Since October 2018, New Hampshire’s governor and Executive Council have approved contracts for more than $64.5 million in federal money to create the Doorway system of referral and treatment for opioid addiction.

The state was awarded $45.6 million for 2019 and 2020 in State Opioid Response funding from the federal Substance Abuse and Mental Health Services Administration, and almost $12 million in additional funding for year one.

Another $6.9 million for the Doorway came from federal sources not linked to the opioid response grant, as the state continues to struggle with one of the highest per-capita rates of opioid addiction and fatal overdoses nationwide.

HUBS Pie Chart_Final

In its final installment of a year-long examination of the project, the Granite State News Collaborative set out to determine where that money has gone and what it has accomplished. A year into the two-year program, reviews are mixed.

There is widespread agreement that the investment has created a group of regional portals for those seeking treatment, but has done little to expand the availability of the treatment itself, particularly in the northern part of the state, and particularly in regard to residential treatment.

Meanwhile, city officials in Manchester have criticized Gov. Chris Sununu and the Doorway for failing to significantly expand treatment services, which they say made the city, where such services exist, a “dumping ground” for other hubs. Mayor Joyce Craig has expressed concern — echoed by the city’s Board of Aldermen — that without a meaningful evaluation of how the opioid response grant was leveraged in 2019, year two will end without a significant return on the federal government’s $64.5 million dollar investment.

In Cheshire County, the Doorway is run through Cheshire Medical Center and located on Route 101 in Keene — but will soon to move to the city's downtown and share space with Monadnock Family Services' behavioral health emergency and substance-use services.

The Doorways in Manchester and Nashua are run by Granite Pathways, an organization that recently had its state contract to operate a residential youth treatment center revoked, while its Doorway contracts are under review, according to the state Department of Health and Human Services.

That’s not to say the effort has not had some impact. Narcan is more readily available throughout the state, as is medication assisted therapy (MAT).

But overdose emergency calls remain at historically high levels, and the state is not likely to see a significant reduction in opioid-related deaths at the end of 2019 compared to 2018, when 471 people died of drug overdoses (down from 490 the year before).

The Office of Chief Medical Examiner puts the death total from drugs for 2019 at 240 as of the middle of October, mostly from opiates, with 72 cases “pending toxicology reports.” They almost always come back positive, which puts the more likely number at 312, with half of October and all of November and December still to be accounted for.

“Of course we have a very long way to go. We are only 10 months into a new infrastructure system,” said Sununu in a telephone interview. “I don’t think we are going to see the number (of fatalities) lower by that much. One thing I’ve learned is the majority of pending toxicology reports will be positive. We’re making progress, but don’t expect us to cut our number in half.”

The deaths that have been averted since the launch of the Doorway are largely attributed to one of its most successful outcomes — the widespread availability of the overdose reversal drug Narcan.

The funding directed to the hubs includes money for Narcan administration. “The state used to distribute Narcan directly, but now with hub and spoke, the hubs are responsible for distribution to all area partners, and that Narcan is at no cost,” said Jarrett Stern, vice president for administration at Littleton Hospital, which operates its hub at a freestanding location off Main Street in Littleton.

Anecdotal evidence has convinced Stern and others that Narcan is only part of the story. “The Doorways have been open for 10 months now,” he said, “and in Littleton, we have 300 people in our program. As far as I’m concerned, that’s 300 people whose risk has gone down significantly. Why the total number of overdoses is still at or approaching levels of the past … I wish I had a better answer.”

In addition to the creation of the hubs and expanded access to Narcan, the increased availability of medication-assisted therapy with drugs like Suboxone is cited as another success story for the Doorway by Health and Human Services Commissioner Jeffrey Meyers.

“We had very few funds before for MAT, other than some small appropriations from the general fund,” he said. “Now there’s tens of millions of dollars paying for MAT. That’s a relief to thousands of individuals.”

New Hampshire was 48 out of the 50 states in terms of MAT providers per capita, with as few as 10 to 12 providers statewide. With the additional funding and a push for more training, the number now has grown to 70, with more in the pipeline.

As our analysis of expenditures reveals, the state has invested heavily in MAT, with more than $5.5 million in contracts approved for MAT administration or training for the two-year period.

Not all hubs are created equal

The largest portion of spending on the Doorway program, almost $24 million, went to standing up the nine hubs.

“It’s like running any clinic,” says Stern. “You have infrastructure, real estate, electric, phone, cable and Internet … just running a space on a day-to-day basis. Then the biggest is staffing: a physician on MAT, licensed drug and alcohol abuse counselors running group therapy, intake and triage, and customer service, clerical, recovery coaches.”

In the Littleton and Androscoggin regions the availability of healthcare providers or counselors to serve as spokes is so limited that the North Country hubs, in addition to Narcan, also offer medication-assisted therapy.

“We’re the hub and the spoke,” said Christine Fortin. “As a hub, we have the assessments and case management support staff the other hubs have, but we also have a therapist here full time, and a MAT provider four days a week.”

The Doorways are all affiliated with local hospitals, except in Nashua and Manchester. The vision for the program was to have hospitals lead the charge in every region, but the two hospitals in Nashua and two in Manchester all declined, without ever saying why.

With four of the largest hospitals unwilling to play a lead role in one of the most ambitious public health initiatives in New Hampshire history, the state turned to Granite Pathways.

The New Hampshire subsidiary of a national federal contracting firm known as Fedcap has been jumping in where others fear to tread on behalf of the Department of Health and Human Services since 2016. That’s when Fedcap took over Granite Pathways, then a faltering peer support organization, as part of an effort to expand its footprint in New England.

In September of that year, the state awarded Granite Pathways a $1.2 million no-bid contract that was needed, according to state officials, to speed up the opening of what were then called regional diagnostic centers “to assist individuals with substance abuse disorder.”

Granite Pathways, operating out of the state’s two population centers, has drawn the largest chunk of Doorway funding directed to a single organization. In addition to its $5 million share of the $16 million initially allocated to the eight hub operators, Granite Pathways later was approved for an additional $90,000 as the “only organization in NH that provides residential treatment for youth diagnosed with opioid use disorder,” and another $1 million for “targeted prevention programming for DCYF involved families.”

More recently, Granite Pathways was approved for a $195,234 contract to provide “workforce readiness and vocational training programs for individuals with opioid use disorder.”

The organization in late November lost its contract to provide residential treatment for youth diagnosed with opioid use disorder, after reports of drug use and overdoses among patients.

“A 30-day review on all contracts the state has with Granite Pathways is underway and additional actions may be necessary based on that review,” according to DHHS spokesperson Jake Leon.

Granite Pathways and Dartmouth-Hitchcock, by far the largest recipients of opioid response funds at more than $6 million each, were the only two hub operators who declined to be interviewed for this report, referring questions to DHHS.

The treatment gap

Patricia Reed, the state director of Granite Pathways, provided a written statement, in which she confirmed many of the observations made by the smaller hub operators.

“Individuals come to the Doorway at their worst and receive initial services in a supportive and non-judgmental environment,” she wrote. “At the same time, implementation of the Doorway system has revealed other system gaps that must be addressed to truly solve this public health crisis.

“As expressed by one Doorway director ‘We do a great job assessing people and figuring out what they need — and then we wait’ largely due to wait lists for residential treatment or safe respite beds.”

According to all hub operators, the wait times for residential treatment, about two weeks or more, have not improved in the year the program has been in operation, despite more than $16 million in contracts for residential treatment.

The Doorway has drawn more people to seek treatment, without a significant increase in certain treatment options.

“If I am going to positively reinforce an individual’s behavior, there has to be something more than the first step,” said Peter Fifield, hub coordinator for the Seacoast region out of Dover. “There has to be the second, third and fourth. The state is open to hearing this and we now have to build more spokes.”

There has been some progress in expanding treatment options, although most of it has taken place in the south and central part of the state. More than $6 million has been poured into recovery services. One example is a $1.4 million contract with Harbor Homes, based in Nashua, to serve pregnant women and parents with young children in recovery.

Harbor Homes was already providing these services in Tilton, Portsmouth and Dover under a previous $515,198 contract, and is using the additional funding to expand to three other locations.

But the demand for services is growing faster than expansion can accommodate.

“There’s been improvement from years past,” said Fifield. “We are making strides forward and are at capacity that could have met historic needs, but not new needs.”

Access times at issue

The Doorway’s promise of 24/7 access to referral and assessment rolled out with an official “Anyone, Anytime can ask for treatment” campaign has been misinterpreted as a promise of ‘round-the-clock access to treatment.

“I don’t think they promised treatment; they promised a place you can go for referral for treatment, and I don’t even know if that’s realistic,” said Keith Howard, executive director of Hope for New Hampshire Recovery, a peer-based recovery and support organization that operates in Manchester and Berlin.

Howard and his team work face-to-face with people in addiction crisis every day, and the feedback they get on the Doorway has been less than encouraging.

“The experience folks have had has not lived up to the hype or the promise,” he said, referring to the Manchester Doorway in particular. “People who are working there have nothing but good intentions, but there are systemic problems in terms of getting folks into treatment right away. There is no place to send them, and if there is, there’s a long waiting period.”

The problem with addiction, says Howard, is that once the crisis forcing someone to seek help has abated, “Most of us in addiction think we really don’t have to quit after all,” amplifying the need for immediate intervention.

Sarah Gagnon, vice president of clinical operations at Riverbend Community Health Center, believes expectations may exceed what is realistically possible when it comes to 24/7 access.

In addition to its $1.5 million share of the $16.6 million hub-setup fund, Dartmouth-Hitchcock got another $2.5 million after it reached an agreement with the other hubs to provide 211 clinical coverage off-hours, on holidays and on weekends.

“Anyone dialing 211 after hours, Dartmouth-Hitchcock will answer. So someone is still able to speak to a clinician at any time,” Gagnon said. “We’ve talked a lot about what it would mean to go 24/7 (at all hubs), but the fact remains, if someone calls or walks into a doorway, even with 24/7 coverage, there are no facilities taking admissions at 2 a.m.”

Marketing campaign

Despite the investment of state and federal resources, and regular reports on the initiative in print, broadcast and digital media, many of those directly or indirectly touched by the addiction crisis claim to be unaware of the Doorway.

The state increased an existing $3.4 million contract with JSI Research & Training by $1.4 million to include restarting the Anyone/Anytime public advertising campaign, which was rebranded as the Doorway once the system was launched. The work on advertising, social media, and more, falls under this contract.

A $200,000 contract was awarded to Portland Webworks (winner of three bids submitted) to develop, design, implement, host and manage a consolidated website for the initiative.

“I think our marketing has been good,” said Gagnon. “We are on the TV news, radio, there are fliers everywhere urging people to call 211.”

While the fire station-based Safe Station programs in Nashua and Manchester continue to serve large numbers of people in addiction crisis, the Doorway has been the go-to option for friends and family, according to Gagnon.

“Word of mouth is definitely a big thing and people are calling to get resources for people they care about. Up to half of our calls are friends and family,” she said.

Whatever marketing has been done has had some effect. In its original SAMHSA grant application, the state predicted the Doorway would serve 5,000 clients per year, a prediction that was surpassed as of Oct. 31, the most recent report on the Doorway website.

The report states that 5,910 individuals were seen in person or assisted by telephone. As of Oct. 31, hubs conducted 2,645 clinical evaluations and provided 4,091 individuals with treatment referrals. In Cheshire County, the Doorway had served 599 people, with 245 completing clinical evaluations — the first step in finding substance-use treatment.

What happens after the treatment referrals is not well-documented, although the Doorway program is required by federal law to report on the status of its clients at intake, six months and discharge — at least for the clients it can keep track of.

Future of funding

As the project moves into the second year, the state will be focused on adding more beds for respite and residential treatment, as well as services to keep individuals who’ve detoxed from sliding back into drug use. Those include transitional housing, ongoing therapy and one of Sununu’s favorites, the recovery-friendly workplace.

The Executive Council approved only $613,096 in contracts for transitional housing in the first year of the program.

Expanding treatment options will require more providers, which has proven to be the highest hurdle. “The biggest barrier we have is workforce,” said Sununu. “It isn’t that we don’t have the money or that it isn’t going to the right places. It’s hiring the people we need.”

Health care providers in the addiction field are hard to come by, and much of their work is paid for through Medicaid. New Hampshire, with some of the lowest Medicaid reimbursement rates in the nation, has been at a disadvantage with neighboring New England states when it comes to recruiting providers from a dwindling pool.

Last year the state increased Medicaid payments for medical detox services and will be increasing Medicaid payment rates across the board by 3.1 percent in fiscal years 2020 and 2021.

“Is that going to solve every gap in every corner of the state? No. But it’s moving in the right direction,” said Meyers. “We’ve added money now three years in a row.”

Meyers will soon leave DHHS and hand the project off to his successor, but he’s confident the state will continue to receive federal funds, given the scope of the crisis in the Granite State and the need to create national models for best practices.

“I don’t think it’s a question of whether we’re going to get more funds,” said Meyers. “I think it’s a question of what we are going to get and how much flexibility we’ll get to use the funds in New Hampshire.”

Next Sunday, we will conclude our two part series with a look at Safe Station and whether it has potential to be a statewide solution. We will also hear from folks in recovery about what it is like to use these systems.

This story was produced by The Granite State News Collaborative, of which The Sentinel is a member, as part of its Granite Solutions reporting project. For more information visit www.collaborativenh.org. Follow us on Twitter @NewsGranite and like us on facebook @collaborativenh.

Editor’s Note:

In January The Granite State News Collaborative — a collective of 17 media and educational organizations from across New Hampshire — launched its Granite Solutions project. The goal was to take a look at the dual challenge of our statewide opioid crisis and its relationship to treatment of mental health issues. Working together as a team we have produced a series of multimedia story packages that do more than explore the problems; our aim is toward solutions. How? By working collaboratively to inform and engage you.

Today we present the final installment off our Granite Solutions project: Follow the Money, in two parts. First, we examine the $64.5 million statewide Doorway system of referral and treatment for opioid addiction. We focus in on how the money’s been spent, what outcomes have been measured, and what’s next as the state considers how it will spend the second year of grant funding. In part 2 we look at Safe Station and whether it has potential to expand into a statewide solution. We will also hear from folks in recovery about what it’s like to use these systems.

While this wraps up the Granite Solutions project, The Collaborative is nowhere near done with its work. Together, we will continue to deliver public-interest journalism and report on New Hampshire’s most seemingly-intractable challenges, with a focus on solutions.

You can view our work on this series at collaborativenh.org and leave us your questions or feedback. Share our stories across your social media circles. Keep the conversation going.