How to find its high-risk drug users before it’s too late

Rio Arriba’s health care providers are pulling together to treat patients and prevent overdoses.


A 46-year-old man, found dead on his bed in 2010 shortly after leaving jail, killed by combining hydrocodone and alcohol.

A 21-year-old woman, released the previous day from rehab, found dead in a bathtub in 2010, a cocktail of cocaine and morphine in her bloodstream.

A 27-year-old man, dead in the back of a friend’s Jeep a day after being released from jail in 2015, fresh tracks on his arm.

A disturbing pattern lurks in coroners’ reports in rural Rio Arriba County, New Mexico, where the rate of accidental drug overdose outpaces rates in even the country’s toughest urban areas. Many overdose victims here share a glaring commonality: a recent release from jail or rehab, where levels of substance abuse drop and the body’s tolerance for drugs weakens. As a result of this diminished resilience, the first big use on the “outside” can be fatal. National studies suggest the first two weeks out of prison are critical: recently released inmates are three to eight times more likely to fatally overdose during those two weeks than at any other time in their first three months of freedom.

But for Lauren Reichelt, the head of the department of health and human services in Rio Arriba County, that is one data point that doesn’t have to be true. Reichelt’s hope: that a new care program will improve the county’s patchwork treatment system and help Rio Arriba identify high-risk drug users before they become the next fatality.

A new five-year, $2.5 million state grant is funding a multi-faceted approach to preventing overdose deaths in Rio Arriba County. Among other things, the grant will pay to boost substance abuse treatment for drug users as they come out of jail; put dozens of doses of an anti-overdose drug called Narcan into the hands of law enforcement; and give Narcan to high-risk inmates before they leave jail. 

But the crux of the enterprise is information sharing among county health care providers, law enforcement and substance abuse treatment centers. Under the program, called the Pathways Community HUB Model, around a dozen local agencies will share a single release form and computer database, allowing case workers and community health providers to communicate about clients’ medical and substance abuse treatment histories, criminal backgrounds and follow-up appointment details. The coordination is expected to eliminate duplications of services – important savings for a cash-strapped provider network – and to more closely track outcomes, like who is sober and in stable housing a year after treatment. 

Watch New Mexico PBS' special report on the Pathways program: 

Instead of being paid for the service they provide, providers in this collaboration will be paid based on whether they meet certain health goals. The program will grow over the next year, until it becomes fully operational in July 2017.

Although this version of the model is new, the idea has precedent in Rio Arriba County. The county tried a smaller version of this outcome-tracking strategy in 2008, targeting women who were at high risk of drinking or using illicit drugs during pregnancy, which can, among other things, contribute to a baby being born underweight. In the first year, 14 of the 15 participating mothers gave birth to babies at a healthy birth weight.

Other communities that have tested the Pathways model have shown big gains. Michigan’s Muskegon County used the program to connect 2,500 prisoners to medical care, contributing to a 50 percent drop in recidivism rates, according to the federal Agency for Healthcare Research and Quality. Trained community health workers helped prisoners obtain medical records, find a primary care provider and secure prescriptions before their release. Recidivism rates for 2-year parolees fell from 46 percent in 2007, when the program began, to 22 percent in 2012.

In California, a similar model in 2006 helped dramatically reduce Emergency Room visits among low-income families. There, after enrolling families in Medicaid, following up annually to make sure they renewed insurance, and connecting new parents with a nearby primary care doctor, only one in 10 children who had previously been heavy ER users – visiting the ER two or more times per year – continued to be heavy users after the intervention.

Rio Arriba County is one of about 20 communities nationwide using the Pathways model, said Sarah Redding, cofounder of the model and of the Pathways Community HUB Institute.

Despite these success stories, obstacles to collaborative care abound. One researcher who studied the Pathways Model warned that communities can run into problems at the implementation phase, thwarted by the massive amount of coordination required to make it work.

And at least one local provider is skeptical of the approach. Inside Out Recovery, a peer-run wellness center in Española, declined to participate in the network, saying the money will benefit providers more than the addicts themselves.

“Addicts don’t want to be tracked,” said Kathy Sutherland-Bruaw, director at Inside Out. “They want to be treated. We wanted to see this $500,000 (per year) go to services.”

She criticized the county for not putting the money into resources that would directly serve addicts – an expansion to local treatment centers, for example, or more detox beds close to town. Due to a lack of funding, she said, her own agency is cutting back its operational hours from five days a week to four.

Reichelt said even if available services could meet the need, the lack of coordination between service agencies would continue to cause problems. She hopes to secure Medicaid funding for the Pathways program by the time the five-year grant runs out.

For providers like Hoy Recovery Center in Velarde, a few miles outside Española, the Pathways program could provide much-needed support. Hoy can serve up to about 50 people at a time, and now saves eight beds for mild to moderate detox cases, according to Ambrose Baros, its executive director. The initiative is a chance to take a hard look at what services exist, Baros said, and how to make the most of them.

Attempts to track outcomes and follow up with clients who leave Hoy and disperse across the state have been ineffective until now, Baros said.

“Pathways could be the answer that bridges that,” he said. “It could help us find (those clients), and do our best to engage them.”

This story is part of the "Small towns, big change" project through the Solutions Journalism Network.

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