Rio Arriba County in northern NM led the nation in heroin overdose deaths for two decades while its sister county, McKinley, struggled with alarming rates of alcoholism. Both counties developed unique responses to the non-infectious epidemics ravaging their residents.
Then, the novel coronavirus roared into the mix, disrupting treatment protocols and producing unintended consequences.
The epidemic of substance use disorders caused by prescription drugs appeared first in Rio Arriba County, New Mexico in the late 1990s and then rippled across America, as evidenced by this series of New York Times maps. (Rio Arriba is the lone red county in the first map). During the height of the “War on Drugs” (which might have been more aptly dubbed “the War on People of Color in America”), residents of Rio Arriba held a series of dramatic marches, demanding treatment for substance use disorder and an end to the jailing of its victims. We established a residential treatment center, the only strategy known to us at that time (early 2000s). Since then we have developed a treatment system that connects providers and includes every component of care.
In McKinley County, residents walked en masse hundreds of miles from Gallup to the state legislature in Santa Fe to demand treatment for the alcoholism that was ravaging their community. They established a residential treatment center, and also a detox facility where police could bring homeless inebriated individuals instead of jailing them or leaving them to die of hypothermia on the streets in the frigid winter blizzards that rage across northern New Mexico.
Both counties sought to end the inhumane and counterproductive practice of jailing individuals for an illness that deserves treatment.
In the past year, New Mexico has experienced a 27% increase in homelessness, the highest in the nation. This stems in part from false accusations of Medicaid fraud made by the previous Governor, Susana Martinez in 2013, resulting in the closure of most of the state’s large behavioral health providers, a reprise of Reagan’s closure of psychiatric hospitals in the 1980s.
Anecdotally, in Rio Arriba, the increase appears also to coincide with efforts to divert non-violent individuals suffering from substance abuse out of correctional facilities and into treatment. An increase in transitional living facilities has not accompanied the 30% decrease in jail census that has resulted from aggressive diversion efforts. Rio Arriba severely lacks affordable rental units, or indeed, rental units of any sort. Other New Mexico counties are also working to divert individuals suffering from substance use disorders into treatment, resulting in a statewide decrease in inmate populations. It is very likely that the spike in homelessness is an unintended consequence.
The problem has been exacerbated by COVID-19 in multiple ways. Initially, testing for the virus was extremely scarce to non-existent, causing loocal residential treatment centers to close their doors to new patients in an effort to keep from introducing infectious illness to the facilities as we struggled to develop new intake protocols to protect staff and residents. Many clinics stopped taking on new suboxone patients and limited face-to-face contact.
Coincidentally, at the onset of the epidemic, responding to an increase in burglaries and complaints from the community, the New Mexico State Police conducted a sweep, driving Rio Arriba County’s jail census from about 80 to 140, interrupting the treatment of those who were newly incarcerated. Alarmed by the danger posed by SARS-CoV-2 in overcrowded congregate settings, the county and judges worked to rapidly release non-violent inmates, causing an increase in homeless individuals in Española, the County’s population center. At the same time, the new shelter, still under construction, was deemed unsafe due to the potential for spread of infectious disease. It closed its doors, providing meals and distributing pup tents to the homeless population, an excellent stopgap measure during the warm spring and hot summer, but untenable in November when SARS-CoV-2 is expected to return, along with the latest influenza virus.
My agency, the Rio Arriba Health and Human Services Department, which provides intensive case management services for individuals with substance use disorders, was no longer able to secure treatment for clients. Without adequate cleaning supplies and protective gear, we also could not transport clients to appointments deemed not medically essential. In December, for the first time in decades, we had seen a dramatic decrease in overdoses and overdose deaths in our local emergency room. With the disruption to treatment in March, the sudden inability to transport clients safely, and a suspected increase in homelessness, we temporarily switched our focus from treatment to harm reduction, aggressively distributing Naloxone to prevent overdose death, and reaching out to clients by phone to help them avoid risk.
Unlike Rio Arriba, which was thwarted for years by NIMBYism in its efforts to start a shelter, residents of Gallup were successfully able to establish a detox facility. Like the Pathways Shelter in Rio Arriba, it takes in clients for the night, and most leave the next day. Unfortunately, with the ferocity of spread of the novel coronavirus among the Navajo Nation adjacent to Gallup, the detox may have acted as an unwitting accelerant. Gallup is currently experiencing one of the most virulent outbreaks in the nation.
Nor is Rio Arriba out of the woods. After remaining relatively stable with 14 confirmed cases of COVID-19, we suddenly experienced 8 cases in two days, a 57% increase. Congregant settings such as residential treatment centers and jails remain a concern. Rio Arriba County Health and Human Services is working to develop telehealth capacity as one potential solution, but this still does not safely house our homeless population in a non-congregant setting.
Rampant homelessness was the inevitable result of the closure, in the 1980s, of psychiatric hospitals. America has never come to grips with the homeless population we created. It is very clear that we need to find a solution that does not involve bringing people into a tightly packed facility for a night. Safe transitional living in individual domiciles is desperately needed for those we have diverted from jail into treatment.
It’s time to send the 80s back to the previous century.