There’s only one place in our region that offers medical detox and extended inpatient substance treatment.
It was agony enough that their 19-year-old daughter died of a heroin overdose.
After all, Brian and Caroline Folker had always thought Fauquier County was a safe place to raise their two daughters. After much research, they had picked it as the place to live when he was transferred from London to a job in Vienna, Va.
But it seemed like unnecessary cruelty to have Kathrine die not long after a stint in an addiction recovery center, after being buoyed by so much relief and hope. Through their terrible ordeal, the couple learned one of the awful realities of addiction. Most addicts relapse. Multiple times. Even after they receive treatment.
Kathrine had been in the Edgehill Recovery Retreat in Winchester for only two weeks when she left. She told her parents she was afraid she would lose her job if she stayed any longer. She also told them she would be fine.
“It turned out to be a perfect storm,” Caroline Folker said. “My anxiety-ridden, naïve follower of a daughter. Very easily influenced and living in a time and place when this epidemic hit. She might as well have had a bull’s-eye on her back.”
Caroline and Brian have since separated, a consequence, she said, of their daughter’s death and her struggle with addiction.
Billions of Pills
Last July, the Washington Post published its analysis of a Drug Enforcement Administration database that tracks every pain pill sold in the United States. The Post found that between 2006 and 2012, the largest drug companies distributed 76 billion oxycodone and hydrocodone pills. In Virginia’s Piedmont region, more than 118 million painkillers were prescribed and sold during that period. Here’s how that breaks down by communities, based on sales by pharmacies or doctors.
Where they went:
24 pills per person per year
48 pills per person per year
45 pills per person per year
43 pills per person per year
39 pills per person per year
38 pills per person per year
31 pills per person per year
18 pills per person per year
10 pills per person per year
6 pills per person per year
Recovery can be a painfully tortuous process, one that often takes years of treatment and counseling, not to mention much patience and support from family and friends. There is no quick fix, no surefire cure. And, unfortunately, Virginia’s Piedmont region is playing catch-up when it comes to both short-term treatment options and long-term assets, such as recovery housing, which can be critical for those trying to make the transition to a more normal life.
That’s a big part of the challenge facing communities like Warrenton, Culpeper and Manassas. Organizations such as Piedmont CRUSH (Community Resources United to Stop Heroin) have taken a crucial first step by bringing together groups dealing with different aspects of the opioid crisis — from law enforcement to social services to health care. But fighting this epidemic requires a long-term commitment to providing the services that help recovering addicts try to pull their lives back together, says Steve Williams, mayor of Huntington, W. Va.
Huntington is often described as ground zero of the opioid epidemic. In 2015 alone, police and first responders in the town of 50,000 people handled more than 700 overdose calls; 58 of its residents died.
“Frankly, I think it’s the greatest existential threat to our nation,” Williams said. “If there was not another opioid tablet sold, or another gram of heroin illicitly distributed, we would still be dealing with the consequences of the opioid outbreak for the next 30 to 50 years.”
Changing the brain
Fewer than one out of five opioid addicts get treatment, according to the National Institute on Drug Abuse. For those who do, the likelihood of relapse is high. A study published in JAMA (Journal of the American Medical Association) concluded that somewhere between 40 to 60 percent of those treated for addiction relapse within a year. Typically, that can be the first of a half dozen or more setbacks.
Ash Diwan, a physician at Piedmont Family Practice in Warrenton and a proponent of prescribing medications to assist recovery, believes the reason has to do with the profound impact opioids have on a human brain.
“If you’re really hungry and you have a delicious piece of chocolate cake, it increases the dopamine released in our brain by 20 to 30 times,” he said. “But with something like heroin or oxycodone, it increases that dopamine about 1,000 times. If that’s done chronically, there’s nothing the body can do to mimic that level of well-being.
“Chronic use resets that reward pathway far away from where it should be. So, even if we detox a person and they are no longer taking any opioids, we haven’t really changed their biochemistry at all. It really takes a lot of time for the brain’s reward center to get back to a normal state.”
Holes in the system
That’s why smooth transitions from one phase of recovery to another are so important. The softer the landings, the more likely a recovering addict can stay on track. Ideally, a well-integrated continuum of services is available — from early intervention to acute care to transition housing. But in this region, there remain significant gaps in that path, says Jim LaGraffe, executive director of the Rappahannock-Rapidan Community Services Board (CSB), which operates the Boxwood Recovery Center in Culpeper.
Boxwood is the only facility in the five-county region that offers medical detox and 28-day inpatient substance treatment. It has six beds dedicated for the former and 26 beds for the latter. As a publicly funded center, Boxwood is for patients on Medicaid or with no health insurance; they pay on a sliding scale. People with private insurance are referred to private addiction treatment centers outside the region. A monthlong stay at those places can cost as much as $20,000. How much insurance covers varies widely, but most private rehab centers offer financing plans.
“Boxwood is an intense treatment facility,” LaGraffe said. “But when people come out of there, some still need a supportive residential program. That’s also really lacking in this area. People have to go to the D.C. suburbs or elsewhere for residential programs. It’s a real hole in our support system.”
He is referring to the absence of residential facilities for patients who would benefit from further clinical oversight -- such as a person who still has cognitive issues from their substance use -- and also to places where recovering addicts live in a supervised environment as they sharpen the skills needed for the outside community.
When there’s not what LaGraffe called a “gentle handoff” to the next stages of recovery, when patients have to make too abrupt a re-entry to a more normal life, the risk of relapse rises.
He said the CSB is moving forward with plans to open what’s known as an Oxford House in Fauquier County, which would be the region’s first. These are the least structured recovery residences, based on a model where rent-paying addicts live together with strict rules against drinking or using drugs. Any violation can get a person voted out of the house.
Fauquier County will be getting a new residential facility later this year when the PATH Foundation and the Herren Wellness Group — created by former NBA player Chris Herren — open a 21-bed center for recovering addicts. With its focus on “spiritual and personal growth,” the Herren Wellness Retreat at Twin Oaks will promote recovery through yoga meditation, exercise and individual and group coaching. The costs of a month’s stay will be about $15,000, and while the center will be self-pay, with no insurance accepted, several beds will be reserved for people paying a reduced rate on a sliding scale.
“The PATH Foundation doesn’t see this as the only answer, but it is a major spoke in the wheel of services needed to address the multi-faceted challenges of recovery,” said Amy Petty, PATH’s director of communications.
Staying in treatment
Residential recovery after detox isn’t an option for many people financially, or they aren’t able to be away from their families or a job for that long. An alternative is an Intensive Outpatient Program (IOP). It requires patients to get three hours of individual or group counseling three times a week for at least three months.
It’s demanding, but permits those who still need concentrated treatment to have flexibility. “The problem is that too many people are lost after they go through a detox program,” said Diwan, who hopes to have an IOP available within the next month. “This is a good way to get them back into treatment.”
Unfortunately, only a few practices in the region offer IOPs. Earlier this month, the nonprofit Youth for Tomorrow began offering intensive outpatient treatment for substance abuse at the Warrenton office it opened in June. But that program is only for teenagers between 13 to 17. They have nine hours of therapy a week, similar to the program at Youth for Tomorrow’s Woodbridge office.
LaGraffe says his agency would also like to be able to offer an IOP. But he has found is that it can be difficult in rural areas to recruit clinicians to work in addiction treatment. Also, the lack of public transportation makes it hard for people to get to therapy sessions, particularly when they’re three times a week.
While cheaper than residential programs, the cost of IOPs is not insignificant. It varies based on a person’s health insurance, but the co-pay can run anywhere from $25 to $40 a day. Without insurance, the cost is about $75 a day. For someone getting counseling three times a week for three months, that adds up. Diwan is arranging to be able to accept Medicaid patients.
“I think it’s better in some ways than someone transitioning into another recovery residence,” he said, “because it makes you have to have some responsibility, and being out there getting your life restarted while you’re still getting counseling.”
“Crawling below the sewer”
When Dan Obarski meets with drug overdose patients in the emergency room of Culpeper Medical Center, the best-case scenario is that they realize their lives have gone off the rails. As a peer recovery specialist, he asks a lot of questions, with the intent of edging them to an epiphany.
“I don’t ask them to do anything,” he said. “My goal is to get them to a place where they’re going to admit they have a problem and that they’re ready to accept help.”
Two years ago, Obarski started a nonprofit called Sex, Drugs and God to help others fighting addiction. As someone who overcame his own alcohol abuse through counseling and a church “accountability” program, he said he can pretty much tell who is serious about taking on recovery and who is telling him what they think he wants to hear. “Addicts are manipulators, but I’m very good at smelling B.S.,” he said.
If a person seems sincere, Obarski will lay out recovery options. It might be 28 days in residential detox. It could be a 12-step program like Narcotics Anonymous, or one that’s deeply Christian, such as Celebrate Recovery. If a patient asks about medication-assisted treatment — which involves using FDA-approved drugs in conjunction with therapy — Obarski will connect him or her to doctors certified to prescribe those medications.
He has a contract with the Rappahannock-Rapidan Community Services Board to see overdose patients at the hospital if they express interest and sign a release. He also meets with a small group of inmates every week at the Culpeper County Jail. Obarski helps them try to prepare for what is often a perilous transition to life on the outside without drugs.
“When you’re coming out of addiction,” he said, “you’re crawling below the sewer.”
Life after jail
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The grim reality is that addicts who have been incarcerated usually restart their lives in a deep hole. They’ve lost their jobs, and often their driver’s licenses, frequently due to unpaid court fees and fines. They’ve likely burned bridges with family members and friends, so they may not have a place to live. And, they’re still addicts.
The relapse rate soon after leaving jail is extremely high. In fact, a study published last year in the American Journal of Public Health found that in the first two weeks after release, former inmates were 40 times more likely to die of an opioid overdose than someone in the general population.
“Recovery, honestly, is a hard life to live,” said Chris Connell, who as program manager for the SpiritWorks Foundation in Warrenton oversees a recovery therapy program at the Fauquier County Jail. One big part of the process, she noted, is staying committed to avoiding the people and places that shaped their lives as active addicts.
“If they don’t have a lot of support on the outside, they fall back into the trap and go right back to what they know,” she said.
Often, after being so intensely focused on doing whatever they felt necessary to avoid being “dope sick,” they struggle with the more prosaic details of recovery, such as making and keeping appointments with doctors and counselors.
So, peer counselors and coaches — people who themselves have battled with addiction — are seen as critical first contacts, then guides.
“For a person like me who has battled with addiction, seeing someone who has been in my shoes and experienced all the turmoil that comes with addiction, and seeing they’re now walking in better shoes, that becomes real,” said Christopher Ronquist, director of the McShin Foundation’s Virginia Recovery and Re-Entry Project at the Rappahannock, Shenandoah, Warren (RSW) Regional Jail in Front Royal.
He said that as much as an addict might learn from a doctor or psychiatrist, as much as he or she might be touched by a preacher or “mommy and daddy crying and begging me to get clean,” only someone who has been addicted knows what it’s like to be willing to do anything to get the next fix.
“There’s authenticity in this person’s story,” he said. “You know, this dude knows what it’s like to be me. He’s giving me hope. If it worked for him, maybe, just maybe, it will work for me. Maybe recovery is possible.”
The Empowered Communities Opioid Project — a collaboration of George Mason University and Prince William County — is building a network of peers working directly with agencies with which addicts need to interact, from the county health department to the regional Community Services Board to the state probation and parole office to the Prince William Adult Detention Center.
Katrina King is one of them. Her title is “senior community coordinator,” but in practice, she is a peer who meets women addicts for the first time when they’re booked at the detention center. She hears their stories, then, to build trust, shares an abbreviated version of her story.
King started using opioids for back pain, became addicted, and says that at one point, she was taking up to 40 pills a day, supplemented by heroin when she couldn’t get painkillers. She got caught forging prescriptions and was sentenced to two years in jail. While incarcerated, King learned that her 20-year-old daughter, Kirstyn, had become addicted to opioids. She overdosed and died before King could get her into treatment.
King knows that recovery comes in baby steps. She understands the fragility of raised hopes. So, one of her top priorities is arranging to get newly arrested addicts into treatment as soon as possible after they’re charged. Usually it means finding them a bed in a facility outside the region, sometimes as far away as California. She says she’s frustrated by the minimal residential options in the region for people trying to rebuild their lives.
“My job is more stressful because there aren’t enough resources available and not enough connectivity between the different agencies these people need to deal with,” she said. “They also can be fighting something so much more severe than substance abuse. There are often mental health issues.
“Things are moving in the right direction,” she added, “but it’s very slow.”
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Not surprisingly, most of the progress has come in places where addicts have both the time and motivation to focus on a different, better future. Almost every regional jail or adult detention center in the area now has some kind of peer-to-peer support or counseling for inmates. Some places, such as the RSW Regional Jail, have gone further.
Inmates who make it through a Recovery/Re-Entry program overseen by the nonprofit McShin Foundation can qualify for scholarships that, after incarceration, can cover their expenses for a 28-day residential program at McShin’s recovery center in Richmond. That’s followed by a move to a “sober living” home, where they can live temporarily while they look for work. So far, 23 former inmates have each received the $9,800 scholarships.
The Prince William Adult Detention Center, meanwhile, has operated a special Drug Offender Rehabilitation Module (DORM) since 1991 for male inmates, and since 1995 for females. Men live in a building separate from the general jail population, while the women are in the main building, but in a section for low- and medium-risk offenders. Both have access to a range of therapy treatments in the four-month program, including sessions focusing on moral reasoning and decision-making, recovering from trauma, avoiding violence and building family relationships.
The program has been effective in reducing recidivism — in fiscal year 2019, 84 percent of former DORM inmates were able to stay out of the detention center for at least a year, according to Sara Wheeler, program manager for Drug Offender Recovery Services. That compares with about 50 percent for the general jail population.
But the stats for how many follow up with treatment after they leave jail is less impressive — fewer than half, said Wheeler.
“It’s really a high-risk time for them,” she said. “A lot go astray when they first get out. It’s not uncommon for people who have been really successful in the DORM program, and they get out and you see them panhandling just down the street.”
“Changing face of addiction”
Attitudes about recovery are shifting, with more programs combining counseling and behavioral therapy with medication-assisted treatment
Peer coaches and counselors in the region will tell you that any kind of sober-living arrangement can still stir up community resistance, even though as Katrina King points out, “If anything, you’ve got pretty safe neighbors with people in recovery. They’re not allowed to use anything or they’re expelled.”
For all the raised awareness about addiction, certain stigmas persist. But the Rev. Jan Brown feels hopeful about where things are headed. She is a deacon in the Episcopal Church and founder and executive director of SpiritWorks, an addiction recovery foundation based in Williamsburg, Va., with an office in Warrenton. She is also a recovering addict who hasn’t used drugs or alcohol since 1987.
The most promising shift she sees in public perception is the recognition that recovery is a process with many ups and downs and that addiction is a chronic illness.
“The negative pushback is beginning to change as the face of addiction is changing,” Brown said. “It’s not ‘those people’ anymore. It’s my child, or my colleague’s son or daughter, or my husband. There can be a sense of hopelessness that leads people to believe that people don’t get better, that they’re going to struggle their whole lives.
“And that,” she said, “is just not true.”
ABOUT THIS SERIES: OPIOID RIPPLES
How the opioid crisis impacts families, public services across the region
Opioid Ripples is an ongoing series produced jointly by four organizations: two independent, nonprofit civic news organizations, Piedmont Journalism Foundation and Foothills Forum; and two media companies, Piedmont Media and Rappahannock Media. The nonprofits provide the research and reporting; the media companies decide when and what to publish in their newspapers and on their websites.
Foothills Forum, founded in 2014, and Piedmont Journalism Foundation, founded in 2018, were created to increase in-depth news coverage and public discussion of issues in their communities.
Foothills Forum focuses on Rappahannock County. For more information, see www.foothills-forum.org.
Piedmont Journalism Foundation focuses on Fauquier and surrounding counties. For more information, see piedmontjournalism.org.
Community support of the nonprofits makes this and other projects possible. Funding for this series comes in part from the PATH Foundation, which provides grants to improve health and vitality in Fauquier, Rappahannock and Culpeper counties.
• How the role of police in dealing with the opioid epidemic is shifting from making arrests to educating the public.
• For all the raised awareness about opioid addiction, its stigma persists and plays out in many ways. Also, how other communities are dealing with the challenges of the opioid crisis.
What do you think so far?
Let us know what you think of this regional reporting project. Send feedback to email@example.com.