Disaster Management

In August of 2005, TOTA’s implementation of access, advocacy, and parity was unexpectedly altered by Hurricane Katrina.  With the mass exodus of evacuees from New Orleans headed towards Houston, TOTA was asked by the Texas Department of State Health Services to work with the local emergency response authority to respond to the reported large number of methadone patients who were on transports to cities across Texas.   The leadership worked nonstop for 96 hours setting up a system of care that included identification, screening, assessment, treatment and referral for this population.  In addition, to address the influx into Houston, financial and programmatic supports were organized and provided to clinics and local health authorities in other cities.  As these impromptu systems of care were beginning to stabilize, Texas was hit with another hurricane, creating a coordination of care nightmare in Houston and the surrounding areas – not only for the Katrina victims, but also for over 2,000 Texas methadone patients in clinics throughout Houston to the Louisiana border.  Again, TOTA was called upon to help coordinate care for the entire affected MMT population, which numbered near 3,000 with both populations. More than 18 months were required to work through the client and clinic care issues to recover from those two hurricanes.  As a result, TOTA designed an internal disaster management plan that attempted to address the issues of planning, preparation, recovery and repair, specifically related to the coordination of treatment services.

In 2008, that plan was tested as Texas was hit with four major hurricanes, three that significantly impacted MMT clinics along the coast.  TOTA immediately implemented disaster preparation working with potential impact clinics and clients, as well as DSHS to ensure continued access to medication. TOTA partnered with several local health authorities and outlying clinics to ensure that clients would be able to receive medication.  In addition, TOTA worked with clinics to take steps to protect property and records and had the potential to affect clinics that sent specific dosing and identification information to TOTA for safe-keeping.  As a result, there were minimal service disruptions and property/record damages.  

However, many issues, especially related to mental health care, crisis intervention, and resource access became apparent in 2008.  Unfortunately, many gaps still exist in a comprehensive coordinated disaster management plan for the state as it relates to MMT.

Beginning in December 2011, TOTA will roll out a web-based community hazard/vulnerability survey.  This will be disseminated via email to all MAT clinics in Texas.  The results will be used to develop a statewide disaster management plan and individual clinic disaster plan templates and suggested policies and procedures.  Check our homepage for a direct link to the survey.

TOTA will also be working with the Substance Abuse and Mental Health Services Administration to enroll clinics in the Digital Access to Medication (D-ATM) project by March 2012.

Disaster Management- Planning, Preparing, Responding, & Recovery

Texas has an extensive history of natural disaster impact.   This year Texas has experienced extreme and destructive weather events as well as some of the largest wildfires in our history.  Additionally, although Texas has been spared a direct hurricane impact this year, over that last five years we have been directly impacted by five major hurricanes. Hurricane Ike in 2008 was one of the largest and most destructive weather events since the 1920’s, resulting in more than five billion dollars in federal assistance.   The northern plains of Texas have seen countless tornados and wildfires with escalating destructiveness.   Since 2005, FEMA has spent over $12 billion dollars on disaster recovery. Disaster recovery research shows that the costly repair and recovery process can be mitigated by coordinated and systematic preparation.   One of the most valuable lessons learned from Hurricane Katrina and many other similar hazard events is the need to better prepare and empower communities to mitigate vulnerable threats and, thereby, increase the chances for shorter, less costly, and more successful recovery periods. 

The ability of a society to anticipate and respond to serious disruptions in services as a result of potential manmade and natural disasters is an important consideration in discussions about community preparedness. While a substantial body of disaster-related research exists on the need to provide for the basics of human life, such as sustenance, shelter, and emergency medical care, much less research attention has been devoted to how disasters affect the substance abuse treatment system and the needs of patients within the system.

Research on the impact of the 9/11 terrorist attacks on the delivery of drug and alcohol treatment services to patients in New York City found substantial disruptions in service delivery by all substance abuse treatment modalities in the aftermath of the attack. Research following hurricanes Katrina and Rita found similar problems.  Both storms had an impact on substance abuse service providers in central, eastern, and southeastern Texas. In the case of Hurricane Katrina, the primary impact was through a sudden influx of hurricane-related evacuees into the state of Texas, who presented with serious substance dependency issues. By contrast, Hurricane Rita directly hit parts of eastern Texas, leading to storm-related evacuations in affected areas of the state and causing substantial damage to local health care systems, including drug and alcohol treatment programs.  These breakdowns in care were again evident during hurricanes Rita, Dolly, and Ike.  Both resulted in the shutdown of treatment services for weeks, and in the case of hurricane Ike, the inability of treatment programs in Houston to provide services resulted in many programs suffering severe economic and financial problems, closing several programs permanently.  More recently, in the wake of wildfires, tornados, floods, hurricanes, and other disasters, substance abuse care systems across the United States have been strained, experiencing response-related difficulties in terms of current and new patient needs.

Within the substance abuse service delivery system and the general healthcare system, persons on medication-assisted treatment programs such as methadone and buprenorphine are especially vulnerable.  It is estimated that over 1 million people in the United States are currently addicted to heroin and/or other opiates.  There are currently 1,252 medication-assisted treatment clinics in the United States that treat over 200,000 people for opiate dependency.  New York, California, and Texas have the highest numbers of clinics and patients, and 75% of clinics are in high risk coastal states (Gulf coast states= 150; Pacific coast states= 181; and Atlantic coastal states= 609). Coastline counties of the United States, located along the country’s saltwater edges, contain 29 percent of the US population (83million), 5 of its 10 most populous cities, and 7 of its 10 most populous counties. Bordering the Atlantic and Pacific Oceans and the Gulf of Mexico, these bands of counties provide the setting for an intense concentration of economic and social activity.  Along with population growth, the socioeconomic status of the coastal states has changed.  Though Atlantic and Pacific coastal regions tend to have income above the national average, real estate values are an indubitable source.  The gulf coast region has historically been inclined towards having low socioeconomic status and the associated costs of having higher rates of poverty.  These states tend to underfund public healthcare and provide limited mental health and substance abuse treatment services.  However, proportional to the population, the Gulf States, especially Texas, have higher rates of substance abuse, opiate addiction, and people enrolled in medication-assisted treatment programs. 

Socioeconomic status and population density are important factors in disaster management planning, especially when resources are allocated based on potential impact.  Disaster research identifies several key factors that are determinants of individual and community quality of life outcomes following a disaster.  Socio-economic inequalities in health are well-documented in the relatively affluent, industrialized world. Components of social status, such as income, education, primary language, legal status, and ethnicity, might seem to have little to do with the impact of ostensibly random “acts of nature”, such as hurricanes, floods, and earthquakes. However, ecological upheavals are not egalitarian; they disproportionately affect those who are in lower socio-economic levels.  Many high-risk geographical areas have a disproportionately high percentage of marginalized populations; this same population is at a disadvantage for preparation, evacuation, response, and recovery. People in poverty are more vulnerable because they live in hazardous areas and have fewer resources, and this lack of resources affects all levels of the disaster vulnerability. People in poverty are less likely to receive timely warnings, and they have fewer options for reducing losses even if a warning does arrive in a timely fashion.

In emergency planning, the needs of persons enrolled in medication-assisted treatment programs are usually categorized within the needs of all “special populations.”  In fact, until Hurricane Katrina, this particular population and the larger addiction treatment population were largely left out of any disaster planning process.  Such general categorization typically fails to consider the unique needs of this population. Failing to explicitly include these individuals in definitions has also resulted in unintended consequences in which people have been denied services. Consistent definitions among State and local government emergency plans will aid in the coordination of services.

The circumstances of substance use and inadequate systems of care have contributed to high rates of mental illness, addiction, and poor physical health among this population. Individuals with serious mental illness may have a difficult time dealing with the abrupt disruption to their lives. The pandemonium of the emergency response may trigger symptoms of Post-traumatic Stress Disorder (PTSD).  For people in recovery, disasters disrupt support systems and create a whirlwind of emotions that interfere with the recovery process. Others who are currently using substances may have difficulty dealing with the disaster or, worse, may experience symptoms of withdrawal. This population also experiences higher rates of acute and chronic illnesses.

In the aftermath of multiple disasters, beginning with 9/11, it is evident that substance abuse treatment providers, especially medication-assisted treatment clinics, are unable to respond and recover from significantly destructive disaster events despite state requirements.  The state health authority requires clinics to have disaster plans, and TOTA encourages service providers to get involved in community emergency planning to increase their communities’ capacities to respond to the needs of their patients during a disaster.  Many providers do not have the training and resources needed to successfully prepare a disaster management plan or participate in local planning and preparation efforts. 

Being prepared and involved in this process is very important.  After a disaster, a community goes through four phases that overlap: the emergency period, the restoration period, the replacement reconstruction period, and the commemorative betterment period. Each phase is contingent on the others and takes about ten times longer than the previous one. The rate of recovery is directly related to the extent of damage, the available recovery resources, the prevailing pre-disaster trends, and community leadership and planning. Public behavioral health preparedness and medical assistance are critical components to any disaster response plan — the faster the behavioral  health community responds, the more quickly control strategies can be developed, the sooner appropriate treatments can be identified, and, ultimately, the faster human suffering is diminished.

See: Disaster Management Goals & Objectives