The worst place for someone to go after they detox from drugs is often where they end up: back to the same place where they used before. That's what happened to Timmy, a 31-year-old father and recovering heroin addict in Boston. He used heroin every day for six years after the murder of his grandmother, until he lost both of his cars and apartment and sixty hour-a-week job. But when he finished a week of detox, he wasn't able to get into further treatment. There were no post-detox beds available and he had nowhere to go. "I was literally thrown back on the street," Timmy says. "It was heartbreaking. I knew exactly what going back to where I was living would entail. It would be just a matter of time." Two months later, after relapsing, Timmy tried again with the same result. "Again, there were no beds available," he says. "I got dropped off at a homeless shelter. One bad decision and I was right back into it." It was as if someone had stopped him from jumping from an overpass, only to leave him at a different ledge.
For many people in search of recovery, completing detox is a small hurdle compared to what they must accomplish next: navigating a referral process for post-detox treatment that leads to facilities that don't have room for them. What that means is people who need help the most are turfed back to the same environment where they used drugs before, except now their bodies have been cleared of drugs and they are especially vulnerable to overdose if they relapse. "It can be a death sentence," says Billie Starks, director of behavioral health services at Boston Health Care for the Homeless.
There's no single treatment path for addiction, but in Massachusetts the road for many includes an acute treatment service (ATS), more commonly known as detox, which may be as few as three days or a week, then a clinical stabilization service (CSS), which is usually two weeks of counseling and support, to transitional support services (TSS), which are short-term residential programs, to sober living back at home.
The problem, however, is that there aren't nearly enough beds in centers that offer the CSS and TSS stage of the process. This is something that public health officials have known for at least two years, but it isn't getting any better. (The Department of Public Health did not respond to repeated requests for comment.)
In 2014, the Massachusetts Center for Health Information and Analysis found that there were only enough post-detox beds for roughly one out of every six people who need them. But depending on the day you need a bed, your chances of getting one might be much, much worse. We can check the real-time availability, thanks to the efforts of the Massachusetts Behavioral Health Partnership, which updates them at mabhaccess.com. At the time of this writing, there were 34 detox beds open, no CSS beds, and only 3 TSS beds available—and those three were only available to women.
That means many only get a chance to receive treatment for the physical, but not the social dimensions of their disease. "When you go through detox, that's just medical clearance," explains Maryanne Frangules, the executive director of the Massachusetts Organization for Addiction Recovery. "But this is a disease that affects you physically, emotionally, and spiritually. You're not going to get it all in detox."
This is a deadly situation for people straight out of detox, because they are especially vulnerable to relapse and overdose. "Fresh out of detox is an extremely dangerous time to be discharged with nowhere to go," says Starks. "People go into these facilities using a certain amount of heroin, but then their tolerance goes down. If they relapse, their bodies can easily be overwhelmed."
We've known for nearly 20 years that the risk of fatal overdose increases after detox. This is especially true for opioid users. For many, their detox unit isn't a medical facility, but a jail or prison. In 1998, Scottish researchers showed that the risk of dying from an overdose was eight times higher in the first two weeks after leaving prison than in the following two and a half months; in 2010, that study was confirmed, when researchers compared prison systems in the US, the UK, and Australia, and found that the risk of fatal overdose was three to ten times as high in the first two weeks than the next ten.
It may seem counterintuitive, but detox is a risk factor for overdose. "This may be due to a loss of tolerance for opiates, but may also be due to a misjudgment in the amount they use, or to a change in purity of opioids if their supplier has changed their time away, or to fatalism about the future following time behind bars," explains Michael Stein, a professor of health services, policy, and practice at Brown University.
Timmy finally got a post-detox bed and now has completed a year of recovery, after many cycles of spinning dry only to eventually relapse. What made him so lucky? What pearl of wisdom can we take from his story to give to someone else who wants the best shot at post-detox care? There really isn't any. "It was a roll of the dice," he says. "The morning of discharge, we got a call that there was a bed available. I was within an hour of being dropped off on the street."