Oregon’s meth problem: More money than leadership

Editor’s note: This is Part 2 of a two-part series about how — despite a windfall of new funding — the state has no plan to address the “new meth” that is overwhelming behavioral health providers and inflaming ongoing crises across the state. Read the first story, about the way meth has changed to be more toxic to users.

In November 2020, when voters decriminalized small amounts of meth and other hard drugs with Measure 110, the rate of meth use in Oregon had already climbed higher than any other state.

Meanwhile, many in Oregon say the meth problem has changed. The drug has become more potent, harmful and ubiquitous. And while not everyone using the drug experiences psychosis, many people who do struggle with more severe and longer lasting mental illness, often punctuated by homelessness.

In approving Measure 110, voters may have thought they were addressing Oregon’s long-standing abysmal rankings in addiction rates and access to treatment. That’s because the new law unleashed a windfall of spending — $300 million every two years — that proponents said would pay for “drug treatment and recovery services.”

But despite widespread awareness among behavioral health providers and policy makers, there’s been little public recognition of the outsized role meth is playing in problems plaguing Oregon’s hospitals, jails, mental health system and homeless communities. And early indications from spending under Measure 110 suggest that addressing the cascading effects of meth won’t be a focus. As a result, important potential responses to the problem won’t get the support they deserve.

Top state officials interviewed for this article conceded that meth and its effects on the behavioral health system have not received enough attention, despite lawmakers’ approval of significant new spending.

“We’ve been fortunate in having a billion dollars in new investments in the behavioral health system, but that’s a lot to implement,” said the state’s behavioral health director, Steve Allen. “So some of the pieces — like a focus on methamphetamine — have had to take a bit of a backseat.”

This blind spot illustrates how the state has failed to map out a plan to ensure the unprecedented spending underway will actually address Oregon’s most pressing needs.

Local officials and experts say that needs to change.

“There is no plan at all, there is no coordination,” said Multnomah County Commissioner Sharon Meieran, an emergency room doctor who has long called for behavioral health reforms. “We are watching more and more people dying, we’re watching the impact on mental health increase. We need to be addressing all of it in a comprehensive way.”

Without a comprehensive plan for combating the effects of Oregon’s growing meth problem, or leadership to drive it, promising interventions fail to be prioritized or are left entirely on the shelf, The Lund Report has found.

A new approach

Measure 110 was intended to reverse the harmful effects of the war on drugs, which disproportionately impacted people of color, by putting people from communities most harmed in charge of spending hundreds of millions of tax dollars to expand addiction and recovery services.

But the law isn’t playing out as expected in a variety of ways — just ask Billy Nunemann.

When voters passed Measure 110, they put in place a hotline for people to call if given a ticket for drug possession. By agreeing to a substance use screening, ticketed people could get their $100 fine waived and be referred to treatment services if they wanted.

Nunemann is the Addictions Recovery Program supervisor at Lines for Life, which oversees the hotline. The problem? He doesn’t get a lot of requests for help, and when he does, he may not have the right kind of help to offer.

Police aren’t writing many tickets for drug possession, and as of April, more than a year after the law went into effect, only about 100 people had called the hotline. Fewer than half asked for resources. When they do ask for residential treatment or detox, they are waitlisted, said Nunemann.

Those services are not prioritized for funding under Measure 110 the way that peer services, harm reduction, housing and low-barrier out-patient treatment are.

Nunemann, who is himself in addiction recovery, said what people recovering from meth really need is their own specialized treatment program — like people with opioid use disorder have. Right now, the system doesn’t offer the long-term recovery that people in recovery from meth use need to clear their “ravaged” brains, he said. “It’s just not how our system is set up.”

Years ago, with available funding targeted to opioid treatment, “we did forget about meth,” said Reginald Richardson, director of the state’s Alcohol and Drug Policy Commission.

The system is the problem

While officials often talk about mental health and addiction services in one breath, calling them “behavioral health care,” the reality is that they are largely two separate systems in Oregon.

This is a problem because about half of the people who have a mental health disorder also struggle with addiction, according to the National Institute of Mental Health. Experts say those patients need integrated care. That includes the growing population of people experiencing meth-involved mental illness in Oregon.

But the separation between addiction treatment and mental health services has been baked into funding, training, staff credentialing, licensing certification and “the hearts and minds” of service providers over many years, Allen, the state’s director of behavioral health, said. Dismantling those barriers will take time, “and that process has only just begun — there’s years in the making to really have people rethink how we do that.”

In 2012, 2016 and 2019, highly touted efforts to integrate the different arms of Oregon’s systems either did not solve the problem or were simply dropped.

Lawmakers tried again in 2021 to tackle the fragmented situation with House Bill 2086, which directed the health authority to take steps toward a more integrated system. But Richardson said the issue is “the speed in which the health authority can implement its provisions.”

Confronted with the absence of a coordinated strategy to address the new meth and the complex needs of its users, officials at the Oregon Health Authority and at the office of Gov. Kate Brown said the state is fixing the system holistically to help all who struggle with addiction and mental health disorders. They pointed to recent investments in “behavioral health care” and largely, to Measure 110.

But much of the infrastructure funded with the Legislature’s billion-dollar investment in the “behavioral health care” system is actually going to mental health services that don’t include addiction treatment.

And when questioned about the state’s approach to combating meth addiction, a spokesperson for a coalition of the law’s proponents said that’s not Measure 110′s job.

“Our interest as a coalition is not necessarily to reduce SUD (substance use disorder) in Oregon,” said Tera Hurst, of the Health Justice Recovery Alliance, “but to stop the ongoing harms of the war on drugs, end fatal overdoses, reduce stigma and make sure that people have access to whatever services they need to stay safe and alive.”

“We have never said that (Measure 110) is the only thing that our state should be doing to address this issue,” Hurst added. “We’ve always said this is a piece of the pie, but it’s not the full pie.”

The council set up to oversee Measure 110 spending is composed of people with lived experience in addiction and who represent various disciplines around substance use and reform. Administering a grant program and designing a system of treatment services is new territory for the council’s members. Despite this, they receive little guidance in spending the river of money voters gave them to fix the addiction services system.

Instead, the council has an agenda that does not prioritize some of the interventions experts say would help people struggling with meth use, mental illness and homelessness: residential treatment beds, secured facilities and programs that treat mental health and addiction simultaneously.

Critics say the state’s new approach doesn’t do enough to get people to enter actual treatment.

“There is an ethos that this is a personal choice and that it’s somehow judgmental or disrespectful of personal autonomy to urge and encourage people to get treatment,” Dwight Holton, CEO at Lines for Life, told The Lund Report.

Promising solution denied

As reported by The Lund Report earlier this week, meth is increasingly driving costly overcrowding at the state’s psychiatric facility, the Oregon State Hospital. The ripple effects are felt system wide, with other hospitals forced to warehouse patients who can’t get in. The problem affects communities across the state and can have catastrophic effects for the people that don’t get the help they need.

Judge Nan Waller presides over Multnomah County’s mental health court, and a significant portion of her docket is filled with people battling meth use, homelessness and mental illness simultaneously. She said many need to be stabilized in a secure setting, and “there is no access to that in the community right now.”

So she has helped plan a proposed meth stabilization center intended for Portland to divert meth users away from hospitals and jails and into a stabilization center instead, where they could be connected to resources instead of criminally prosecuted or discharged back to homelessness. The idea has been a focus for local officials and providers. Waller said while the initial focus will be on meth, the facility would also “provide triage, assessment, warm handoff to services — a much more comprehensive vision than simply stabilization.”

Organizers in Multnomah County recently asked the Measure 110 oversight council to help fund the effort, only to be turned down, sparking a backlash from supporters.

Such a facility would have helped one Portland-area woman, who told The Lund Report about her experiences on condition of anonymity due to the stigma around mental illness and meth use.

She has bipolar disorder with schizophrenic side effects, she said. Her only diagnosis when she began using meth was depression. The hallucinations and “grandiose thoughts” — like thinking the U.S. president was going to buy her a car — came with drug use, though they persist without it. She’s not sure if meth caused her disorders; her family has a history of mental illness.

In 2014, the woman was high on meth for three days when she began to believe that a house down the street from where she lived in Beaverton had been built especially for her. Her delusions led her onto the property, and her acute psychosis elevated the situation when she was asked to leave. Eventually police removed her from the property where she believed she was supposed to be living. She was taken directly to the jail in Hillsboro, where she waited for admittance to Oregon State Hospital to be restored to competency to face charges. She said staff at the jail gave her little information about her situation.

“I felt scared. I felt alone. I felt like I was locked up for no reason,” she said. “I started seeing things, like vampires.”

Opportunities missed

Part of the problem is a lack of focus and leadership, many say. In 2019, the state’s Alcohol and Drug Policy Commission created a strategic plan for strengthening Oregon’s treatment and recovery system. The state is two-and-a-half years into the five-year plan, but many of its ambitious goals haven’t moved far off paper. Richardson, the commission’s director, cites a lack of funding and administrative support. “I’ve got myself and two staff. There’s a lot of things we have to do, but it gets down to a bandwidth issue,” he said.

Creators of the plan coordinated with the Governor’s Opioid Epidemic Task Force, but there was little strategizing around meth, which Richardson said is a bigger problem in Oregon than opioids. There was more focus on opioids because that’s where the federal funding was, he said. “We don’t have good treatment options” for meth use like there are for opioid use, Richardson said. “I’ve got no answer for meth.”

But experts say there are promising and emerging approaches to address meth use, and they suggest that treatment that tackles addiction and mental health disorders in tandem would be the best approach for many people struggling with the drug.

One promising method of treatment is known as “contingency management,” referring to programs that reward meth users with money or gift cards for drug-free urine samples or successful engagement in treatment. A large body of evidence shows it’s highly effective, but while Measure 110 has funded some rewards-based programs that tackle meth, it hasn’t done so in a methodical way.

There are also medications shown to reduce methamphetamine cravings or use in some patients. Though two providers in Portland have recently established programs offering these prescriptions, their enrollment is strikingly low. Some providers around the state who offer medications to ease opioid addiction told The Lund Report they were unaware of medications that could help methamphetamine addiction.

The addiction treatment advocacy group Oregon Recovers has recommended the addition of 500 detox beds to Oregon’s system, a 500% increase in residential treatment beds, as well as the creation of 7-day respite centers that would have beds for people who need to transition between detox and treatment —which advocates say would be especially beneficial to meth users.

But there has been “no progress” on any of these initiatives, said Mike Marshall, the group’s co-founder and director. He said state officials “are simply not taking responsibility for building the infrastructure needed to end the crisis. They are simply focused on distributing money.”

The Oregon Health Authority is working on plans for crisis stabilization centers that would “provide specialized short-term care in a residential setting for individuals experiencing behavioral health crises and are meant to serve as an alternative to placements in emergency departments and jail,” said Rusha Grinstead, Behavioral Health Crisis System and 988 Lead for the Oregon Health Authority.

Crucially, it’s not yet known whether they will house people for up to five days, which experts say is what people coming down off meth need to stabilize.

The state has not given meth enough focus, the state’s behavioral health director, Allen, said.

“We haven’t been able to elevate it to the level that it really deserves,” he added. “This is a big problem. And it’s likely to get worse.”

Need for leadership

Marshall, of Oregon Recovers, used meth for 10 years before entering recovery 14 years ago. He said he’s “always assumed that our mental health problems are largely being driven by meth.”

He said state leadership, at the governor’s office and health authority, have failed to prioritize the state’s existing strategic plan for building a system of care in the first place.

“There’s no behavioral health system relative to SUD (substance use disorder)” Marshall said, “it’s fractured and incomplete.”

He said the health authority has focused on administering legislative directives, but has failed to lead and innovate to address problems it’s responsible for addressing — such as the state’s addiction crisis.

A plan for meth should not overshadow the many other areas that need attention, many Oregon experts said. But meth is causing high-impact, high-cost problems that deserve focused attention.

In 2004, when the state was also in the midst of a meth surge. Then-Gov. Ted Kulongoski convened an interdisciplinary task force that brought together experts in prevention, treatment and law enforcement. Allen told The Lund Report he suggested convening a similar task force to Gov. Kate Brown, one aimed at synthetic drugs, including fentanyl. He said he brought it up this past fall, and then again in the spring, but there’s been no follow-up.

Charles Boyle, spokesperson for the governor, said Allen’s suggestion came as the state was dealing with the omicron surge.

“Rather than standing up a new task force in the midst of that surge, we instead prioritized actions that could be taken immediately to address synthetic drugs,” he said, and then listed actions taken to address synthetic opioids, though not meth.

“While Oregon has made historic investments to address substance use disorder and behavioral health,” Boyle said. “This implementation work will continue into the next administration.”

Leadership at the state’s health authority also urged patience.

“Oregon’s underfunded and fragmented behavioral health system hasn’t worked well for many decades …but that’s changing,” said Pat Allen, the director of the state’s health authority. “This transformation is fully underway, but it can’t happen overnight.”

But others stress the need to come up with an integrated approach now — while the state has unprecedented resources for behavioral health at its disposal.

Meieran, the Multnomah County commissioner, said the state should appoint a “meth czar” with accomplished staff to tackle the “inextricably linked” issues around meth holistically, in close coordination with the justice system and agencies tackling homelessness.

“We need to have been addressing this yesterday. And watching it unfold is like watching the slow-moving train coming towards you and not being able to stop it,” she said.

“We need to be the ones on the cutting edge looking for the answers, implementing innovative approaches that other jurisdictions are looking at — rather than just waiting for the train to hit.”

This story about the Oregon government’s response to the meth problem was produced by The Lund Report, an independent nonprofit health news organization based in Oregon. The Lund Report is tracking addiction issues as part of a reporting fellowship sponsored by the Association of Health Care Journalists and The Commonwealth Fund. Emily Green can be reached at emily@thelundreport.org.