Crisis to Care: NJ’s Battle with Addiction and Homelessness

Vrinda Modi

Crisis to Care: NJ’s Battle with Addiction and Homelessness

    “Roll a rig!”, I hear over the radio a second after the tones drop. As an EMT in Hoboken, it's all too common for me to respond to at least one 911 call per shift for an individual under the influence passed out on the sidewalk—usually flagged by a concerned bystander or a police officer who believes they might need medical attention. More often than not, the real issue isn't just medical; it's societal. These individuals, often homeless, have become part of the city’s landscape, invisible to most but impossible to ignore. When I ask for their address, it's almost always the local shelter. When we arrive at the ER, we’re often greeted by familiar eye-rolls from disgruntled hospital staff. The ER clerk barely glances up, lets out a sigh, and asks, “Substance abuse?” I nod. “Who is it this time?” By now, the hospital staff know each chronic substance abuser in the city by name. Behind the hospital curtain, the patient receives temporary care—stabilized until they sober up—but within a few hours, they're discharged, back on the streets to repeat the same tragic cycle. It’s a revolving door between the shelter, the hospital, and the sidewalk, with no real intervention, and no end in sight.

    This is not just my personal anecdote. NPR highlighted the story of Larry Moore, a Camden resident described as “sick, homeless, and close-to-death drunk — on mouthwash, cologne, anything with alcohol.” Over two years, Moore visited the ER nearly 70 times. His addiction was so severe that he would wait for ER nurses to turn away, seizing the opportunity to grab hand sanitizer and drink it in the hospital bathroom. Unlike many unhoused individuals in the state, Moore was able to reclaim his life with the help of the Camden Coalition, a nonprofit dedicated to addressing the deeply interconnected challenges of housing and addiction treatment. Larry’s story is rare. For many experiencing homelessness and addiction, the reality is a stark and unending cycle.

Figure 1. Larry Moore (left) in 2020 with staff members from the Camden Coalition. The housing and addiction treatment the organization helped him get has been life-saving.1

    A meta-analysis by the Institute of Applied Health Research revealed that approximately 25% of persons experiencing homelessness (PEH) suffer from at least one serious mental illness, yet many struggle to access medical care when needed. Barriers like difficulty navigating services, healthcare costs, and pervasive stigma prevent PEH from seeking primary care, driving them instead to rely on emergency departments (EDs)—a costly and inefficient solution for their complex health issues. Many of these physical and mental health struggles compound into substance abuse and addiction issues, including alcohol and illicit drugs, and heightened overdose events in PEH.

    While fentanyl has long been considered a major overdose threat, New Jersey State Police have identified a new danger in street drugs: xylazine. This veterinary sedative, not approved for human use, was found in nearly half of the heroin and fentanyl samples tested in the second quarter of 2023. Though xylazine-related overdose statistics are still emerging, fentanyl alone claimed nearly 3,000 lives in the state in 2019, according to the Office of the Chief State Medical Examiner.

    These public health crises unfold against the backdrop of a growing homelessness problem in New Jersey. Chronic homelessness has risen by 21.2% over the past five years, with 24% of the state’s unhoused population concentrated in Essex County and 9.6% in Hudson County. Furthermore, 33% of these individuals report living with a disability, most commonly related to mental health or substance abuse disorder (SUD).

Figure 2. 48% of heroin/fentanyl tested by the New Jersey State Police contained xylazine in the second quarter of 2023.3

    So what’s going on? Why is there such a prevalence of substance abuse amongst the unhoused and why do they need to resort to emergency departments to help them? Why are these individuals 3-4 times more likely to have an ED visit in a year? It’s impossible to point at one reason. Still, the numbers paint a stark picture: PEH account for nearly 26% of public hospital expenditures for mental health and SUD treatment and approximately 1/3 of ER visits. These services come at a steep cost—averaging an astounding $44,000 per person annually.

    The strain is also palpable at the provider level, especially in New Jersey. Camden first responders report administering naloxone, a life-saving opioid overdose reversal drug, roughly three times a day. Dr. Rick Rohrback, EMS medical director at Cooper University Health Care, recounted: “They would come in at 7:00 in the morning, they would go out, they would reverse an opioid overdose and, by the end of their shift, they were going out and reversing the same patient with another opioid overdose.” This grim reality echoes my own experience in Hoboken, where I have encountered the same patients overdosing time and time again.

Figure 3. Bystanders watch as an EMT responds to a man who overdosed in Feb 2022 in San Francisco.11

    New Jersey’s approach to SUD and overdose treatment in EDs emphasizes the use of medications for addiction treatment (MAT). Among the three primary MAT drugs, buprenorphine is the top choice for many ED physicians. As a partial opioid agonist, it alleviates withdrawal symptoms and blocks the effects of other opioids, while producing only a limited euphoric effect due to its ceiling effect, which prevents stronger reactions at higher doses. One significant advantage of buprenorphine is that withdrawal symptoms after discontinuation are less severe than those associated with other MAT options. However, prior to 2017, providers faced significant barriers in accessing buprenorphine, with prior authorization processes taking days or even weeks. Delays in access often result in relapse. A pivotal change occurred in 2017 when UnitedHealthcare, healthcare providers, and the Camden Coalition collaborated to pilot the removal of prior authorization for MAT for Medicaid beneficiaries statewide. The pilot program, involving 112 patients, resulted in $59,000 in cost savings from avoided ED visits, demonstrating the impact of timely access to MAT.

    The second drug, methadone, is a synthetic opioid used to reduce cravings and block the euphoric effects of other opioids. However, methadone carries its own risks, including potential addiction and a more prolonged and challenging withdrawal process compared to buprenorphine. The third drug, naltrexone, is an opioid antagonist that binds to μ-opioid receptors, preventing the effects of opioids. Unlike buprenorphine, naltrexone requires complete opioid withdrawal before use, which can take 7–10 days under clinical supervision. This prerequisite limits its immediate applicability compared to buprenorphine, which can be started during mild withdrawal symptoms.

    In recent years, New Jersey has also made strides in expanding MAT accessibility, prioritizing marginalized populations such as pregnant women, individuals recently released from jail, patients with HIV/AIDS, and IV drug users through Opioid Treatment Programs (OTPs). Beyond MAT, Governor Phil Murphy introduced a take-home naloxone program in January 2023. Naloxone, an opioid antagonist available as a nasal spray, reverses overdoses quickly. This program allows anyone over 14 to obtain Narcan Nasal Spray for free and anonymously at participating pharmacies. In its first year, over 132,000 doses were distributed to individuals, shelters, and first responders.

    Other models like the Substance Use Disorder Treatment Program at Bergen New Bridge Medical Center also highlight the importance of bridging emergency care with long-term treatment. Patients frequently admitted to the ED for SUD are immediately connected to ongoing care rather than being discharged after stabilization through this program. Michael Paolello, clinical director at the center, emphasized the critical nature of timing: “One of the most important lessons I’ve learned in my career is that when someone with a SUD decides that they need help, you don’t let that moment pass. You need to seize the opportunity and get them the treatment they need.”

    However, New Jersey’s initiatives are not limited to these examples. In 2018, Coriell Institute for Medical Research, Cooper University Health Care, and Cooper Medical School of Rowan University launched the Camden Opioid Research Initiative (CORI), a three-part research initiative tackling opioid addiction. Their research method primarily involves biobanking, which involves collecting and storing biological samples from individuals who have died of overdose for research. One of the studies is Optimizing Pain Treatment In New Jersey (OPTIN), which aims to investigate genetic and non-genetic factors in chronic pain patients. The study will aim to provide physicians with genetic reports on opioid metabolism, enabling them to understand more about drug safety, efficacy, and dosing at the individual level. Another clinical study, the Genomics of Opioid Addiction Longitudinal Study (GOALS), aims to investigate the role patients’ genetics can play in determining optimal treatment regimens in MAT. This data could be used for pharmacogenetic medical monitoring, for example, the A1 allele of the DRD2 gene reduces the binding to opioid delta receptors in the brain, which may potentially reduce Naltrexone’s effectiveness in affected patients. While CORI is still in its early stages, the applications of this research in personalized medicine are promising as we know not every treatment for SUD is equally effective for every patient.

    Furthermore, the New Jersey 2020 State Health Improvement Plan outlines several forward-thinking policies to address the state’s substance use crisis. One notable initiative is the expansion of Harm Reduction Centers by the New Jersey Department of Health. Currently, 7 centers operate in areas with high rates of injection drug use, offering syringe access, outreach programs, and drop-in services, with plans underway to open 3 additional centers.

    Another significant measure is the Opioid Overdose Recovery Program (OORP), which connects overdose survivors in every county with recovery specialists. The program is set to expand beyond its current scope of serving only emergency department and overdose cases. The new vision for OORP includes 24/7 availability and coverage for all substance use-related admissions, not just ED/overdose cases, ensuring broader and more consistent access to recovery support for individuals struggling with addiction.

    These solutions, while promising, are not enough. They must reach individuals where they are—on the streets, in shelters, and in EDs. Success requires collaboration among healthcare providers, policymakers, and social workers, with a focus on treating addiction and homelessness as interconnected public health crises. As an EMT, I’ve witnessed firsthand the revolving door of temporary fixes. Yet, stories like Larry Moore’s remind me that change is possible. For the patients I regularly interact with, hope may seem distant, but it exists. Addressing this crisis requires acknowledging a hard truth: we are all one unexpected event away from becoming the people we seek to help.




References

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