Drugs a 'rational response to hopeless situation:' 55% of Coachella Valley homeless struggle with addiction

Robert Hensley typically asks visitors not to come by until after 10:30 a.m. By then, he has injected himself with a $10 dose of heroin, a twice-daily dependency.

Then, he can brush his teeth.

Maybe he’ll make breakfast, whatever that might look like — even though heroin tends to make users indifferent to food. That can be a bonus if he doesn't have enough money to buy food anyway. The drugs come before food, he said.

The Desert Sun surveyed 200 people experiencing homelessness in the Coachella Valley as part of a University of Southern California Annenberg Center for Health Journalism 2019 Data Fellowship. The survey focused on health needs and access to health care for those who are homeless, and Hensley is one of several people who self-reported struggling through substance abuse. 

According to the 2018 point-in-time count conducted by Riverside County, 438 people were experiencing homelessness in the Coachella Valley during a single night that January. Results of The Desert Sun's 200-person survey have a margin of error of plus or minus 5.1 percentage points.

Of those surveyed, 55% reported they abused drugs and alcohol, while 44% reported they suffered from mental health issues — mostly depression, but also conditions like bipolar disorder and schizophrenia; 31% of those surveyed had a dual-diagnosis of both substance abuse and mental health issues.

While free and reduced medical services are available for those experiencing homelessness in the Coachella Valley, many of the clinics don't include robust behavioral health care services or substance abuse services. Both those who are experiencing homelessness and those who provide medical care to that population said that is one of the valley's greatest needs.

Fifty-three percent of respondents said they need access to a greater variety of medical care, including psychiatric services, counseling, Suboxone or methadone clinics, and other substance abuse services. 

Interestingly, 86% reported they had health insurance, such as MediCal, which covers substance abuse treatment like medicated therapy to wean users off opioids and heroin, inpatient beds, counseling and case management. But that benefit is moot if the service isn't available or requires transportation to access it. Officials working in the field say while Riverside County has behavioral health outreach workers, the staff isn't large enough to consistently cover every pocket of the county.

As the unsheltered homeless population continues to rise in the valley, providers say it is disconcerting that individuals aren't able to access the behavioral health and substance abuse care that could be the key to getting them off the streets. While the overall number of people experiencing homelessness in Riverside County decreased from 2017 to 2018, the number of unsheltered individuals increased. In 2017, 1,638 people in Riverside County had no shelter during a single day in January, and in 2018, that number hit 1,685.

Through the Riverside University Health System Behavioral Health department, Riverside County has 23 outreach workers to serve the county's entire  homeless population, said Tom Peterson, Riverside behavioral health spokesman. The outreach team focuses on homelessness. The outreach program provides mobile behavioral health screening and linkages, housing linkage services, and intensive case management.  The county also has substance abuse clinics in Desert Hot Springs, Palm Desert, Indio and Cathedral City. All offer crisis intervention, medication services, case management, recovery management and dual-diagnosis treatment.

Additionally, the county recently opened an intensive case management mental health program in Rancho Mirage that serves adults who have had contact with the criminal justice system. And in Palm Springs, the county has a mental health urgent care that is open 24 hours a day and provides treatment regardless of ability to pay.

In Indio, residents also have access to the Oasis Behavioral Health clinic.

Greg Rodriguez, policy analyst for the Riverside County Supervisor Manuel Perez, District 4, said a major challenge in the county is the lack of crisis stabilization housing and permanent supportive housing that includes wrap-around mental health and substance abuse services for the county's homeless population.

Rodriguez said he hopes the county will receive an allocation from Gov. Gavin Newsom's budget to address some of those needs. During a recent panel discussion in the Inland Empire, Newsom said some of the most important items his budget will fund are housing programs and behavioral health programs. 

Hensley, 42, learned at an early age to do what he could to survive and make life better for his family. That mostly meant stealing, until it also meant selling drugs.

He’s had more than a handful of stays in every jail around the Coachella Valley, mostly for stealing or drug-related charges. 

He was raised alongside two sisters and three brothers by a single mother in the valley. (Fifty-five percent of those surveyed are from the Coachella Valley.) His mother did the best she could, he said. He moved a lot as a child, was homeless at times and switched schools often. 

“We would go to school and all the other kids had clothes that were in fashion,” said Hensley. “They used to call us ‘Kmart kids,’ because we wore the poor people stuff and the hand-me-downs and we got picked on.”

He thought that one day he might get away from everything that crippled him, but he hasn’t.

The small scars that follow Hensley’s veins are barely noticeable at first glance — they are blurred beneath an infection and skin that has aged with the sun. He says it’s not the drugs that are the problem, but the pain he masks by using drugs.

“I’ve been to detox about eight times, to every program around here,” he said. “But it never worked because the programs treat the addiction, not what you’re trying to use the drugs to cope from.”

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Robert Hensley pushes himself with one foot in his wheelchair. He was hit by a car three years ago. (Photo: Jay Calderon/The Desert Sun)

By that, he meant the existential pain that comes with being homeless — there is no safety or security or relaxation or pride. And the physical chronic pain that has persisted since he was a victim of a hit-and-run crash a few years ago. And the pain he has from an infectious disease that has spread across his skin. And the emotional pain of not having a family or children or career he loves, along with memories of a traumatic childhood. He said he watches cars drive by the encampment where he squats and imagines the people inside those vehicles are a happy, vivacious family — something he has never had and likely never will. His depression is persistent.

But it all disappears with heroin, he says. The drug alters people’s consciousness in ways to create temporary happiness. It mimics the warm feelings that love and friendship create. It makes him sleepy, though, and he needs energy to panhandle to make enough cash for his next day’s fix. His remedy is meth.

“In some cases, substance use is a very rational response to a pretty hopeless situation, whether that’s generational poverty, homeless-helpless syndrome, homelessness or trauma,” said Kawika Liu, Health to Hope Clinics chief medical officer. The clinic offers free or reduced-price medical care to those in poverty. "That being said, we still need to focus on harm reduction and teaching people that, ultimately, using is harmful and that while it is a way to escape and distance their mind from an emotion, it is not a way to solve the problem.”

Liu said he tries to meet people where they are, while still working on reducing his patients’ needs for drugs. He said the biggest thing that could positively impact health and drug abuse outcomes is a variety of housing options built to fit the need of the client, from supported group homes to rapid rehousing programs, and everything in between. Even temporary shelter offers an entry into structure.

According to The Desert Sun's survey data, 75% of those staying in emergency shelters or transitional housing reported they had seen a doctor within the past three months, which is likely due to the fact that the Health to Hope Clinic has offices on the campuses of the Coachella Valley Rescue Mission and of Martha's Village and Kitchen.

Of those who were living unsheltered, 30% reported they hadn't seen a doctor in the past year and 45% of those respondents said the last time they saw a doctor was in an emergency room.

Until this week, Hensley’s home was a tarped hut shared with a few other people. The hut sits on tribal property within the boundaries of the Cabazon Band of Mission Indians land that abuts One Stop Shoppe, which includes a convenience store, a pawn shop and a taco shop clustered together on the corner of Indio Boulevard and Van Buren Street. But eviction notices were handed out at the encampment by the federal Bureau of Indian Affairs in mid-April and residents had to be out by April 17. Hensley said he didn't plan to leave.

Of those experiencing homelessness surveyed by The Desert Sun, about 52% reported they were living on the streets, without shelter; 27.3% were staying in an emergency shelter, 13.6% in transitional housing and 6.1% were staying with a family member or a friend. 

Does Hensley want housing? Sure, he said. In the way that anyone would want to live in a safe, stable home. But he knows what would happen. He wouldn’t get clean — a presumption he mostly accepts as his future — so he shrugs off the suggestions of both housing and medical treatment for his disfigured ankle.

He says he mostly just wants to keep using and doesn't want to be bothered with anything else. 

“I was clean for two full years once, and that whole time I felt like my heart was ripped out and I didn’t feel normal,” he said. “I felt awful around people and I couldn't talk or relate to anyone. As soon as I started doing the drug again, I could relate to people and get along. Now it feels like torture without it.”

Some days, Hensley will say that he definitely wants housing. On an evening in early April, Hensley said his plan was to check himself into a detox center, get off heroin, have surgery to address his ankle, take care of other health needs he has and then be placed in housing.

Liu said patients like Hensley would most likely not be successful in a traditional housing setting, but could possibly benefit from a group home setting that offers all supportive services in one location. The housing structure removes barriers of transportation.

For those who are unlikely to initiate the work of going to a detox center or Suboxone clinic themselves, receiving a monthly Suboxone injection on the street could be a successful first step to recovery, said Brett Feldman, University of Southern California Keck School of Medicine street medicine director in Los Angeles. 

Feldman said that kind of street outreach eliminates the barriers of motivation, transportation and the difficulty of managing daily pills. 

When asked what would improve the health for some of the most challenging patients on the streets, Liu quickly answered, “Various kinds of appropriate housing.”

Treating health issues would be more successful if providers aren't also trying to tackle substance abuse; and treating addiction would be more successful if patients were living in a stable setting, he said. 

However, providers know that isn’t the reality — they say there aren’t diverse enough housing options in the Coachella Valley and the wait list is long, and, with the housing-first model being used, which places clients in a home first and then connects them to recovery services, it isn’t uncommon for those with substance abuse to be evicted before they successfully become clean — bottomless forgiveness isn't bottomless when  taxpayer funds are attached to housing. 

Hensley is well-known throughout Indio. The police know him — he says they’re tough on him. The cops say they’re tired of his attitude.  Hensley wants outreach services, but isn't ready to give up using heroin.

The Coachella Valley Volunteers in Medicine doctors know him, too. The nonprofit in the eastern Coachella Valley deploys teams of medical professionals once a week to provide street medicine, ranging from checkups to minor surgeries. The organization also has a brick-and-mortar clinic in Indio. 

The physicians chuckle when Hensley asks for a prescription of ibuprofen, because its powers are dwarfed by the heroin they know he already has. But the medical volunteers are there to provide help to all with no judgment, even if they wish he would consent to the surgery he needs. Hensley does not feel an immediate need to treat his medical issues and said he knows he's able to panhandle more money when he looks ill.

Hensley is known at the Coachella Valley Rescue Mission down the street as well, but he’s no longer welcome there: He falls into the category of “doesn’t follow the rules,” as drug use is not tolerated at the mission.

For patients like Hensley, the health care must consistently come to him. 

Rosa Lucas, who leads the Coachella Valley Volunteers in Medicine street outreach team, said it's important to bring health access to where people are. Lucas can quickly rattle off her patients' stories and she knows who is serious about wanting help and who isn't. But none of that matters, she said. The Volunteers in Medicine team is there to offer services to everyone and sometimes it can take multiple interactions until enough trust is built for someone to ask for help.

The organization's work also keeps patients out of emergency rooms.

"We are out here doing real medical care and minor surgeries," Lucas said. "We can diagnose people before there's an emergency. We can identify if someone is diabetic and provide medication; we can treat infections before they become terrible; and we can treat bronchitis before it becomes pneumonia."  

Coachella Valley Volunteers in Medicine has a psychologist on its team, but he is not able to do a complete psychological evaluation on the streets. Lucas said she would love to see the organization expand to include a full behavioral health and substance abuse program, but that would take a heavy stack of grant money or a robust team of volunteers made up of addiction specialists and other experts.

She said the team wouldn't be able to start offering services like Suboxone treatment without having someone on the team who is certified to administer the drug. She would like to have a full behavioral health program to support the treatment before offering it as well.

Of those surveyed, about 11% reported they received care from the street outreach team. Of those respondents, 80% rated the care they received as "good" or "great." Of those who hadn't been in contact with a street medicine team before, 70% said they weren't knowledgeable about how to access such a team or lived outside of the service area. 

In addition, 67% of east valley respondents said they received medical care in the past three months, while 57% of west valley respondents did. Those in the west valley were 3.5 times more likely to access that care at an emergency room, likely because the west valley doesn't have services such as the Health to Hope Clinics or the Coachella Valley Volunteers in Medicine. 

Lucas said she recognizes there's a need for street medicine services and a clinic in the west valley as well. She would love to see the clinic expand, but that, too, would take an immense amount of funding. The clinic takes about $1 million to operate each year, with the funding coming from local hospitals, donors, grants and revenue from low-cost services offered.

Rodriguez said while there are many services for both substance abuse and mental health services in the valley — provided by Riverside County, nonprofits and private providers — the challenge of offering enough affordable mental health care to all is still one of the county's biggest challenges.

Some of that will be solved, he said, by the repurposing of the former Roy's Desert Resource Center into a behavioral health board and care facility, and the opening of the Acadia facility in Indio.

In the meantime, local police have said their jobs have shifted into more of a social worker role as they try to meet the needs of the community.

Jose Ibarra, Indio police homeless outreach officer, said while he still has to enforce the law, instead of arresting someone who might be using narcotics in public, he tries to work with them to offer different options, like access to recovery care.

Ibarra said what he finds most frustrating is the lack of behavioral health professionals who are doing street outreach. He said that's mostly because Riverside County's behavioral health team is short-staffed, but he wishes there would be a greater priority placed on that need.

"As law enforcement, we advocate for people and try to make those connections to recovery if that's what they want, but I'm not a mental health expert," Ibrarra said. "We need mental health workers and substance abuse workers to be on the street, too. We need their help."

Feldman, the USC Keck School of Medicine street medicine director, said providers must continue to radically go to the people and to pivot medicine to fit the specific needs of someone experiencing homelessness.

“There’s a tendency for us to want people to force people to transition to traditional clinics, we call that retreat from the streets,” Feldman said. “But going to them, physically being in their space and home, gives so much more information about who that person is and how we can best treat them.”

The service also requires a shifting of recommended best practices. When treating patients for hypertension, providers can’t recommend a low-fat or low-salt diet because folks don’t have control of what they eat as often their meals are from the shelter or closest gas station or fast food restaurant. It would also be impractical to recommend patients join a gym.

Feldman said even medications need to be reconsidered. The recommended medication for hypertension is a mild diuretic, which isn’t safe for someone who doesn’t have consistent access to food and water. Not consuming even water while on a diuretic can be harmful, so Feldman finds other medications to recommend.

When talking about health care access, Feldman said it’s not just about doing checkups on the street, but about bringing access to medications and lab tests to the streets. He said he pretty much delivers equal care as he would in a clinic setting on the street, about the only thing he can’t do on the street are pelvic exams.

Providing things like Suboxone, which helps people stay off intravenous drugs, can be managed on the street, said Feldman, who is certified to administer the drug. Also, medications for people with schizophrenia or bipolar disorder are given in monthly injection doses by medical providers, meaning patients don’t have to remember to take a pill every day or worry about their medication getting stolen, which happens often. 

“It’s actually pretty easy to track people down once a month,” Feldman said. “Once you learn their daily routine, people don’t usually stray from that, so we figure out the most logical time to insert ourselves into that routine.”

In Los Angeles, Feldman also works with county-funded outreach teams. The teams can vary based on need, but mostly are made up of a peer support worker, a social worker, a drug and alcohol counselor, a housing specialist and a medical worker. The teams are assigned geographic locations in the city with the goal of coordinating wrap-around care for unsheltered individuals. Lucas said Coachella Valley Volunteers in Medicine plans to continue fostering partnerships in the community to mimic a similar model.

[This story was originally published by The Desert Sun.]