is the cause of her problem, and wants to wean off the drugs,” Reyes said. ​“We have an epidemic right now in New Haven. They are contributing to this epidemic.”

Behavioral Health

APT CEO Madden responded that APT does have counselors onsite to help clients. But like other agencies, it doesn’t have money for all the psychiatrists it needs. So sometimes that means waiting for an appointment with the first available person. She added that some clinics don’t have any psychiatrists at all. APT also runs group psychotherapy sessions.

Mayor Toni Harp argued that counseling should be available immediately, especially for methadone users whose urine tests positive for other drugs. She cited the interview with the accused shoplifter, to which she has listened, as an example.

“The arrestee basically was saying, ​‘I’m depressed. I need something else.’ That’s why she was saying she is taking those other drugs,” Harp argued during her latest appearance on WNHH FM’s ​“Mayor Monday” program. ​“People become addicted because they’re trying to self-medicate around behavioral issues they have. If all you’re doing is giving them methadone, you’re not addressing the underlying problems. It could be depression. It could be anxiety. It seems that where you go to get your methadone should be the place” to get that help.

Cornell Scott Hill Health Center immediately assigns a counselor to new clients to whom it distributes methadone at a clinic it runs at the South Central Rehabilitation Center (SCRC) on Cedar Street.

The idea is to focus on the root psychological as well as the physical challenges the clients face. Doctors consider that as an essential part of drug treatment. They emphasize the importance of having each patient assigned a licensed therapist, who can build a therapeutic rapport and employ evidence-based practices like motivational interviewing and cognitive behavioral therapy.

“You can’t just give somebody medication and expect them to get clean and sober. A lot of other things need to be addressed,” said Ben Metcalf, who directs SCRC.

In surveys, APT clients have generally reported being pleased with the care they get, APT’s Madden said. She said APT, like clinics such as SCRC, also monitors patients’ use of other drugs to determine how best to help them get better.

“I’m sorry if she’s not having a positive experience,” Madden said of the interviewed woman. ​“It sounds like if she’s come out of treatment more than one time. It sounds like somethings she’s committed to.” She urged the woman to ​“make her concerns known and we will try to address” them.

Encourage Or Discourage Weaning?

APT does often assess whether people are ready to stop receiving methadone treatment, Madden said. Sometimes a client might be motivated by the difficulty of traveling from, say, Waterbury every day to get doses, which may not be the best reason to stop.

Madden cautioned against ​“hasty” decisions.

“We are reluctant sometimes to discharge someone from treatment for opioid treatment disorder if that treatment is working,” she said. ​“Opioid disorders are life-threatening. … When a person requests to taper, we talk with them about what we understand best practice to be. How long one should stay on a medication. How the length of time on a medication affects your long-term wellness.” She said that peer-reviewed literature on the subject concludes that staying on methadone a minimum of three to five years ​“is a predictor of longer-term abstention from misuse.”

Harp agreed that many methadone clients benefit from remaining on the drug for years. ​“That’s fine if that works for them,” Harp said. ​“I know it doesn’t work for the people that hang out on the Green and the people that have dirty urines. I think they ought to have different practice models for them.”

“The idea that you have to be on methadone the rest of your life may seem depressing, but lifelong treatment is not necessary in all cases,” said Ece Tek, chief of behavioral health at Hill Health and assistant clinical professor at Yale.

Tek and SCRC’s Metcalf went on to state that each patient’s needs have to be individualized, and depending on the patients circumstances the length of time in treatment can vary. The overall goal is to prevent relapse, overdose, and death while simultaneously promoting recovery and wellness.

She and Metcalf agreed that in some cases patients need to take methadone for many years, especially if they have already struggled with addiction for that long. Young people in particular may be able to cross the ​“bridge” from methadone to suboxone and recovery, Metcalf said. If a client expresses a desire to move from methadone to more counseling, that would fit into what Tek called Hill Health’s behaviorally focused ​“holistic approach.”

“Benzos” & The Dirty Urine Dilemma

One big difference between APT and other methadone clinics, and the main reason people fighting addiction come to New Haven from throughout the state: They report that APT is far more likely to distribute methadone to clients whose urine tests positive for use of other drugs.

Madden defended the decision to administer methadone to some clients who test positive for other drugs. Methadone works specifically on opiates. And opiates like fentanyl can kill. So methadone can keep a user alive, even as that user is battling with other substances, she noted.

“We really try to make sure that people live to make decisions another day,” APT’s Madden said.

“This is really that urgent.”

APT and Madden have been pioneers in pursuing a ​“open access” model that seeks to reach more people who may be kicked out of other programs with counterproductive strict rules. This recent article in a Yale publication notes how the ​“open access” model helped APT’s patient census grow 183 percent, from 1,431 to 4,051, in nine years. Madden reported in a research paper that the model helped APT increase its operating margin from 2 to 10 percent at a time when it lost 14 percent of its government block-grant funding.

At Hill Health, clinicians seek to avoid distributing methadone to clients whose urine tests positive for other drugs, especially benzodiazepines, or ​“benzos.” The term refers to medications like Xanax, Klonopin, Ativan, and Valium.

For starters, people sometimes accidentally overdose and stop breathing if they have both methadone and benzodiazepine in their system, Tek said. ​“They may die in their sleep.”

If SCRC discovers that a patient has been on benzos while receiving methadone, Metcalf said, it will work with them for a ​“short period of time, while they taper off of that medication. Any patient being prescribed benzodiazepines has to sign a release of information, and allow for SCRC staff to communicate with their prescribers. All methadone patients are monitored by SCRC staff using the Prescription Monitoring Program website. Patient’s prescriptions for controlled substances are recorded there per state law. Any individual patient who is found to be pursuing benzodiazepines from other providers and purposefully not reporting it must discontinue this practice in order to remain in good standing with the treatment program.

Metcalf said the policy has succeeded in reducing multiple-substance abuse and improved patients’ outcomes.

Metcalf and Tek made a point of not criticizing APT for the widespread misuse of benzos. Rather, they said, the fault largely lies in overprescription of benzos by practitioners in the community.

They said they make a point of reaching out to prescribers to tackle the problem. Often, prescribers just don’t have the information about their clients because prescriptions of methadone, unlike that of other drugs, are not included on the shared prescription monitoring website. The intent of keeping that information secret is to de-stigmatize methadone use. But it has the unintended consequence of failing to inform some prescribers that patients are using multiple drugs that can conflict your recovery.

“That’s actually the crux of a lot of what’s going on,” Metcalf said.

“This is a giant public health issue,” APT’s Madden remarked. ​“Citizens and community members wishing it would not be as big an issue as it is — that doesn’t help things very much. We’re going to continue to do our part in terms of providing good information, providing treatment, and really optimizing care.”

Reyes called APT’s arguments ​“convenient.” He questioned whether ​“monetary gain” influences decisions more than ​“the individual progress of their clients.”

“I know they get paid every time they dose,” Harp added. ​“If they’re saying that they can show that the amount that they get paid per dose per visit is not adequate for there to be case management, they should be going to the legislature asking to get an added payment for behavioral health intervention. During the years I was in the legislature, I don’t remember them ever coming to ask for that.”

Madden said APT does regularly ask DMHAS for more funding.

The state monitors methadone clinics to ensure they follow these federal regulations. If they do, then they are free to pursue different policies based on what they consider the most effective approach. Mary Mason, a spokeswoman for the Department of Mental Health and Addiction, compared the process to the way doctors treat cancer. Some will advise chemotherapy or radiation more readily than other doctors will, for instance. As long as they follow the rules, as with clinics that distribute methadone, it’s up to members of the public to decide which approach makes sense for them.

Click on the video to watch the full episode of ​“Mayor Monday” on WNHH FM. 

This episode of ​“Mayor Monday” was made possible with the support of Gateway Community College and Berchem Moses P.C.