Silos in substance use disorder service providers create frustration among experts; call for creation of substance use disorder continuum of care

April 10, 2024

On Thursday, April 4, a group of substance use disorder service providers convened by Commissioner Sharon Meieran presented to the Multnomah County Board of Commissioners on the need to create a continuum of services for substance use disorder.

“As county commissioners, we are the Local Mental Health Authority and we have a role ensuring a full continuum of care exists for substance use disorder and for mental health, collectively behavioral health, and whether or not we’re the actual entity providing the specific services,” said Commissioner Meieran.

Commissioner Sharon Meieran

“Currently we don’t have a continuum of care. Not having a system has resulted in our behavioral health crisis, that preexisted COVID-19, but was absolutely exacerbated and compounded by COVID-19, the fentanyl crisis, homelessness and a whole array of stressors. Things are really challenging right now and so the time is right.” 

With Multnomah County and the Board focused on addressing the dual behavioral health and substance use disorder crises, the commissioner convened 15 leaders and experts in the field as a first step toward filling the gap. Over the course of three meetings, the group reached a consensus on a framework for a basic substance use disorder continuum of care and identified where major investments should be prioritized to have the biggest impact in the short term.

Commissioner Meieran observed that leaders representing an array of local substance use disorder service providers — who often feel like they are in competition with each other for limited funding or don’t necessarily share the same viewpoints — were able to agree on so much. 

“What struck me was the community’s spirit and true desire to build a system,” said Commissioner Meieran. “There was not an official facilitator but the message was clear: We don’t need to spend more time and energy on consultants studying the problem. We need to listen to what the people doing the work in the real world have been telling us for decades. And we need to act on it and we can.”

A group of substance use disorder service providers presents to the Board

Mental Health and Addiction Association of Oregon Executive Director Janie Gullickson spoke of a glimmer of hope that in the last several months, she is starting to see people coming together to work to solve the substance use disorder crisis in a way she has never seen before.

She shared that since she is embedded in this field, friends and family often call her asking for help, and too often she does not know who to call or how to get them into detoxification services or treatment within 24 hours.

“Yesterday, I can say it happened for the first time in 10 years in this work where a friend called me to get their child into care, and we got them into care,” she said. “That was not me. That was because there is communication and coordination like I have not seen before in this system.

“Everyone in this room can agree that recovery is possible. But how do we make it probable and increase the probability and make it accessible for folks? I believe that about the system, too — recovery is possible for that. We recover in community and so the system is going to recover in community as well.”

Commissioner Meieran explained the system of substance use disorder care as it currently exists is set up so a person in recovery goes from program to program, and that those programs do not necessarily connect. “We need to change that to a person-based system where we are always focusing on the person who we are serving who is moving through this process.”

Oregon Change Clinic Founder and CEO Shannon Jones spoke to the need to have consistent language when talking about recovery and housing.

“Sometimes when you are in the work, you’re not necessarily thinking about how people are needing to get access to other services,” she said. “As we work to understand the continuum itself, we must have the same language and know how to access different services for people.”

Jones also called out the need to support funding for culturally specific services — a high-priority area that is sometimes missed when looking to where people can access services.

Devarshi Bajpai, CEO of Fora Health and a former senior manager in the County’s Behavioral Health Division, explained that the system will not properly function without creating adequate housing resources for people to enter once they exit detox or withdrawal management services.

“We shouldn’t be shortsighted and create a model where we’re creating services that get people in the front door but there’s nothing behind it,” said Bajpai. “When you go down the street at Universal Studios, there’s those streets that look like a residential neighborhood. But that’s just the front of the house, there’s nothing behind it. We don’t want to create that. If we look at only getting people in that front door, that’s what we’re going to have. We’re going to be shoving people in through a front door where there’s nothing behind it. We need to think about the entire house when we’re creating our system.”

CityTeam Executive Director Lance Orton shared that the reason his recovery from heroin was successful was that when he was ready to enter recovery, the system was ready to take him that day. “If they (CityTeam’s residential program) hadn’t grabbed me in that first three-day period, I would have been back out on the streets.”

Orton explained that although CityTeam has been in Portland for 24 years, they still operate in a silo.

“We need more beds and we need to be able to communicate with other providers out there, and vice versa, so we can attack this problem in a way that is holistic and efficient, and it grabs the person when they need to be grabbed,” said Orton. “We can come up with this centralized brain where we are all communicating and sharing our resources.”

Central City Concern’s Vice President and Chief Strategy Officer Sean Hubert noted the system’s housing response capabilities and substance use disorder services are not robust or formalized enough to fully leverage each other.

“There are front doors and key care delivery points like sobering, withdrawal management, outpatient and residential treatment,” he said. “Those front doors need back doors: Those are things like recovery-oriented shelters and shelter alternatives, transitional supportive recovery housing, intensive co-occurring transitional housing, as well as permanent (housing).”

Hubert explained that to solve the crisis of untreated substance use disorder, an established and sufficiently resourced care coordination system must be connected to the County’s Homelessness Response System. Having a safe place to live waiting for a person who completes treatment can greatly improve their chances of staying in recovery.

“Every time we discharge someone back to the street, we know most likely 90% of the time we'll have to re-admit that person back into a bed,” he said.

Key findings and recommendations for urgent actions, as well as a full list of participants, can be found in this report.

Board comment

Commissioner Julia Brim-Edwards drew a parallel between how difficult it is for someone experiencing homelessness to find an open shelter bed to how difficult it is for someone with a substance use disorder to find a detoxification bed.

“Why don't those systems exist?” asked Commissioner Brim-Edwards “Is it that we had smaller problems and we had a lot of organizations doing good work on those smaller-scale problems, and now we just have an overwhelming issue with record number of homelessness and fentanyl?”

Hubert responded that historically there have been good people trying to do good work, but within silos.

“The opportunity now is to bring some of those together in a joint function that is looking to reduce street homelessness, improve our behavioral health system of care outcomes, and carve out some overall population health goals that touch all those systems and people at the center of the work,” he said.

Commissioner Lori Stegmann commented on the fact that although the Legislature has provided a record amount of money to fund behavioral health projects, there needs to be a workforce accompanying the projects.

“Who’s going to come and do these jobs?” she asked. “People that literally make $20, $25 an hour, that have master’s degrees, that have a hundred thousand dollars in debt, that are leaving your industries by the droves?”

Commissioner Stegmann also spoke to the importance of embedding this work into the Health Department so it outlives elected officials.

“Every time you have somebody brand new coming in and learning everything brand new, which is part of the process, there has to be institutional knowledge that’s passed on so we don’t have to reinvent this wheel every four or every eight years” she said.

“This has been a very long-standing problem and it is not because there aren’t amazing people doing amazing work,” said Commissioner Meieran. “It is because there has not been the consolidated leadership putting this together… We are the Local Mental Health Authority and so we have the statutory authority, we have the convening power… We have the opportunity now to do it as this Board and hopefully…we will move this forward at this moment in time.”

Chair Jessica Vega Pederson applauded Commissioner Meieran for bringing the experts together. “We know where we are going. Now it’s how do we get there together.”

Chair Vega Pederson also spoke to how the County is breaking down other silos.

“In the 90-day fentanyl emergency, there has been a lot of discovery of the breaking down of the silos and how people need to be talking and how we can be working together if we had the right data that we were sharing,” she said. “The Homelessness Response System is the same concept of breaking down the silos to really how do we serve the person… to get the system created where we need to be.”