State officials and healthcare workers are on a mission to end the suffering through rehabilitation and preventive measures.
Michael McGowan’s memories of the week he spent in a drug-induced psychosis are both incomplete and terrifyingly vivid.
“I had hallucinations that I was buried underground and couldn’t get back out,” he recalls. “I really thought I was dead.” He doesn’t remember talking incoherently to family members visiting him at the hospital. He does remember returning to lucidity, though. “The doctors and nurses on the eighth or ninth day were telling me, ‘Oh, you’re back to normal.’”
Still, McGowan was far from well. He spent three weeks in the hospital being treated for a bowel obstruction he says was caused by abusing drugs. By the time he was released, he was so weak he couldn’t walk. He’d also gone through painful withdrawal. McGowan hadn’t planned to detox; he just couldn’t get street drugs while in the hospital. But what he describes as his near-death experience birthed a commitment. He left the hospital on April 16, 2021, and a couple of days later went to American Treatment Network (ATN), a Pennsylvania-based addiction treatment provider with locations in Newark and Dover. He says he hasn’t used since and is confident he never will again.
“There’s nothing that anyone can say or do that would get me to get high,” the 40-year-old McGowan says. “I struggled for years and years…and until now, I’ve never been clean.”
McGowan’s story can be seen as one of determination: months of attending group therapy three days a week at ATN; going through intensive physical therapy to regain his ability to walk; and strictly adhering to a regimen of Suboxone (a drug used to treat opioid addiction) that requires submitting to a monthly urine test.
It’s also a story of good luck. McGowan is fortunate to have a mother who provides him with a home as he builds a new future. He is lucky to have discovered a treatment program that works for him. Above all else, he is lucky to have survived behavior that kills hundreds of Delawareans every year—and shatters the lives of countless more.
Last year, there were 537 confirmed overdose deaths in Delaware—up from 514 in 2021 and 447 in 2020, according to the state’s Division of Forensic Science. While the increase is part of a nationwide trend, Delaware has been hit especially hard by the opioid abuse epidemic, ranking near the highest in the country in per capita overdose deaths in recent years, according to the Centers for Disease Control and Prevention.
There is new hope, though, as an anticipated $250 million—Delaware’s share of the billions obtained in national settlements against prescription opioid manufacturers, distributors and retailers—has begun flowing into the state. Its Behavioral Health Consortium (BHC) is allotting the money in the form of grants to fund efforts that address the crisis. The first two rounds, totaling $13.6 million, were allotted this year, and the state is now sifting through applications for a third phase of funding.
“The funds will be a game-changer,” says Delaware Lt. Gov. Bethany Hall-Long, who chairs the BHC, a group comprising community advocates, law enforcement, healthcare professionals and state officials, that focuses on substance abuse and mental health issues. Hall-Long says Delaware is well positioned to get the money out quickly to where it will do the most good.
“One thing that has spread quickly in the illicit drug supply is xylazine, an animal sedative also known as ‘tranq.’ In April, the Biden–Harris administration designated the combination of xylazine and fentanyl as an ‘emerging threat.’ For doctors in Delaware, this was old news.”
“The [BHC] has spent the last seven years listening to community, working through community, determining where the needs are geographically, working on 24/7, 365 service needs,” she says. “So we knew where we needed to go.”
The need is vast—far greater than can be met by the settlement money. Still, the grants provide a welcome boost to the agencies, healthcare providers, treatment centers, professional organizations and community nonprofits that are working with urgency—whether it’s educating children about the dangers of illicit drugs, providing emergency help to reverse overdoses, treating addiction or supplying resources for those in recovery—to fight the deadly opioid epidemic in Delaware.
Among them is AtTACK Addiction, a nonprofit Don and Jeanne Keister founded after their son, Tyler, fatally overdosed in 2012. The all-volunteer agency works in a variety of ways, including providing drug-abuse prevention education and scholarships to help people in recovery with necessities such as housing. To Don Keister, the decade-long rise in overdose deaths in Delaware—there were 126 the year his son died—feels deeply personal.
“I think it’s sad. I do feel discouraged,” Keister says. “I wish I could say we’ve been able to do more. I wish I had the silver bullet. But I do know that we have to keep trying.”
In July, AtTACK addiction received a $300,000 grant from the BHC to fund a statewide campaign to educate people about the dangers of drug abuse and to connect those with substance abuse disorder to treatment resources. The multimedia campaign will be shaped to reach a range of ages, cultures and locations and will include a Spanish-language outreach.
As director of Addiction Medicine Services at ChristianaCare, Lisa Wallace sees daily how drugs ravage the body. Patients come in with bacterial infections that attack the heart valves, which causes abscesses in the brain and vertebrae. They arrive with devastating skin- and soft-tissue injuries that require skin grafting and, in the worst cases, can lead to amputations. Healthcare providers simultaneously treat these issues and the complications of addiction.
A nurse practitioner whose career spans more than 36 years, Wallace says she wants people struggling with substance abuse to feel safe coming to the hospital. “We want to effectively manage whatever opioid withdrawal they are having and to address their pain.
“Often, patients delay seeking much-needed medical treatment because they fear how they will be treated by healthcare providers,” she continues. “And they fear inadequate management of withdrawal and pain. Our patients need understanding and acceptance as much as they need medical treatment.”
It doesn’t stop once the immediate medical crisis is over. After the patient has gone through withdrawal and is medically stable, Wallace and her team begin talking with the person about the future. “Our focus becomes, ‘What would you like your life to look like? How can we help you live the life you want to live?’”
The BHC awarded ChristianaCare a $100,000 grant to expand its social work unit, which helps discharged patients find outpatient treatment for their addiction. This work is part of what distinguishes the hospital’s approach. The healthcare team works closely with ChristianaCare’s Project Engage, a program staffed by peer counselors who are in recovery and can help patients access services that might include residential treatment, outpatient counseling and medically assisted treatment, or MAT.
“Every patient deserves to live a life in recovery,” Wallace says. “No matter how many times they present, no matter how difficult the withdrawal, no matter how many times they have relapsed, our team and our hospitals will be here for them.”
It was a Monday in July—a return to work for Delawareans who’d taken Independence Day week off. Yet on this Zoom call, the prior week was remembered not for fireworks and cookouts but instead for the high number of suspected overdose deaths in the state.
“We lost 17 lives last week. And one life is one too many. Seventeen is horrific, frankly,” says Delaware Attorney General Kathy Jennings, co-chair with Hall-Long of the Delaware Prescription Opioid Settlement Distribution Commission (POSDC), a subcommittee of the BHC.
“Every dollar we spend must be used to save lives in our state,” Jennings told the group.
The competition for each dollar is fierce. In April, the group awarded its first $13.6 million in grants. On this July day, they were voting on where to recommend the BHC send another $10 million. The POSDC received 98 valid applications requesting a combined $74.3 million.
In the end, 38 grants were awarded: 16 for statewide initiatives, 15 for initiatives in New Castle County, three in Kent County and four in Sussex County. The smallest, $2,625, went to the Seaford–Laurel Police Department to obtain a service dog who will provide comfort for people on the scene of an overdose. The largest, $600,000, went to the Delaware Division of Substance Abuse and Mental Health (DSAMH) to pay for housing and other basic necessities for people in recovery.
A number of the grants were awarded for education and prevention: $100,000 went to the Richard J. Caron Foundation for a program targeting people ages 65 and older, and $100,000 to the Rodney Street Tennis and Tutoring Association to provide healthy alternatives to drug use for children starting at age 5. Other grants will fund training about and distribution of naloxone, a prescription drug used to reverse an overdose. (Naloxone is commonly referred to as Narcan, the brand name for the device that delivers naloxone.)
The nonprofit Supporting Kids received $300,000 to expand a grief counseling program for children who have lost parents to an overdose—a reminder that prevention, treatment and emergency lifesaving efforts fail too often.
The work of scrutinizing the applications is led by Susan Watson Holloway, executive director of the POSDC. She stepped into the role two years ago after serving as associate deputy director of DSAMH for 21 years.
“There are a lot of things at play,” Holloway says of why the opioid crisis has hit the state so hard. “Some people think it’s geographically where we sit between Philadelphia and Baltimore. There has been a lot of drug activity in those cities, and we are right off the I-95 corridor. Also, when you look at our industry, there is a lot of incentive for people to use painkillers, whether you’re in construction, restaurants, the trades. Typically, these are hourly jobs where if you don’t work, you don’t get paid, so they look for ways to keep working.”
She believes Delaware’s size is also a factor. “We’re not like other states that are spread out by many, many miles,” Holloway says. “You can get from the most northern tip to the most southern tip in a two-hour time frame. So, typically, when something starts developing in Delaware, it can—and has—spread pretty quickly.”
One thing that has spread quickly in the illicit drug supply is xylazine, an animal sedative also known as “tranq.” In April, the Biden–Harris administration designated the combination of xylazine and fentanyl as an “emerging threat.” For doctors in Delaware, this was old news.
Charles McClure, M.D., an addiction specialist at ChristianaCare, says the overwhelming majority of patients he screens for xylazine test positive for the substance.
“For humans, it’s very toxic. It causes horrible wounds and can cause overdoses that don’t respond well to Narcan,” he explains. The BHC has awarded a number of grants to fund wound care for people who inject xylazine, including $390,000 to Brandywine Counseling.
Xylazine costs less than fentanyl, produces a longer high and can be legally purchased since it is approved for use on animals, all of which have made it increasingly popular among drug traffickers.
Because xylazine is not an opioid, naloxone doesn’t reverse its effects on a person who has overdosed. For years, advocates and healthcare providers have worked to increase awareness and distribution of naloxone among first responders, educators, social workers and people who use illicit drugs. Now xylazine is thwarting this powerful lifesaving tool.
Xylazine is even endangering the lives of Delaware’s infants and toddlers. At Nemours, Stephanie Deutsch, M.D., has seen young children enter the emergency room with such symptoms as severely low heart rate and breathing problems, the result of ingesting xylazine. Months before the White House declared the substance a threat, Deutsch brought national attention to xylazine’s youngest victims with an article in the journal Pediatrics, detailing the cases of three children who had been exposed to a combination of opioids and xylazine. All three had severe symptoms; two experienced cardiac arrest. It took specialized toxicology testing to detect the tranquilizer, which might not show up in standard urine drug screening.
“It’s xylazine today. …What is it going to be tomorrow?” Deutsch wonders. “Now we have growing interest in the topic, and we have growing awareness of the lethal nature of the combination of xylazine and opioids. There is certainly the risk that this time in 2024 we will be talking about another adulterant that is posing a risk to the safety of children and adults.”
The ever-changing nature of the threat makes fighting it all the more difficult. Since taking a job at addiction treatment center AMS of Delaware, Erin Fox has seen the state’s opioid crisis evolve.
“When I came here 12 years ago, there was almost no heroin use at all. It was all prescription. There was such a free flow of prescription meds,” recalls Fox, now the center’s executive director. In Delaware, as in states all over the country, tighter controls on prescribing opioids led those who had become addicted to turn to street drugs—first heroin, then heroin laced with fentanyl, now fentanyl combined with xylazine—each innovation more profitable for illicit drug dealers and more damaging to their customers.
Fortunately, accepted treatment protocols have also evolved, Fox says, especially when it comes to MAT. “We’ve made a lot of progress, at least in the treatment community. …I feel there is a great acceptance of medication maintenance now,” she continues. “Opioid treatment providers were the outcasts, even in the treatment world, for the longest time. There is still some stigma attached to it. I’ve heard it: ‘Oh, you’re working at the meth clinic.’”
The FDA has approved three drugs for treating opioid dependence: buprenorphine, methadone and naltrexone (more commonly known by brand names including Suboxone and Vivitrol). While the drugs can be misused, taken properly they relieve the craving for opioids and, experts say, increase the chances of long-term recovery.
Still, lingering stereotypes about MAT frustrate Matthew Sullivan, CEO of American Treatment Network.
“The fact that you’ve got a standard of care that is not done by the whole industry is mind-blowing,” he says. ATN is the provider that prescribed Suboxone to Michael McGowan and that continues to monitor his use of it. Sullivan and Fox both stress that MAT should be used in combination with counseling and proper supervision.
Stigma is one barrier to getting the best treatment. Money is another. Making sure that everyone has access to state-of-the-art care is a top priority for Joanna Champney, director of DSAMH. Patients who are covered by quality private insurance or by Medicaid have plenty of options. The state contracts with providers, including ATN, to accept patients who fall in between.
“We don’t have waiting lists at any of the levels of care,” Champney says. “We are able to meet the demand currently for uninsured and underinsured clients. However, we know that we need to be assessing and screening and referring more and more people who have opiate use disorder who are suffering silently and have not reached out to get treatment. So we know we need to keep building the capacity.”
Part of building that capacity has been establishing “bridge clinics” in every county in the state. The program began in 2019 to provide free screening, referrals and other addiction-related services. Last year, the clinics began providing medication assisted treatment.
But staying in recovery takes more than addiction treatment. The $600,000 DSAMH received in the second round of opioid settlement grants will pay for necessities like housing, transportation, food, education and job training for people building new lives after breaking the cycle of addiction.
In almost any discussion of substance use disorder, the word stigma is likely to come up. Not just stigma about certain types of treatment, but about what addiction—and those who are addicted—look like. Advocates stress that anyone can become addicted and that addiction should be treated like a disease, not a moral failure. On that front, Keister sees reason for optimism. When his son Tyler died, his obituary listed overdose as the cause of death. At the time, this was nearly unheard of. Now, Keister says, it’s common.
“There are still people who don’t want others to know,” he says. “But it’s improved. It’s getting better.”