This Program Offers New Hope for Fentanyl Users

[00:00:10] Hello and welcome to another episode of Seattle Nice. I'm Erica Barnett, he's Sandeep Kaushik, and this week we have three special guests to discuss a potentially game-changing new breakthrough in treating opiate addiction. Richard Waters is the Medical Director at the Downtown Emergency Service Center, Penelope Toland is the Nurse Supervisor for the Opioid Treatment Network, and Daniel Malone is the Director of DESC. Welcome to Seattle Nice, everybody. Great to be here. Thank you. Good to be here. What am I, chopped liver? Everybody but Sandeep.

[00:00:42] No welcome to me. I said everybody. It's all inclusive. Also, we should mention that our third, David Hyde, is not here this week. He's away on vacation. We're pretending he doesn't exist. He's working on his stand. So the reason we're talking to DESC this week is that they have started using a different method to treat people with opioid addiction, and I tried to explain it in our first attempt at doing this intro and realized that I'm in way over my head.

[00:01:09] So I'm going to turn it over to Richard Waters, the Medical Director at DESC to explain what they're doing. Oh, hey. Thanks, Erica. Thanks, Sandeep, for having us. Yeah, we're really excited about our work. Maybe just to kind of launch into it. We're using medications that have been around, FDA approved for the treatment of opioid use disorder.

[00:01:33] And through the observations of our team, the feedback of our patients, through kind of an iterative improvement process. I feel that we've kind of found a way of helping people initiate buprenorphine, which is one of the gold standard treatments for opioid use disorder. Initiate buprenorphine in a way that is more feasible, smoother, a little more accessible, and just kind of makes the pathway to treatment initiation easy for folks.

[00:02:02] But because it's been easy, we're seeing a lot of demand. We're seeing a lot of interest and a lot of good outcomes. Can you talk a little bit for people who aren't familiar with how medications for opioid treatment work? What is buprenorphine? And what are some of the challenges that people have acclimating to it or, you know, getting initiated on it right now that kind of keep them from continuing in their course of treatment?

[00:02:29] Buprenorphine is one of several FDA approved medications for the treatment of opioid use disorder. All the medications help people not have cravings for kind of unregulated or illicit opioids. Buprenorphine and methadone have really good evidence at reducing death rates, reducing overdose death rates, all-cause mortality rates. Buprenorphine is a partial opioid.

[00:02:55] So it has kind of some different properties that both make it really useful in treatment continuation. It kind of binds more strongly to opioid receptors. It doesn't activate them like other opioids do. But some of these different properties can make it a little, can definitely make it tricky to start for people who are in active opioid use, who have active opioid use going on, active fentanyl use.

[00:03:24] And that starting process has really been a rate-limiting step in getting people on treatment. You know, the way it works in the body and on the receptors in our brain, if somebody has opioids on those receptors and the medication comes into the system too quickly, too fast, it can kind of kick off some opioids from those receptors. And that's what causes some intense withdrawal symptoms. And so kind of the magic is, you know, working with folks to get the medication into their system

[00:03:53] at a rate where it's going to be effective quickly, but also slowly enough that they're not going to go through really intense withdrawals. And unfortunately, a lot of the folks that we work with have had that experience before and may be very cautious, understandably, in restarting the medication. But we know that the medication is so extremely effective in helping control cravings and withdrawal symptoms, and people are really eager to give it another try.

[00:04:20] So obviously, you all, I'm on the DSE board, as our listeners will know, and you all presented to the board about this new protocol, this new onboarding protocol a number of weeks ago. And I was super excited to hear this presentation. As a former heroin addict myself, right,

[00:04:39] I understand both how difficult it is to kick opioids and how much this kind of medically-assisted treatment can be a lifesaver. I mean, I've said before, I'll say again, that methadone saved my life. Puprenorphine wasn't really around in the 90s and early 2000s when I was addicted to heroin.

[00:05:03] But there's also, I was particularly excited about this because there is a significant difference between fentanyl and heroin, right? And, you know, the analogy I make is that fentanyl is to heroin, is sort of crack cocaine is to powder cocaine, right? The intensity, the duration of how long the high lasts, the intensity of the withdrawal, you know, the whole thing is sped up in this way.

[00:05:29] That makes addressing fentanyl addiction that much more challenging than heroin addiction. And so I guess my question here is prior to kind of establish where we were prior to this new protocol getting set up. Penelope or Richard, what would typically happen? You'd have somebody kind of come in, walk in the door. Maybe they say they want to try to kick. They want to try to get help. What would happen? And I know what you guys are going to say.

[00:05:59] In many cases, it wouldn't work or it wouldn't last or they wouldn't be able to kind of hack what happened next. So explain kind of what it used to be prior to this protocol coming into effect. And I guess you guys started in mid-August of last year. You know, as I said before, really the name of the game is trying to find a slow start to medication. So for folks who, you know, haven't been able to stop using opioids, they can walk in and start that treatment same day without it making them too sick.

[00:06:25] And a really useful way to do that is, you know, this medication comes in films that goes under the tongue. And so starting with low doses of that, extremely low doses, and then somebody takes a tiny bit every couple hours. And then the next day they take, you know, a little bit bigger piece. And then, you know, slowly increasing until they get on to a therapeutic level of the sublingual medication, which works really well for folks.

[00:06:52] The other option, too, in starting would be going through a period of stopping your opioid use. So some of those receptors I was talking about can start to open up. Some of the opiates come off those receptors. So then when you take the medication, it binds onto those receptors without making you sick. Yeah, I would just add, in the heroin era, it was really easy to start buprenorphine for most people. It was a bridge that you could cross without a lot of difficulty.

[00:07:19] And most of the patients in the heroin era, they knew how to start buprenorphine. This is buprenorphine under the tongue, kind of dissolved, taken daily. And many of them didn't even need advice from us, the medical providers or nurses. They just needed the medication and they knew how to start it. Fentanyl changed the game in two ways. It's got some different properties. And more people are smoking fentanyl than before,

[00:07:45] which is the fastest way to get a drug to brain and requires you to smoke multiple times a day. And those two things, the different properties of fentanyl and the increased frequency with which people need to use it, made the process of starting much more difficult. Many of the folks, when fentanyl started to emerge, you would hear these stories of people saying, you know, I tried to restart buprenorphine just like I used to, but it made me sick.

[00:08:13] And that's because they tried the old playbook for starting it and it didn't work. And so we had, you know, in 2021, 2022, a lot of people get really fearful about this really incredible medication, buprenorphine, that saves lives, can make people feel much better, take them out of that cycle of cravings, use and withdrawal. And they got really nervous.

[00:08:37] And we didn't really have a feasible way to help people who were not in an emergency department or a hospital, which is a much more controlled setting where you can manage the process of buprenorphine much more closely. The outpatient world, we didn't have a solid way that worked for the majority of people who walked through the door. So the Seattle Times article about this this week mentioned or described this as a game changer. I want to know a little bit about how you're measuring success.

[00:09:06] You know, what is the successful use of this new way of administering buprenorphine? How will you know that it's working? And what are the results you've seen so far? Yeah, I think that, you know, the words game changer, I think, was from another provider at a different clinic who's finding a lot of benefits. But we certainly see this as an advance, you know, definitely not a panacea, a lot more to do.

[00:09:32] We are seeing success in terms of if a patient walks through the door and says, I'd like to start buprenorphine. How many of those, what percentage of those people end up getting to a therapeutic dose? And there's other ways to measure success. How many people are going to still be taking this fantastic med that reduces mortality rates, reduces ER visits, hospital stays, you know, engagement in illicit activities?

[00:09:59] You know, you could measure how many people are still on it at six months, a year. We see the difference kind of interface daily in clinic. People are coming back to bring in their friends. But we also see that if you come through the door and somebody asks for buprenorphine, about 70% of the people who choose this method kind of get to the second month. And that's just a lot higher than what we were seeing.

[00:10:25] Yeah, I mean, I think something that's maybe harder to quantify, but feels so important to touch on is the way that we've seen the word of mouth about, you know, this method explode our intakes. And for example, our team went out to a tiny house village in North Seattle and got a couple people started. And then we came back the next week and those people had gone around to the tiny house village in that community and told people about their experience.

[00:10:54] And we started five more people. And then the next week we came back and that word had spread even more. And I think what I view as a positive, you know, experience is that a patient comes in, they feel like they're listened to, they feel like they're cared for, they don't feel judged. I think our team does a really good job of catering the medication, you know, the way we're getting it started for somebody based on what they feel like they can tolerate.

[00:11:20] And then above and beyond the way that people are really spreading the word about this, it's nothing like I've ever seen before. And it's really impactful and amazing to be a part of and very cool to see. So just for the sake of our audience, I mean, Richard, you were saying you're getting 70, about 70% of people to the second month, right? So that they're coming in for a second dose. Once they get on that first monthly, there's a 30-day version of the medication called Sublocate.

[00:11:49] So you go through this initial onboarding process, you get them to take that first Sublocate shot, and then 70% of people are coming back for a second shot of Sublocate. And as I understand it from the presentation you guys did, prior to this new protocol, we were talking about, what, less than 20% of people, right? Making it to that second month. Is that right? Yeah, yeah, that's about right.

[00:12:13] I think in our practice, again, we're working with a pretty high-risk population, often at the intersection of severe mental illness, homelessness. 10% kind of, call it kind of stability rate, kind of people who, one out of 10 who stabilize.

[00:12:33] There was a study that recently published in February, looking at folks in San Francisco, and they had retention rates at, I believe it was 30 days of about 20%. So I know for some people, you might be listening to this and say 70%, you know, that's not 95%. That's not great. But if you see a lot more people kind of achieving the goals that they set out for, they walk into clinic.

[00:13:02] And for us, it's a big jump. I wanted to ask, you know, about some of the limitations of, you know, of any drug treatment. I mean, if you're talking about a medication that allows people to get their lives back and start, you know, getting their, just getting their shit together. That's, you know, incredible.

[00:13:21] But I know there are a lot of other supports that people need, particularly people who are living on the street, that will allow them to, you know, to make it past that second month and that third month, you know, and reach their, you know, their life goals. And so I'm wondering, you know, what are some of the limitations you're seeing and other, and, you know, maybe Daniel, if you want to come in here, just some of the other supports that would make people more able to be successful long-term, you know, using this kind of treatment. Thanks, Erica.

[00:13:51] I was just enjoying listening to Penelope and Richard talk about all this stuff. You know, just as an executive director of an organization, couldn't be more proud that our team has gone through a set of steps to try to improve the protocol. And they've hit on something that has, in fact, improved the protocol a great deal and is resulting in so much better care for so many more people.

[00:14:18] It's just super gratifying to me to be able to see that work that they're doing. But, yes, you hit on an extremely important point here, Erica, about even if people get stabilized and are not so much in the throes of fentanyl consumption over, you know, the bulk of their day, so many other aspects of life still need to be dealt with. And people need a lot more support. They need places to live.

[00:14:47] They need places or they need support for what they do with their time, with dealing with other underlying conditions they may have, including psychiatric conditions. And so this is a stabilizing step, but really needs to pair with all of that other stuff that people need for sure.

[00:15:10] Yeah, I mean, I was just thinking today about, you know, like Sandeep, I mean, I'm a person who used to be in the throes, I guess, of addiction. I wish we had a better term for that. But, you know, I mean, and I was just thinking like how supported I was and how, you know, much easier it was for somebody like me to to like get out of those those habits and get out of a tailspin.

[00:15:32] And somebody who is using fentanyl on the sidewalk, you know, is treated like a pariah by everybody in society, is targeted by law enforcement and doesn't have, you know, a stable home or any home at all. Yeah, I'll just reinforce that, man. I mean, I had an apartment and a job and I still had a fucking hard time kicking dope, right? It was not not easy. You know, the hardest battle of my life. Right.

[00:15:57] And and and I had the wherewithal to pay 10 bucks a day to go get my methadone every day and all of that stuff and do it for 18 months. And so to do it while you're on the street, it's got to be, you know, that much that much more challenging to following up on Erica's question, though, the Daniel or others weigh in here because. So there's all these other supports that are necessary. All of those cost money.

[00:16:21] But how much does it does this this approach, this sort of medically assisted bup and supplicate oriented approach to to dealing with fentanyl addiction? What is the cost here? How many folks are actually benefiting from this at this point? And how is how is that cost being being born?

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[00:17:36] And those are coming from two different sources. In this particular case, it's principally federal money, though, in that the federal substance abuse, Mental Health Services Administration, SAMHSA, it's called, is the primary funder of the money that flows through the state of Washington that comes to us that allows us to have the team in place to do this work.

[00:18:03] And then the cost of the drugs is primarily covered by Medicaid because that's the health insurance that most of the clients have. And it's not cheap, right? The medication itself. No, these injectables, injectable buprenorphine that we're using, we're using, you know, they come in different formulations. And I guess we kind of skipped over what's the, what is the protocol. Yeah.

[00:18:31] If there's any medical listeners, they might be curious, but we use kind of a, you know, three shots over three days. I think, you know, what's been really useful is we don't need, kind of like Penelope was saying, some of the existing methods either require folks to follow a complicated regimen for several days or to stop using fentanyl and wait until they're in a sufficient amount of withdrawal.

[00:18:55] This protocol allows folks to get their, you know, three shots over three days, a first very small injection on the first day without needing to stop fentanyl use. So you kind of remove that barrier, kind of a medium dose on the second day, and then a monthly dose on the third day.

[00:19:15] Those first two doses cost about $350 per injection and the monthly doses, depending on the type used, range from kind of $1,600 to $2,000. So yeah, the medicines themselves kind of aren't cheap. I am certainly looking forward to the day when other competitors get into the market, generic manufacturers get into the market and bring these prices well down.

[00:19:41] I don't think the costs are because they are expensive to manufacture. And I suppose it's worth noting none of us here have any links to the pharmaceutical companies that manufacture them or any financial ties. But I think it's worth noting that the gold standard treatment for opioid use disorder are medications, buprenorphine or methadone, and kind of remove that foundation. And you really struggle to call your program a treatment program if you're not using meds for someone in active opioid use.

[00:20:11] And something too, I'd love to jump in here, which feels important is, I mean, we hear these numbers and yes, it's very expensive medication. And cost is so relative. I mean, we know the average ED visit can easily cost $1,000. It costs a lot of money to incarcerate somebody. So I feel like when we're talking about it and you hear that price tag on the injection, it's so jarring.

[00:20:34] But when you put it into context of, you know, we know when somebody gets on this medication, you know, their risk of overdose goes down by so much. And, you know, when people are more stabilized on this medication and not in, you know, really intense withdrawal, needing to get their needs met, potentially some of the actions that they might take in their day-to-day life might change. So it just feels like we need to put it into a bigger perspective as well. Absolutely.

[00:21:00] You mentioned SAMHSA and Medicaid, and those are two programs that are being targeted. Well, I mean, SAMHSA, I believe, is like in the process of shutting down right now. I don't know if that's reversible. But the Medicaid cuts, Daniel, you've talked about, you know, potential huge Medicaid cuts that are coming for everybody, but for DESC in particular relies on Medicaid pretty heavily.

[00:21:23] So, I mean, how is that, you know, maybe broadening out just a little bit, you know, how does that affect programs like this that are, you know, trying to meet people where they're at? And how is it going to affect DESC's substance use treatment program, you know, more broadly? It's a huge worry for sure.

[00:21:44] This current action about SAMHSA being shut down or, you know, folded into a bigger unit of the Department of Health and Human Services may not have the effect of killing the funding for this program. That part is totally unclear, but chances are it'll screw up something about the administration of the flow of that money. And so that could have some disruptive effect.

[00:22:12] But on the Medicaid side of it, and I think this will be coming up in the ensuing debate over what the president and Congress are going to do about the next federal budget, that has enormous implications.

[00:22:28] If there are huge cuts to that program, people presumably start to get kicked off the program or the program is unable to sustain paying for the different kinds of treatment and medication that people need. And so it's a giant worry.

[00:22:45] And I hope that by making the public more aware of the importance of what that kind of funding does and what it can do for communities, like getting more and more people off of fentanyl on the streets of Seattle, I think is a real positive story about what the investment the federal government makes in the Medicaid program can do.

[00:23:14] And we certainly don't want to be jeopardizing that. Yeah, I would just say, I mean, again, when you all told me about this new protocol and that showed the DSC board some of the statistics sort of before and after, it's not just that we've gone from a 10% to 20% success rate of getting folks to the second month of sublocate, but up to 70%.

[00:23:37] But Penelope, as you were saying, you've got, you know, kind of three times as many people on a monthly basis sort of walking through the door at DSC or otherwise initiating treatment. And Penelope, to your point, it means like word was getting around, like this actually works. You should try it, right?

[00:23:56] And to have all of that finally, for one, some good news, right, about addressing the problem of fentanyl on our streets and the harm that it's been causing at that moment to potentially have the rug pulled out from under us, right, in terms of being able to fund this promising new approach seems really, I don't know what it seems. It seems fucked up. It doesn't seem good. Yeah. Yeah, right?

[00:24:25] Well, you know, here's another angle on why it's such good news is that, of course, we have these local debates and discourse about the state of our streets and so many people suffering in public. And some of that debate, as you know, Sandeep and Erica in particular, has gotten into the realm of involuntary treatment.

[00:24:51] You know, should we be grabbing people up off the streets and putting them away in facilities where they can get treatment? Well, one thing that this protocol is showing is that so many people don't need to be forced into treatment. They will come running to it when they have awareness that what's being made available is better than what they had been familiar with before. So there's that angle on it that the public should really understand.

[00:25:19] People want to change their circumstances very desperately. They want to get better and they most often don't have to be forced into making that kind of choice for themselves. But let's say this didn't exist and then the conversation around involuntary commitment continued to heat up.

[00:25:40] Well, how much would it cost us to start involuntarily treating people for these kinds of things if this protocol didn't exist? So I think that's another important part here of this very likely is saving us from some other actions we might have ended up taking as a community. One thing that I hear pretty consistently from local leaders and, you know, we're in an election year.

[00:26:06] So that's maybe more true than ever is, you know, impatience about the situation on the streets. And like, I mean, this is a perennial issue, you know, that there's there's a lot of impatience from political elected officials to get something done. And I'm wondering what kind of response have you gotten from from folks at the local level about to this this this this kind of program? And, you know, are you telling them, like, have a little patience? It's going to take some time.

[00:26:35] I've been having a little bit of that kind of conversation with people and letting them know, look, well, we've got some really promising results happening and there's going to be more attention coming on that. And I think you'll be pleased with what you hear, that kind of thing. And I've certainly that's been met with positive reactions when I've talked with people about that. But we haven't really gotten to the next phase of the conversation, which is really scaling this up.

[00:27:04] And I think what what Penelope and Richard really haven't gotten to at this point is that they're close to being overwhelmed with demand here. And DSE isn't going to be able to, using existing resources, meet the needs of everybody who might want to take advantage of this kind of treatment.

[00:27:23] And so there's going to need to be additional investment in scaling this up and taking it to more people who I think will eagerly want to be part of it. But it's just not really available to everybody yet. So that does seem to be a need that's going to have to be addressed in the coming conversations. Yeah, I mean, there's there's obviously a lot of other great clinics out there that are doing great work.

[00:27:51] So this is not all good work has been happening. It's been happening for years through community health centers, hospital clinics, public health system who are caring for an immense number of people. I think it has been that there is the demand, the need for treatment has kind of outweighed the existing system capacity.

[00:28:14] And this, you know, what Penelope is, I think, talked about before is this idea of going to people where they are. That is a model of care that does not exist in a lot of ways. Clinic, you know, come to us, you, the patient, come to us. That exists in a lot of different ways, a lot of different settings. But models of care, there aren't too many out there. There are some others. Harborview has one. There's a public health street medicine team.

[00:28:43] But these models of care where teams are going to people, bringing care to them. We found that really effective at building trust, at helping start people on treatment who may not seek it out. And then once they have a great experience, like everybody around them is seeing that positive experience. That's in some ways unmasking this kind of latent demand for treatment. It's demand that is there because people are unhappy with fentanyl. They're scared of fentanyl.

[00:29:12] They don't like their state of being with fentanyl. Fentanyl's got very, I would say it's got very, very poor favorability ratings, like very poor polling numbers amongst people who use fentanyl. People don't like it. And when you offer a way kind of out that feels walkable, that's really doable. Methadone clinics in town, we've got a number of great methadone providers also are feeling, also are experiencing surges in their demand.

[00:29:41] Just another example of if you build the capacity, build the pathways that people can walk down very feasibly, a lot of people are going to walk down those pathways. Yeah, and just on this point, Richard, you were making about how important the kind of going where people are at, the outreach piece of this, rather than sort of passively waiting for them to come to you.

[00:30:05] Obviously, Penelope, you were saying, you know, going out to the tiny home villages, getting people started, you know, particularly homeless people who are having chaotic lives. Maybe a month goes by after their first sublocate shot and they're not in a place where they're going to come in for their second one. But if you get out there and meet them where they're at, they will take that second shot, it sounds like.

[00:30:24] Or just to think of some of the other stuff that's happening in the city that's also been promising, like Richard was talking about methadone, Evergreen Treatment Services has been doing the mobile treatment van. And they're adding a second one that the city funded recently that hasn't been deployed yet, but actually going out there and going out to Pioneer Square or wherever and sort of meeting folks where they're at on the streets and getting them the care that they need that they otherwise might not come in to get.

[00:30:55] Penelope, talk a little bit more about that, about that outreach piece. Hey, Seattle nice listeners. Seattle politics got you low. Well, get high with Uncle Ike's. Pissed at the mayor? Relax with a dollar joint. Pop a tire in a pothole? Eat a $2 gummy and chill.

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[00:31:48] You know, it's a lot to ask of anyone to take an hour-long bus ride and then have to sit and wait. And I think what makes it really complex and what a lot of people don't realize is with fentanyl, a lot of people are having to use fentanyl so often to stay well. And so sometimes it's just simply like the time component that can take for people when they're really struggling and feeling really sick. And I think the other piece is people want to do this.

[00:32:18] People are, no one's, as Richard said, no one's using fentanyl really because it's fun. They're using it because without it, they feel extremely ill and they can't accomplish any goals. And I think when we go out there and show up for somebody, it's one, this sign of like, okay, like you guys really care. You're here and you're willing to be creative about a care plan. And also you're recognizing that like my life is really hard.

[00:32:44] Like as somebody who's experiencing housing instability and doesn't have, you know, access to a bathroom or a phone or a watch, like it's, it's, I can't imagine how hard that day to day is. And living like that is a full-time job, truly a full-time job. And you're worried about your belongings being stolen. Like there's just so much, it's so complex. So I think when we show up and meet people out in the field, you know, we're recognizing like that they're doing their best and they're trying very hard.

[00:33:12] And if we can, you know, meet them in the fields and get them on the injection. And then a beautiful thing about the injection is then, you know, withdrawal symptoms are so much better controlled. So it is going to be easier for them to walk into a clinic and wait and then get their injection in a more traditional way. So can one of you guys tell us about the Orca Center that's going to be opening up soon? So the Opioid Recovery and Care Access Center, a program that is starting thanks to the effort from many, many people.

[00:33:42] UW, ADAI, funds from city, county, state, Seattle Fire, Harborview. So a lot of partnerships going into this idea, formulating the idea. But this is going to be a place that is open 24-7, located in Pioneer Square, within a floor of the kind of existing Morrison Hotel that DESC operates, even though it'll be a separate space.

[00:34:10] It'll be part of DESC's new downtown behavioral health clinic. So it'll occupy a space, open 24-7, a place where first responders can, who are responding to opioid overdoses in the field, doing good care. Seattle Fire has been a leader in administering buprenorphine.

[00:34:32] Paramedics and EMTs administering buprenorphine to individuals in the field in the immediate kind of post-recovery period from an overdose. Those individuals can be brought to the Orca Center, receive medical care, a safe place to kind of recover and stay for up to 24 hours, and get started on medication treatments if they haven't already been in the field or receive their next dose of medication treatment.

[00:35:00] So it's meant to be a way to fast-track individuals at a critical moment in their life where they, by definition, nearly died, to start them on a path on a very different trajectory. We will also be able to see individuals kind of walking in as well. So this has been a long time in coming, and we're super excited.

[00:35:23] I think it's going to increase our capacity overall to meet the needs of people who are using fentanyl, but it'll add a new dimension to the overall system of care, which is really cool. I'm curious, you know, with co-locating or locating close near each other, you know, the new, and forgive me, I don't remember what it's called now, the new Navigation Center is called? Star Center. Star Center.

[00:35:50] Star Center and Orca Center are going to be, you know, on 3rd Avenue. It's been a very contentious block or two of downtown for a very, very long time. And I'm wondering, you know, are you getting pushback politically on, you know, from the courthouse, or just in general from the judges, whoever, about locating services in this specific location? I mean, the Navigation Center, which was at 12th and Jackson, or 12th and King, was also really controversial.

[00:36:18] So what are you hearing so far and how are you dealing with that? And I guess political questions maybe are for Daniel. Well, we've definitely had some conversations. I've had conversations with the current and previous presiding judges of Superior Court, which is located across the street from where the Orca Center and our downtown behavioral health clinic is going to go.

[00:36:42] And then the next block up, 3rd Avenue, is where the Star Center has opened. But I wouldn't call it pushback that we've gotten there. We've been working closely with the city and the county to make sure that we have as much resource as possible to help make sure that that whole environment in those several blocks is as welcoming to everybody as it possibly can be.

[00:37:12] And that's a huge priority for DESC to make sure that the people we want to welcome into CARE feel like it's a place they want to go. And if they've got to sort of run a gauntlet to get there, that interferes with us achieving our mission. And so we're working hard on a lot of different steps to help improve those environmental concerns there.

[00:37:42] The Star Center, what's I think especially cool about it is that we have been able to design this shelter to prioritize people with really high needs due to behavioral health conditions that will give us an outlet for people, for example, who get post-overdose care at the Orca Center

[00:38:10] but don't have a place to go stay, don't have a place to live, can then go get one of the spaces at the Star Center and stay there while they further stabilize and then move on to some other kind of housing or if need be emergency housing or shelter after their stay at the Star Center.

[00:38:35] So feeling like it's an outlet that doesn't currently exist or hasn't currently existed for a long time for people who have been on the streets in crisis to be able to go to and have some further stabilization. So it feels like a really important set of services located in proximity to one another. Yeah, and just in terms of the street scene there, I think it's important to note, Daniel, you've talked about this with me, that the city stepped up to put some additional money

[00:39:04] into the Star Center's funding so that DSC can proactively do some, you know, have staff out there sort of going out on the street in front of the place to try to make sure that it doesn't turn into a place with a lot of activities that are not conducive to the actual work that's happening there, right? Yeah, that's exactly right.

[00:39:31] Both the city and the county have provided us with some resources aimed at supporting that kind of activity where DSC staff people are out there engaging with folks and helping produce a better environment and better outcomes for people who are out there and might need and benefit from our services.

[00:39:53] There is a, this has been one of the city's pockets of a drug market for as long as I've worked at DSC, which is a really long time. And that had mostly existed at the corner of 3rd and Yesler for many years. It, it essentially got moved a block north when some work was done to physically seal off the area that people would occupy

[00:40:21] in the outdoor drug market at 3rd and Yesler. And so it's produced some additional challenge for us, I will say. And there, there's clear activity of people coming in, in vehicles, uh, to 3rd and James, which is a destination place for some, uh, drug transaction stuff. So that, that complicates matters for us. It's, it's somewhat like the situation in little Saigon where the navigation center was,

[00:40:50] was located a couple of blocks away from a longstanding outdoor drug market at 12th and Jackson. Uh, and then there was a lot of conflation in people's minds with the, uh, presence of the navigation center being somehow related to that outdoor drug market. And so it's a real challenging situation for us to manage in terms of neighbor relations,

[00:41:15] but also just in terms of, uh, operation of our programs where, you know, there's a challenging behavior happening. Sometimes it, it, uh, bleeds into incidents of violence and, you know, nobody wants to be around that. Can I ask, I mean, that, I think of that block where the star center is located as one of the blocks where I most often see, I mean, I wouldn't even call them sweeps, um, because it's not people even living there, but I see the, uh, unified care team out there.

[00:41:45] Um, and I see police out there and I see parks department, you know, all the time, um, removing people. And I'm wondering if that is something that's, you know, DESC is, um, encouraging or if it's going to continue or, you know, how, how to navigate, you know, creating a space where people feel safe coming in with, you know, a lot of enforcement activity that's always going on right there. Yeah, that's a really insightful question.

[00:42:10] And you can imagine it is a little tricky for us to, to sort of balance all these competing interests where we don't want harm to anybody who doesn't have other places to be and so forth. But, uh, we also don't want to have, uh, a physically degraded environment that nobody wants to come through.

[00:42:34] And so, uh, you are correct that the, to, to say it's not really sweeps because there aren't people who are, you know, staying there. Um, that's, that's, that's sort of where they've made their, their temporary shelter. It's, it's, it's really people congregating there to transact, uh, business and, and use drugs.

[00:42:57] And, um, so the activities that are happening there usually are fairly transitory in nature. They're, they're literally cleaning the sidewalks and that does require, uh, moving people around and then it kind of reconstitutes itself. A lot of our focus is making sure that the people who are out there in those settings who are, who need more help, they need change happening in their lives.

[00:43:25] They need places to live and so forth that we are talking with them about that and working to find them better arrangements. That stuff gets mixed in with the fact that, um, there are many of the folks who are using those spaces who, um, they don't actually need a place to live. They have other places to stay and they come in because this is a place of business for them.

[00:43:51] Um, and so we are, um, cooperating with the city in various ways, including the police and the sheriff's department to do more, to disrupt that from being so persistently in this one spot there.

[00:44:08] Because, um, it's highly problematic for us as an operator of various services around there to have that be there and make for an uncomfortable environment for the people we're trying to help and for our staff and all that. Thank you all so much for being our guest this week. Uh, Richard, Penelope, Daniel, um, it's been a great conversation and that is the end. Uh, oh, and Sandeep too. Thank you. Thank you. No, no, no. Erica, Erica, thank you.

[00:44:38] D-E-S-E board member Sandeep Kaushik, also here. Uh, that is the end of another episode of Seattle Nice. David Hyde will be back next week keeping things, uh, in control again. Um, and our editor is Quinn Waller. And thank you all for listening. Thank you.