The Town that Tried it All
What we can learn from the fight against addiction in a small New Mexico town
ESPAÑOLA, N.M. — Fernando Espinoza has known dozens of people killed by addiction to drugs and other substances. An aunt. An uncle. A cousin. Too many friends and fellow inmates to count.
Espinoza, 32, has spent 14 consecutive birthdays in jail. When he’s out, he lives with his mother at her home in Española. He has two daughters, a GED, and an addiction to heroin that feels like something scratching inside his brain.
Against steep odds in this dusty New Mexico town, he is still alive.
Here in Rio Arriba County, where one in five residents lives in poverty, people overdose and die more often than almost anywhere else in the country. Over the past five years, the county’s overdose rate was three times the statewide average, and more than five times the national rate. According to a 2013 survey of 969 Española teenagers, nearly 5 percent of high school students had used heroin within the last month, as opposed to 2.9 percent statewide.
New Mexico has not stood by as fatal overdoses skyrocketed in Rio Arriba County — from 7 in 1990 to 40 in 2014, according to state health department data — and statewide, from 131 to more than 500. The state boasts one of the most sweeping harm reduction programs in the nation. Rio Arriba County is home to a nationally recognized doctor who prescribes proven anti-addiction medications, several local drug treatment centers, and an anti-overdose strategy that puts lifesaving drugs into the hands of law enforcement. Drug-ridden towns elsewhere are just discovering strategies Española has been practicing for decades.
So why, given New Mexico’s pioneering efforts, hasn’t the situation improved?
Attempts to treat addiction here have been undermined by a failure to focus on prevention, a lack of resources and an unanticipated boom in prescription drug sales. And for all the state and county have tried, their efforts have not changed the factors that drive people here to addiction in the first place. Among them: generations of poverty and a lack of jobs that leave people with few good alternatives.
On a hot day in late July, Phillip Fiuty, an outreach worker with the Santa Fe Mountain Center, stood quietly as a petite woman shook hundreds of tiny used syringes from a plastic bottle. They clattered into a box inside Fiuty’s unmarked white van, parked under the awning of the woman’s trailer home in Española. In exchange for her used needles, the woman will receive hundreds of new ones, along with other supplies she needs to inject and smoke heroin: rubber straps, tiny metal cookers, clean cotton filters.
Five days a week Fiuty and harm reduction program manager Dave Koppa drive the streets of Española, visiting homes, stopping in parking lots and open fields, and pulling over when people wave at them from sidewalks. They offer tips on how to shoot heroin without creating infected abscesses. They explain the dangers of mixing pills and alcohol, and give out for free an overdose reversal drug called Naloxone.
In between, they talk with people. About the weather, about a mother’s new child. Some addicts apologize, saying they messed up when they started using again. Most don’t.
Before Fiuty left the woman’s house, they hugged.
Needle exchanges like this one have existed here since the New Mexico Harm Reduction Act of 1997 charged the state Department of Health to launch the controversial programs that now serve thousands of people across the state. The idea is to prevent unnecessary harm — like Hepatitis C or HIV — among drug users while building trust and helping those who are ready into treatment. In the past year alone, the Santa Fe Mountain Center’s needle exchange programs collected over 1 million needles, gave away more than 3,000 doses of Naloxone, and recorded more than 700 successful overdose reversals.
While New Mexico has more than 30 needle exchange programs, neighboring Colorado, where syringe exchanges were illegal until 2010, has only seven. In Appalachia, another region hit hard by substance abuse, there are just a handful.
Needle exchanges are only one fix among many. In 2007, New Mexico adopted the nation’s first “Good Samaritan Law,” protecting people who call 911 during an overdose from prosecution for possession charges. Today, most states have some version of the law. New Mexico was also one of the first states to allow pharmacists to give out Naloxone without a prescription, and the first to permit all emergency medical responders to administer the drug.
Hailed as a solution, too, is an opioid replacement drug called buprenorphine, which blocks cravings and withdrawal symptoms. The drug’s potential to help people addicted to opioids is clear: a 2003 study of 40 opiate addicts in Sweden found that of 20 people prescribed group therapy and a daily dose of the drug, 75 percent stayed in treatment a year later. Of the 20 people who received the same counseling but just a placebo, none stayed in treatment, and four died.
More doctors have the certification needed to prescribe the drug in underserved areas of New Mexico than the national average, thanks in part to an aggressive outreach strategy from the University of New Mexico’s nationally acclaimed Project ECHO, which has conducted teleconference trainings for doctors to earn the waiver for more than 10 years.
Among those doctors is Leslie Hayes, a family physician in Española prescribing buprenorphine to about 95 patients, who recently won national recognition for her work.
Family and home life tend to improve and job stability often increases for patients who stay on the medication, Hayes said. Free from aggravating cravings, people can begin to build a better life.
Among the Rio Arriba County residents trying to fight his addiction is Fernando Espinoza, the 32-year-old heroin user, who continues to rotate in and out of jail. Every time he leaves, he said, it’s the same story.
“I come back to nothing,” he said. “I don’t have a car, a license, don’t have a home.”
Would-be employers call him a liability. He’s worked as a mechanic, laid concrete, drilled wells, sold burgers at fast food restaurants. He said he was once enrolled in a diesel mechanic college in Colorado, but lost his scholarship after a DUI. His treatment history is sporadic, too. He lasted a week at a substance abuse treatment center in California, and about a month at a center in Albuquerque. Once, while incarcerated, he was temporarily prescribed buprenorphine, but that didn’t last either.
This time, since being out, Espinoza has spoken at a county meeting about a new initiative meant to curb overdoses by tracking outcomes for substance abuse treatment services. He attended a daylong substance abuse conference with his mother, Lupe Salazar, 49, who is raising Espinoza’s 2-year-old daughter, Estrella, just like her mom raised Espinoza. Salazar, a quiet woman with a soft smile and piercing eyes, is dedicated to reuniting Estrella with her dad. She recently founded a nonprofit group to bring holistic healing to families suffering from addiction.
“By the grace of God, I still have my son,” she said. “But there’s a lot that don’t.”
One afternoon in June, Espinoza played with Estrella on a swingset in front of his mother’s home. He had been out of jail for a week, and wore a white undershirt and baggy khaki pants. They stood together, pushing the swing back and forth. After one energetic shove, Estrella tripped and fell to the dirt. Espinoza lurched toward her.
“You OK?” he asked. “Let me see.”
The swinging began again. Espinoza cooed softly to his daughter.
Espinoza’s talk about his recovery is rife with contradictions. One moment, he is hopeful, saying he wants his daughters to know how important they are to him. The next, he is frustrated with how little he feels he has accomplished.
“I don’t have nothing,” Espinoza said. “It’s not because I don’t want it. It’s because I’m never around long enough to establish myself. Every time I get out, I go back.”
He talked with reverence about the day, a year from now, when he would be “off paper,” his parole over.
“Until that day comes, I’ll constantly be looking over my shoulder,” he said. “I’ll be nervous. I won’t have any peace until then.”
That such recidivism persists despite the state’s efforts haunts Salazar and other advocates. For one thing, the community’s need has always exceeded its resources. Except for pregnant women, Hayes, the buprenorphine-prescribing doctor, has hardly taken a new patient in three years. A local residential treatment center, Hoy Recovery, has nearly 50 beds — eight of them for detox — but they are regularly full of people from around the state. On a recent afternoon at Hoy, the waitlist for men was 28 people long.
“The services that are available work,” said Lauren Reichelt, head of the department of health and human services in Rio Arriba County. “Just not at a scale to meet the need.”
In recent years, too, sales of addictive prescription opioids like oxycodone and hydrocodone have soared in the U.S. — quadrupling since 1999, according to the CDC — despite no change in the amount of pain Americans report. That corresponds with a nearly identical increase in deaths nationally due to opiate prescriptions, which also quadrupled since 1999. Since 2006, overdoses involving prescription drugs in New Mexico have outnumbered those involving illicit drugs.
Prescription drug addiction is a problem created by the health care system, said Tim Condon, a professor in the University of New Mexico’s Center on Alcoholism, Substance Abuse and Addictions. Aggressive marketing by pharmaceutical companies coupled with archaic prescription monitoring programs led to a rise in prescriptions, and doctors are now grappling with the effects.
“People keep asking, have you made a difference?” said Hayes. “It’s like, no, it’s gotten much worse since we’ve been doing this. I know I’ve made a huge difference in individual patients’ lives. I haven’t yet seen that it’s made a difference in the community.”
A few promising strategies also aren’t available in Española: there is no transitional housing available for addicts coming out of jail or rehab, and little substance abuse treatment in jail. Providers say prevention efforts are the last to receive funding, and the first to be cut.
“What happens so often is we are not diagnosing substance use disorder until the alcoholics have cirrhosis, or until the people with opiate use disorder have several overdoses,” Hayes said. “We are not trying to catch people early.”
Other promising programs have met a dysfunctional death in the local political system. The county, for instance, recently began training teachers to use a prevention program in local schools called the Good Behavior Game, which rewards good group behavior rather than individual behavior. A study of the game in high-poverty Baltimore schools showed the program helped improve graduation rates and reduced the likelihood of drug abuse and dependence disorders.
But the school superintendent who supported the initiative resigned. (She was the 10th schools chief there in 13 years.) As of early August, Reichelt hadn’t met the new superintendent, and didn’t know whether the program would continue.
Untouched by every anti-overdose initiative, doctor and treatment center is the crippling influence of poverty and the uniquely intergenerational nature of drug abuse here, where some family members use together.
Even for those not addicted to substances in Española, the economic picture is grim. At 8 percent, unemployment in Rio Arriba County tops both state and national averages. The city’s schools graduate just 60 percent of their students, compared to nearly 70 percent statewide. Median incomes and home values are lower than statewide averages, and according to a local community services agency, more than half of all children under the age of 6 are cared for by their grandparents.
An economic uptick wouldn’t solve Española’s drug problems, Reichelt said, but it would sure help.
Chronic financial instability often goes hand-in-hand with regular drug use in Española. Among 15 pregnant women at high risk for alcohol or substance abuse surveyed during an intervention program in Rio Arriba County in 2009, for example, only one was judged to be financially stable. Eleven said financial instability was a barrier to accessing or receiving treatment services. On the other hand, research shows that getting and keeping a job is among the best predictors of long-term recovery. One study of 59 women in a long-term treatment facility found that reductions in substance use were associated with greater economic autonomy.
Without a job, people like Espinoza reenter the exact same environment after treatment or jail, simply expecting a different outcome.
Given his bleak job prospects and largely untreated addiction, it was, perhaps, only a matter of time until Espinoza relapsed.
On Sunday, July 17, Espinoza turned 32; Salazar and Estrella sang him happy birthday. Later that day, Espinoza ran into cops in the Wal-Mart parking lot, where he had shoplifted once about eight years ago. Police say Espinoza assaulted an officer.
By 4 p.m., he was behind bars for violating his parole.
Jail is at once painful to Espinoza, and oddly comfortable. “All of our pain in here, we share it,” he said from behind a glass window at the Rio Arriba County Detention Center in Tierra Amarilla, 70 miles north of Española, on July 22. In jail, things feel normal, Espinoza said. He’s with the same 50 or 60 guys who have rotated in and out with him over the past decade, the friends he’s known since he turned 18.
A sleeve of dark tattoos covers Espinoza’s left arm, a mural of flames and skulls. This is his bad side, Espinoza said. Engraved here are images that represent temptations, vices. His right arm is nearly bare, save for his daughters’ names tattooed below his wrist and a tiny pair of hands pressed together in prayer — his good side, he said.
Treatment didn’t come soon enough for Espinoza: He was four days away from an appointment at a treatment center in Santa Fe when he was arrested. He was working on getting his Social Security card, which he’d need if an employer ever took a chance on hiring him, breaking his cycle of chronic unemployment.
Now, Salazar is again caring for Estrella. The little girl was just getting to know him, Salazar said.
By now, it’s a familiar drill. Salazar will wait. She will call the jail. She will sit in near-empty courtrooms for hours, waiting for her son’s 15-minute proceeding. Whenever he gets out she will be there. And maybe they’ll try again.