How one addiction clinic in Baltimore has found success combining addiction care with support for the many other health problems older Americans often face.
The pain in Renee Gray’s right hip had gotten so bad, not even the heroin could help.
Through nearly three decades of addiction to heroin and cocaine, Gray’s physical health — her joints, her blood pressure, her teeth, her vision — had been an afterthought.
Now, on this October night in 2023, Gray’s daughter and granddaughter watched as the then-64-year-old writhed on the ground — high and in agony.
“It hurt me so bad that my granddaughter [had] seen me like that on the floor,” Gray says.
Just 72 hours later, Gray walked through the doors of REACH Health Services, a methadone clinic in Baltimore that primarily serves older adults grappling with opioid addiction.
Nearly 20,000 people over the age of 55 died of an opioid overdose in 2023, and the number of seniors living with opioid addiction has climbed in recent years to roughly 1 million. Like Gray, many have other health problems such as arthritis, diabetes and heart failure. Social issues like housing, hunger and loneliness also pose increasing challenges for many people as they age.
Doctors, nurses, researchers and policy experts say many of these older patients are falling through the cracks of a health care system that is not built to meet their needs. Those same experts say there are clear ways to fill in those cracks, and this clinic in Baltimore offers one model for how to do that.
Many patients at REACH are like Gray: aging, addicted and low-income. Malik Burnett, the clinic’s medical director, believes that combination puts people in unique danger.
“If you have unmanaged substance use disorder and multiple chronic medical conditions, none of which are getting managed, you’re just going to die,” he says.
Much of REACH’s work to keep their patients healthy and alive can be boiled down to three key steps: treat addiction, repair trust and coordinate care.
The first step that REACH takes when a new patient like Gray arrives is to start them on medications for their opioid addiction.
One federal study found that less than 16% of people on Medicare with opioid addiction receive medications such as methadone or buprenorphine, which are proven to save lives and help people stay in recovery. That rate can sink even lower in corners of the health care system that older adults use more often, like nursing homes and hospitals.
REACH finds ways to smooth some of the bumps, like a lack of transportation, that can derail older patients. For example, they’ve taken advantage of a recent regulatory change that allows patients on methadone to bring more doses of the medication home rather than having to pick them up in person nearly every day.
Finally, REACH offers services beyond medication, like a peer support group specifically for older patients and a mental health therapist for those with more serious behavioral health needs.
Gray looks forward to her twice-weekly support group so much, she says, that she lays out her outfits for those days every weekend as she does her laundry.
As patients settle into addiction treatment, REACH staff work on rebuilding people’s trust in the rest of the health care system. Many people with addiction avoid getting care, in part because bad experiences with doctors and nurses haunt them.
Gray says she used to hate going to see her primary care physician because “she would stare at me like I was dirt or something.”
In one recent study that surveyed hundreds of doctors and dentists, 34% admitted they prefer to avoid patients with opioid use disorder. Just 9% said they felt the same about patients with HIV or depression.
REACH employs two staff members who have lived experience with addiction — known as peer specialists — to help patients build comfort and confidence navigating the very system that has often spurned them. One of those specialists, 61-year-old Phyllis Lindsay, works closely with Gray.
“She sees that I’ve been through this process,” says Lindsay, who has been in recovery from heroin addiction for nearly 20 years. “I take care of myself. I get checkups. And she’s like, if Phyllis can do it, then I can too.”
Together, the pair have gone to get Gray’s eyes checked and her teeth pulled — two procedures Gray had been dreading.
REACH Executive Director Vickie Walters says the clinic tries to foster a culture that is more trusting and less paternalistic toward their patients. For example, the clinic maintains an “open door policy,” meaning patients can return no matter how many times they’ve relapsed. That’s in stark contrast, she adds, to policies she’s seen at other treatment facilities, like one place she used to work that cut ties after three tries.
“It was an arbitrary rule that was created by a system that really looked at treatment like punishment almost.”
As patients grow more aware of their health needs and more comfortable with the health care system, REACH staff flip into care coordination mode.
They chase down referrals to specialists, arrange transportation for patients to get to the doctor and decipher hospital discharge instructions. Staff even dip their toes into social work, linking patients up with food stamps and affordable housing.
“We see our role as getting people connected to the care that’s already in the community,” Walters says. “Helping to facilitate that, helping them to follow through.”
While many people turn to family and friends for that sort of support, peer specialist Phyllis Lindsay says many of her clients lack those ties to lean on.
“When you’ve been addicted for a long time, people disown you and don’t want to have anything to do with you,” she says. “So you have nobody to reach out to for help.”
A growing body of evidence from hospitals and clinics treating addiction, as well as other medical conditions, shows this type of coordination work can improve people’s health, get them into recovery, and in some cases, even save money. That’s got more health insurers willing to pay for these services — and more clinics and hospitals willing to add them.
Still, researcher Lisa Clemans-Cope, a senior fellow at the Urban Institute, says there are fewer than 10 states where methadone clinics like REACH can get paid to do this extra work — and even in those states, many choose not to.
“Comprehensive care for these incredibly complex patients is definitely a needle in the haystack kind of thing,” she says.
A lack of investment, according to the 20 people Tradeoffs interviewed for this story, is one of the biggest barriers to improving care for older adults with opioid addiction.
They pointed to a wide range of gaps that result from insufficient funding — from a lack of proper addiction training and staffing at nursing homes to a shortage of affordable housing for seniors, which can destabilize people’s health and recovery.
Policy experts did highlight one potential pot of new money: the billions of dollars heading for state and local government coffers as the result of legal settlements with opioid drugmakers and distributors over those companies’ roles in the overdose epidemic. One state, Connecticut, has already directed some of their dollars toward expanding access to methadone in nursing homes.
Further starving an already underfunded field would be shortsighted, says Maggie Lowenstein, assistant professor and addiction medicine physician at the University of Pennsylvania Perelman School of Medicine.
“ When you do care badly, that’s also really expensive,” she says.
Researchers estimate that the federal government spends north of $10 billion a year for people on Medicare with unmanaged opioid addiction.
Doctors and researchers have yet to reach a clear consensus on the best way to deliver higher quality care to people aging with addiction. REACH has never completed a rigorous evaluation of their program. Some studies of other similar approaches have shown promising results, but Lowenstein cautioned that what works in one hospital or clinic may flounder in another.
Still, Lowenstein has seen enough positive data as a researcher — and witnessed too many opioid overdoses and deaths as a physician — that she doesn’t need to wait for what she called “that one perfect study.”
“ There are some things that we really know work, and then there are some things that are probably never going to be studied fast enough to keep up with the pace of how this crisis evolves,” she says. “But it’s incredibly important to do our very best to apply what we do know works urgently so that we can save lives and help people get into recovery.”
Renee Gray believes deeply that she is one of the lives this work has saved.
With help from REACH, she has been off of heroin for 14 months. She’s lowered her blood pressure and nearly kicked her smoking habit. She even moved into an apartment all her own.
Next on the list this year: finally getting her right hip replaced.
Episode Transcript
Dan Gorenstein (DG): America is aging and so is its opioid epidemic.
Nearly 20,000 people over the age of 55 died of an opioid overdose in 2023.
As of right now, some 1 million seniors are living with opioid addiction.
And they’re often grappling with problems like arthritis, diabetes, heart failure.
Plus, housing, hunger, and loneliness.
Add all that up and getting many of these patients the help they need is hard.
Phyllis Lindsay (PL): You fall in between the cracks. I mean, you just fall. There’s just nothing there to help you.
DG: Today, we go inside one clinic catching some of those people falling through the cracks and explore what it would take to make care better for more Americans aging with addiction.
From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.
*****
DG: 67-year-old Renee Gray is ready. For more than two years, she’s been wanting to do something about her hip.
Renee Gray (RG): I can’t walk a whole block. I have to keep stopping and sit down because that’s how bad it hurt.
DG: When we met in mid January, Renee finally got relief in sight — a hip replacement scheduled for February. And to prepare for it, she’s come to what may seem like an unusual place.
RG: These are the papers, Dr. Burnett, for my operation.
Malik Burnett (MB): Okay, cool.
DG: A methadone clinic for people with opioid addiction in Baltimore, Maryland.
MB: Have you talked with the surgeon?
RG: No.
DG: It’s called REACH Health Services.
MB: Okay. They may tell you that they want you to stop taking your methadone beforehand.
RG: I know. They did.
MB: Don’t do that.
DG: The kind of place that knows Renee can get her hip replaced without stopping medication that’s kept her off heroin these last 14 months.
The day I was there, REACH’s Executive Director Vickie Walters told me that she thinks the clinic plays this dual role for their patients: part advocate, part air traffic controller.
Vickie Walters (VW): In a sense, we call what we do primary care light. We see ourselves, our role, as getting people connected to the care that’s already in the community and helping to facilitate that, helping them to follow through, and to really go the extra mile.
DG: REACH is less a primary care clinic where people get check-ups, more a place that’s equally on top of patients’ addiction, their blood pressure, their housing — a clinic that quarterbacks all of a person’s care.
Malik Burnett, who directs medical care at REACH, says this is critical for their more than 300 highest-need patients.
MB: It’s not easy to navigate the health system for anybody, right?
DG: But, Malik says, U.S. health care is particularly treacherous for older Americans dealing with addiction, especially if they’re low-income. Many of Malik’s patients getting this extra help, including Renee, check all three boxes.
It’s a combination that, Malik believes, puts people in unique danger.
MB: If they fail to engage in the health system as they get older and they have more chronic conditions, they’re going to die. If you have unmanaged substance use disorder and multiple chronic medical conditions, none of which are getting managed, you’re just gonna die — from something.
DG: Accurate numbers on opioid addiction — a condition often shrouded in shame and secrecy — are hard to come by. But the best numbers that we do have, point to a growing problem that America’s health care system is struggling to meet.
Between 2013 and 2018, the share of seniors on Medicare with opioid addiction tripled. Much of this group suffers from at least half a dozen chronic physical conditions.
Yet all-in-one support like the kind REACH provides — coordinating a person’s mental, medical and social needs — is rare.
Lisa Clemans-Cope (LC): Comprehensive care for these incredibly complex patients is definitely a needle in the haystack kind of thing. It’s really very uncommon
DG: Lisa Clemans-Cope, is a senior researcher at the Urban Institute, a Washington, DC think tank. Lisa says there are fewer than 10 states where methadone clinics can get paid to do this extra work — and even in those states, many choose not to.
But failing to address the full suite of these folks’ needs can come at a big cost. One study found that the federal government spends north of $10 billion a year for people on Medicare with unmanaged opioid addiction.
To be clear, providing more comprehensive care for this population costs money too — and it’s pretty hard to do— but Renee Gray will be the first to tell you, the results, they can be extraordinary.
RG: Do I think I’d be alive if I didn’t come here? No.
DG: Renee started using heroin in the 1990s. It took her about 30 years to stop.
The turning point came in the fall of 2023. Renee was living with her daughter and she’d been using heroin to numb this excruciating pain in her hip.
But the drug had stopped helping. That night, she was high — and she was in agony.
RG: Crying and twisting and turning on the floor. When I think about it, it makes me feel bad. But I was really crying because I was in so much pain. And then using them drugs, too, it seemed like the drug was making it worse.
DG: Renee’s daughter, Latea, was terrified — seeing her on the floor like that. Instinctively, she reached for her phone.
RG: My daughter recorded me just so she could show me how I was acting.
DG: Latea played it back for her mom the next day.
RG: When she showed me that, I felt this small. I couldn’t lie, I said, “Yeah, that’s me.” And I just, like, I told her, I said, “I don’t care who’s getting high, who’s doing what. Renee ain’t going to do it.”
DG: 72 hours later, Renee walked through the front doors of REACH.
Like a lot of people who have used street drugs on and off for decades, she was in pretty rough shape.
RG: I was really doing bad when I first came in here. I wasn’t going to my primary care doctor or nothing — none of that.
DG: Teeth decaying, vision shot, sky high blood pressure, that debilitating pain in her hip — Renee will tell you, for decades, her health was an afterthought.
Addiction was a huge part of that, but shame was part of it too. Past visits to her primary care doctor had left Renee feeling low.
RG: She would stare at me like, ‘Mm, why you use drugs?’ Or you know, like I was dirt or something — and just made me feel bad. I know I look bad, but you ain’t got to, you know, talk to me like that.
DG: Research suggests Renee is not alone. One study asked several hundred doctors and dentists for their honest opinion about the types of patients they prefer to see.
A full one-third admitted that they would rather avoid patients with opioid use disorder — a far more negative response than any other patient group, including people with alcohol addiction, HIV or diabetes.
DG: REACH estimates that about 95% of their highest-need patients have no connection to primary care when they first show up. So the clinic makes rebuilding people’s bridges to the rest of the health care system a central part of its work.
Phyllis Lindsay (PL): That’s what I’m here for — to make them feel comfortable and more relaxed about taking care of their health problems.
DG: Phyllis Lindsay works as a peer specialist — a kind of coach for REACH patients, including Renee. She’s part of a super team to address people’s recovery AND their physical, mental, emotional – even social needs. Together, this team lines up appointments, referrals, rides to the doctor.
As important as navigating the health care system may be, Phyllis says most folks at REACH need that and something that too often is in short supply.
PL: They need attention. They need somebody to listen to them. They need somebody to really hear them and internalize what they’re trying to say to them.
DG: That need, that’s why Phyllis, nearly 20 years into her own recovery journey is here — and why REACH has a mental health therapist too.
Sometimes the clinic even fills the role that a close friend or family member might — someone who’s got you, will go to that doctor’s appointment you’re dreading.
The sad reality, says Phyllis, is that many of her clients don’t have a person like that in their lives.
PL: When you’ve been addicted for a long time, you get cut off from reality. People disown you, stigmatize you, and don’t want to have anything to do with you. And so you have nobody to reach out to. And, we all need help, you know. We all need help.
DG: Help is exactly what Renee Gray needed last fall when she realized that before she could fix her hip, she first needed to get 4 bad teeth pulled. They could pose an infection risk.
Renee turned to Phyllis.
PL: She didn’t wanna go to the dentist. She had a fear of going to the dentist for a long time.
RG: I had to get teeth cut out my gum, you know, that’s how bad it was. I was really scared.
DG: Phyllis knew Renee could be at a crossroads moment in her recovery. Pain and discomfort from festering medical issues are a top reason Phyllis sees people relapse.
So, she made a plan for her and Renee to ride to the dentist together. She assured Renee she’d be right there waiting for her after the appointment was over.
RG: I’m older than her and I know this, but it’s like she was my mother, because I felt safer with her going with me and staying there. I wasn’t by myself.
DG: The procedure went off without a hitch. Afterward, the pair caught an Uber to Renee’s apartment, Phyllis making sure Renee got inside okay.
When we come back, why providers like REACH are so rare, how to improve care for older adults with opioid addiction and Renee gets ready for surgery.
BREAK
DG: Welcome back.
Before the break, we heard how one Baltimore methadone clinic is going the extra mile to improve care for their patients aging with opioid addiction.
For the second half of the show, we’re going to talk with Tradeoffs senior producer Leslie Walker to put that care into some context.
Hey Leslie.
Leslie Walker (LW): Hey Dan.
DG: So look, while I was riding the Amtrak from Philly to Baltimore, you were making calls around the country talking with docs, researchers, policy experts to get a handle on what better care could look like for this group of people. What did you learn?
LW: Yeah, when it comes to care for older adults with opioid addiction, we know REACH is this kind of unicorn, right?
But most of the people I talked to — about 20 folks in total — told me there is some good news. There’s a lot about REACH’s approach that plenty of other places could copy.
I’m really talking about 3 big elements here, Dan. And honestly, these three steps are so universal that if more places took them, a lot of people with addiction could benefit.
DG: That sounds very promising. So what’s step 1?
LW: Very basic start here, Dan: Get more people on medication to treat their addiction.
Specifically, I’m talking about drugs like methadone and buprenorphine proven to keep people alive and in recovery. One federal study found that less than 16% of people on Medicare with opioid addiction are getting these meds.
DG: 16%, Leslie? That is brutal.
LW: It is. I mean, there is a big mountain of work to do here, Dan.
One priority for older folks: boosting treatment rates in places they’re more likely to end up like hospitals and nursing facilities. Some nursing homes just flat out refuse to admit folks who need medication for addiction.
DG: That sounds illegal?
LW: It is. The federal Department of Justice has actually taken several nursing home chains to task over this very issue.
DG: What’s getting in the way of nursing homes? What’s making it so hard for them to do this?
LW: It’s a thorny issue. We could — and should — do a whole separate episode about it, but bottom line: These facilities argue they need more training, more staffing and higher pay to get these patients the medications and the care they need.
All that said, there is some progress here. One big thing: Medicare finally started covering methadone a few years back and now 8 out of 10 methadone clinics accept that coverage.
DG: Ok. It sounds like treatment is becoming more available, but, as you say, slowly.
So that’s step 1. Step 2?
LW: Number 2: Build trust with patients.
Like Renee Gray explained in the first half of our show, if your doctor makes you feel bad, no matter what they’re offering, you’re less likely to go see them.
DG: Right, this issue of stigma or bias seems to run real deep, especially for older patients who have sometimes been mistreated for decades. I saw some of this play out in Baltimore.
LW: Exactly, and I think that’s why I heard in the conversations I had about people tackling this from a whole bunch of different angles. I heard about medical schools changing how they train future doctors trying to build empathy and reduce bias. Clinics are adding staff like Phyllis Lindsay who have lived experience and better understand what folks are going through.
DG: I noticed this is top of mind for REACH, too. One thing that stuck with me was what their executive director Vickie Walters called their ‘open door policy’ — that folks can relapse as many times as it takes and still come back for treatment.
That’s the polar opposite of this one clinic where she used to work.
Vickie Walters (VW): There was a rule that you had three, three strikes and you’re out. So you could only come to treatment three times. It was an arbitrary rule that was created by a system that really looked at treatment like punishment almost.
DG: Vickie pointed out, Leslie, that many of REACH’s older patients have been subject to this really kind of punitive, paternalistic system for years. So Vickie’s always trying to find little ways to build up trust wherever she can. She gives staff this stack of McDonald’s gift cards that they hand out sometimes.
VW: It’s only $5, but you can get a cup of coffee and an Egg McMuffin in the morning for five bucks. People say to me — program directors say to me — ‘Well, don’t they just leave with the gift card?’ No, they leave, they go get their food and they come back. They don’t even sit at McDonald’s and eat it. They bring it back here and sit in the waiting room.
LW: Now all those little things Vickie’s doing for sure add up. There’s no doubt.
But experts told me, Dan, we also need some larger policy reforms to fix this culture of mistrust too.
For example, historically, people have had to go in person nearly every day to pick up their dose of methadone. The Biden administration loosened those rules, but early data suggests methadone clinics have dragged their feet in adopting that new flexibility.
DG: Alright, so we’ve got increasing access and building trust. Leslie, final step?
LW: More coordinating, navigating, whatever you want to call it, Dan. In fact, I think you called it ‘air traffic controlling’ at the top of our show.
DG: I thought that was descriptive.
LW: It was! So, this type of work is especially important for the subset of older Americans who have lower incomes and higher needs — challenges like housing, hunger and a lack of transportation.
DG: On top of all the medical challenges that come with aging.
LW: Exactly. And that’s a whole bunch of stuff that almost no doctor in America has time to deal with.
The good news is there’s a growing body of evidence that adding these extra team members — they go by many names: case managers, care coordinators, community health workers…
DG: Air traffic controllers…
LW: Yes. The evidence is growing that air traffic control work can improve people’s health, get them into recovery and in some cases, even save money.
That has got more primary care clinics and hospitals providing these sorts of services; and, importantly, it’s got more health insurers willing to pay for them.
DG: Alright, so your 3 steps: access, trust, coordination. There’s something you just touched on there at the very end that I assumed would have been one of the three steps. It starts with the letter M and rhymes with honey…
LW: Ah yes, good ol’ money, Dan. You’re absolutely right: More money would make all these steps — all of this progress — go further, faster.
I mean, if you want busy providers to counsel patients on their treatment options or connect them to a housing shelter then you’ve got to pay them enough to do those things.
The folks I spoke to were totally clear that this work is woefully underfunded across the board.
DG: Just for a second, Leslie, let’s assume that money came pouring in and overnight, care in a whole lot more places looked like what’s happening at REACH.
What would our return on investment look like — in terms of money, in terms of improved health for people? Would it change?
LW: Yeah, so there is clear evidence that getting more people on medication to treat their addiction saves lives — and money. And we just said there’s also pretty good evidence for the air traffic control work too.
What’s less clear is exactly how all of these pieces should work together. How many air traffic controllers do you need? Where should ‘home base’ be for these patients? A methadone clinic? A primary care office? Somewhere else?
DG: Key questions to answer if you want to see this kind of work scale, especially on a tight budget.
LW: Exactly, but you know, evidence in this field is tricky.
I was talking with University of Pennsylvania researcher Maggie Lowenstein, who’s also a doctor working at a program similar to REACH.
She told me a lot of this work is what she called ‘bespoke’ — each clinic, each hospital putting these pieces together a bit differently, and that makes studies of this stuff hard to generalize.
DG: Plus, I’ve got to think the opioid crisis constantly evolving, the drug supply itself changing, makes researching this hard too.
LW: Totally. But still, Maggie thinks programs like REACH are on the right track.
Maggie Lowenstein (ML): If we address people’s medical needs through primary care, if we give them medications for their opioid use disorder and if we address their social needs, their outcomes are going to improve. Those are things that we know work — whatever the drug supply is — and things that we really need to put into practice urgently to save lives.
LW: Look, Dan, there’s a lot we still don’t know about older adults with addiction.
That’s something I learned in reporting this story. I mean, this is a deeply understudied population that’s growing and changing.
At the same time, I mean the overdose death rate for seniors quadrupled in the past two decades. And in my mind, that’s clear enough data that we’ve got to do something differently here.
DG: Leslie Walker, thanks for your work on this story.
LW: Thank you, Dan.
DG: As for Renee Gray, she’s now been a patient at REACH for almost two and a half years.
She’s accomplished a lot in that time: 14 months off of heroin; blood pressure doing better; smoking habit nearly kicked; finally moved into an apartment all her own.
Renee’s partner in much of this progress — peer specialist Phyllis Lindsay — says she has witnessed Renee undergo a metamorphosis.
PL: Since I’ve been here, I’ve seen a major change in her and, you know, in her behaviors, in her attitudes, in her thinking process, her mindset.
DG: One other major change: the bridges that Renee has rebuilt.
RG: My son told me now that, ‘Mommy, I am so proud of you that you stopped doing drugs and got yourself together and, you know, you’re trying to make the rest of your life a lot better.
DG: When we last spoke, Renee was still waiting for her surgery date.
Phyllis has offered to be by her side — like she was at the dentist — but this time around, Renee says she has her own people to call on.
Her son has volunteered to take her in. Her daughter is ready to care for when she gets home.
RG: That’s what really makes me just say, ‘Girl, go ahead and get this thing done.’ I got so much support. That’s what makes me just keep going, keep going ahead.
DG: I’m Dan Gorenstein. This is Tradeoffs.