By 2009, evidence of an epidemic in Washington was already widespread. More than 5,400 people had died of opioid overdoses since the beginning of the decade. Another 7,500 had been hospitalized for their addictions, and the phrase “opioid crisis” was beginning to creep into everyday conversation.
But legislators that year were focused on a different crisis. The Great Recession had decimated government budgets, and over the next few sessions lawmakers were forced to trim state funding across the board. Among the more significant cuts: $35 million for addiction treatment and prevention. At the height of the opioid wave, at least four drug-treatment centers closed.
In recent years, the state has reversed that trend, pouring hundreds of millions of new dollars into intervention. Yet the rate of fatal overdoses in Washington has barely budged.
Addiction is a slippery condition, easy to overlook or deny unless a person is in full-blown meltdown. But the growing number of patients hospitalized after drug crises hints at the long-range reverberations of those crucial decisions made 10 years ago.
“We knew prescription opioids were a huge problem, and we knew we were making lots of bad choices,” said state Rep. Eileen Cody, a trained nurse and chair of the House Health Care Committee, thinking back to those fraught, recession-era negotiations in Olympia. “It was a dismal time. We knew people would be hurt.”
Many lawmakers, including Cody, also understood how expensive those decisions would become in the long run because Washington’s analyses on the spiraling costs of untreated addiction — to the court, welfare and Medicaid systems — were so authoritative even the Congressional Budget Office used them.
Drug treatment could save Washington’s courts $275 million, cut public emergency-room costs by 35 percent and effectively pay for itself, according to a raft of reports written between 2004 and 2009 by state economist David Mancuso. Yet his work sat unused as the economic crisis starved state budgets.
Frustrated that these big-picture impacts were being ignored, Ken Stark, director of the Division of Alcohol and Substance Abuse, quit in 2008. During the next decade, more than 9,000 people died of overdoses, and each year another 6,000 were hospitalized for their addictions — at public expense. Today, Stark said, there are fewer detox beds in King County than there were in 2000.
“You can’t exactly draw a straight line from those cuts then to where we are now. But they did have something to do with it, because the result was an alcohol and drug system that is not nearly as comprehensive as it used to be,” he said. “I mean, we knew about the opioid crisis — with oxycodone — way back in the early 2000s — because we saw it in the data. And when people who were addicted to prescription painkillers got cut off, where did they go? They went to heroin, and you saw a huge increase in those numbers, right up to today.”
Among the front-line personnel lost during those years of contraction were drug counselors stationed at welfare and child-protective-services offices, who’d been assigned to connect addicted parents with treatment. That cut in outreach may be one reason behind current treatment-penetration rates of only 46%, meaning fewer than half of those who need treatment for an opioid addiction are getting it. Meanwhile, the number of children removed from opioid-addicted parents and taken into foster care has steadily increased.
Often, those children can cost more to educate than their peers. The Office of Superintendent of Public Instruction does not track the number of students who may have been exposed to drugs in utero, but researchers in other states have drawn links between infants born in withdrawal and developmental delays eventually requiring special education.
During the past nine years, the number of Washington children receiving special services for emotional or behavioral problems before age 9 has skyrocketed by 43%.
Mancuso, the state economist, could have predicted many of these trends.
“Those were the darkest days in my 17 years of public service,” he said, recalling the battles 10 years ago around drug-treatment funding. “Untreated addiction underlies so many other problems. But not enough people understood that then.”
In the intervening decade, addiction treatment itself began to change. Increasingly, it no longer means 30 days in a residential clinic. The new trend, similar to the way antidepressants revolutionized mental-health care, centers on doling out medications such as methadone or Suboxone, with less emphasis on intensive counseling. By 2018, state funding for anti-addiction medications was nearly 30 times larger than in 2010.
“It’s very much influenced by the medical field: If you have a problem, take a pill,” said Stark derisively.
That approach, when used for pain management, resulted in off-the-charts overdose rates attributed to methadone during the early 2000s. But methadone prescribed for opiate addiction is so highly regulated that users don’t get enough to overdose, according to behavioral-health experts at the state Health Care Authority.
Addiction experts hail the new, medication-based approach as a vast improvement.
“Beds don’t necessarily equal treatment, because inpatient treatment is not necessarily what people want,” said Brad Finegood, a drug and alcohol counselor who now advises Seattle-King County Public Health on combating opioid addiction.
In 2015, Finegood was part of a team of researchers with the University of Washington’s Alcohol and Drug Abuse Institute who surveyed more than 1,000 IV-drug users statewide and found that 43 percent would be willing to take an anti-addiction medication if it were available.
“Mostly, these people are not using to get high,” he said. “They’re using to not be sick.”
That aptly describes Brittney Morse, 25, who began smoking heroin in high school, and by age 18 was addicted and homeless.
Eighteen months ago, pregnant and kicked out of a treatment program in Yakima, Morse wound up back on the streets. Her two older children had already been removed by the state and placed in foster care — a program that costs $54 million annually in payments to foster parents.
Eventually, Morse found her way to the Evergreen Recovery Centers in Everett, where she detoxed and was put on methadone, which became a lifeline.
“Addiction is very strong,” Morse said, staring down at her lap. “It’s ruined my life and turned me into a monster. I wouldn’t wish it on anyone.”
For years, data crunchers like Mancuso hoped their analyses would convince legislators that drug treatment could curb the enormous costs to foster care and other social programs driven by addictions like Morse’s. But until recently, that research fell on deaf ears.
“People with alcohol and drug addictions were not popular,” Stark recalled. “We couldn’t run out and ask for compassion. We had to show there was a negative impact — economically — in not treating them.”
In this connect-the-dots approach, Washington was so far ahead that addiction experts from other states used Stark and Mancuso’s reports to push for more drug-treatment funding within their own legislatures — even if Olympia wasn’t using them. Today, however, the breadth of addiction in Washington is so widespread that lawmakers can’t help thinking of their own families when considering treatment budgets.
“It’s become a bipartisan effort in Olympia because everybody — and I mean everybody — knows someone addicted to opioids,” said Cody, D-Seattle. “In the last six years, people have started to talk about their brother, their sister, their kids, and that really did change their world view.”
This shift is clear in the numbers. Last year Washington devoted $450.8 million to addiction treatment and prevention, more than double the $189.3 million budgeted in 2013.
Back in his office at the Division of Research and Data Analysis in Olympia, Mancuso no longer sweats over proving the savings realized through treatment — that’s been clearly established. His new frontier is monitoring access to it, and there is a long way to go.