Substance users fall through the cracks as overdose epidemic rolls on

Fentanyl graphic.
Fentanyl graphic.
Published: Jul. 10, 2023 at 2:52 PM CDT
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ST. LOUIS (KMOV) -- Missouri recorded 2,178 overdose deaths in 2022. The crisis far outpaces vehicle fatalities and gun deaths in the state.

Overdose deaths have steadily risen in Missouri and across the U.S. in the last decade. The influx of illicit fentanyl into the U.S. created another wave of the overdose crisis, which shows no signs of slowing down.

News 4 detailed fentanyl’s toll on St. Louis in the 2022 documentary Contaminated: The fentanyl crisis in St. Louis. This report is aimed at digging deeper into the issue locally to identify why so many people fall through the cracks when it comes to getting substance use treatment and recovery.

Analyzing the issues

For starters, Assisted Recovery Centers of America (ARCA) Founder Percy Menzies said community support for substance users has long been lacking.

“Describing the problem as an incurable disease has done a great disservice to the field because it implies there is no hope in getting well,” he said.

Menzies, who founded ARCA around 20 years ago, said new patients at the clinic are often people who have struggled with addiction for years without receiving the help they need. Standardizing substance use treatment, he said, would be a good start in addressing the shortfalls of the epidemic response.

“There are too many barriers for people to seek help,” Menzies said. “And we said those barriers should come down.”

He used an addiction awareness walk from 10 years ago as an example of the lack of support he sees for substance users. ARCA planned the walk with the hope of spreading the word about addiction treatment and recovery, but it was a flop. Only 15 people or so showed up, Menzies recalled with a sarcastic laugh.

He argued the attitude around addiction hasn’t changed much since then.

“The stigma is so well entrenched,” Menzies said, “and what bothers me so much is people say stigma is the biggest barrier to treatment, but what have we done to remove the stigma?”

Rachel Winograd, Ph.D., saw firsthand the barriers veterans faced at a local VA treatment clinic in the early days of her addiction science career. The treatment practices stuck out to her as odd.

At the time, they weren’t giving out naloxone to patients, a missed opportunity to prevent overdoses. There were also requirements patients had to meet to get their life-saving medication, like showing up in person every day or having to attend a certain amount of counseling sessions every week.

“That was just one small clinic within the VA but it was replicated at almost every clinic across the state,” she said.

Winograd leads the addiction science team at The University of Missouri-St. Louis-Missouri Institute of Mental Health(UMSL-MIMH). She’s been fighting an uphill battle with a contaminated drug supply that is now leading to thousands of deaths every year in the state.

UMSL-MIMH adopted a medication-first initiative to better serve people seeking substance use treatment. The approach was met with pushback from the public, she said. Winograd said people have trouble understanding why drugs like methadone and buprenorphine, both opioids themselves, would be used to treat an addiction to other opioids.

“I was actually surprised that there was more pushback to the medication than there was to naloxone access,” she said.

Methadone and buprenorphine, Winograd said, reduce the risk of overdose on drugs like fentanyl and heroin by 50 to 80 percent.

Menzies said getting medication to patients the first day they walk into the clinic should be the norm.

“When it comes to addiction, the withdrawal symptom is the easiest to treat,” Menzies said. “And why is that not treated as a first-line treatment? And why is it that only a small fraction of patients go home with the appropriate detox meds?”

Substance users going back out on the street means a much higher risk for overdose.

“(Medication first) doesn’t just mean get it to people quickly,” Winograd said. “It means this should be our priority in treatment given the high overdose risk when people go back out using.”

ARCA heavily utilizes the drug naltrexone to treat opioid and alcohol use disorders. He argued the drug is vastly underutilized in the face of crises that claimed more than 200,000 lives in 2022 in the U.S.

The fact that methadone, buprenorphine, and naltrexone are the only three FDA-approved medications to treat opioid use disorder is another example, Menzies said, of the lack of support he spoke of.

“We need dozens of new medications to treat addictive disorders,” he said. “Not just three.”

Stigma’s tight grip on the issue

Those affected by the overdose crisis continue to point to stigma as a main reason for the lack of progress.

Missouri State Sen. Holly Rehder pointed to it in an interview with News 4 last year as the main reason she said addiction isn’t taken seriously by the state legislature. St. Charles County paramedic Lisa Cassidy said “stigma is killing people more than people realize” after seeing firsthand the rise in overdoses. A Jefferson County mother got the cold shoulder at the grocery store after telling someone she knew that her daughter died of an overdose.

Winograd said the stigma toward addiction has manifested itself into real-world policies, using an example of nursing facilities not allowing someone to reside there if they’re on suboxone, a drug with buprenorphine and naloxone that reduces withdrawal symptoms to powerful opioids.

“We send people so many mixed messages like we care about the overdose crisis and want to save lives,” she said. “And here we have these tools that could cut the overdose rate in half or more, and we discourage them in so many of our policies and statements. And that is a death sentence for so many people.”

Not advancing treatment practices, Menzies said, is another consequence of stigma.

“For the longest time, the treatment (has been) three hots and a cot,” Menzies said. “And that’s jail…Instead of seeing that as an opportunity to help people, we just incarcerate them and expect they will magically get well.”

A knowledge shortage

Greg Boal, the first responder outreach coordinator at UMSL-MIMH, said there is a shortage of knowledge rather than a shortage of resources when it comes to the overdose issue. Missouri’s budget for substance use disorders for fiscal year 2023 was $241 million, according to the Department of Mental Health.

Eighty percent of that goes toward treatment. The funding comes from general revenue, federal Medicaid match, grants, opioid settlement money and temporary American Rescue Plan Act funds.

“There are people out there and resources out there to help people who are struggling with crises, but the information is just not out there about how to access them,” Boal said.

Menzies agreed wholeheartedly.

“That is exactly the situation,” he said. “We have so much in funds and resources now but there’s such a sparsity of knowledge, it’s shocking.”

Boal is one of many people at UMSL-MIMH that pack overdose kits that are sent out into the community on a weekly basis. They include information on the Good Samaritan law, treatment agencies, recovery housing, and naloxone.

The Community, Engagement, Trauma, Equity and Renewal (CENTER) project at UMSL-MIMH is aimed at reducing overdoses in St. Louis’ Black community, which has been hit particularly hard by addiction.

“Access for Black clients has not expanded nearly as much as it has for white people,” Winograd said. “And when Black people do get engaged in care, they are not retained nearly as long by our treatment providers for this region.”

Winograd referred to “care deserts” in north St. Louis where there is less access to treatment than surrounding areas. A community-academic partnership grant is allowing UMSL-MIMH to research the problem and advocate for better practices.

“So not only looking at the drivers of overdose deaths,” Winograd said, “but also our treatment system and its gaps and how are people falling through.”

ARCA found out 29 percent of its patients weren’t filling prescriptions for suboxone at one point. Patients were able to get them filled at certain area grocery stores free of charge, so it confused Menzies and ARCA leadership that so many people weren’t doing it.

Patients would have to wait 30 to 45 minutes to get their prescriptions filled. They were sometimes looked at suspiciously, especially because they were there to get medication to treat addiction.

It’s something that affected ARCA’s Black patients in a segregated city like St. Louis.

“I did not realize it was such a humane problem that we had overlooked,” Menzies said. “These are actual barriers.”

ARCA wanted to increase the prescription fill rate so it added an on-site pharmacy. Now, 97 percent of patients’ prescriptions get filled, Menzies said. All they have to do is walk across the hall.

Through ARCA, he hopes to show addiction treatment and recovery are possible by showing better outcomes.

“(Fighting) stigma is when you show better outcomes, you’re more compassionate, you make treatment attractive, you have a passion to help these people,” he said.

Part of creating better outcomes is addressing people’s needs in addition to medication, like housing and jobs. Without those two things, Menzies said a patient’s chance for relapse is practically 100 percent.

“Getting them out of the environment is very basic housing,” he said. “Because what good does it do that at every street corner, there’s either a crack house or a drug dealer that are there. And then when they are in a house, what do I do? I can’t just sit there and smoke cigarettes all day. So then when you offer them job training and jobs, that is the two critical factors that allow people to recover.”

Providing housing, Winograd said, gives the community’s vulnerable population an opportunity for stability.

“The biggest gap I think we have is a place for people to go and lay their head that is safe, caring and non-judgmental, and harm-reductionist in its values, while people are figuring out their next step,” she said.

For more stories, resources, and education on the overdose crisis, visit