Across the U.S., more than 20 million people abuse drugs or alcohol or both. Only about 1 in 10 is getting treatment.
People seeking treatment often have to wait weeks or months for help. The delays can jeopardize the chances they'll be able to recover from their addiction.
In Baltimore, Health Commissioner Leana Wen has been pushing for treatment on demand, so that the moment people decide they're ready for help, it's available. It's something other health officials have sought to achieve, without success.
The need for quick access to treatment came into focus for us when we caught up with Andrea Towson, whom we first met last September.
Towson, known in her West Baltimore neighborhood as Teacup, has used heroin on and off for more than 30 years. She considers herself an active user.
By mid-December, she was looking to change that. "For the new year, I want to be in treatment," she says.
With the help of health department outreach worker Nathan Fields, Towson was able to get an appointment at a rehab center just before Christmas. But Fields, a former heroin user, says even a wait as short as a week can be too long.
"So many other things can happen," he says. "One thing, she could die. She could overdose, because if she's feeling dopesick she's going to use."
Fields knows that beating an addiction doesn't often happen on the first try. He also knows that the feelings of loneliness that can drive a person to seek help can be fleeting.
"Heroin has always been a great companion for people that are dependent," he says. "Best friend. It can talk to you. It can reason with you."
In Baltimore, Wen says there are an estimated 20,000 people who use heroin and 65,000 with some kind of addiction to drugs or alcohol or both, even after decades of focus on the issue.
In the 1990s, Baltimore made headlines when then-Mayor Kurt Schmoke introduced what he called a medicalized approach to the drug epidemic. His view, that the drug epidemic was a public health problem and not just a criminal justice one, was highly controversial at the time.
In 1997, billionaire George Soros gave the city $25 million to come up with innovative ideas for addressing, among other things, drug addiction, and the movement for treatment on demand gained momentum.
Nearly two decades later, Wen, who has been the city's health commissioner for a little over a year, isn't certain that treatment on demand is even possible. "We can progress, because we're so far off from it," she says. "We're so far off."
A bright spot is a 24-7 phone line for addiction and mental health resources the city launched last year that is fielding about a thousand calls a week. It's a big improvement from the past, Wen says, when it wasn't even clear whom one could call.
"It's not getting them treatment on demand," she says. "But it's getting them treatment at some point soon and resources right now."
Wen's team is also working on bigger projects she hopes will shorten wait times for treatment. One is a database that would show how many treatment slots are available at that moment across the city.
"What I worry about is, maybe there are spots that are available, but we're not able to fill them," she says.
Even with a tool like the database, Wen says it is time to rethink options for addiction treatment. "Maybe some people don't need treatment as an inpatient stay at the moment they request it," she says.
Another option, medication-assisted treatment on an outpatient basis, still carries a stigma, which concerns Wen. "There is the misguided belief out there that methadone, buprenorphine treatment is replacing one addiction with another," she says. "That is not true. Methadone and buprenorphine are proven, evidenced-based treatments endorsed by every medical organization."
There are other services she sees as critical to the recovery process that she wants recognized as part of the treatment system, such as peer-recovery specialists and case managers, who follow people through the process.
Wen is calling for Medicaid and insurers to cover the services, which are largely paid for now by grants. She hopes the national conversation taking place around addiction will lead lawmakers to spur such a change.
Still, all of this seems a long way off for Teacup.
In the middle of January, Andrea Towson was back on a park bench in West Baltimore, having missed her goal of getting into treatment by the new year.
"I want this chapter of my life to close, just end. I'm done. And it's not happening fast enough," she said, "Right now, I'm just ready."
Towson had yet another appointment at a rehab center the following week, but she was pretty sure it was just an interview and that she would have to keep waiting. She says, even if she were offered a spot, she wasn't sure she had the will to go.
"If somebody came up and said 'Andrea, you can get into treatment right now,' you know what I would say? Can you get me well first," she says.
This is how she talks about her addiction. She's well when she's had a hit. She's sick without the drugs.
"I just want to wake up and eat breakfast and be normal, no matter what that might be," she says. "I'm just ready to be Andrea. Teacup is done. She'll always be a part of me, but I no longer want to be her. Teacup is a full-blown drug addict. Full-blown. I choose to live now."
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