By Maxine Bernstein
oregonlive.com
PORTLAND, Ore. 鈥� Millions of dollars and tens of thousands of hours over the last four years have gone into trying to reopen a bigger and better sobering center as the need has grown more urgent.
More than 80 groups involving nearly 200 people from varied backgrounds came to the table 鈥� healthcare executives, addiction service providers, police and the people who have needed the help.
The stakes were as high as they were vital: Portland鈥檚 decades-old and transport vans, the only drop-off program of its kind in a city of 635,000 roiled by an epidemic of drug overdoses, had abruptly shut down in late 2019.
The broad new group mapped out a vision for a substantial upgrade: A place that could handle an influx of more profoundly disturbed people often agitated by the intertwined complications of fentanyl, methamphetamine or alcohol use and mental illness.
It would serve as a 鈥渇ront door鈥� for police and other first responders to take people for immediate help and where nurses, doctors and peers could give them a chance to sober up, assess their problems and connect them to treatment or other services.
The underlying principle of the group鈥檚 proposed : 鈥淕et people the help they need as early as possible in the safest and most supportive setting as possible,鈥� while diverting them from overrun hospital emergency departments or jail.
But their enormous effort collapsed in a thicket of conflicting city and county interests. A sobering center now appears at least another year away, if it ever becomes a reality.
The broad coalition fell victim to competition for money, the lack of a single, strong champion and a schism between public safety and behavioral health priorities, according to interviews with more than two dozen people directly involved.
Also contributing to the demise, they said: a reluctance to expand involuntary holds for intoxicated people, rapid turnover among county health managers and a frosty relationship between the mayor and former county chair.
Since the work began, heavy fentanyl abuse has gripped the city and state. Oregon has the second highest rate of substance use disorder in the nation and ranked 50th for access to treatment, according to the state鈥檚 public health authority.
Portland firefighter paramedic David Fredericks, who testified before the City Council in September, estimated Fire Station 1 in downtown Portland responds to about 300 overdoses a month. During a 48-hour shift that month, he responded to 16 overdoses, he said.
Meanwhile, smaller communities, including Washington County and Klamath Falls, have been able to plan, design and set aside money for their own addiction and mental health crisis drop-off centers, as people eager for one in Portland are still trying to convince Multnomah County leaders of its worth.
The county, as the local mental health authority, has taken over the project. The county chair recently set aside $150,000 for more planning and asked another commissioner to return with a full proposal for the 2024-2025 budget.
鈥淭o see other jurisdictions have been able to develop and implement and build what we were talking about 鈥� what we鈥檝e been talking about four years ago, I think it鈥檚 distressing on many levels,鈥� said Laura Cohen, one of the key architects of the failed plan.
STARTING POINT
The Sobering Station had served the Portland metro area since 1971. The nonprofit Central City Concern took it over in 1985, along with two white transport vans. The city began funding it in 1991.
Van drivers roamed the city looking for intoxicated people and brought them back to the station in Northeast Portland to dry out, usually for a couple of hours. At first, it mostly handled alcohol cases.
Police and fire paramedics were frequent customers, dropping off people they encountered on the streets or in response to 911 calls.
By December 2019, the station was unable to handle Portland鈥檚 growing population of people on meth suffering drug-induced psychosis. They were harming themselves and the staff. It closed after reported egregious safety problems in the station鈥檚 isolation cells and lack of safety checks and regulations.
鈥淚t left a big hole in what we can do,鈥� said Portland police Officer Daniel DiMatteo, with the Police Bureau for 14 years and now working Central Precinct patrol. 鈥淲hat am I going to do with you? I can鈥檛 just leave you here because you鈥檙e going to go in the street trying to fight every car that goes past.鈥欌��
Police now take people to either a hospital ER, jail or the Unity Center for Behavioral Health, a psychiatric emergency department run by the area鈥檚 four major hospital systems.
But 鈥� aggressive and angry on meth, for example 鈥� and often won鈥檛 accept them or quickly releases them.
Officers see people back on the street within hours without support or services in a 鈥渞evolving door,鈥� DiMatteo said.
When the Sobering Station shuttered, Cohen was a senior director of diversion services at Cascadia Behavioral Healthcare, a major provider of mental health and addiction treatment.
She said her team members came to her because they couldn鈥檛 find safe places for clients who were in the throes of severe drug addiction or mental illness.
Cohen learned that others in the city, including Multnomah County Circuit Judge Nan Waller, also were exploring ways to fill gaps in the system.
The judge presides over the county鈥檚 mental health court and cases involving people facing criminal charges but who aren鈥檛 well enough to assist in their defense.
In the summer of 2019, Waller had attended a regional state court gathering with Oregon behavioral health leaders.
She said they learned about an around-the-clock center in Arizona where police and first responders take people suffering from intoxication or drug-induced psychosis, so they don鈥檛 end up in the criminal justice system.
Cohen and Waller saw the Sobering Station鈥檚 closure as an opportunity to develop a more modern and responsive sobering and mental health crisis triage center in Portland. The old sobering model had dedicated staff 鈥� typically one emergency medical technician and two peer supporters during a shift 鈥� but no doctors or nurses regularly on site.
Cohen and others approached Mayor Ted Wheeler鈥檚 staff, seeking the city鈥檚 support.
The mayor soon hired Bob Day, a retired Portland police deputy chief, to lead the rebuilding effort. ( Wheeler recently tapped Day to become Portland police chief.)
GAINING MOMENTUM
The organizers wanted to provide one place for police, firefighters, mobile crisis workers and other first responders to take someone in distress.
Once the person is there, 鈥渓et the clinicians, let the psychiatrists, let the social workers, let the nurses figure out what鈥檚 happening and figure out what the next steps need to be,鈥� Cohen said, while allowing people to 鈥渃ome down off of whatever it is they鈥檙e on.鈥�
By the end of 2020, Day urged the mayor to hire someone with public health experience to move the work forward. Those involved up to that point were largely volunteering their time.
CareOregon, the biggest health insurer for people on the Oregon Health Plan, brought in Lones Management Consulting run by Aaron Lones, who had done prior project management work with local healthcare providers, in December 2020.
The city and CareOregon together paid about $1.5 million for Lones鈥� company to lead the planning. While county representatives participated, county leaders refused to help fund the effort at that time.
The group became known as the Behavioral Health Emergency Coordination Network, or BHECN (pronounced Beacon). Members met via Zoom through the pandemic.
Lones set up committees to drill down into details: criteria for admission, services offered, lengths of stay, licensing requirements, best way to transport people to the center, funding sources, how Medicaid might be billed, whether police could place intoxicated people on involuntary holds and for how long.
The network pictured a 鈥渕ore trauma-informed version鈥� of the white van, with an EMT and peers taking people to an appropriate place for treatment 鈥� sometimes the new sobering center but sometimes Unity or a hospital, if necessary.
The center ideally would be located next to a hospital, they said. It would serve up to 50 people at a time.
The network鈥檚 in 2022 estimated the first year of leasing a space and operating the center would cost about $15 million, then $8 million to $10 million annually.
It would cost about $500,000 to start a special transportation service, they estimated, and the group obtained a three-year $550,000 federal grant to develop it. (Recently, the city forfeited the grant because of lack of action).
A delegation including Day traveled to Tucson, Arizona, to learn about its Crisis Response Center and came away impressed with Margie Balfour, an associate professor of psychiatry who helped write a 鈥淩oadmap to the Ideal Crisis System,鈥� and is chief of clinical innovation for the contractor operating Tucson鈥檚 crisis center.
鈥淥ur philosophy is that substance use and mental health issues go hand in hand so you know, we address both,鈥� she said. 鈥淲e want the people that are agitated, potentially violent, psychotic, hearing voices, intoxicated, in need of withdrawal services.鈥�
鈥淭hey can show up voluntarily or it can be involuntarily as well. 鈥� Those are the people who are most in need of specialized care,鈥� Balfour said.
They don鈥檛 belong in a hospital ER, she said.
Balfour said the Tucson center has a separate entrance for police that allows them to quickly drop someone off, with a turnaround time of less than 10 minutes.
In her Multnomah County courtroom, Waller said she has lost count of the people appearing before her who have cycled in and out of jail or an ER.
She鈥檚 advocated for years for an improved crisis drop-off center offering immediate care and connections to the next treatment steps 鈥� a place that would help people like a man who recently begged her to put him in jail for his safety and to break away from drugs. He had been in a hospital ER 30 times in September alone, she said.
She ordered him taken into custody on a probation violation, but the jail wouldn鈥檛 accept him because he was suffering from a suspected fentanyl overdose and was unable to stand up. He was taken to Unity but released. In the following day and a half, he showed up at hospital ERs two more times seeking help, Waller said.
鈥淎s judges, we want people to get what they need, when they need it and to be stable,鈥� Waller said, and not pull people into the criminal justice system if they don鈥檛 need to be there.
PEER INPUT
Amee McFee, in recovery for drug and alcohol abuse and clean since January 2017, joined the network and lobbied the group for a central location where peer supporters, nurses and addiction counselors would all be in the same building to provide 鈥渨rap-around support.鈥�
She discussed what the center should look like when someone walks in: Should there be security, and if so, what kind of uniform should they wear? Who鈥檚 going to staff the front desk?
Judges, police, EMTs, addiction counselors and peers were all talking, she said.
McFee had lived outside for several years along the Springwater Corridor Trail in Southeast Portland. She said her sobering center had been jail or a hospital.
Her turning point came when she was throbbing in pain from blood clots and tracked down her brother, who took her to OHSU Hospital in October 2016. She was diagnosed with endocarditis 鈥� a rare heart infection that most likely resulted from taking heroin and meth intravenously.
A peer was there when McFee was released from the hospital, when she relapsed, when she got kicked out of drug treatment, when she attempted suicide and when she tried to regain custody of her children.
Now, McFee, 37, is a regional director of peer services for 4Dimension Recovery, which provides mentorship and addiction recovery for young people.
鈥淚 was so excited about it,鈥� she said of the work to create a better solution. 鈥淭hat was a beautiful experience to just sit, even virtually, with different people who work in different systems, because we all wanted to help individuals who don鈥檛 even know they need the help per se.鈥�
Others who have struggled with alcohol or drug abuse and added their voices to the network likened accessing services in Portland to trying to open a locked door that requires a secret combination.
Kevin Fitts, an advocate with the Oregon Mental Health Consumers Association, favored having the future sobering center accept involuntary admissions 鈥渢o save lives鈥� in extreme cases. He said his nephew died of a fentanyl overdose and he has a good friend who uses meth daily.
鈥淭he biggest need is the individual suffering severely with methamphetamine and extreme states of psychosis who is turning tables upside down and slugging people,鈥� he said.
The network considered extending holds for people intoxicated or suffering from psychoses.
Officers can now put people on a civil hold if they鈥檙e a danger to themselves or others. Under state law, people who are intoxicated or under the influence of drugs in a public place can be sent home or taken to a sobering or treatment facility and held up to 24 hours. People severely intoxicated can be held for up to 48 hours at a hospital or treatment facility.
Those who pose an immediate danger to themselves or others from mental illness and can be held up to 72 hours if they agree to stay. If they鈥檙e held involuntarily, a community mental health program director must investigate within three business days whether to pursue involuntary commitment and issue a notice of mental illness.
Some in the network considered seeking a revision in the law to extend an involuntary hold to five days for people suffering from drug-induced psychoses, because it usually takes longer for people to come down from meth intoxication.
Jason Renaud of the Mental Health Association of Portland said he and other mental health advocates would oppose extending any involuntary hold times without a judge鈥檚 involvement.
George Keepers, chair of OHSU鈥檚 psychiatry department, said 35 states including Washington allow involuntary treatment for victims of substance abuse through a civil commitment process. Oregon does not.
Keepers said many people with substance use disorders aren鈥檛 competent to consent or to refuse treatment for their addiction. This is particularly the case for users of fentanyl, meth and cocaine, he said.
The network didn鈥檛 reach consensus on extending involuntary holds.
Fletcher Nash, who also participated in the discussions, shared how he used to live beside the Steel Bridge in Portland, addicted to crack cocaine. He said he had no idea where to go for help.
In a last-ditch attempt, he said he flagged down a police officer he recognized from a newspaper feature he read and she helped get him into subsidized housing that offers drug treatment.
Nash is now the human resources director for the Miracles Club, a community recovery center that provides addiction and recovery help to Black residents.
When he was strung out on drugs, he said, 鈥淭here鈥檚 an overwhelming urge to get more. You鈥檙e on autopilot until you get a moment to stop and sit.鈥�
That鈥檚 what a sobering center can offer people like him, he said.
COUNTY STEPS IN
Among the biggest hurdles for the plan was how to cover the costs of a new sobering center and who would operate it. A rift between law enforcement and behavioral health executives also emerged on what services to prioritize.
Those issues turned out to be part of the group鈥檚 undoing.
Network members talked about seeking a 鈥渂raiding鈥� of funding from many sources.
In 2020, voters passed Measure 110 to decriminalize possession of small amounts of drugs including meth and heroin and divert marijuana tax dollars to pay for treatment and recovery services across the state. Soon, hundreds of agencies would vie for the money.
On April 5, 2022, top officials from Unity, Portland Providence Medical Center and CareOregon 鈥� who had been part of the network鈥檚 governance committee 鈥� asked for a private meeting with then-Multnomah County Chair Deborah Kafoury.
They urged Kafoury to have the county take over the network, she said. The county had representatives involved but wasn鈥檛 running or funding it.
Kafoury said in a recent interview that the network 鈥渢ried to have it be more of a community partnership where it鈥檚 governed by a committee.鈥�
But, she said, 鈥淵ou really do need to have one entity as a driving force, one entity to sign the contract and one entity to apply for the grants.鈥�
The following month, a state committee reviewed a request by Cascadia Behavioral Healthcare, on behalf of the network, for about $3 million from Measure 110 for initial funding for the Portland Sobering & Crisis Center.
The four-member Measure 110 subcommittee of volunteer community members considered the proposal on May 17, 2022. Groups making the requests weren鈥檛 allowed to speak.
Listening to the hearing on Zoom, those who had worked so hard to collaborate and recommend a more sophisticated sobering center with medical staff cringed as one subcommittee member argued against the request, likening the proposal to a 鈥渄runk tank.鈥�
Then the sobering center backers said they were stunned when they heard separate proposals for Measure 110 money submitted by Unity and Providence Portland to add eight sobering beds each at their facilities. No one aside from the network鈥檚 governance committee had been told ahead of time of the competing hospital proposals.
The language in the separate Unity and Providence Portland proposals read as if it had been plucked from the network鈥檚 funding request, promising a 鈥渟obering and recovery鈥� area supported by social workers and peer counselors.
Unity described itself as an 鈥渆nthusiastic partner鈥� of the broad network yet sought $3.6 million for its own sobering beds.
鈥淲e are applying independently,鈥� said Providence Portland鈥檚 proposal seeking $3.7 million, adding that the hospital remains 鈥渄eeply committed鈥� to the network.
Both Unity and Providence Portland said intake would be through their emergency departments.
Providence received about $4 million. Unity got turned down and so did the network.
NEW DIRECTION
The Unity and Providence Portland requests ran contrary to the network鈥檚 goal of diverting people from institutional settings, said those involved from the network鈥檚 inception.
鈥淚 thought we were all working together to get this thing built,鈥� said one veteran network member who spoke on condition of anonymity for fear of jeopardizing county relationships or funding going forward.
Another longtime organizer said, 鈥淚t just felt dirty to me.鈥�
Hospital officials moved to get some sobering beds funded because they saw paralysis from what they considered an unwieldy network of stakeholders with no ultimate arbiter, others involved said.
Providence鈥檚 eight sobering beds will be in renovated space inside the hospital鈥檚 emergency department with safety enhancements for patients and staff, said Jean Marks, a spokesperson. They鈥檒l be available sometime this year, she said, but couldn鈥檛 give a specific date.
Because Unity didn鈥檛 get the Measure 110 money, Health Share, an Oregon Health Plan benefits administrator, put up $4 million for capital construction of nine beds at Unity and CareOregon will pay $3.5 million a year to cover operating costs. toward capital costs. The beds are set to open by April.
They will offer a much-needed service quickly, said hospital and healthcare providers.
Maggie Bennington-Davis, Health Share鈥檚 chief medical officer, said the beds allow 鈥渇or medically supervised, medication-assisted treatment,鈥� particularly because more people are suffering from meth and fentanyl use and take longer to recover.
With fentanyl so potent and cheap, people are sometimes using it up to 24 times a day, needing it every 30 to 45 minutes, said Jill Archer, vice president of behavioral health for CareOregon. If they鈥檙e put into sobering, they鈥檙e going to go into immediate withdrawal, so they need more medical oversight and support for longer than a matter of hours.
Patients at Unity, for example, are projected to stay in the beds for two to three days.
On May 23, 2022, just six days after the Measure 110 subcommittee nixed the network鈥檚 proposal, Kafoury and Wheeler signed an agreement to have Multnomah County take over the network.
The agreement promised the county, as the local mental health authority, would work in 鈥渃lose consultation鈥� with the city, current network partners and the wider community. The city and county, it said, would work 鈥渃ollaboratively鈥� to identify and secure future funding.
Kafoury jettisoned the city-hired consultant who had been working with the network. She said the services 鈥渨eren鈥檛 needed any longer.鈥�
She supported the Unity and Providence Portland proposals to build up their own capacity with sobering beds.
The wide network that had worked together for years toward a shared goal got summarily pushed aside.
Many people who had been attending the network meetings, thinking their ideas might finally gain some traction, never heard anything about the county鈥檚 new direction.
鈥淧eople on the governance, stakeholder and other committees who had spent a ton of time invested in BHECN were cut off,鈥� said County Commissioner Sharon Meieran, an emergency room doctor who had been on the network鈥檚 governance committee and involved in the network since its start.
鈥淢eetings were canceled without explanation; fragmented groups had their own conversations,鈥� she said.
Some behavioral health professionals didn鈥檛 recognize the public safety need to have somewhere safe to take troubled people who were endangering themselves or others, she said, while police didn鈥檛 understand the massive regulations, clinical oversight and costs inherent in a sobering and crisis center with medical staff.
鈥淔actions developed, and ultimately public safety virtually disappeared from the table鈥� and Kafoury didn鈥檛 bridge the gap, Meieran said.
OTHER PRIORITIES
Some involved said they believe Kafoury didn鈥檛 want a sobering center to compete with her push to open the $24 million , a place for homeless people to go during the day to warm up, use bathrooms, wash laundry and take showers.
Others said the strained relationship between Wheeler and Kafoury also tanked the project.
Chris Bouneff, executive director of the National Alliance on Mental Illness Oregon, was involved in the network early on but then stopped participating.
鈥淭he problem in Portland is we have both the county and city involved 鈥� and I don鈥檛 know if it鈥檚 because of the complexity, the politics, the egos 鈥� but between the two entities you wonder if either can manage their way out of a paper bag,鈥� he said.
Kafoury dismissed the criticism that she couldn鈥檛 work with Wheeler but acknowledged that the county was focused on opening the $24 million drop-in day center for homeless people in downtown Portland.
鈥淚t wasn鈥檛 about people鈥檚 personalities,鈥欌�� she said. 鈥淲e were trying to open the (drop-in center), which similarly involved beginning something that hadn鈥檛 been done before. Trying to create something from nothing is challenging. We were just coming out of COVID. There was just a lot going on.鈥�
Kafoury said people had different views about what type of new sobering center should be created and some were frustrated by the months of talk with little action.
鈥淚 kind of likened it to that old adage about the elephant and everyone鈥檚 touching a different piece of elephant and so have a different idea of what it is,鈥� she said.
The city didn鈥檛 fight turning over the project to the county.
In the fall of 2022, the city issued a general request for information to see if any providers would be available to run a more robust sobering center with crisis services. No one responded, though some privately expressed interest, according to those involved.
The city鈥檚 request wasn鈥檛 an invitation to bid on a defined project, so the lack of a response didn鈥檛 overly concern those in the network still hopeful their vision would materialize.
The city pledged to help contribute money to a future network project but was now relying on the county to pick up the ball via their mutual agreement.
Wheeler said Portland needs something much different from the old sobering center, pointing to people under the influence of P2P methamphetamine 鈥� a higher potency 鈥渟uper meth.鈥� They鈥檙e experiencing extreme paranoia, violent outbursts, and antisocial behavior and are 鈥渄angerous to themselves and everybody around them,鈥欌�� he said.
With the proliferation of fentanyl use, Wheeler said, 鈥淧eople look like they鈥檙e dead on the sidewalk. They too need to be revived and can create some safety issues.鈥�
At a community forum this fall, he said: 鈥淲e鈥檒l help in any way we can. We need it. We needed it yesterday.鈥�
GOING FORWARD
Turnover in top county positions didn鈥檛 help. Since early 2020, the county has had three different Health Department directors and five Behavioral Health Division directors, including three who were in the post as interim directors.
Jessica Vega Pederson , the current county chair who inherited the project, recently won board approval of $7 million for a different kind of addiction service. The vote came shortly after the county announced in late September that it was representing the network.
The money would support a 20-bed stabilization center, a place for people to stay voluntarily from 30 to 90 days after being discharged from drug withdrawal treatment or other acute treatment.
That was the priority of many of the same healthcare executives who had been part of the network, she said. 鈥淪o we鈥檙e not releasing folks out on the street,鈥� she said.
Vega Pederson considered 鈥渨hat could we be investing in immediately to build up the system now,鈥� she said, given that no provider responded to the city鈥檚 prior request for information for a sobering center.
She said she supports Unity and Providence Portland鈥檚 sobering beds for patients who may have deeper medical needs.
鈥淭here is investment happening in sobering in a hospital environment because the sobering needs of today were a lot different than even seven years ago,鈥� she said. 鈥淭hat鈥檚 really why a higher level of medical care is needed for people who are sobering for polysubstances and fentanyl.鈥欌��
But many involved in the network鈥檚 original plan believe those services, while important, miss the point.
The county funding decisions don鈥檛 provide the one-stop drop-off center where police and other first responders can take someone struggling from a variety of problems, according to Cohen and others.
鈥淭here was a vision that many voices in the community had to develop a model that involved the ability for first responders to get people off the street to where they needed to be,鈥� said Lones, the city consultant. 鈥淲e strongly believe that needs to happen, and we don鈥檛 think that鈥檚 in lieu of other treatment models that鈥檚 developed downstream.鈥欌��
Shannon Smith-Bernardin, co-founder and president of the , said sobering beds in hospitals are more expensive to run and hospitals don鈥檛 allow for an easy drop-off for first responders. The national nonprofit was founded in 2015 by three medical professionals to support sobering care services outside of jails and emergency rooms.
鈥淲ith the number of individuals who are experiencing homelessness, including unsheltered homeless, with the amount of substance use, Portland would benefit dramatically from being able to get first responders an alternative to the ED (emergency department) and jail,鈥� Smith-Bernardin said.
At the insistence of county Commissioner Julia Brim-Edwards, Vega Pederson set aside $150,000 to enable Brim-Edwards to consult with others and propose a design for a more narrowly tailored drop-off sobering center for drug and alcohol users. It won鈥檛 be focused on mental health, Brim-Edwards said.
At a recent board briefing, county officials sounded as if they were starting from square one.
Commissioner Lori Stegmann urged the planning to be 鈥渋nformed鈥� by people with lived experience and said it didn鈥檛 make sense only to focus on people intoxicated and not those with mental illness.
鈥淒o you have any ideas about locations 鈥lose to jails?鈥� Stegmann asked a panel of police.
鈥淚 think we need a location,鈥� deadpanned Portland police Cmdr. Craig Dobson, who oversees Central Precinct in downtown Portland.
Meieran said later, 鈥淚 feel like I鈥檓 living in a dystopian version of the movie 鈥楪roundhog Day.鈥�
鈥淚t would almost be laughable,鈥� she said, 鈥渋f it didn鈥檛 have such tragic implications for real people desperately in need of a functioning behavioral health system and first responders and providers trying to do their jobs in the midst of unprecedented crisis.鈥�
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