What can we learn from the nation’s first 24/7 methadone clinic?
In October 2017, Community Medical Services (CMS), an Arizona-based addiction treatment provider, opened America’s first medication-assisted treatment (MAT) clinic that operates 24 hours a day, seven days a week. It’s a level of accessibility that will sound almost unimaginably helpful to anyone used to organizing their life around restricted clinic hours.
The first-of-its-kind program, which offers methadone, buprenorphine and naltrexone among other services, is located in North Phoenix near I-17—an area where drug fatality rates are among the highest in the state.
CMS hoped that 24-hour availability in this strategic location would help reach people who need its services the most—people who may not have sought help otherwise. In addition to MAT, the site also offers counseling and community resources.
Setting it up wasn’t easy. Arizona drug laws are notoriously harsh and unyielding, and general attitudes toward people who use drugs are similar. Indeed, many community-members, politicians and local business-owners voiced opposition when rumors surfaced that the existing clinic would go 24/7.
I wondered what CMS has learned from its experience of operating a 24/7 clinic for over a year and a half, in a country where MAT access is typically restricted. And I wanted to know what, if anything, about the CMS model is worth replicating, as other agencies begin expanding hours nationwide (there is now also a 24-hour clinic in Tucson and one in Wisconsin). So I visited Phoenix to ask these questions and more.
Community Medical Services has been providing addiction treatment since 1983, when it opened a relatively small program, I learned at its headquarters in Scottsdale. It’s now the largest OTP (opioid treatment program, licensed to dispense methadone) in Arizona.
Having expanded rapidly, CMS is no longer exclusive to Arizona. The agency currently operates 32 OTP sites in nine states, said CEO Nick Savros, serving a current total of 10,600 clients. The large majority take methadone; a small minority—those who ask for it—take Vivitrol (naltrexone).
While CMS primarily treats people with opioid use disorder, it takes the approach that drugs are only one part of a person’s addiction experience.
“It’s not about treating patients; it’s about treating the community—treating humanity,” Stavros told Filter. And he frames the idea to open a 24/7 clinic as a response to a community need.
Launching the 24-hour Program
CMS had been discussing going 24/7 even before it looked like a realistic possibility—it just seemed practical for many reasons. For one, it was clear that opening hours were a major barrier for some people.
“Construction workers work long hours, beginning early in the morning. Many are unable to get to a facility during normal hours.”
Tina Braham, CMS’s regional operations director, explained that many local people who wanted help with substance use issues were working long hours. Their availability just didn’t match the typical 9-to-5 window of most clinics.
“One example: There are many construction workers in our community looking for help,” Braham told Filter. “Construction workers in the area work long hours, beginning early in the morning. Many are unable to get to a facility during normal hours of operation without missing work.”
All-day availability also facilitates initiation. For some, the decision to seek help occurs spontaneously—perhaps in the middle of the night—and motivation may be fleeting. What if the only barrier to seeking MAT at a crucial moment is the fact that a clinic is closed?
This concept is more than just a thought experiment to John Koch*, the CMS community impact manager.
Koch began using opioids as a teenager, when he found that the drugs provided a sense of serenity. His opioid and heroin use became gradually more habitual. “They shut my big head down for a little while,” he said.
He became absorbed in destructive, cyclical behavior, and shut out other once-meaningful dimensions of his life: his family, his job, his health and his sense of purpose.
“I let my family down, I didn’t graduate from high school, couldn’t hold a relationship,” he said. “I had done awful things to people. I wanted to forget about all of this for a little bit … heroin would do that for me.”
Late one night, just over five years ago, he was pulled over. He was sure he’d be taken to jail: The car he was driving was not his; he had an outstanding warrant; he was high; and there were 20 bags of heroin on the seat next to him, which he didn’t even bother to hide. Homeless at the time, he had been in and out of jail several times already. He had no support or meaningful human connection; jail, he said, was at least a community in which he could contextualize himself.
But the officer made an unlikely decision. Instead of arresting him, he handed him the phone number of a (non-MAT) treatment facility, whose intake operators were available 24 hours, seven days a week, and told him to ask for help.
That was the moment when Koch began to change his life. He said he doesn’t know what might have happened were it not for the around-the-clock accessibility of that program.
CMS experienced its own transformative moment in September 2017, when the state of Arizona announced the allocation of funds from an OTP-access expansion grant made available under the federal 21st Century Cures Act.
The money was swiftly put to use. Going 24/7 didn’t require a new building; it was simply a question of extending hours and staffing at an existing location—CMS’s largest, which was already serving just under 1,000 people.
“CMS opened the 24-hour clinic in our northernmost location only 30 days after receiving funding,” said Braham. Over 6,000 people have come through its doors since, many of them accessing services after finding that insurance complications or long waiting lists were barriers elsewhere. “It’s been amazing; we’ve just seen lives change across the board.”
Help for People Who Are Homeless or Incarcerated
Beneficiaries have included some of the most marginalized people of all. A CMS street team works to engage people who are homeless, and in a county with around 26,000 unhoused people—at least 59 percent of Arizona’s homeless population—this is critical.
“We spend a lot of time talking about our ‘opioid epidemic,’ said Koch. “Well here in Arizona, we have a homelessness epidemic.” And of the many variables associated with long-term addiction to drugs, homelessness is the greatest contributor.
People involved in the criminal justice system are another area of focus. CMS’s correctional health program, led by Marlayna Anderson, provides educational opportunities and resources to people who are incarcerated. It sends a peer support mentor to speak with incarcerated people about post-incarceration treatment options, working with jail staff to coordinate services including MAT (whether from CMS or another agency) from the moment of a person’s release.
This can be lifesaving for people who used heroin before going to jail and are likely to use again when released. Resumption of opioid use after enforced abstinence carries an increased risk of death due to lowered tolerance, and of course fentanyl is present in the heroin supply.
As Filter has reported, incarcerated people are scandalously underprovided with MAT across the US, with the CDC noting evidence that around 10 percent of opioid-involved overdose deaths are of people who were released from institutions in the month prior. MAT can provide stability, and even if patients return to using illicit opioids, they will do so having once again increased their tolerance.
“There is no ‘right way’ of treatment. They don’t need us to tell them what they can and can’t do.”
Employing peer support workers is an important way for CMS to foster personal connections for clients. Those I interviewed were notably practical, down-to-earth and passionate—seeing their role as showing clients, through meaningful conversations, that they can be themselves without fear of judgement.
“There is no ‘right way’ of treatment,” said worker Anthony Dunkerly. “Everyone is going to have slips and falls in recovery. They don’t need us to tell them what they can and can’t do.”
“When clients come here, we tell them we are a harm reduction-based program,” said Jessika Miller, a supervisor at the 24-hour clinic. Yet she also explained that state laws make harm reduction difficult to pursue. For instance, fentanyl test strips are considered illegal “drug paraphernalia” under Arizona law, and syringe exchange programs are forbidden. The clinic is therefore limited in its ability to provide essential harm reduction services.
But that doesn’t stop it from thinking creatively. CMS works closely with Sonoran Prevention Works, a grassroots organization that provides harm reduction services, training and education in Maricopa County. The group is the brainchild of Haley Coles, a hero of Arizona harm reduction, who also operates an unsanctioned syringe program called Shot In The Dark.
These harm reduction programs regularly refer people to the 24-hour clinic if they want MAT. In turn, when the clinic’s clients seek harm reduction help that it is unable to provide, it will refer them to outside services like those Coles operates. The law creates many shortfalls, but the clinic strives to reduce risk in any way possible.
Being Good Neighbors
The program’s expansion sparked mixed emotions among locals. While many were intuitively supportive of the program’s objectives, Braham described “a lot of community pushback.”
Some concerns were practical, like complaints of traffic congestion and increased competition for parking after the influx of new clientele. Others included philosophical objections to MAT and harm-reduction—like the notion that MAT enables people to pursue their addictions legally. A few locals, including business-owners, have also expressed fears that crime, public disturbances and decreased property values may stem from inviting people with addictions to their area.
The clinic has been diligent about responding to these concerns—even those that are based in prejudice or completely unfounded.
CMS collaborated with the state to provide a 24-hour taxi service, covered by Medicaid, to and from the clinic to reduce traffic, and hired folks to direct traffic. It also hired off-duty police officers to reassure the community about public order—albeit this is an unsatisfactory concession to local opinion.
CMS employees also attend and host community forums, hoping to facilitate communication and find common ground when possible. When it’s not, they try to work through disagreements and solve problems collaboratively. Koch said that CMS takes criticism seriously and responds respectfully, taking feedback as an opportunity to learn about improving community involvement.
Although I was unable, for privacy reasons, to have on-the-record conversations with CMS clients when I toured the 24-hour facility, many of them find that positive community involvement is key to their journey.
CMS clients engage, for example, at an independent living retirement community, where they tend a garden, prepare and serve meals to residents using the vegetables they’ve grown, and conduct arts and crafts activities. Clients are also involved in monthly “community cleanups,” picking up trash and syringes (most of which are not associated with CMS clients).
Disease Concepts and Common-Sense Compassion
The work of the 24/7 clinic is overwhelmingly valuable, lifesaving and rooted in common sense and compassion. If I were to find fault, it would be with the theoretical basis of its approach.
“We are evangelists for practices grounded in science and evidence,” states one of the agency’s declared values. When I asked Nick Stavros, via email, whether science and evangelism can go hand-in-hand, he responded:
When I speak about evangelizing, it is definitely not in a religious sense but is indeed in an effort to gain converts to a few simple points:
*Addiction is a disease, not a moral failing and the stigma associated with addiction being a moral failing is what keeps people from getting into treatment and also prevents treatment from expanding to keep up with the growing need;
*Thus, to succeed in eliminating the consequence of SUD in our communities (that’s CMS’ vision statement) we need to treat addiction from a place of compassion, not from a punitive perspective;
*And, in spite of all of the doom and gloom we hear about the opioid crisis, there is hope in the fact that we have a highly effective modality of treatment that works for 92% of the population.
Of course, Stavros is coming from a place of caring about people who use drugs in a state where negative judgements against them are pervasive. He also has plenty of support in his views: NIDA, the organization that funds 90 percent of America’s drug research, defines addiction as a “chronic brain disease,” emphasizing that drugs cause long-lasting brain changes that embed addiction for the individual.
“Anyone who remembers what Maricopa County was like under the jurisdiction of Sheriff Joe Arpaio should marvel at how productive CMS has been.”
This is where I personally pause. My own work as a counselor is non-labeling, and oriented around skills and values. My own journey of recovery from heroin addiction reflected the expansion of other areas of my life through building skills and relationships.
While I certainly agree that addiction is not a moral failing, I do not agree that it is a disease. This distinction matters—even when you’re engaged in providing life-preserving MAT, as I have argued in Filter—because a disease/”addict” identity can become self-fulfilling, holding people back from positive life transformations and exposing them to further risk.
Addiction is far better conceived, I believe, as a relationship that people form—to drugs or to something else—which they rely on to provide experiences they can’t achieve on their own. A relationship which, given normal developmental opportunities and improved life circumstances, most people will grow beyond. The non-judgemental attitudes of the CMS peer support workers I spoke with allowed for this.
None of this is in any way to disparage or deny the fundamentally valuable work of CMS. Anyone who remembers what Maricopa County was like under the jurisdiction of Sheriff Joe Arpaio should marvel at how productive Nick Stavros, CMS and its compassionate, intelligent and industrious staff members have been in so little time.
The 24/7 clinic is special in many ways. The staff here believe in their clients; they believe in human beings. They treat them as people who deserve dignity and respect, who are worth helping—and going out of their way to help, as 24/7 availability reflects. This practical, common-sense compassion is what’s worth evangelizing for.
Zach Rhoads’ full interview with John Koch will feature in an episode of The Social Exchcange Podcast.