The central act of Larry Harrison’s day is to tip back a couple of ounces of liquid that tastes like pink cough syrup. On this day in early December, he has ridden a half hour in a white Helping Hands minivan from an apartment halfway across town to do so. He did the same thing yesterday; he will do it again tomorrow.
The pink liquid contains a precise dose of methadone – in Harrison’s case, 130 milligrams of it. Methadone binds to the same brain receptors as opioids such as heroin, cutting cravings and quelling withdrawal symptoms that, in Harrison’s case, “get so bad I wish I was dead.”
Harrison, 50, has been sober for two years now. He has been clean thanks to a collaboration between UCHealth University of Colorado Hospital on the Anschutz Medical Campus and the University of Colorado School of Medicine Department of Psychiatry program called ARTS – Addiction Research and Treatment Services. Since 2018, UCHealth specialists have been identifying inpatients with substance-use disorders and enrolling them; ARTS, which has been helping those with addiction since 1972, takes it from there. While one can’t know what would have happened to Harrison otherwise, he has an idea.
“I had been on an 11-year heroin binge,” he says. “I was killing myself with heroin.”
Harrison, who was homeless for much of those 11 years, has come close before, overdosing a handful of times to the point he stopped breathing and turned blue. Abscesses have left deep scars on his forearms and lower legs and required skin grafts on his shoulders. The infections developed because he resorted to injecting under the skin rather than into veins so destroyed from years of puncturing three to four times a day that, when hospitalized, nurses have had to put IVs in his forehead, he says.
He has been hospitalized a lot. Asked how much time he’s spent in inpatient beds over the past decade-plus, he estimates: “Three years.”
A thousand days, give or take. Dirty needles brought infection after infection, and most stays involved intravenous antibiotics and observation that went on for a couple of weeks or longer. He has suffered three major and six minor strokes which have long been tied to heroin addiction (often, endocarditis – another affliction common among intravenous drug users – is the trigger). The strokes have left his left arm and leg weakened and the left side of his face partially paralyzed. He moves slowly. He tires easily. He walks with a cane.
Opioid addiction: A ‘Slave to the molecule’
Harrison is far from alone in suffering irreparable damage from what he describes as “chasing the dragon” of opioid addiction. In fiscal 2019-20, ARTS treated about 1,500 outpatients among its three clinics, and ARTS’s Potomac Street clinic that Harrison frequents is one of 28 opioid treatment centers statewide. They’re all working to slow the growing damage the opioid epidemic continues to do. Colorado saw about 1,500 deaths from drug overdoses in 2020 – up 38% from the previous year. Opioids caused more than half of them, with fentanyl being the prime culprit. Nationally, more than 75,000 people died of opioid overdoses in 2020 – nearly twice the 42,000 U.S. automotive fatalities that year.
While opioid addiction is a vexing problem, the solutions are well understood. Forcing someone who’s addicted to go cold turkey is not one of them. The gold standard is called medication-assisted treatment, and that’s what Larry Harrison is doing through ARTS. MAT recognizes that opioids can change brain chemistry in ways that overwhelm conscious resistance and that pharmaceuticals such as methadone and buprenorphine are often crucial to long-term recovery. But getting off opioids is about more than prescription drugs.
Dr. Tyler Coyle, a CU School of Medicine psychiatrist and addiction specialist at ARTS, put it this way: “Your brain just becomes a slave to the molecule, and you are not able to break free. It doesn’t matter if you have children; it doesn’t matter if you have willpower of iron. You can’t do it on your own. You need a whole team.”
In a 2020 Colorado Health Institute report, opioid experts also cited inpatient, residential, and outpatient treatment as well as “recovery supports” as being vital levers in tackling the opioid crisis. Those recovery supports include access to housing, health care and other resources – from counseling to reliable rides to methadone clinics – designed to promote recovery.
Root cause of UCHealth-ARTS connection for patients with opioid addiction
ARTS has been doing all this for years. UCH and has been treating patients for infections and other maladies caused by opioid addiction for years. It wasn’t until Dr. Susan Calcaterra arrived at UCH in 2018 that the UCHealth-ARTS connection happened.
Calcaterra, who directs UCH’s Addiction Medicine Consultation Service, came from Denver Health, where one of those 28 opioid treatment centers happens to be. She saw how the typical cycle of treating the medical maladies of those addicted to opioids and then sending them back out on the street to use drugs again, get infected again, and land in the hospital again could be broken. Infections looked like a health problem, but they were really just symptoms of the deeper disease of opioid addiction.
Her inquiries led her to ARTS Director Angela Bonaguidi, and soon Calcaterra was training as an opioid treatment provider – a precondition for enrolling patients in methadone programs. State Opioid Response Grant money channeled through ARTS would pay for a slice of her time far thinner than that which she would commit.
The program works like this. When someone with substance-use disorder gets admitted, Calcaterra visits them, assesses them, and asks if they’re interested in being a part of ARTS’s drug-treatment program.
She’ll tell them things like, “I’m here to offer you a couple of things. It’s up to you whether you want to take them. My goal is to make you feel a little bit better. And, by the way, you matter,” she explains.
For many, she says, the chaos and uncertainty of day-to-day survival has been too great a barrier to overcome. They haven’t even considered treatment programs. If they choose to participate – and often they do, as was the case on a recent Friday, when Calcaterra enrolled three patients – Calcaterra signs them up and brings in UCHealth nurse Emma Maki-Gianani, a specialist in case management and substance-use counseling. Maki-Gianani spends about four hours with the patient working through the details of their lives, explaining the ARTS program, and dealing with a lot of enrollment paperwork.
The descent into opioid addiction
With Larry Harrison, that session and the ones that followed educated him on the path forward as he educated her on what he had been through. Following a childhood in and out of foster care, a telephone-sales job in Oklahoma City turned quickly into a telephone-sales management job. He later worked for years as a property manager. He married, had two kids, and was approaching his 40s in a stable, middle-class life when, in the late-2000s, kidney stones led to an overzealous Percocet prescription, and the sorts of pill mills that have made the Sacklers infamous finished the job. The opioid addiction that roared in unraveled his life.
He, his then-wife, and two kids – a 12-year-old son and a 7-year-old daughter – came to Colorado as the weather turned cold in 2011. Robbed of what valuables they had at the bus station, they were forced to beg at intersections. Harrison resorted to selling drugs. Someone called the state Child Abuse and Neglect Hotline, and the kids were soon back in Oklahoma with his wife’s sister. He hadn’t seen them since, he told Maki-Gianani. He had been in and out of jail, in and out of hospitals, living in a vacant lot behind a Taco Bell near Interstate 225 and Peoria Street and lots of other places no one imagines themselves ever having to live, and propelled from hour to hour and day to day more or less solely by a primordial drive to feed his insatiable opioid receptors.
Calcaterra emphasizes the importance of empathy and being nonjudgmental. Harrison saw that immediately, he recalls.
“They actually care – I was so blown away by it,” he says. “I’m at a place where they care about me and won’t just throw me back out on the street. If you treat and then just let them go, they’re right back where they were. It’s kind of hard for anybody to be productive when they’re sleeping under a tree or in a mud puddle.”
Once enrolled, the patient can start on an effective dose of methadone while in the hospital. That’s important because methadone takes time to settle in, so having a good start prior to discharge boosts the odds of the patient staying with ARTS and away from used needles. UCH becomes a smooth on-ramp into the outpatient program.
“For me, it’s been very rewarding, Calcaterra says. “We’re actually treating the underlying cause for their hospitalization – the opioid use disorder which led to their infection or endocarditis. We used to send them on their way without ever addressing the underlying reason they were in the hospital.”
Cost, benefit of a partnered opioid treatment program for inpatients
For Harrison, that program included a year at Christopher House in Wheat Ridge and, since December 2020, “recovery supports” including a furnished apartment in south Denver, counseling, transportation, and the ARTS clinic, among other services.
Ultimately, that costs public money, and that gets us into politics. A commenter below a Denver Post article on methadone treatment summed up the instinctive resentment many feel: “Taxpayers must pay for more treatment options for junkies/addicts so they don’t/wont feel bad withdrawing… taxpayers shouldn’t foot the bill for weak people’s risky behavior!”
Dr. Joshua Barocas, a CU School of Medicine and UCHealth infectious-disease specialist and addiction researcher, has heard those arguments. They’re fueled by a belief that, as he puts it, “Substance-use disorders and addiction are so stigmatized, and we think of it as the fault of the person – that this is a choice. People in the general population believe that we shouldn’t be willing to pay as much.” His research focuses on health care cost-benefit analyses of addiction treatment.
“We have evolved so much as a society that we have to make an economic argument,” he says. “It’s not enough these days to say, ‘It’s the right thing to do.’ We need to pull people into the conversation by saying, ‘Look, this actually is not only the right thing to do because we’re human beings. If that’s not enough for you, we can show that this is economically cost-effective compared to what we’ve been doing.’”
The results of a recent Barocas-led study found addiction treatment programs such as ARTS to be vastly cheaper than, for example, familiar therapies for chronic health problems such as diabetes. Those figures don’t include other societal costs such as those associated with crime reduction.
The health care savings from getting people who inject drugs into long-term recovery can be astronomical. In addition to the sort of care Harrison needed, HIV is spread through those injections, Barocas reminds.
“If you prevent one HIV infection, you save $2 million in lifetime medical costs,’’ he says. “If I pay your rent for three months or three years, and that intervention gets you stabilized on buprenorphine or methadone, gets you a job and prevents you from getting HIV – isn’t that investment worth it? Even if you don’t care about the ethical side?”
Coyle added that MAT keeps addiction treatment in the preventive realm, where it can be managed with medications in much the same way that diabetes is managed with insulin or asthma with inhalers.
“That ends up making a huge difference in the health care costs, and the health care costs trickle down to everybody,” he says. “It helps people be the best versions of themselves. And that’s what we want because it’s going to benefit everybody.”
Patients with opioid addiction get back to life
It has certainly benefitted Larry Harrison. When he feels like he can handle it, he will start to taper his daily methadone dose down from 130 milligrams to, eventually, zero. But just as Calcaterra gave Harrison the choice to enter the ARTS program two years ago, the ARTS team is leaving that timing up to him.
“Having a voice has been a pivotal part of my transition,” Harrison said.
He is grateful to both organizations.
“I was on the street. I was so filthy. I was worse than a person living in a garbage can. And I was treated the same way by society, by everybody. But UCH, there’s something different about that hospital. They’re treating these drug addicts like human beings: ‘What do you think?’ ‘How do you feel?’ ‘How are we going to get through this together?’ They said, ‘We’re actually going to treat the problem.’”
With the basics of food, shelter, and MAT taken care of, Harrison has been sober for two years. As he works through his own transition to recovery, he hopes to start peer-counseling others just starting theirs.
“The whole transformation just has been so easy on me,” he says. “I’ve gone from being on the streets for 11 years to being on a path towards becoming a productive member of society again.”
From ethical, societal, and economic perspectives, that’s good news for us all.