The furniture is not fancy — a single bed bumps up to a leather recliner just steps from a small desk. But sunlight pours in from a large window, and friends are there.
The small room is part of the Journey to Recovery Community Center in Newport, located in a woodsided office building, across the street from North Country Hospital and a short walk from the eastern shore of Lake Memphremagog. The space opened six weeks ago to provide an option for short-term, 24-hour peer support for people in crisis from substance use who want to begin their recovery. The first day was, so far, the busiest.
“It was the day after Thanksgiving,” said Lila Bennett, the center’s executive director since 2020. “We had one person in the bed and three people in the emergency room.”
Since then, 10 people have stayed over, some for one or two nights, others for four or five — some struggling with alcohol, others opioids, Bennett said. They all come by choice, straight from the hospital, after being examined for immediate physical or mental health risks and being cleared to leave by a clinician.
The neutral environment helps people stay focused on what they want to change while they develop a treatment plan with an outpatient clinic or wait for an opening at an inpatient rehabilitation center.
“This is voluntary. You are here for yourself,” Bennett said. “But we’re going to be here to hold you to that standard.”
With around 4,400 people, Newport is among Vermont’s smallest cities. But it is the largest municipality in rural Orleans County, where, like the rest of the state, opioid use and overdoses have increased dramatically over the past decade. In 2022, there were 11 overdose deaths countywide by the end of September, according to the latest figures available from the Vermont Department of Health, compared with nine throughout 2021 and just three in 2011.
The emergency department, open to anyone all the time, is where many people in the midst of a health crisis related to substance use disorder end up, said Javad Mashkuri, an emergency medicine doctor at Central Vermont Medical Center in Berlin. Until recently, it was not a particularly supportive place to find care.
In 2016, Mashkuri and his colleague Mark Depman began to change that. The two physicians began working with the Turning Point Center of Central Vermont to bring peer counselors into their hospital’s emergency department. Two years later, they launched a project with medication-assisted treatment centers in the region. Emergency clinicians would provide an immediate course of buprenorphine to stabilize patients while simultaneously enrolling them in a longer-term course of treatment.
“I say this all the time — that addiction is the hardest disease we take care of in the emergency department. There are so many layers,” Mashkuri said. “At least now we have things we can do. Before, we didn’t have much. It has really evolved.”
Reducing the strain
That model of collaboration with recovery and substance use treatment providers has been embraced by emergency departments around the state, including at North Country Hospital. In addition to helping those struggling with substance use, Bennett hopes the center’s work with the hospital helps reduce the strain on the emergency department and on clinicians themselves.
“When you get into the nursing profession or become a doctor, especially in an ED, it’s because you want to help people and you want to help people right then,” Bennett said. “But if you have someone come in who is dying of a drug addiction, and you can’t save them, it’s really demoralizing.”
The effort has gained momentum. Journey to Recovery Community Center moved from its previous downtown Newport location to a former ophthalmology office, which it purchased in 2020 under Bennett’s leadership. Since then, the recovery center and hospital have strengthened their ties.
Hospital staff started paging peer counselors employed by the center in substance use cases, Bennett said. More recently, emergency department clinicians have provided rapid access to suboxone when appropriate, said Marc Bouchard, the North Country emergency department’s medical director, in an email.
Soon after the move, Bennett began to notice another stumbling block. People came to the emergency room wanting to enter recovery, but could not get into formal treatment right away. During the height of the pandemic in particular, it took weeks to get someone into residential treatment, she said.
“People would go to the hospital, and then they would have to wait two weeks, and that was just too long. It’s too hard to go back to your triggering environment,” Bennett said. “They would end up using or drinking and going back into the cycle until another crisis happened.”
That cycle can be seen in a recent study of emergency room usage from the Vermont Department of Health. Emergency room visits for non-fatal opioid overdoses have been increasing across the state, up by 44% since 2018. Of the 1,631 people visiting the emergency room over that three-year period, the report concluded 15% visited more than once, and 4% more than two times.
Bennett saw in the center’s new location that the organization had the space to be able to help. She began to keep a record of the need, and promoted the idea of a “social detox” facility at meetings of a regional community health working group called Vibrant ONE, an acronym for Orleans and Northern Essex counties. The program is called “social detox” to emphasize that only social support, not medical care, is being provided.
Between February 2021 and July 2022, Bennett recorded certain details about 46 people visiting Journey to Recovery who wanted to enter treatment after a visit to the emergency room, with 11 repeat visitors. Her records show their difficult circumstances: More than a quarter were homeless, four reported having engaged in sex trafficking and five had children in the custody of the state. Among those for whom outpatient medication-assisted treatment made sense, most were able to access it. But for people seeking residential treatment, around half never made it there.
The data helped convince the working group to recommend Journey to Recovery Community Center for a $50,000 grant to fund renovations and start-up staffing for the bed. The funds help cover additional wages for two counselors who are present whenever someone is there. The staff was already on call during that time, so the add-on costs were lower than otherwise, Bennett said.
The project is one of 10 that promote health equity that were recently funded in the NEK, said Kari White, who coordinates the working group and the grant program for Northern Counties Health Care. The funding comes through the Vermont Department of Health, part of a larger grant from the federal Centers for Disease Control and Prevention.
But it is the kind of program that likely could be funded directly by a hospital or OneCare, the statewide accountable care organization, under Vermont’s health care payment reform system, White said. For example, Northeastern Vermont Regional Hospital in St. Johnsbury invested $58,000 a year between 2020 and 2023 in launching a community space downtown to link residents to social and financial resources. The funding for the project comes out of bonuses the hospital receives from OneCare.
At Journey to Recovery Community Center, North Country Hospital provided the physical bed. Its support staff members change the sheets and towels and bring meals to people staying at the recovery center. While hospital clinicians are not involved in the service, they appreciate its value.
“Journey to Recovery has been a great resource for helping patients,” said Denise Carter, the hospital’s new emergency department nursing director, in an email. Depending on the needs of the patient, “I think they offer hope for someone who is seeking help with an addiction and in some cases are really a bridge until formal treatment can be found,” she said.
‘Spaces are really important’
Central Vermont Medical Center and a regional group of substance use treatment providers are now trying to recreate just that kind of a bridge.
“When someone has overdosed, a lot of times they go to the emergency room, but then they go right back into the environment they were in. You’ve got a super-high risk of recurrent use,” said Mashkuri. “If you can remove them from that environment into a safe, supportive space, then there are a variety of things that can happen.”
Before the pandemic, the hospital had been able to make use of an open bed in a nearby mental health respite facility for a similar purpose. Peer counselors could visit, though the program was mostly oriented toward alcohol use, he said. But as mental health needs grew, the space was no longer available. The regional group is now looking into other options.
“These spaces are really important,” Mashkuri added. “If you really look at recovery-oriented care, we have treatment providers, we have prevention providers, the recovery centers — but what’s missing is this idea of short-term stabilization.”
One option may be what Vermont health regulators call “crisis beds,” which are generally provided by social service agencies around the state as part of the “public inebriate program.” There are currently state-funded crisis beds in Bennington, Berlin, Burlington, Morrisville, St. Albans, St. Johnsbury and Wallingford, said Cynthia Seivwright, director of the substance use prevention division of the Vermont Department of Health, in an email.
Crisis beds were originally designed for short-term stays, during which an intoxicated person could be observed until they were sober. They are often utilized by law enforcement as an alternative to jail. But with strong links to treatment and peer resources, they can become more, Mashkuri said, pointing to the Howard Center’s complementary Act 1 and Bridge residential programs in Burlington as a success story.
Such facilities are harder to access in rural parts of the state. Bennett considered applying for the “public inebriate” funding to launch the new bed, she said, but the recovery center does not have the certification necessary. The crisis bed program in St. Johnsbury, about a 40 minute-drive away, is operated by Northeast Kingdom Human Services, which serves all three NEK counties. But the need in Caledonia County is also large.
“We have never been able to get anyone from here in there because they are always full,” Bennett said.
Different regions will find different solutions to this gap, Mushkari said. But key to all the efforts will be collaboration among all types of health service providers and involving peer recovery counselors, either by hosting beds or assisting other regional social services or mental health agencies that do.
“If you want to look to any one thing that has been a significant gain in our ability to do this work, (it has been) incorporating peers into the emergency department. No one else can provide the experience,” he said. “When a recovery coach walks into a room, you can feel the energy relax.”
But funding peer recovery counseling for substance use disorder is a challenge. Recovery centers do receive some state money, but they struggle to provide benefits or pay staff reasonable rates.
The Vermont Department of Health signed a new agreement with the federal government in September for its administration of the Medicaid program, which currently pays for health care for around a quarter of the state’s population. The new agreement extends and expands flexibility around some spending rules, which the department says will allow it to begin funding peer support services for substance abuse more substantially in 2025.
Bennett is glad that the work she and her colleagues do is being taken more seriously. But she didn’t want to wait any longer to try something new. She hopes that the “social detox” program will show another dimension of what peer support is able to do.
She is still keeping records, and is proud of what they are already seeing of the potential in one little room. Eight of the 10 people who have stayed there entered a residential program. This past week, one of the bed’s first occupants to enter treatment returned to the center, thankful and glowing, ready to access outpatient medical support and job coaching, she said.
“It’s giving people a place to be and to hope,” Bennett said. “We need to close this one gap. So we’re going to do that with one bed, and keep it really simple, and keep it really safe, and see what happens.”