THE SUDDEN LOSS of detox beds throughout Massachusetts means more than forcing people in need of treatment to crisscross the state in order to get it. To hear advocates tell it, the decline will leave more and more people without any substance-abuse treatment, especially since detox programs act as gateways to long-term rehabilitative care. And when those who abuse substances can’t get treatment, they fall prey to their addictions. They inject drugs. They drink. Untreated, they present a hefty price tag to society at large. Says Spectrum’s Faris, "These people will clog the courts, the emergency rooms, the shelters. In every respect, they’ll be shifted to systems that cost more."

During the current FY ’04 budget debate, Elizabeth Funk, of the Mental Health and Substance Abuse Corporations of Massachusetts (MHSACM), the trade organization that represents detox providers, is often at the State House calling attention to this ripple effect. She and her colleagues have calculated the savings Massachusetts will gain from the funding cuts. But if half of the 15,000 people who’ll be denied detox next fiscal year end up in hospitals or jails — the two most likely scenarios — the state, it seems, can claim no financial benefit. The Medicaid cuts to detox programs are expected to save $15 million in FY ’04. However, it costs $600 per day for a hospital bed — as compared to $200 per day for a detox bed. So if 7500 addicts wind up in ERs for five days — the average length of a detox stay — the state would have to spend $22.5 million to pay for their hospitalizations. Regardless, cuts that purportedly save money will cost the state’s taxpayers in the end.

The ramifications of such numbers are already becoming clear. In Greater Boston, emergency-room personnel are noticing more and more addicts in their midst. CASPAR, for one, reports that its street-outreach teams have escorted greater numbers of people in need of detox to ERs since the closure of its own facility. In April, CASPAR transported 56 people to Cambridge and Somerville hospitals — more than double the average number of 25 transports per month over the past two years. Similarly, Ed Bernstein, an attending ER doctor at Boston Medical Center, has cared for more intoxicated patients at the hospital’s emergency department in recent weeks. Some of them were found down on the streets, and brought into the hospital by ambulance. Others were sick, desperate to find a detox center. More often than not, he says, these patients represented one-time MassHealth Basic recipients. "We’re seeing more homeless, alcohol-dependent, uninsured people coming into the ER," Bernstein says. "They’re coming from all over, from as far as New Bedford" to get relief.

Bernstein directs a BMC program known as "Project ASSERT" (an acronym for Alcohol/Substance-abuse Services Education Referral Treatment), which, since 1994, has placed an average of six addicts per day in local detox centers. Lately, however, Project ASSERT counselors have been hard-pressed to find available beds in and around Boston. They keep an ever-growing waiting list. They look for beds beyond the city borders. Three weeks ago, they sent a heroin addict who, in Bernstein’s words, "begged and pleaded for help," via taxi to Brockton, where employees had located the only available detox bed at the time.

Down in New Bedford, the ripple effect is showing up in other ways. In the six weeks since the demise of MassHealth Basic, advocates report a spike in petty crimes. Carl Alves, president of the New Bedford–based advocacy group Positive Action Against Chemical Addiction, says that neighborhood activists are witnessing an unusual increase in car and home burglaries, panhandling, and prostitution. At the same time, he says, he and his fellow advocates have recorded as many as 10 heroin overdoses since April; typically, the group would see 10 overdoses over a three-month period. According to a May 7 article in the New Bedford Standard-Times, Bristol County district attorney Paul Walsh publicly confirmed that his office is investigating seven heroin-overdose deaths in the city over a span of just two weeks. "More and more," Alves adds, "these are becoming desperate times for many who struggle with addiction. Just because you cut the services doesn’t mean the need goes away."

Even the most vulnerable and needy among substance abusers — those who’re legally committed to drug treatment — are bumping up against the system. Under state law, any family member, doctor, or police officer can petition the Massachusetts district courts for "an order of commitment," as it’s called. The courts can force chronic addicts who are at risk of harming themselves or others into detox and rehabilitative treatment for up to 30 days. The law, known as "Section 35," calls for men to be sent to Bridgewater State Hospital, where they stay in the prison’s health-care unit. By contrast, the state has placed women in community-based programs to avoid sending them to MCI-Framingham, the state’s prison for female convicts. Yet the drastic drop in detox beds has left in service only eight "Section 35" beds for women — down from an all-time high of 60 beds in the late 1990s. As a result, more and more Section 35 women are finding themselves at Framingham prison. In 2002, only 22 women ended up behind the wall, out of 480. This year, the number has reached 10 so far — six of whom landed in Framingham in the past six weeks alone.

According to Norma Finkelstein, the director of the Cambridge-based Institute for Health and Recovery, which places Section 35 clients in detox beds for the state, "These women are in severe trouble." The women, she explains, often suffer from mental illness or severe trauma from abuse. "They need treatment, not prison." The current trend, she adds, shows how the demise of detox presents a public-health and public-safety dilemma.

OFFICIALS AT the Massachusetts DPH, which licenses detox programs in the state, recognize that the system has taken a huge financial hit. Deborah Klein Walker, the associate commissioner in charge of the Bureau of Substance Abuse Services, expects detox programs to receive $27.9 million in FY ’04 — $21 million from Medicaid, and $6.9 million from the DPH. But the figure pales in comparison to the $54.5 million spent on substance-abuse treatment this fiscal year. And because the DPH acts as payer-of-last-resort — funding detox beds for the uninsured — the demise of MassHealth Basic has made its mission especially difficult. With just $7.2 million currently slated for detox services, the department, Klein Walker says, "doesn’t have enough money to cover all the new people who’re uninsured. It’s a big problem."

Nevertheless, Klein Walker seems optimistic. Though she acknowledges that swaths of the state now lack detox facilities, she suggests that the DPH can counter disparities through its distribution of funding. "Detox is being reduced," she explains, "but it won’t be eliminated from our point of view." How can the department ease the pain? "We will allocate our own monies so as to maintain a balance," she replies. "We will make sure that there’ll be services in every part of the state, and that the number [of detox beds] in each region is equitable given other regions." However strained the system, "the damage has been done," Klein Walker insists. "It won’t get any worse."

But things could easily spiral out of control. Two weeks ago, House members passed a FY ’04 budget proposal that continues the assault on drug-treatment programs. The House budget would eliminate Medicaid funding for methadone treatment by July 1. In addition, it would slash $3.8 million — or 10 percent — of the DPH’s $37 million budget for substance-abuse services. Furthermore, the budget includes language that would forbid the DPH from contracting with agencies providing methadone. All this, advocates say, will only compound the crisis for detox clinics that have managed to keep it together thus far. "It’s awful," says Funk. "Not only have we lost half the detox beds in this state, but we could lose methadone services entirely." She estimates that up to 12,000 residents would be affected by elimination of methadone treatment — in addition to the 15,000 affected by the drop in detox beds. "Things certainly can get worse," she adds.

In many ways, the cuts in the House budget come down to ideology. Legislators, after all, have chosen to deny medical benefits to an unsympathetic population. Drug addicts and alcoholics rank low on the totem pole of valued lives on Beacon Hill — indeed, they don’t elicit the same empathy as, say, mentally retarded children. Methadone treatment, in particular, faces what advocates call "an absolute prejudice" at the State House. Spectrum’s Faris, for one, sees "no fiscal gain" to the methadone language in the House budget — language, he claims, that would force Spectrum to close four clinics serving 1000 people. "There’s a moral decision-making here," he explains. "People perceive substance abuse as a self-induced problem. As someone once said to me, ‘I quit smoking. So why can’t these people kick heroin?’"

Community Healthlink’s Eliadi puts it more bluntly: "All of a sudden, methadone treatment has become the next abortion debate. It’s irrational."

Even some legislators agree that the House budget has gone too far. State Representative Martin Walsh (D-Dorchester), a vocal supporter of drug treatment, had filed several amendments to restore methadone and detox services in the House budget — most of which failed. Walsh disputes that the House cuts reflect an ideological bias, noting, "There were other priorities that we wanted to restore, such as prescription drugs for seniors." But he admits that drug-treatment services have absorbed disproportionate hits. "Some of the cuts made to these programs," he says, "I feel went too far."

And so, for the treatment community, the future seems tenuous at best. To be sure, the budget process isn’t over yet. And providers find hope in the fact that the Senate has proposed to ease the draconian cuts to drug-treatment programs passed in the House. Indeed, in its FY ’04 budget proposal unveiled on May 21, the Senate leadership would restore funding for methadone and detox services, as well as scratch the language banning state contracts to methadone clinics. They find hope, too, in both the Senate leadership’s and Governor Romney’s commitment to restore some Medicaid coverage to the 36,000 people who lost MassHealth Basic. Although details about the Senate plan on MassHealth Basic were not yet public as the Phoenix went to press, those familiar with the administration"s intentions say officials are creating a "limited benefit" for former recipients, including chronic substance abusers — which, presumably, would help pay for more detox beds in the state.

But even so, providers dislike the direction in which they’re headed — one that keeps inching closer and closer toward the edge. Without an influx of cash soon, they predict a grimmer picture than the one they paint today. More programs will be gutted, more will be forced to close. Eliadi sums up the sentiment best: "It’s like wait-and-see here. Every day is a new day. We’re just holding our breath."

For addicts like Sean P., taking things one day at a time is all they can do. Life exists in the here-and-now, not in the future. As Sean ponders his 11-year ordeal with heroin addiction, he clings to the prospect of a clean-and-sober existence. "You have to think you’re going to make it," he says. But given that 88 percent of detox patients in Massachusetts end up relapsing, the odds, sadly, are against him.

And that’s not even taking into account that the system set up to help him now seems designed to help him fail.

Kristen Lombardi can be reached at klombardi[a]phx.com