HomeMy Public PortalAbout8.2.23BOHPacket
Barnstable County Department of Human Services
Substance Use Assessment
January 2023
Contents
EXECUTIVE SUMMARY .................................................................................................................................. 1
Introduction ............................................................................................................................................. 1
Methods .................................................................................................................................................... 1
Key Findings ............................................................................................................................................. 2
Key Recommendations ............................................................................................................................ 5
INTRODUCTION ............................................................................................................................................ 8
Changes in the Field of Substance Use.................................................................................................... 8
Land Acknowledgement ........................................................................................................................ 10
Social Determinants of Health Framework and Health Equity ............................................................ 10
METHODS ................................................................................................................................................... 11
Qualitative Data ..................................................................................................................................... 12
Secondary Data ...................................................................................................................................... 12
Limitations.............................................................................................................................................. 13
PROFILE OF COMMUNITY ........................................................................................................................... 14
Impact of Social Determinants of Health .............................................................................................. 18
Housing ............................................................................................................................................... 18
Transportation ................................................................................................................................... 20
Insurance coverage ............................................................................................................................ 22
Prevalence and Perceptions of Substance Use in Barnstable County ................................................. 23
Mortality & Morbidity ......................................................................................................................... 23
Hospitalization, Emergency Department Visits, and Treatment Admissions .................................. 26
Adult Substance Use .......................................................................................................................... 27
Youth Substance Use ......................................................................................................................... 31
Perceptions of Substance Use ........................................................................................................... 36
FINDINGS .................................................................................................................................................... 38
Prevention .............................................................................................................................................. 39
Existing Programs and Services ......................................................................................................... 39
Barriers to Access ............................................................................................................................... 40
Needed Programs and Services ......................................................................................................... 41
Cost of Substance Use Prevention .................................................................................................... 42
Harm Reduction ..................................................................................................................................... 43
Existing Programs and Resources ..................................................................................................... 43
Barriers to Accessing Existing Services.............................................................................................. 44
Needed Programs and Services ......................................................................................................... 45
Cost of Substance Use Harm Reduction ............................................................................................ 46
Treatment ............................................................................................................................................... 48
Existing Programs and Services ......................................................................................................... 48
Barriers to Accessing Existing Services.............................................................................................. 48
Needed Programs and Services ......................................................................................................... 49
Cost of Substance Use Treatment ..................................................................................................... 51
Recovery ................................................................................................................................................. 52
Existing Programs and Services ......................................................................................................... 52
Barriers to Accessing Existing Services.............................................................................................. 53
Needed Programs and Services ......................................................................................................... 54
Cost of Substance Use Recovery ....................................................................................................... 56
Resource Inventory ................................................................................................................................ 57
Cost of Substance Use in Barnstable County ........................................................................................ 59
KEY FINDINGS AND INITIAL RECOMMENDATIONS ..................................................................................... 63
Overall..................................................................................................................................................... 63
Prevention .............................................................................................................................................. 64
Harm Reduction ..................................................................................................................................... 65
Treatment ............................................................................................................................................... 65
Recovery ................................................................................................................................................. 65
ACKNOWLEDGEMENTS .............................................................................................................................. 67
APPENDICES ............................................................................................................................................... 70
APPENDIX A: Discussion Guide .............................................................................................................. 70
APPENDIX B: Resource Inventory .......................................................................................................... 76
APPENDIX C: Additional Cost Data Details ............................................................................................ 77
Prevention .......................................................................................................................................... 77
Harm Reduction ................................................................................................................................. 77
Treatment ........................................................................................................................................... 78
Recovery ............................................................................................................................................. 78
CITATIONS .................................................................................................................................................. 79
1
EXECUTIVE SUMMARY
Introduction
Substance use has continued to be a critical community concern in Barnstable County. To examine
the current impact of substance use, Barnstable County Department of Human Services (BCDHS)
undertook a comprehensive community assessment in 2022 focused on substance use to:
Describe the mortality, morbidity, and societal costs of substance use
Understand the community needs related to substance use
Learn how these needs are and are not being met in the community
Identify strengths and gaps in available resources
The 2022 assessment builds on a previous assessment in 2014, both conducted in partnership with
Health Resources in Action (HRiA), a non-profit public health organization. To reflect changes in the
field of substance use since the previous assessment, some changes in approach were made for this
2022 assessment. Specifically, the domains of focus were updated to be prevention, harm reduction,
treatment, and recovery. The results in this 2022 report will be used to guide development of a 5-year
action plan to direct future programming, policy, and funding priorities related to substance use in
Barnstable County.
In doing this assessment work, we acknowledge that Barnstable County is on the lands of the
Wampanoag Tribe, including the former Nauset Tribe. We recognize that Indigenous people are the
traditional stewards of the land that we now occupy, living here long before Massachusetts was a
state and still thriving here today. As we live and work on this land, we have a responsibility to
acknowledge the Native people and work together with them to create healthy communities. By
taking this small action in making a land acknowledgment, we hope the message will inspire others to
stand in solidarity with Native nations.
Methods
This assessment utilized a community engaged assessment approach with ongoing input on
assessment approaches and results from the Barnstable County Regional Substance Addiction
Council Prevention Workgroup as well as through two public launch meetings held in September 2022
to gather broader community feedback on the assessment approach and goals. The results of the
assessment will also be made accessible for the community through presentations by county staff to
Barnstable County municipalities and other local entities (e.g., organizations, programs, groups, etc.).
The assessment was conducted using a mixed methods approach to gain a robust understanding of
substance use in Barnstable County including secondary data collection and qualitative data
collection through group interviews and discussions with community members.
Nineteen interviews were conducted with 36 participants in total with perspectives in the areas of
substance use prevention, harm reduction, treatment, and recovery. Interviewees included service
providers at local organizations, community members, and other local stakeholders working in or
with experiences related to substance use. Many of the individuals participating in these discussions
brought multiple critical perspectives through sharing their lived experience with substance use.
2
Prevalence data related to substance use was collected from existing public data sources to describe
the issue of substance use in Barnstable County. Indicators related to the cost of substance use
services were requested from local service providers, organizations, programs, and other
stakeholders to estimate the cost of substance use in Barnstable County. These cost data were
analyzed by domain and, where possible, by substance.
Key Findings
The Barnstable County community is primarily White non-Hispanic and older compared to
Massachusetts overall. The housing cost burden is higher for those in Barnstable County than in the
state and a greater proportion of the county has public health insurance than the state overall. Very
few people use public transportation; more renters than homeowners lack access to a vehicle.
In recent years, Barnstable County has had higher rates of opioid-related overdose and alcohol-
impaired driving deaths than the state. In 2020, there were higher rates of hospitalization and
emergency department visits for drug poisonings compared to the rates in Massachusetts. At state-
funded treatment facilities, most of the admissions for those in Barnstable County were for alcohol
and fentanyl or heroin. A higher percentage of adults in the county reported using alcohol and
marijuana in the past month during the pandemic compared to Massachusetts; more than a third of
adults in the county reported increased substance use since the pandemic started. Youth in
Barnstable County report more current substance use of alcohol, marijuana, and vaping, than youth
in the state overall.
Perceptions of Substance Use
Overall, service providers, community members,
and other local stakeholders note that there are
major concerns about opioids and overdose in
their community; further elaborating that today
these substances are different and stronger than
in the past. According to their observations and
experiences, there are two sides to the perception
of substance use. There are those in the county
who deny substance use is an issue in the
community and pointed out the related issue of stigma related to this view; individuals noted a
contributing factor to this perception is the fact that the county is a tourist destination and can be said
to have a “look to maintain”. On the other side,
there are those who work collaboratively to address
substance use and who have seen the awareness of
substance use and its related issues increase,
particularly the co-occurrence of mental health,
trauma, and substance use. Those who have seen
these positive changes in their community do note
that more progress has been made in some
communities than others and there are geographic
inequities in availability of supports and services.
“I feel that we have grown very much on
Cape Cod. It’s talked about, I don’t feel
strange bringing it up to people, it’s
more of a fluid conversation. I can say
I’m a person in recovery. It’s not a big
shock to anyone and I wouldn’t have
done that years ago.”
-Service Provider with Lived Experience
“Cape Cod is tourist community [with
a] huge income that comes from that
for people. There is a look that we need
to maintain and I think that there is a
lot of stigma around substance use.
You encounter ‘not in my back yard’
stuff.”
-Service Provider
3
When thinking about the issue of substance use among youth, people shared that substance use is
starting at younger ages and that there is a significant impact of intergenerational substance use.
Substance Use Services and Barriers to Access
Qualitative findings highlighted many impactful services across the domains including early
childhood focused prevention programs, expansion of harm reduction services like Narcan
distribution, effective treatment facilities with long-standing history in treating substance use in the
county, and a supportive and diverse recovery community.
Those who shared their perspectives on prevention
services noted there are few available and the
primary venue for these is currently schools. They
emphasized the importance of doing prevention
work early in childhood and consistently through
adolescence. There was also discussion of how non-
traditional programs, such as those utilizing open
conversations with young people, have the potential
to impact both substance use and stigma. Another
overall theme for prevention was isolation among
young people and how having safe spaces where
they can spend their time and connect with others
could lead to a reduction in youth substance use;
these spaces also present an alternative venue for
prevention programs to reach young people.
Service providers, community members, and other stakeholders emphasized that harm reduction
services are lifesaving and are effective when delivered using an affirming approach. They not only
present the opportunity to provide substance use specific harm reduction services, but also to
connect individuals to other needed resources such as treatment for substance use and related health
concerns (e.g., Hepatitis C). Stigma related to harm reduction from different groups, including some of
those in substance use work, was raised as a major contributor to the opposition experienced by
those trying to implement and expand these critical services.
“Those [harm reduction] are the first people that talked to me like I was human, they
didn’t shame or guilt me.… Those were the first people that interacted with me like I
mattered. People walk by and judge and shame you, you’re already struggling
internally. These harm reduction programs provide safety, they kept me alive.”
-Participant with Lived Experience
“When we have a guidance counselor
do [a] lecture, people listen less. But
we did have someone who went
through rehab and had [an] incredibly
different life; a lot of people [were]
saying they really liked it. [It] struck a
chord. Hearing it from someone who
went through it and struggled
through [the] ramifications works a
lot better.”
-Participant with Lived Experience
4
The available treatment services are highly regarded
by those who shared their perspectives for this
assessment; however, they note these services are not
able to meet the full extent of these needs, especially
for co-occurrence of mental health and substance use.
A major concern discussed by many of those
interviewed was the beds available for treatment are
not enough, particularly those focused on specific
populations such as youth, parents of young children,
and those transition from correctional institutions.
There is also growing concerns expressed about the
number of private facilities opening in the county and
the affordability for those with different types of
insurance (e.g., public insurance) and the coinciding
closings of facilities that were having a positive impact
on the community.
Those with perspectives on recovery in Barnstable
County shared there is strong community of
support and connection among those in recovery
and many effective services available. They also
lifted up the importance that these services are
supportive of each individual’s path in recovery
and not only one “right path”; different types of
services mentioned were focused on wellness,
mindfulness, and grief/loss support. Even with
these services people shared it is important to
expand programming across the municipalities in
the county to address barriers (e.g.,
transportation, availability) as isolation and lack of
connection were noted as some of the harder
things for someone in recovery to manage.
Several cross-cutting barriers to accessing substance use services were identified. The most common
barriers were:
Impacts of individual and community level stigma
Lack of affordable housing overall and specifically focused on those with substance use
disorder (SUD)
Transportation and insurance related challenges
Difficulty navigating the existing services and resources
Geographical inequities in available services
“Even though [in] our programs we
really work hard for same day
initiation of treatment, there aren’t a
lot of opportunities for folks
struggling with active use if they
walked into [somewhere] using right
now at this moment and wanted
treatment to start. [We] need a
bridge, [an] easy access clinic.
Someone should walk in and be able
to find options [and be] referred to
whoever is the right choice…”
-Service Provider
“[We need] to have places where there
are these options and people can choose
whether or not it’s for them. We’re an
intelligent group emotionally, which is
very much undermined. We talk about
feelings all the time, we’re very
emotionally aware of our needs for each
other. It’s just being heard and being
provided the space. We’re told what we
need a lot. That’s why I appreciate the
time to be able to say what we need.”
-Participant with Lived Experience
5
Costs of Substance Use
Using locally provided cost data for substance use services, the estimated cost of substance use in
Barnstable County is $48,333,708.77. Below is a table breaking down the total cost by domain as well
as by substance were appropriate and data were available. The domain with the highest cost was
treatment ($45,073,325.80 or 93.5% of reported estimated costs), and alcohol was the substance with
the highest associated cost across the domains.
Prevention Harm
Reduction Treatment Recovery Total
Alcohol -- -- $22,492,262.77 $218,988.00 $22,711,250.00
Marijuana -- -- $730,129.01 -- $730,129.01
Opioids -- $460,263.12 $14,529,837.56 -- $14,990,100.00
Other
Substances -- -- $2,345,548.32 $444,612.00 $2,790,160.32
Unspecified
Substance -- $176,471.85 $3,062,374.88 $605,960.00 $3,844,806,73
Total $1,189,438.00 $636,734.97 $45,073,325.80 $1,323,210.00 $ 48,222,708.77
These data show a large disparity with much of the costs attributed to treatment related services;
services in the other domains present critical opportunities to save lives as well as costs. While
representing only 2.5% of the total reported estimated costs, prevention activities have the potential
to result in over $21 million in savings based on estimates that every $1 spent on school-based
prevention programs could save $18.1 Harm reduction services represent just 1.3% of these costs but
investment in these services has immense potential to save both costs and lives. Recovery costs also
represent a small percentage of reported costs (2.7%). One study found that a program focused on
recovery may have similar costs to traditional clinical approaches to substance use but led to more
positive outcomes for individuals to maintain long-term recovery.2
Key Recommendations
The results of this assessment highlight the importance of regular, ongoing data collection and
assessment to understand the issues related substance use as well as the context in which they are
happening. To continue to utilize community perspectives and data to drive decisions regarding
substance use services in the county the following should be considered:
Conduct an assessment of this nature every 3 to 5 years with the goal of understanding both
ongoing needs and emerging trends related to substance use.
1 Miller, T. and Hendrie, D. Substance Abuse Prevention Dollars and Cents: A Cost-Benefit
Analysis, DHHS Pub. No. (SMA) 07-4298. Rockville, MD: Center for Substance Abuse
Prevention, Substance Abuse and Mental Health Services Administration, 2008.
2 McCollister, K. E., French, M. T., Freitas, D. M., Dennis, M. L., Scott, C. K., & Rodney, R. F. (2013). Cost-
effectiveness analysis of recovery management checkups (RMC) for adults with chronic substance use disorders:
evidence from a 4-year randomized trial. Addiction, 108, 2166-2174. https://doi.org/10.1111/add.12335
6
Engage with key stakeholders to emphasize the importance of this work, and their
contribution to it, to the community to facilitate this type of regular data collection.
Conduct additional community engaged assessment work, with specific populations and
topics of focus, to gain a deeper understanding of needs and trends identified as well as fill
any gaps in knowledge.
These assessments should aim to guide decision-making and action planning from an evidence-
informed perspective, which includes but is not limited to research as the only form of evidence (i.e.,
evidence-based practice).3, 4 With an evidence-informed approach, decision-makers ensure both
research and community expertise and experience are integrated to create more equitable and
inclusive action.
Participants shared their suggestions and recommendations related to substance use services in
Barnstable County specific to each domain as well as those that cut across all domains. Regarding
those that should be considered across domains participants identified a need to understand and
integrate the impact that social determinants of health – particularly housing, transportation, and
insurance – have on accessing resources when developing and implementing substance use services.
Interviewees expressed a desire to see more cross collaboration and coordination between
organizations providing substance use services in each of the domains across the county. Individuals
shared they thought encouraging and facilitating this collaboration would have far reaching impact
including increased awareness, among different providers and in the community in general, of what
resources and services are available. Furthermore, interviewees shared that it would be useful to put
in place systems to help individuals navigate the existing services; one key piece to this navigation
that was identified was a form of person-to-person support, e.g., service navigator, to ensure those in
Barnstable County seeking substance use services can get connected.
Based on the input provided during the discussions with these service providers, community
members and other stakeholders, the following should be considered when planning future actions to
provide substance use services in these domains:
Prevention
Focus on holistic approaches to prevention as an effective form of substance use prevention,
including addressing co-occurring mental health and substance use and providing safe and
healthy outlets for youth to spend their time.
o Provide these holistic services starting in early childhood (0-5 years) and consistently
through young adulthood to build and maintain these skills.
3 Kumah, E. A., McSherry, R., Bettany‐Saltikov, J., Hamilton, S., Hogg, J., Whittaker, V., & van Schaik, P. (2019).
PROTOCOL: Evidence‐informed practice versus evidence‐based practice educational interventions for
improving knowledge, attitudes, understanding, and behavior toward the application of evidence into practice:
A comprehensive systematic review of undergraduate students. Campbell Systematic Reviews, 15(1–2).
https://doi.org/10.1002/cl2.1015
4 Bowen, S., & Zwi, A. B. (2005). Pathways to “Evidence-Informed” Policy and Practice: A Framework for Action.
PLoS Medicine, 2(7), e166. https://doi.org/10.1371/journal.pmed.0020166
7
Utilize non-traditional approaches to substance use prevention – not only providing
education on risks/abstinence, but also using approaches such as open and authentic
conversations with young people about what people’s experiences have been and engaging
parents, families, and other adults connected to youth in these conversations.
Harm Reduction
Bring resources to where higher risk populations are to make them as low barrier as possible.
Address individual level and community level stigma impacting both the ability to bring new
harm reduction services to a community and access to existing harm reduction services.
Treatment
Expand and build on existing long-term treatment options with a focus on specific
populations: youth, mothers and caregivers with young children, those transitioning from the
jail system.
Create more access to medication-assisted treatment (MAT), specifically those for opioid use
disorder such as Methadone.
Prioritize services for those with cooccurring mental health and substance use disorders.
Recovery
Establish more sober housing, specifically for those with public or no insurance as well as
parents with young children; emphasize integrating some form of regulation or monitoring of
the effectiveness of these homes to ensure they are providing the needed safe space for those
in recovery.
Expand support services focused on grief and loss, both for those with SUD and their families,
as well as services focused on holistic and diverse approaches to recovery.
Offer services to help those entering recovery navigate the available services as well as
provide support related to challenges such as transportation and insurance.
8
INTRODUCTION
Substance use has a significant impact on individuals, families, and society. Provisional data from the
Centers for Disease Control and Prevention indicate that in 2021 over 107,000 people lost their lives to
drug overdose deaths in the United States. The impact of substance use is much greater when taking
into account morbidity and hospitalization, lost wages, health care utilization, and costs of
prevention, treatment, and recovery services.
Substance use has continued to be a critical community concern in Barnstable County. To examine
the current impact of substance use in the County, Barnstable County Department of Human Services
(BCDHS) undertook a comprehensive community assessment in 2022 focused on substance use to:
Describe the mortality, morbidity, and societal costs of substance use
Understand the community needs related to substance use
Learn how these needs are and are not being met in the community
Identify strengths and gaps in available resources
This substance use assessment was funded by a MassCALL3 grant from the Bureau of Substance
Addiction Services (BSAS) from the Massachusetts Department of Public Health. To support the
assessment’s data collection and analysis, Barnstable County Department of Human Services
partnered with Health Resources in Action (HRiA), a non-profit public health organization. The 2022
assessment builds on a previous baseline substance use assessment conducted by BCDHS, in
partnership with HRiA, in 2014.1 The results of the 2014 assessment were used to develop an action
plan for substance use related efforts in Barnstable County.
The results in this 2022 report have the potential to greatly impact the community members of
Barnstable County, including those who have substance use disorder (SUD), their family, friends, and
loved ones, and the community as a whole. The information gathered through this assessment will be
used to help BCDHS, the Barnstable County Regional Substance Addiction Council (RSAC), and other
community leaders and decision‐makers, to develop a new 5-year action plan to direct future
programming, policy, and funding priorities related to substance use in Barnstable County.
Changes in the Field of Substance Use
One of the important drivers for this updated assessment has been the changing context within the
field of substance use over the past eight years. Recently, there has been a strong infusion of funding
directed at addressing substance use from multiple sources. This additional funding has highlighted
the need even more to conduct an assessment so that decisions on how to utilize these funds could be
data informed.
Since the baseline assessment was conducted in 2014, the field of substance use has evolved through
its greater recognition of the impact of stigma on individuals who use substances and people with
substance use disorder. A major component of this is the shift to approaching substance use as a
public health, rather than a criminal issue;2 coupled with an understanding that individuals respond
best to voluntary services rather than mandated services. To reflect this, the domains discussed in this
assessment have changed since the baseline study was conducted in 2014. The domains in the 2014
assessment were prevention, harm reduction, treatment and recovery (combined), and law
9
enforcement. To align with current approaches, the domains used for this assessment are
prevention, harm reduction, treatment, and recovery. While law enforcement plays a role in
responding to substance use in the community, services and programming involving law enforcement
can operate within these four domains.
Another change in the field is the understanding of the impact of language and terminology on
perception of substance use. The National Institute on Drug Abuse published information on how the
language used when talking about those with SUD has the power to reduce stigma and negative bias.3
In 2017, a memo sent to heads of executive departments and agencies described the impact of
terminology that creates and perpetuates stigma related to substance use and misuse and asked
these agencies to consider the language used in their internal and external messaging around
substance use.4
At a state level, there have been recent changes in Massachusetts regarding medications used to treat
opioid use disorder (MOUD). In April 2022, the U.S. Attorney’s Office, District of Massachusetts,
announced that all state and county correctional facilities will be required, under the Americans with
Disabilities Act, to maintain all MOUD for people utilizing this treatment prior to entering.5
In February 2022, nationwide settlements were reached for all opioid litigation brought against three
pharmaceutical distributors and a pharmaceutical manufacturer resulting in a total of $26 billion to
be allocated to states.6 These settlements resulted in more than $525 million funneled to
Massachusetts to fund prevention, harm reduction, treatment, and recovery in its communities.7
Below are the estimated amounts to be received by Barnstable County and its 15 municipalities
starting in 2022 through 2038.
Table 1. Allocation Costs from Opioid Settlement Funds, by County and Town, 2022-2038
Municipality Total Allocation (17 payments)
Barnstable County $134,456
Barnstable $1,803,656
Bourne $795,605
Brewster $270,070
Chatham $354,356
Dennis $203,989
Eastham $165,455
Falmouth $1,394,606
Harwich $602,243
Mashpee $727,313
Orleans $196,602
Provincetown $188,184
Sandwich $1,039,704
Truro $127,048
Wellfleet $140,412
Yarmouth $275,099
TOTAL $8,418,798
Data Source: Massachusetts Office of Attorney General Maura Healey website https://www.mass.gov/service-details/learn-
about-the-ags-statewide-opioid-settlements-with-opioid-industry-defendants
10
In May of 2021, the Substance Abuse and Mental Health Services Administration (SAMHSA) announced
it was distributing $3 billion to states through the Community Mental Health Services Block Grant
(MHBG) Program and Substance Abuse Prevention and Treatment Block Grant Program (SABG) that
derived from the American Rescue Plan Act funds for the COVID-19 pandemic.8 Massachusetts
received $28,589,013 in MHBG funds and $32,254,331 in SABG funds.
Land Acknowledgement
We acknowledge that Barnstable County is on the lands of the Wampanoag Tribe, including the
former Nauset Tribe. These ancestral lands were the territory of this tribe prior to their forced
removal.
The county is currently home to 3,801 tribal members. We recognize that Indigenous people are the
traditional stewards of the land that we now occupy, living here long before Massachusetts was a
state and still thriving here today. As we live and work on this land, we have a responsibility to
acknowledge the Native people and work together with them to create healthy communities. By
taking this small action in making a land acknowledgment, we hope the message will inspire others to
stand in solidarity with Native nations.
Social Determinants of Health Framework and Health Equity
This assessment uses a broad definition of health that recognizes and emphasizes numerous factors,
beyond individual behaviors, that impact individual, community, and regional health. It is important
to recognize that these multiple factors, referred to as the social determinants of health, have a
downstream impact on health outcomes and that there is a dynamic relationship between real people
and their lived environments. In addition to recognizing and emphasizing these social determinants of
health, this assessment was also undertaken with an understanding that health equity (or inequity)
precedes these social determinants.
In the United States, social, economic, and political processes ascribe social status based on race and
ethnicity, which may influence opportunities for educational and occupational advancement and
housing options, which are two social determinants that profoundly affect health. Institutional
racism, economic inequality, discriminatory policies, and historical oppression of specific groups are a
few of the factors that drive health inequities in the U.S. Understanding the factors (Figure 1), their
relationship to community health and wellness, and how they contribute to health patterns for these
populations can facilitate the identification of data-informed and evidence-based strategies to
provide all residents with the opportunity to live a healthy life.
11
Figure 1. Social Determinants of Health Framework
DATA SOURCE: Health Resources in Action, 2018
METHODS
This assessment utilized a community engaged assessment approach with ongoing input on
assessment approaches and results from the Regional Substance Addiction Council (RSAC) Prevention
Work Group (Core Planning Group). The RSAC’s purpose is to establish a communication
infrastructure across towns, providers, organizations, and individuals on Cape Cod to help the region
identify and address gaps and disparities in the service system, maximize inter-agency collaboration
and to maximize funding and resource opportunities, all with a focus on substance use in Barnstable
County. The RSAC membership is comprised of three RSAC Co-Chairs and one Co-Chair from each of
the four Work Groups (Prevention, Treatment, Harm Reduction and Recovery), each with a designated
alternate. A multi-sector representation from stakeholders and organizations working on the issue of
substance use in Barnstable County participate and attend meetings as members of the public.
BCDHS and HRiA engaged with the Core Planning Group through five meetings over the course of the
assessment as well as email communication where the members provided input and feedback on
assessment methodology, data collection instruments (e.g., focus group and interview guides), local
data sources, and priority stakeholders and population groups to engage in discussions. Members of
the RSAC also provided outreach support for Barnstable County Department of Human Services
12
(BCDHS) and Health Resources in Action (HRiA) to connect with stakeholders with access to local data
sources and connections to specific population groups. See the Acknowledgements section for a
complete list of the RSAC members.
In addition to engagement with the RSAC, two public launch meetings were held in September 2022 to
announce the assessment and gather broader community feedback on the approach and goals. The
results of the assessment will also be made accessible for the community through presentations by
county staff to Barnstable County municipalities and other local entities (e.g., organizations,
programs, groups, etc.).
This assessment was conducted using a mixed methods approach to gain a robust understanding of
substance use in Barnstable County. This approach included secondary data collection and
qualitative data collection through group interviews and discussions with community members.
Qualitative Data
Qualitative data collection aimed to gather a range of perspectives from those in the community
related to substance use. The goal of this process was to intentionally include individuals whose
voices are typically not heard. The interviewees selected included service providers with lived
experience and those providing direct service as well as community members with lived experience.
Including these individuals alongside other community stakeholders ensured a deeper and unique
understanding of the experiences in Barnstable County. A total of 15 interviews with 27 individuals
were conducted in the areas of prevention (4 interviews, 9 interviewees), harm reduction (4
interviews, 6 interviewees), treatment (3 interviews, 4 interviewees), and recovery (4 interviews, 8
interviewees). These interviews ranged from 1-3 participants per group. An additional 4 groups were
held with a total of 9 community members with lived experience including youth, individuals engaged
with harm reduction services, individuals engaged in substance use treatment, and individuals who
identify as in recovery. There were a number of individuals who were contacted to participate but
were unable to and therefore these findings do not include their perspectives.
Two HRiA staff, a facilitator and a notetaker, were present at each interview. All interviews were
conducted via Zoom and lasted approximately 60 minutes. The assessment team used a semi-
structured interview guide to ensure consistency in the topics covered across interviews (see
Appendix A for the full interview guide). HRiA staff coded and thematically analyzed notetaker
transcripts using NVivo 12 (QSR International Pty Ltd.). Key themes were identified based on the
frequency and intensity with which they appeared in the transcripts. It is important to note that
quotes reflect the language used by the speaker and therefore may not use person-first language.
Secondary Data
The secondary indicators of interest for this assessment built on the indicators used for the 2014
assessment. Many of the same indicators were used while some were removed and others
recategorized to fit current approaches in substance use as well as based on the expertise of those
who provided data. The indicators include those to describe Barnstable County (e.g., demographics,
social determinants of health , substance use prevalence data) and those focused on youth focused
and school-based prevention activities; harm reduction activities such syringe exchange and disposal,
Narcan and fentanyl test strips, and community outreach; inpatient and outpatient treatment at
13
hospitals, community health centers and state-run facilities; and supports for recovery such as sober
homes and recovery coaching.
Secondary data were gathered from existing public sources such as the American Community Survey
(ACS) from the U.S. Census Bureau, the National Survey on Drug Use and Health (NSDUH) from
SAMHSA, and various sources, including the Massachusetts COVID Community Impact Survey (CCIS),
from the Massachusetts Department of Public Health. Data from the 2022 Cape Cod Health Care
Community Needs Assessment were also included. Additional data were received from local sources
to describe the substance use services and programs provided in the county. Local cost data related
to service delivery, program implementation, staff, and other relevant costs were requested via email
from individuals identified by BCDHS staff as potential resources for data. When necessary, follow up
phone calls and emails were utilized.
Limitations
As with all data collection efforts, there are several limitations to note. With many organizations and
community members focused on the pandemic and its effects, community engagement and timely
response to data collection requests were challenging. While interviews and focus groups provide
valuable insights and important in-depth context, due to their non-random sampling methods and
small sample sizes, results are not necessarily generalizable. Due to COVID-19, interviews were
conducted virtually, and therefore, while both video conference and telephone options were offered,
some individuals who lack reliable access to the Internet and/or cell phones may have experienced
difficulty participating. Multiple secondary data sources were used to gather data for this assessment
each source has its own set of limitations.
Overall, due to data reporting lag as well as additional burden due to the COVID-19 pandemic, the
timeframes for these publicly available data may vary. In many cases, prevalence data were not
available for all municipalities in the county, either due to data suppression rule – i.e., small
percentages not being reported – or due to lack of recent data collection – e.g., the Youth Risk
Behavior Survey. Available data from select municipalities are included to represent a local estimate.
The cost data in this report represents the information received from local outreach. While every effort
was made to receive data from each contact, not all organizations responded to the request and
others were unable to provide all the requested data which is a limitation of these data.
An additional limitation of the secondary cost data is the overall comparability of these data to the
findings of the 2014 baseline assessment. Due to the time between assessments, in some cases data
available then was not available for this assessment. On the other hand, new data not available for the
baseline assessment are included in this report. The structure of data presentation has also been
adjusted in this report to align with the current frameworks and approaches to substance use services
which limits the ability to do comparison.
Both qualitative and quantitative data are limited in that not all that were contacted were able to
participate in interviews or share their local level data. In particular, the lack of tribal participation
limits the information provided and should be addressed in future efforts. Furthermore, major
treatment providers did not participate in interviews (e.g., Gosnold) or provide data (e.g., Gosnold,
14
Community Health Center of Cape Cod) and therefore these results to not include their perspectives
or cost data.
An exhaustive inventory of substance use treatment programs and other services, public and private,
in the county does not currently exist. This assessment provides details of many services and
programs; however, the resource inventory will need to be added to and upkept for complete and
accurate data on an ongoing basis.
PROFILE OF COMMUNITY
The following sections present the findings detailing the existing and needed substance use services
in Barnstable County, as well as barriers to and cost of those services, in the areas of prevention, harm
reduction, treatment, and recovery. Additional data are included describing the demographics, social
determinants of health, and prevalence and perceptions of substance use to understand the context
in which these services are being provided.
To better inform services, overall and those aimed at reaching specific populations, it is important to
understand the characteristics of the communities being served. The section presents key
demographics for Barnstable County.Barnstable County is made up of 15 municipalities and had a
total population of 228,996 people in 2020; a growth of 6.1% from 2010 (Figure 2). Almost all
municipalities have seen growth in population between 2010 and 2020.
Figure 2. Population Count and Change, 2010 and 2020
DATA SOURCE: U.S. Census Bureau, Decennial Census, 2010 and 2020
Figure 3 presents the racial and ethnic breakdown of Massachusetts, Barnstable County, and each of
the municipalities. In Barnstable County and its municipalities, the majority of the population (>80%)
identify as White non-Hispanic.
2010 2020 % Change
Massachusetts 6,547,629 7,029,917 7.4%
Barnstable County 215,888 228,996 6.1%
Wellfleet 2,750 3,566 29.7%
Provincetown 2,942 3,664 24.5%
Truro 2,003 2,454 22.5%
Eastham 4,956 5,752 16.1%
Harwich 12,243 13,440 9.8%
Barnstable 45,193 48,916 8.2%
Chatham 6,125 6,594 7.7%
Mashpee 14,006 15,060 7.5%
Orleans 5,890 6,307 7.1%
Yarmouth 23,793 25,023 5.2%
Brewster 9,820 10,318 5.1%
Bourne 19,754 20,452 3.5%
Dennis 14,207 14,674 3.3%
Falmouth 31,531 32,517 3.1%
Sandwich 20,675 20,259 -2.0%
15
Figure 3. Race/Ethnicity Distribution, by State, County, and Town, 2016-2020
DATA SOURCE: U.S. Census Bureau, American Community Survey 5-Year Estimates, 2016-2020; NOTE: Additional Race(s), non-Hispanic include residents who identified as
Native-Hawaiian/Other Pacific Islander, some other race, or as two or more races. Data labels under 4.0% are not shown.
6.7%6.8%
5.6%
4.9%
12.0%
5.4%
4.5%
6.3%
7.3%
4.1%
70.8%
88.3%
81.9%
89.5%
96.0%
94.8%
89.2%
93.1%
90.8%
93.2%
84.3%
94.7%
87.2%
91.6%
96.3%
82.8%
85.9%
6.2%
4.4%
4.1%
4.5%
6.9%
Massachusetts
Barnstable County
Barnstable
Bourne
Brewster
Chatham
Dennis
Eastham
Falmouth
Harwich
Mashpee
Orleans
Provincetown
Sandwich
Truro
Wellfleet
Yarmouth
American Indian/Alaska Native, non-Hispanic Asian, non-Hispanic
Black/African-American, non-Hispanic Hispanic/Latino, any Race
White, non-Hispanic Additional Race(s), non-Hispanic
16
Figure 4 presents the age distribution in Massachusetts, Barnstable County, and its municipalities. Overall, Barnstable County has a larger
percentage of older adults 65 years or older (30.4%) compared to the state (16.5%).
Figure 4. Age Distribution, by State, County, and Town, 2016-2020
DATA SOURCE: U.S. Census Bureau, American Community Survey 5-Year Estimates, 2016-2020; NOTE: Data labels under 4.0% are not shown.
19.8%
15.0%
18.1%
17.0%
13.7%
9.8%
11.5%
10.5%
14.5%
12.9%
16.0%
12.0%
8.4%
16.7%
8.4%
13.0%
14.5%
10.1%
7.0%
7.1%
9.9%
6.3%
5.3%
6.8%
4.4%
7.2%
7.2%
5.4%
9.5%
7.9%
5.6%
26.6%
17.8%
22.0%
17.5%
13.8%
13.3%
15.7%
12.4%
16.8%
16.7%
20.8%
13.9%
22.7%
16.1%
10.9%
16.6%
17.7%
26.9%
29.7%
29.4%
28.5%
32.5%
25.0%
30.7%
29.8%
29.1%
29.6%
28.2%
25.8%
38.5%
33.0%
49.3%
28.1%
28.6%
9.5%
17.2%
13.0%
15.7%
20.0%
22.6%
19.7%
23.4%
18.7%
20.7%
17.0%
27.9%
17.2%
16.7%
18.8%
18.0%
15.7%
4.6%
8.8%
6.9%
7.0%
8.8%
16.6%
12.0%
12.5%
8.7%
8.6%
9.0%
12.1%
7.9%
6.0%
7.6%
12.3%
10.8%
4.4%
4.5%
5.0%
7.5%
3.5%
7.1%
5.0%
4.3%
5.5%
4.1%
7.1%
Massachusetts
Barnstable County
Barnstable
Bourne
Brewster
Chatham
Dennis
Eastham
Falmouth
Harwich
Mashpee
Orleans
Provincetown
Sandwich
Truro
Wellfleet
Yarmouth
Under 18 18 to 24 25 to 44 45 to 64 65 to 74 75 to 84 85+
17
Less than 10% of Barnstable County population 5 years or older speak a language other than English
at home (Figure 5). For some municipalities – Barnstable, Provincetown, Wellfleet, and Yarmouth –
the percentage is higher, ranging from 10.6% to 17.4% of the population.
Figure 5. Population Aged 5+ That Speak a Language Other Than English at Home, by State,
County, and Town, 2016-2020
DATA SOURCE: U.S. Census Bureau, American Community Survey 5-Year Estimates, 2016-2020
When looking at the top languages other than English spoken in Barnstable County, more than a third
(39.5%) of non-English speakers speak Other Indo-European languages, which includes Portuguese.
The next most spoken language is Spanish (22.1%).
Figure 6. Top Languages Other Than English Spoken at Home, Barnstable County, 2016-2020
DATA SOURCE: U.S. Census Bureau, American Community Survey 5-Year Estimates, 2016-2020; NOTE: Other Indo-European
languages includes Albanian, Lithuanian, Pashto (Pushto), Romanian, Swedish; Armenian; Bengali; French (incl. Cajun);
German; Greek; Gujarati; Haitian; Hindi; Italian; Malayalam, Kannada, or other Dravidian languages; Nepali, Marathi, or other
Indic languages; Persian (incl. Farsi, Dari); Polish; Portuguese; Punjabi; Russian; Serbo-Croatian; Tamil; Telugu; Ukrainian or
other Slavic languages; Urdu; Yiddish, Pennsylvania Dutch or other West Germanic languages
23.9%
9.4%
17.4%
7.1%
4.5%
3.5%
7.3%
7.1%
6.8%
4.4%
6.3%
6.1%
10.6%
5.6%
5.1%
13.2%
13.2%
Massachusetts
Barnstable County
Barnstable
Bourne
Brewster
Chatham
Dennis
Eastham
Falmouth
Harwich
Mashpee
Orleans
Provincetown
Sandwich
Truro
Wellfleet
Yarmouth
39.5%
22.1%
10.0%
9.0%
7.9%
Other Indo-European languages
Spanish
French, Haitian, or Cajun
Russian, Polish, or other Slavic languages
Other and unspecified languages
18
Impact of Social Determinants of Health
To provide the most effective services to address SUD, it is necessary to understand what additional
societal and environmental factors can impact an individual’s ability to access these services. This
section provides key social determinants of health data that should be integrated into county-wide
efforts to address substance use.
In assessment discussions, community members, service providers, and other stakeholders discussed
how the impact of the social determinants of health (such as housing, transportation, and
unemployment) had on a person’s ability to access substance use services was discussed. This section
presents data on relevant social determinants of health to provide context for findings presented in
later sections of this report. The most commonly discussed determinants were housing,
transportation, and insurance. One participant discussed the social and economic challenges that
residents face and how services do not seem to keep up with demand:
“Cape Cod has a huge housing crisis. Difficulty accessing general medical providers. People may
not have health insurance. Transportation is poor, public transportation is really poor. All these
barriers exist and affect those who use substances… General lack of resources, support structure
in most of the towns on Cape.”
Housing
Safe and affordable housing is integral to the daily lives, health, and well-being of a community.
Housing can play an important role in an individual’s life as safe and affordable housing can reduce a
range of negative health outcomes from asthma to poor mental health; housing location also
influences an individual’s health as easy access to transportation, medical care, good jobs, etc. may
help reduce incidence of diseases, including mental health disorders.9 Experiencing homelessness
significantly impacts health behaviors and health outcomes, including increased risk of developing a
substance use disorder.10 It is important to note that some communities in particular, including
communities of color and formerly incarcerated individuals, experience homelessness at a much
higher rate than other populations.11,12 An estimated 14.8 per 10,000 people on Cape Cod and the
islands are homeless.13
“[The] housing that is available is very expensive, and there’s not a lot of housing here in general.
It’s not cheap to be on the Cape; a lot of people are either on vacation or retired here. You have
the “haves” and “have nots.” Housing down here has always been a challenge.”
Many participants in this assessment discussed the lack of affordable housing in Barnstable County
and its impact on substance use. Participants explained that there is a critical need to develop more
affordable, transitional, and low-barrier housing. Participants shared that these needs are
particularly acute for people experiencing homelessness, people who are being released from
jail, and people who are transitioning out of substance use treatment. Participants explained that
without transitional or low-barrier housing options, people may be reincarcerated or forced to live in
unsafe conditions where other residents may be actively using substances, which poses major
challenges to treatment and recovery. One participant commented that they could not “imagine
going through treatment” while living in an unsafe or unstable environment.
19
Housing in Barnstable County and its municipalities is predominantly owner-occupied with less than a
third across the geographies being renter-occupied housing (Figure 7).
Figure 7. Home Occupancy by State, County, and Town, 2016-2020
DATA SOURCE: U.S. Census Bureau, American Community Survey 5-Year Estimates, 2016-2020
When considering the burden of housing costs on those living in Barnstable County, high percentages
of renters have housing costs that are 30% or more of their household income (Figure 8). In almost all
towns in the county, with the exception of Harwich and Wellfleet, just about half or more renters are
considered housing cost burdened.
62.5%
79.6%
72.4%
73.8%
74.2%
75.2%
77.4%
79.2%
79.8%
80.5%
84.6%
84.9%
85.3%
85.7%
86.2%
89.4%
91.0%
37.5%
20.4%
27.6%
26.2%
25.8%
24.8%
22.6%
20.8%
20.2%
19.5%
15.4%
15.1%
14.7%
14.3%
13.8%
10.6%
9.0%
Massachusetts
Barnstable County
Dennis
Barnstable
Bourne
Provincetown
Wellfleet
Falmouth
Yarmouth
Orleans
Mashpee
Brewster
Truro
Harwich
Chatham
Sandwich
Eastham
Owner-occupied Renter-occupied
20
Figure 8. Percent Households Whose Housing Costs are 30% or More of Household Income, by
State, County, and Town, 2016-2020
DATA SOURCE: U.S. Census Bureau, American Community Survey 5-Year Estimates, 2016-2020
Transportation
The built environment is designed for people to live, travel, learn, and work. Specifically,
transportation is an important connector for communities, and an important part of shaping the
infrastructure of communities. Transportation can be a promoter of health by enabling individuals,
29.5%
37.5%
36.3%
35.5%
29.5%
46.6%
33.1%
46.6%
39.5%
43.4%
43.7%
35.9%
39.3%
32.6%
39.2%
46.5%
37.3%
9.3%
10.1%
10.0%
13.5%
7.4%
3.7%
7.1%
2.6%
10.1%
7.6%
16.3%
7.9%
11.5%
13.7%
13.2%
12.0%
10.3%
48.9%
56.2%
55.5%
49.7%
66.7%
62.8%
62.2%
87.9%
56.4%
35.4%
60.9%
55.0%
62.3%
46.3%
50.0%
33.2%
63.1%
Massachusetts
Barnstable County
Barnstable
Bourne
Brewster
Chatham
Dennis
Eastham
Falmouth
Harwich
Mashpee
Orleans
Provincetown
Sandwich
Truro
Wellfleet
Yarmouth
Owner with mortgage Owner without mortgage Renter
21
families, and communities to access resources and opportunities, including employment, health care,
education, and other goods and services (e.g., grocery stores, parks).14 Conversely, without access to
cars, particularly in more rural or suburban areas like many places in Barnstable County, people
experience limited access to necessities, health care, services, and jobs.15
“Transportation is huge, [it’s] number one. [It] comes down to access [to] services. The Cape is
funny—you [have] to travel long distances to get certain services that may be needed.”
Many participants described transportation as a key barrier to accessing substance use-related
programs and resources. Participants noted that lack of access to a vehicle and an inadequate
public transport system prevent people from accessing needed services. Limited transportation
options present additional challenges for people who live farther away from existing services and for
people in recovery who may be unable to obtain a driver’s license.
In Barnstable County, only 1.5% of workers 16 years or older indicated they used public transportation
to get to work. Further exacerbating the transportation barrier is lack of access to a vehicle. Very few
owner-occupied households lack access to a vehicle; in most municipalities, 10% or more of renter-
occupied households lack access to a vehicle (Figure 9).
Figure 9. Percent Households (Renter v. Owner-occupied) Without Access to a Vehicle, by State,
County, and Town, 2016-2020
DATA SOURCE: U.S. Census Bureau, American Community Survey 5-Year Estimates, 2016-2020
3.5%
2.4%
2.0%
1.3%
4.9%
4.4%
1.3%
1.2%
2.3%
2.7%
2.2%
1.2%
6.1%
2.1%
3.9%
1.9%
2.9%
26.8%
13.3%
13.9%
12.1%
8.4%
16.6%
15.9%
15.5%
17.1%
5.6%
5.6%
21.5%
28.6%
10.6%
0.0%
7.3%
15.1%
Massachusetts
Barnstable County
Barnstable
Bourne
Brewster
Chatham
Dennis
Eastham
Falmouth
Harwich
Mashpee
Orleans
Provincetown
Sandwich
Truro
Wellfleet
Yarmouth
Owner-occupied Renter-occupied
22
Insurance coverage
Having health insurance coverage is an important part of accessing comprehensive and quality health
care services. Since 2007, prior to the federal level Patient Protection and Affordable Care Act,
Massachusetts has required all adults to have medical insurance in 2007.16 Due to these policies, a
high percentage of residents of the state have health insurance. However, inequities exist and not all
who need high quality health care are able to access it. Residents who face barriers to access are less
likely to receive medical care, more likely to delay care, and less likely to use prevention services,
resulting in poorer health status and outcomes.
“[If] you are a Medicaid client, your only option is to go to [the] short-term program. [That’s the]
primary problem. There once was very good treatment and it’s gone. On the other hand, if you
have [the] right insurance, you can get good long-term, well-fed, well-housed centers that are
doing a good job.”
Many participants described insurance coverage as a barrier to accessing needed substance use-
related services. Participants shared that insurers are reducing covered benefits (e.g., decreasing
coverage for detoxification services from 30 days to two weeks) and that some providers are limiting
the number of MassHealth-covered patients they will admit. Several participants explained that
there is a divide or “hierarchy” between people who have private insurance or can pay out of
pocket compared to people who have MassHealth. Participants noted that although a number of
private treatment facilities offering longer-term stays have recently opened in Barnstable County,
they do not accept MassHealth.
In Barnstable County, almost half (48%) of the population has public health insurance; a much smaller
percentage (3.1%) are uninsured (Figure 10). These percentages are higher in comparison to
Massachusetts overall. In many municipalities in the county, the percent with public insurance is more
than half of their community.
23
Figure 10.Percent of Residents with No Health Insurance or Public Insurance, Barnstable County,
2016-2020
DATA SOURCE: U.S. Census Bureau, American Community Survey 5-Year Estimates, 2016-2020 NOTE: Coverage may be alone
or in combination with another insurance type
Prevalence and Perceptions of Substance Use in Barnstable County
To understand the scope of substance use in Barnstable County, the following section details
prevalence data as well as the perceptions of substance use for both adults and youth.
Mortality & Morbidity
Figure 11 presents the estimated mortality rates related to substance use in Barnstable County from
2010 to 2020. The rate of overall drug-induced causes in 2020 was 35.6 per 100,000; higher than the
rate in the state overall (30.6 per 100,000). The mortality rate has been trending upward since 2010,
with a drop from 2016-2017, before continuing its upward trend.
2.7%
3.1%
5.1%
2.2%
2.0%
2.2%
3.6%
2.1%
1.9%
3.7%
2.4%
1.8%
2.4%
2.8%
2.1%
2.5%
3.5%
36.1%
48.0%
44.6%
42.4%
47.9%
56.3%
56.7%
59.3%
50.6%
47.4%
47.3%
55.8%
50.0%
34.8%
40.2%
55.1%
55.1%
Massachusetts
Barnstable County
Barnstable
Bourne
Brewster
Chatham
Dennis
Eastham
Falmouth
Harwich
Mashpee
Orleans
Provincetown
Sandwich
Truro
Wellfleet
Yarmouth
No Health Insurance Coverage Public Health Insurance
24
Figure 11. Estimated Opioid-Related Overdose Mortality Rate, 2010-2020
DATA SOURCE: Massachusetts Department of Public Health, Registry of Vital Records and Statistics, Current Opioid Statistics,
current data as of November 2021 NOTE: Rates are crude rates; Calculated based on population estimates reported by US
Census Bureau, American Community Survey 5-Year data sets (2011-2015 and 2016-2020)
Figure 12 presents the percentage of driving deaths that involved alcohol between 2008 and 2020. In
recent years (since 2018), Barnstable County has had higher percentage of driving deaths with alcohol
involvement compared to the state and nation; there was a noticeable drop in this percentage
between 2019 and 2020 though still higher than Massachusetts and the U.S.
Figure 12. Alcohol-impaired Driving Deaths, by County, State, and Country, 2008-2020
DATA SOURCE: Fatality Analysis Reporting System, County Health Rankings, 2008-2020 NOTE: Alcohol-impaired driving
deaths defined as percentage of driving deaths with alcohol involvement.
9.3 8.8 11.2
20.0
24.7
31.2
37.9
31.4 33.3 34.2 35.6
8.2 9.8 10.9 14.2
20.2
26.0 30.7 29.2 29.3 29.2 30.6
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Barnstable County Massachusetts
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Barnstable County 24% 33% 29% 23% 23% 17% 25% 25% 30% 29% 50% 57% 33%
Massachusetts 33% 26% 33% 25% 29% 29% 31% 24% 31% 30% 32% 32% 26%
U.S.33% 33% 32% 31% 31% 31% 30% 29% 26% 26% 25% 26% 26%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Barnstable County Massachusetts U.S.
25
Table 2 presents the rates of substance use related cancers for Barnstable County, Massachusetts,
and the U.S. Barnstable County had higher rates of all cancers (492.0 per 100,000) compared to the
state and nation. Rates for specific cancers were higher than both the state and nation for breast,
esophageal, and oral cavity and pharynx cancers. Rates were lower than both for liver and bile duct
cancers. For colon and rectal cancers Barnstable County rate was higher than the state but lower than
in the U.S. overall.
Table 2. Cancer Incidence, Age-Adjusted Rates per 100,000, 2015-2019
Barnstable County Massachusetts U.S.
All Cancer Sites 492.0 454.8 449.4
Breast 154.4 137.6 128.1
Colon & Rectum 34.1 33.5 37.7
Esophagus 6.5 5.3 4.6
Liver & Bile Duct 7.6 8.6 8.6
Oral Cavity & Pharynx 13.7 11.7 12.0
DATA SOURCE: State Cancer Profiles, National Cancer Institute, 2015-2019 NOTE: Breast cancer rate includes females only
Table 3 shows the Massachusetts rates of new HIV diagnoses overall and in those who inject drugs.
The diagnoses of HIV among those who inject drugs was 22.4% of all new diagnoses in the state.
Table 3. New HIV Diagnoses Overall and Among People Who Inject Drugs, Massachusetts, 2020
n Crude Rate per 100,000 Population
New HIV Diagnoses 437 6.4
New HIV Diagnoses Among People Who Inject Drugs 98 1.4
DATA SOURCE: Massachusetts Department of Public Health, Bureau of Infectious Disease and Laboratory Sciences, HIV/AIDS
Surveillance Program, 2020 NOTES: Data are as of 01/01/2022 and are subject to change; Rates are crude rates; Calculated
based on population estimates reported by US Census Bureau, American Community Survey 5-Year data (2016-2020); People
who inject drugs includes individuals with injection drug use (IDU) or male-to-male sex (MSM)/IDU as their primary exposure
mode
The rate of confirmed and probable Hepatitis C cases was lower in Barnstable County than in the state
(Table 4).
Table 4. Number and Rate of Confirmed and Probable Hepatitis C Cases, State and County, 2021
n Crude Rate per 100,000
Massachusetts 4,006 57.3
Barnstable County 96 42.1
DATA SOURCE: Massachusetts Department of Public Health, Bureau of Infectious Disease and Laboratory Sciences (BIDLS),
2021 NOTE: Data are current as of 9/30/2022 and are subject to change; Rates are crude rates; Calculated based on
population estimates reported by US Census Bureau, American Community Survey 5-Year data (2017-2021)
26
Hospitalization, Emergency Department Visits, and Treatment Admissions
Figure 13 presents the rate of inpatient hospitalization in Barnstable County and Massachusetts by
substance. The rate in Barnstable County for all substances was higher than in the state (126.0 per
100,000).
Figure 13. Inpatient Hospital Stays, by Type of Drug Poisoning, 2020
DATA SOURCE: Center for Health Information and Analysis, Massachusetts Inpatient Hospital Discharge Database and
Outpatient Observation Stays Database, 2020 NOTE: Rates are crude rates – calculated based on population estimates
reported by US Census Bureau, American Community Survey 5-Year data sets (2015-2019 and 2016-2020)
Figure 14 shows the rate of emergency department visits for Barnstable County and Massachusetts by
substance. The rate in Barnstable County for all substances was higher than in the state (252.0 per
100,000).
Figure 14. Emergency Department Visits, by Type of Drug Poisoning, 2020
DATA SOURCE: Center for Health Information and Analysis, Massachusetts Outpatient Emergency Department Discharge
Database, 2020 NOTE: Rates are crude rates – calculated based on population estimates reported by US Census Bureau,
126.0
8.4
30.0
9.8 5.6
119.1
8.3
34.7
11.0 5.2
All Drug
Poisonings
Alcohol Opioids Cocaine Cannabis
Barnstable County Massachusetts
252.0
NA
124.6
NA 14.1
230.4
4.6
96.3
5.6 9.7
All Drug
Poisonings
Alcohol Opioids Cocaine Cannabis
Barnstable County Massachusetts
27
American Community Survey 5-Year data sets (2015-2019 and 2016-2020); NA indicates that data were suppressed due to a
count of fewer than 11 people
Figure 15 presents admissions data for Department of Public Health (DPH)-licensed facilities for
Barnstable County. More than half (52.6%) of the admissions for those in Barnstable County were for
alcohol and more than a third were for Fentanyl or Heroin (34.7%).
Figure 15. Treatment Admissions to DPH-licensed Substance Use Treatment Programs, by
Primary Substance, Barnstable County, 2022
DATA SOURCE: MA Department of Public Health, Bureau of Substance Addiction Services, Office of Data Analytics and
Decision Support, 2022
Adult Substance Use
Figure 16 presents substance use-related outcomes for adults in Barnstable County compared to the
state. The county had a higher percentage of adults reporting binge drinking (19.8%) compared to
Massachusetts; the percentage of adults who are current smokers in the county (13.2%) is also higher
than the state.
52.6%
34.7%
4.2%
4.0%
1.7%
1.7%
1.0%
Alcohol
Fentanyl or Heroin
Other Opioids
Crack or Cocaine
Marijuana
Other Substance
Other Stimulants
28
Figure 16. Binge Drinking and Current Smoking among Adults, Barnstable County and
Massachusetts, 2020
DATA SOURCE: MA Department of Public Health, Behavioral Risk Factor Surveillance System, Profile of Health Among MA
Adults, 2020 (MA estimates); Centers for Disease Control, PLACES Local Data for Better Health, 2020 (county estimate)
Recent data on past month use of different substances are not available at the county level. Below are
data describing past month use among adults in the state of Massachusetts by age group (Figure 17).
Higher percentages of adults 18-24 years old report illicit drug use (31.8%) in the past month
compared to adults 25 years or older (17.4%). The percent of 18-24-year-olds reporting past month
marijuana use (30.4%) is two times that of adults 25 years or older (15.2%) Adults 25 years or older
report somewhat higher alcohol use in the past month; however, binge drinking is reported in a higher
percent of the 18-24-year-olds. Lower percentages report cigarette and other tobacco product use in
the past month, with slightly higher percentages of 18-24-year-olds reporting use.
15.8%
11.3%
19.8%
13.2%
Binge drinking among adults
Current smoking among adults
Barnstable County Massachusetts
29
Figure 17. Self-Reported Past Month Drug Use Among Adults, by Age Group, Massachusetts
DATA SOURCE: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2018,
2019, and Quarters 1 and 4, 2020. NOTE: Illicit Drug Use includes the misuse of prescription psychotherapeutics or the use of
marijuana, cocaine (including crack), heroin, hallucinogens, inhalants, or methamphetamine. Misuse of prescription
psychotherapeutics is defined as use in any way not directed by a doctor, including use without a prescription of one’s own;
use in greater amounts, more often, or longer than told; or use in any other way not directed by a doctor. Prescription
psychotherapeutics do not include over-the-counter drugs. State and census region estimates, along with the 95 percent
Bayesian confidence (credible) intervals, are based on a survey-weighted hierarchical Bayes estimation approach and
generated by Markov Chain Monte Carlo techniques. For the “Total U.S.” row, design-based (direct) estimates and
corresponding 95 percent confidence intervals are given.
In Fall of 2020, Massachusetts conducted the COVID-19 Community Impact Survey (CCIS)17, a
statewide survey of over 33,000 residents, to gather information on how communities had been
affected by the pandemic. One area of data collection was around substance use in the pandemic.
More than a third (35%) of Barnstable County adults reported their substance use had increased since
before the pandemic began (data not shown).
Figure 18 and Figure 19 show the self-reported substance use from the CCIS. Ranging from just about
half (46%) up to almost three quarters (74%) of adults in Barnstable County towns reported using
alcohol in the last month; the overall percentage in Barnstable County (61%) was greater than the
state overall (48%).
31.8%
30.4%
57.6%
37.3%
18.9%
15.1%
17.4%
15.2%
64.0%
26.2%
17.2%
12.8%
Illicit Drug Use in the Past Month
Marijuana Use in the Past Month
Alcohol Use in the Past Month
Binge Alcohol Use in the Past Month
Tobacco Product Use in the Past Month
Cigarette Use in the Past Month
Age 18-25 Age 26+
30
Figure 18. Percent of Adults 25 Years or Older Reporting Using Alcohol in the Past 30 Days, by
State, County and Town, 2021
DATA SOURCE: Massachusetts COVID-19 Community Impact Survey, 2021 NOTE: Data for towns of Eastham, Orleans,
Provincetown, Truro, and Yarmouth suppressed due to small cell sizes
The percentages using tobacco and marijuana in the past 30 days were lower with Barnstable County
and the state having similar rates (Figure 19). Looking at these data by age group, a smaller
percentage of those 65 years or older in Barnstable County reported marijuana (9%) and tobacco use
(6%) than the percentage in the county overall. Data for other substances have not been publicly
shared at the state, county, or town levels.
48%
61%
53%
52%
64%
74%
67%
66%
60%
59%
46%
61%
Massachusetts
Barnstable County
Barnstable
Bourne
Brewster
Chatham
Dennis
Falmouth
Harwich
Mashpee
Sandwich
Wellfleet
31
Figure 19. Percent of Adults 25 Years or Older Reporting Using Tobacco or Marijuana in the Past
30 Days, by State, County and Town, 2021
DATA SOURCE: Massachusetts COVID-19 Community Impact Survey, 2021 NOTE: Tobacco data for towns of Brewster,
Chatham, Eastham, Mashpee, Orleans, Provincetown, and Truro suppressed due to small cell sizes; Marijuana data for towns
of Chatham, Eastham, Mashpee, Orleans, Provincetown, Truro, and Yarmouth suppressed due to small cell sizes
Youth Substance Use
Figure 20 shows the self-reported current substance use among high school students in
Massachusetts and from two Barnstable County high schools, Monomoy and Nauset. As only two
schools’ data are reported, it is important to note these data do not represent the full county
11%
10%
11%
14%
18%
11%
9%
14%
8%
13%
14%
15%
19%
11%
21%
9%
15%
18%
17%
Massachusetts
Barnstable County
Barnstable
Bourne
Brewster
Dennis
Falmouth
Harwich
Sandwich
Wellfleet
Yarmouth
Tobacco Marijuana
32
population and should not be interpreted as such. Rather, these data describe the self-report
experiences and behaviors of a subset of the youth population in the county.
Compared to the state, a higher percentage of high school students in these Barnstable County
schools report current alcohol use, marijuana use, and vaping. A small percent reported current
prescription drug misuse; however, these data were not available at the state level for comparison.
Figure 20.Self-Reported Current Substance Use Among High School Students, 2019
DATA SOURCE: Massachusetts Youth Health Survey 2021; Monomoy Regional High School, Youth Risk Behavior Survey, 2019;
Nauset Regional High School, Youth Health Survey, 2019
Middle school students (8th grade) in these Barnstable County schools were also asked about their
current substance use (Figure 21). A higher percent of the 8th graders reported current alcohol use
compared to the state. For vaping, the percentages were only slightly higher in these Barnstable
County schools than in Massachusetts. Only one school asked its 8 th graders about current marijuana
use; that percent was much higher than in the state (14% compared to 2.5%).
22.3%
17.6%
17.8%
30%
26%
26%
2.50%
23.8%
16.9%
24.5%
3.0%
Alcohol, current
Vaping, current
Marijuana, current
Misuse Prescription drugs, current
Massachusetts (2021)Monomoy Regional HS (2019)Nauset Regional HS (2019)
NA
33
Figure 21. Self-Reported Current Substance Use Among 8th Grade Students, 2019 and 2021
DATA SOURCE: Massachusetts Youth Health Survey 2021; Monomoy Regional Middle School, Youth Risk Behavior Survey,
2019; Nauset Regional Middle School, Youth Health Survey, 2019
One school’s survey of students asked for self-reported sources of different substances. Figure 22
presents the sources indicated by high school students for alcohol and marijuana. For alcohol, the
most frequently reported sources were getting it at parties (32%), getting it from friends (23%), and
having someone else buy it (23%). For marijuana, almost half (48%) get it from their friends and more
than a third (35%) get it from someone else.
Figure 22. Self-Reported Source of Substance for High School Students, Monomoy High School,
2019
DATA SOURCE: Monomoy Youth Risk Behavior Survey, 2019
Figure 23 presents the self-reported sources for vaping products. Most high school students reported
borrowing vaping products form someone else (41%).
3.1%
10.1%
2.5%
12% 12%
14%
5.2%
10.5%
NA
Alcohol, current Vaping, ever Marijuana, current
Massachusetts (2021)Monomoy Regional 8th Grade (2019)Nauset Regional 8th Grade (2019)
32%
23%
23%
18%
4%
NA
9%
48%
NA
6%
2%
35%
I get it at parties
I get it from my friends
I have someone else buy it for me
I got it at home
I buy it from a store/restaurant
I bought it from someone else
Alcohol Marijuana
34
Figure 23. Self-Reported Source of Vaping Products for High School Students, Monomoy High
School, 2019
DATA SOURCE: Monomoy Youth Risk Behavior Survey, 2019
The MA Alliance of Boys and Girls Clubs conducted a survey of 40 of its clubs to gather self-reported
data on abstention from substances. The Boys & Girls Club of Cape Cod plays an important role in the
providing young people in Barnstable County with a safe space to spend their time. It is important to
note, these data represent responses from clubs across the state of MA and therefore may not be
representative of the experience of those engaged with the club in Barnstable County.
As they are a prevention focused organization, these data are presented as members abstaining from
substance use (Figure 24). Higher percentages of young people involved with a Boys and Girls Club in
Massachusetts reported abstention from all substances compared to the state overall and the nation.
41%
15%
15%
13%
13%
2%
1%
I borrowed them from someone else
A person who can legally buy gave them to me
I bought them
I got them some other way
I gave money to someone to buy them for me
I got them on the internet
I took them from a store or another person
35
Figure 24. Self-Reported Abstention from Substance Use, MA Alliance of Boys and Girls Clubs,
Massachusetts, and the U.S., 2019
DATA SOURCE: MA Alliance of Boys and Girls Clubs and CDC Youth Risk Behavior Survey, 2019
The COVID Community Impact Survey (CCIS) also reported data on youth and young adults (those less
than 25 years of age); however, the sample size of respondents from Barnstable County was not
sufficient and cannot be reported. Figure 25 shows the percent of young people in Massachusetts
who reported increased substance use since before the pandemic started. More than a third of those
under 18 (44%) and those 18-24 (39%) reported increased use across the state.
Figure 25. Percent of Youth Aged 14-24 Reporting Increased Use Since Before the Pandemic, by Age
Group, by State, 2021
DATA SOURCE: Massachusetts COVID-19 Community Impact Survey, 2021
97%
98%
92%
95%
92%
90%
84%
93%
66%
NA
76%
80%
87%
89%
70%
86%
80%
NA
0% 20% 40% 60% 80% 100% 120%
Abstention from binge drinking
Abstention from cigarette smoking
Abstention from drinking
Abstention from prescription drugs
Abstention from marijuana
Abstention from vaping
MA Alliance of Boys and Girls Clubs Massachusetts U.S.
44%
39%
Under 18
18-24
36
Figure 26 presents CCIS data on the types of substances used by youth in the past 30 days in
Massachusetts. Less than 10% of those under 18 reported using any of the listed substances in the
past 30 days. Use was higher among those over 18, with almost half (48%) reporting alcohol use and
more than a quarter (27%) reporting marijuana use.
Figure 26. Types of Substances Used in the Past 30 Days by Youth Aged 14-24, by Age Group, by
State, 2021
DATA SOURCE: Massachusetts COVID-19 Community Impact Survey, 2021
Perceptions of Substance Use
In addition to examining the prevalence of substance use and its related issues, it is also critical to
understand the perspectives of those in the community regarding substance use.
When participants asked about the most pressing substance use concerns in their community, many
participants discussed opioids, including prescription opioids, heroin, and fentanyl. Participants
described the prevalence of opioid overdose and the frequency with which they administer Narcan.
Several participants also commented that “drugs today” are “different” and “stronger.” One
participant commented on the prevalence of fentanyl sharing that “People think they are just using
one more time and it’s not. I can’t tell you how many people I’ve known [that] have died. It’s scary.”
Other substances mentioned by a smaller number of participants included alcohol, Adderall,
marijuana, MDMA, GHB, benzodiazepines, and xylazine.
When asked to describe perceptions of substance use in their community, many participants reported
widespread stigma against people who use substances. Participants shared that people who use
substances are “looked down on” and that many community members continue to view substance
use disorder as a personal choice, rather than a treatable disease. Participants also reported that
stigma comes from many sources, including the health care system, the criminal legal system, and
from within the substance use community itself. Participants shared that many communities,
particularly wealthier ones, deny that substance use is an issue in their community, despite
1%
3%
4%
6%
7%
6%
6%
10%
27%
48%
Conventional tobacco
Prescription drugs
E-cigarettes/vapes
Marijuana
Alcohol
18 or older Under 18
37
evidence to the contrary. One participant explained that because Barnstable County is a tourist
destination, there is a “look to maintain.” Many participants reported significant pushback and Not
In My Back Yard “NIMBYism” from communities who do not want substance use resources or
services sited in their communities. Ultimately, the combination of stigma, denial, and “NIMBYism”:
Results in the discrimination and mistreatment of people who use substances
Limits the availability of evidence-based services (e.g., methadone, syringe exchange, Narcan)
Prevents people from accessing needed services (e.g., people do not want others to know that
they are seeking support for substance use)
Overall, participants described Barnstable County as a collaborative place where communities are
“invested in the people that live there” and “want things to get better.” A few participants also
reported that general awareness of substance use has increased. As one participant shared:
“I feel that we have grown very much on Cape Cod. It’s talked about, I don’t feel strange bringing
it up to people, it’s more of a fluid conversation. I can say I’m a person in recovery. It’s not a big
shock to anyone and I wouldn’t have done that years ago.”
Participants also reported that more progress has been made in some communities than others. A
few participants shared that initially contentious conversations with community members (e.g.,
regarding the offering of syringe exchange services) became opportunities for education and growth.
Still, some communities have remained resistant, which has contributed to geographic inequities in
the availability of services and supports. One participant shared that “each community has its own
personality” while another commented that there are some “towns that feel more supportive” than
others. As a result, people have varying degrees of success accessing treatment, harm reduction, or
recovery services, particularly in the absence of public transportation.
Finally, participants discussed the importance of recognizing that substance use is often rooted in
experiences of trauma and co-occurring mental health issues. Participants emphasized the
importance of addressing underlying trauma and using trauma-informed practices to break the
“constant cycle.” A few participants commented on the need for early education and intervention to
address childhood trauma before substance use becomes the primary coping tool.
Youth
Participants also shared their perceptions specific to youth substance use in their communities.
Notably, many participants commented that substance use is starting at younger ages. A couple of
participants reported seeing substance use beginning as early as the 6 th grade and emphasized the
need for school-based education and services. Several participants also discussed the importance of
recognizing the impacts of intergenerational substance use. Participants commented on the
frequency with which grandparents are raising their grandchildren due to parental substance use and
the need to address that this “causes all kinds of things down the road.” Participants perceived
tobacco and nicotine, marijuana, and alcohol to be the most used substances among youth.
Participants shared that young people use e-cigarettes to consume both nicotine and marijuana. A
couple of youth participants commented that while vaping nicotine is more common in middle
school, marijuana and alcohol use are more common in high school. A couple of participants
expressed that the legalization of marijuana resulted in “kids [not] see[ing] it as a drug” and believing
38
that “it’s just not a big deal.” One participant shared that the state missed an opportunity to educate
youth regarding the potential negative effects of youth marijuana use.
Results from the 2022 Cape Cod Health Care Community Needs Assessment survey conducted in
Barnstable County collected data on the levels of concern community members had about various
substances (Figure 27). The largest percentages of survey respondents had high concern about opioid
misuse (42.4%) and alcohol use or binge drinking (40.9%).
Figure 27. Percent of Community Survey Respondents Reporting “High Concern” for
Community, by Substance Use Issue, 2022
DATA SOURCE: CCHC Community Health Survey, 2022 NOTES: Percentages were based on sample size of n=964
FINDINGS
The following sections describe themes discussed by community members and stakeholders around
services to address substance use in Barnstable County in each of the four domains – prevention,
harm reduction, treatment, and recovery. To present a full picture of the landscape of services, these
results highlight successful existing programs, describe challenges with and barriers to accessing
these services, and identify opportunities for implementing new and expanded services. Cost data are
provided for each domain to serve as an estimate of how much current services cost to provide. While
these sections are organized by domain, it is important to recognize these should not be viewed as
separate in practice. Similarities and connections across these domains are highlighted to further
inform the action plan in including multifaceted efforts to address cross-cutting needs in the
community.
The resource inventory section describes different types of resources and services available in the
county identified through this assessment; as this is not an exhaustive list, the intent is for the county
to use and update this tool on an ongoing basis.
The final section of these findings delves deeper into the cost data presented in each domain,
including describing the differences in costs reported by domain and substance as well as highlighting
42.4%
40.9%
31.4%
25.1%
22.2%
20.1%
17.6%
Opioid Misuse
Alcohol Use or Binge Drinking
Other Illicit Drug Use
(cocaine, ecstasy, meth, etc.)
Stigma associated with seeking care
Vaping or E-Cigarettes
Tobacco Use or Smoking
Recreational Marijuana Use
39
the cost saving potential of investing more in the domains of prevention, harm reduction, and
recovery alongside treatment services.
Prevention
Prevention of substance use is often thought of as an issue of
adolescence and one focused primarily on encouraging abstinence
and/or highlighting the risks of substance use to teenagers.
However, a large and still growing body of research shows that
experiences in early childhood5 have an impact on later behavioral
health. In discussions, service provider participants discussed the
connection of early childhood, mental health, and adolescent
substance use. For example, one provider noted the importance of
reaching children early on:
“By the time we get to adolescence [and] high school, we see
[young people] again in different areas: detox, court related.
To me, I think if we could just put as much effort into our
little ones [0-5-year-olds], we’d see a level of foundation our
kids could have where mental health is prioritized.”
Prevention is also a cross-cutting aspect to substance use work. It
is a primary service aimed at early intervention around substance
use and it also is integrated into the other domains – e.g., recovery
services for adults providing resources for their children as a form
of prevention.
Existing Programs and Services
Overall, participants shared that there are very few substance use prevention programs and
services available, including resources for youth who may have just started experimenting with or
using substances. While more services are needed, participants highlighted many successful youth-
and prevention-focused programs including the Boys & Girls Club, Calmer Choice, Cape Cod Children’s
Place (including FIRST Steps Together), Herren Project’s prevention services, Positive Alternative to
School Suspension (PASS), Sharing Kindness, and Youth Villages’ Intercept and LifeSet programs.
While these were discussed in multiple conversations, other services and programs exist in the county
such as the YMCA, other school-based prevention programs through the sheriff’s department, Gosnold
(Cape Cod Lighthouse Charter, Cape Cod Tech, Falmouth, Mashpee, Provincetown, Truro), and Outer
Cape Health Services (Nauset), as well as other individual school or town programming. Please note
this is not an exhaustive list of the prevention programming and services available.
When asked to describe existing resources, participants most frequently discussed the
Barnstable County school system. Many participants described schools as an important venue for
substance use prevention education and programming, but reported numerous barriers, including
teacher and counselor burn out and insufficient pay; lack of dedicated time in the curriculum for
5 Defined as birth through age 8. https://www.aap.org/en/patient-care/early-childhood/
Prevention Programs
B Free Wellness
Boys & Girls Club
Calmer Choice
Cape Cod Children’s Place
Herren Project
Positive Alternative to School
Suspension (PASS)
Sharing Kindness
Youth Villages
(Intercept and LifeSet)
40
prevention education; and rules and regulations regarding what can be discussed in the school
setting. As one participant shared:
“We are so bound by so many rules and regulations about what we can talk about. There is
always an opt out. [It is] usually families that have [the] most issues with substance use that opt
out… We can get our day in school, [but] we can’t get through materials, or we won’t be allowed
to talk about it.”
Further, several participants explained that conventional prevention programming and messaging
(e.g., D.A.R.E. (Drug Abuse Resistance Education), “just say no”) does not work. One youth participant
shared their perspective on this type of prevention:
“We had to do a semester of health where they did a week of substance use. That doesn’t do
much. In [students’] minds doing drugs is cool; that’s how they get in certain crowds. When they
weigh benefits and negatives, being part of [a] friend group wins. Health class is just another
class to us. We’re not going to look back and say health [class] taught me this. It’s going to be
something more important.”
Several participants described connecting young people to individuals with lived experience as a
more effective prevention strategy. One youth participant compared two different approaches to
discussing substance use prevention:
“When we have a guidance counselor do [a] lecture, people listen less. But we did have someone
who went through rehab and had [an] incredibly different life; a lot of people [were] saying they
really liked it. [It] struck a chord. Hearing it from someone who went through it and struggled
through [the] ramifications works a lot better.”
Several participants, including young people, shared that parts of Barnstable County are very
isolated and that there are limited activities for youth to participate in, particularly during the off-
season for tourism. Participants highlighted the importance of providing young people with “places to
belong” where there is a “caring adult they can talk to” and “peers they can commiserate with.” There
is research to support the positive impact of community and connection, overall and as it relates
directly to preventing substance use.18 Participants highlighted several of these resources that already
exist including the Boys & Girls Club of Cape Cod, non-profit organizations like the Herren Project,
school clubs, and substance-free athletics. Several participants described the Boys & Girls Club of
Cape Cod as a particularly important resource because it provides youth with positive role models in a
safe and fun space to spend time.
Barriers to Access
The most frequently described barrier to accessing existing prevention resources, including mental
health services, was a lack of awareness about what resources exist and how to navigate them . As
one participant summarized:
“People shouldn’t have to seek out these services – it should just come to them.”
41
Participants suggested increasing communication efforts (e.g., school flyers, RSAC emails) to raise
awareness of available resources. There were also calls for an easy-to-use centralized repository of
resources available across Barnstable County. One participant commented:
“[Awareness] is a big barrier, like, I didn’t even know [other services] were there. [Cape Cod]
Children’s Place created [a] finder and there is something you can plug in… I found it a little bit
cumbersome to find where that is. If you make this hard, how do you expect people to find it.”
Another participant described the need for navigators who can support people in accessing needed
resources:
“In one of our meetings, I think [name] was talking about navigators. I don’t know what that position
is, but I think that is someone who has good hold on all resources. [With all the services we provide
and work we do for families,] there is no time to navigate system. It’s easier to say I’ll try again
tomorrow or forget it.”
Other barriers discussed related to accessing existing services were transportation, lack of
services in languages other than English, and geographic inequities or “gaps” in available
services across communities. For example, the Boys & Girls Club is an important resource but was
noted as not as accessible for those on the lower or outer Cape. Describing the need for culturally and
linguistically appropriate services, one participant explained:
“There are big [Brazilian and Jamaican] communities here. We haven’t figured out how to
connect so they can get full access.”
Needed Programs and Services
Participants described three primary prevention-related needs: 1) developing more robust mental
health resources, supports, and interventions; 2) starting prevention education, programs, and
services at much younger ages; and 3) facilitating more open and frank conversations with young
people about substance abuse.
Many participants discussed the need for more robust mental health resources, supports, and
interventions for young people and their families, including the need for greater recognition of the
links between substance use and mental health. In particular, participants described the importance
of teaching young people coping skills, emotional regulation, and resiliency so that they have the
tools to manage the challenges they will inevitably encounter as they get older. Participants also
discussed the need to cultivate these tools among parents, families, and other adults (e.g., teachers)
who play a major role in young people’s lives. Participants mentioned several existing resources that
provide all or some of these supports, including Calmer Choice and Sharing Kindness. Two other
programs, B Free and the Cape Cod Children’s Place FIRST Steps Together program, which provide
services focused on recovery were noted to have an important role in prevention work.
Participants also discussed specific gaps in mental health and substance use prevention resources for
youth who have parents and other family members who are using substances. As one participant
shared:
42
“I work in middle school, but also with high school counselors. There is next to nothing in terms of
support for kids who have family members that may be using or on the verge of using. There isn’t
much of anything. I get calls from school counselors saying, “Do you know any 12 step programs
for teenagers?” I don’t think it’s seen as comprehensively as a youth problem as it needs to be.”
Many participants discussed the need to start providing prevention education, programs, and
resources, including mental health services, at much younger ages. Participants discussed
misperceptions regarding the age at which it is appropriate to start having conversations about
substance use and expressed that it is sometimes “too late” once the programming begins. As one
participant shared:
“So, to say that 15–16-year-olds don’t need to learn about this is incorrect. I think the more we
talk about this stuff, [the] less stigma and anxiety. If it’s more commonly taught and referred to,
it’s easier for people to understand what is happening... Ideally, as young as you get, they need
to be talking about this stuff.”
Several participants discussed the importance of having open and frank conversations with young
people about substance use. Participants expressed that open conversations can help reduce stigma
surrounding substance use and provide young people with the opportunity to ask the questions that
are on their mind. As one participant explained:
“I have frank conversations with kids. ‘What made you decide to vape and what made it
attractive... Did you know when you tried it that it would be so addictive and dangerous? And did
you know it would be hard to quit?’ And they said they didn’t… nobody had talked to them.”
Cost of Substance Use Prevention
To quantify the programs and efforts described above, local programs provided estimates of the costs
associated with implementing their prevention programs, including youth focused prevention
activities, prevention programs focusing on healthy coping, stress management, and mindfulness,
and school suspension diversion.
Table 5 presents the overall estimated cost of prevention. It is estimated that nearly $1.2 million is
spent on substance use prevention activities in Barnstable County. The provided estimated costs are
about evenly distributed between youth focused prevention activities (51.3%) and school suspension
diversion programs (48.7%). Costs for diversion of youth involved with the court system were
requested but not received. These costs, alongside the cost of the other domains, are further
discussed in a later section of this report; see Appendix C for full details of these estimates.
Table 5. Estimated Costs of Prevention Activities
TOTAL % OF TOTAL
Prevention
Youth-focused prevention activities & engagement $ 610,438.00 51.3%
School suspension diversion programs $ 579,000.00 48.7%
PREVENTION TOTAL $ 1,189,438.00
43
Harm Reduction
Overall, participants described harm reduction6 services as
critical, life-saving resources – including methadone7,
Narcan/naloxone, syringe exchange, fentanyl test strips, and
supervised consumption. One assessment participant
described the importance, and responsiveness, of these
services:
“I can literally call or text [name] and say, ‘so and so needs this,
and make sure you bring Narcan… make sure you don’t just
bring a couple, bring enough to give out and say here’s a couple
Narcan or stuff to clean syringes.’ It’s huge and it saves lives. It
saved mine.”
Another participant noted these services are not only accessed
by those who are at highest risk, but also those around higher
risk individuals:
“Narcan has gotten out into the community and a lot of people we see in the office might not be
high risk all the time, but they know people who have struggled with this and just want to have
Narcan in case – that’s been positive.”
One participant reflected on the ways in which harm reduction services may reduce overall substance
use:
“I think one thing that works is [that] when someone is more careful when they use [and] have [a]
clean area, they use less. Slip a little love in… don’t use as much.”
These benefits of harm reduction have garnered new and growing attention in the field of substance
use services. They are recognized as a critical part of addressing those with SUD on its own as well as
in coordination with the work in other domains.19
Existing Programs and Resources
When asked to share existing harm reduction programs and services, assessment participants most
frequently discussed the Narcan and syringe services provided by AIDS Support Group of Cape Cod.
Other services mentioned included the harm reduction services provided at Duffy Health Center,
Yarmouth Comprehensive Treatment Center, One Shared Spirit, Access HOPE, and newer services
offered by Health Imperatives. As one participant shared:
6 SAMHSA defines harm reduction as “an approach that emphasizes engaging directly with people who use
drugs to prevent overdose and infectious disease transmission, improve the physical, mental, and social
wellbeing of those served, and offer low-threshold options for accessing substance use disorder treatment and
other health care services.” https://www.samhsa.gov/find-help/harm-reduction
7 While methadone is a method of treatment for opioid use disorder interviewees frequently discussed it in
relation harm reduction services, emphasizing the overlap of the services provided across these domains.
Harm Reduction Programs
Access HOPE
AIDS Support Group of Cape
Cod
Duffy Health Center
Health Imperatives
One Shared Spirit
Yarmouth Comprehensive
Treatment Center
44
“AIDS support group is awesome. [It’s] all harm reduction. You can go in [and] they can help you
navigate treatment systems. You can call them and be like ‘Can I [get] 10?’ and they can drop
off.”
Several participants shared that providing harm reduction services also offers an opportunity to
connect with people, provide them with support, and link them to other needed services,
including Hepatitis C treatment. As one participant shared:
“When you deliver, [you] can give way more [than] Narcan; just make [a] connection so they
know they have someone to talk to. [It’s a] huge opportunity for all kinds of other services.”
Participants also characterized harm reduction services and providers as non-judgmental, affirming,
and respectful. One participant shared their thoughts based on their lived experience:
“Those [harm reduction] are the first people that talked to me like I was human, they didn’t
shame or guilt me. They looked me in the eye and showed up even though I didn’t want to…
Those were the first people that interacted with me like I mattered. People walk by and judge
and shame you, you’re already struggling internally. These harm reduction programs provide
safety, they kept me alive.”
Barriers to Accessing Existing Services
While a number of barriers were mentioned, discussions around barriers to harm reduction services
primarily focused on stigma.
Stigma
Many participants noted that significant stigma makes it extremely difficult to access the few
resources that do exist. One participant with lived experience explained how the stigma around
harm reduction can prevent people from accessing life-saving services:
“The stigma around methadone was terrible and it would scare you away from trying to get on
it, but it was all bullshit and I wish I hadn’t heard it because it took me too long to try it.”
Another participant shared:
“There’s still a lot of people [who] don’t support [methadone]. I’ve always presented it as an
option, a choice. It’s so nice for people to feel like they have a choice. When you have a choice,
you feel like there’s hope.”
Participants also described experiencing stigma, discrimination, and poor treatment when seeking
harm reduction services from many sources, including police officers, ambulance services, and
even people within the substance use community. A couple participants with lived experience
shared the following thoughts:
“When you want to get clean syringes, the pharmacist looks at you like you’re a scumbag and
follows you around the store. I’m just trying to be healthy… I was spending like a $120 a week or
something getting syringes because none of these pharmacies were selling them to me.”
“[We’ve] got these councils that have ‘substance use’ in their name and [they] look at you with
more stigma than someone at the grocery store.”
45
Another participant with lived experience recommended training police officers on how to
compassionately interact with people who are using substances, experiencing mental health issues,
and/or experiencing homelessness:
“The county needs to have a class for the police on how to handle the homeless, drug addicts,
alcoholics with mental issues, and not just yell at them and tell them to leave. There needs to be
more communication and understanding. I’ve had cops come up to me at like 3 in the night and
tell me you gotta move, and it’s like, where do you want me to go? They need to treat people like
humans.”
Participants also described how stigma makes it challenging to discuss harm reduction with
young people, despite its importance. Several participants discussed the need for harm reduction
education in schools, even for youth who are not using substances. As one participant shared:
“A few years ago, if you bought Adderall, it was Adderall. But now, if you buy it, chances are there
is fentanyl. [The] education system tends to be cautious about messaging because these are
other people’s children. Most people have contradicting views… harm reduction becomes [a]
necessary part of prevention. Educating them more on what harm reduction looks like with
underage substance use.”
Other Barriers
Participants described several other barriers to accessing and benefiting from harm reduction
services, including the need for low-barrier housing that does not require abstinence; the need for
more providers of color; the provision of services in other languages; and transportation. One
participant explained the critical need for low-barrier housing:
“The other thing that comes up… is low-threshold housing [for] folks with substance use
disorder… If folks have the means and desire to get into sober homes, [they] can access that
treatment. If you are actively using or sliding into one of those categories, [there is] no place to
hang your hat. Low threshold housing within [the] harm reduction model – that in itself is
treatment. Create safety and be available to continue their health and wellness.”
Participants also described the need for more culturally responsive services, including more providers
of color and services in other languages.
“Right now, [we have] four people on [our] team, two people of color and two white. [It’s] super
important to bring people to [the] table and [we] can’t focus on just white people… men of color
[have the] highest rate of deaths.”
Needed Programs and Services
Overall, participants shared that there is a critical need for more harm reduction services,
particularly methadone clinics and other providers who offer medications for opioid use disorder
(MOUD), as well as Narcan distribution, drug checking, syringe exchange, safe consumption sites, and
related services like Hepatitis C treatment. As one participant shared:
46
“If we are looking to target overdose deaths, anything having to do with expanding MOUD,
ideally in [Federally Qualified Health Centers], and harm reduction—those are the two areas
[that are needed].”
Another participant explained how the stigma discussed above has prevented new harm reduction
services from opening:
“They won’t allow a methadone clinic here, the closest is 45 minutes away… they were supposed
to open [one] a year and a half ago and the town shut it down saying there were too many 'drug
addicts' here.”
Participants also emphasized the need to ensure that services are low barrier and as easy to
access as possible. Participants discussed the need for more outreach, service provision, and “boots
on the ground” in areas where people who are using substances live and/or use, including homeless
camps and public restrooms. One participant shared:
“We go out and deliver [Narcan, fentanyl test kits, and clean/safety syringe kits] no questions
asked. I know hangouts and they are all ages, so I just drive to the site [and see if] anyone needs
Narcan and clean needles. It’s just amazing.”
Relatedly, participants described the importance of maintaining a low profile and protecting the
confidentiality of people who are accessing harm reduction services, in part because of the
significant stigma that exists in the larger community. As one participant explained:
“Supervised injection doesn’t need to be a huge brick and mortar – no one is going to travel to [a]
harm reduction center to use. [We need to] figure out how to have individualized supervision and
monitoring of people using drugs and mobile outreach where it’s inconspicuous.”
Cost of Substance Use Harm Reduction
To understand the costs associated with providing harm reduction services, this assessment collected
data related to programming to collect and dispose of excess prescription drugs and syringes/needles
as well as outreach activities for resources and harm reduction from local municipal departments and
the Cape Cod Cooperative Extension (CCCE) in Barnstable County. Additional costs of providing harm
reduction services such as syringe exchange and naloxone distribution were shared by two
organizations: AIDS Support Group and ACCESS Hope and a local EMS.
Table 6 presents the overall estimated cost of harm reduction. It is estimated that more than $600,000
is spent on substance use harm reduction activities in Barnstable County. Over one third (38.5%) of
the provided estimated costs have gone to naloxone distribution and about a quarter was associated
with community outreach in collaboration with PD (27.7%) and needle exchanges (25.0%). These
costs, alongside the cost of the other domains, are further discussed in a later section of this report;
see Appendix C for full details of these estimates.
47
Table 6. Estimated Costs of Harm Reduction Activities
TOTAL % OF TOTAL
Harm Reduction
Programming that manages community-based collection and
disposal of excess prescription drugs. $ 3,256.18 0.5%
Programming to manage appropriate community-based syringe and
needle disposal. $ 52,701.84 8.3%
Programming to manage community -based syringe and needle
exchange. $ 158,994.60 25.0%
Programming providing education and naloxone to prevent death
from opioid overdose. $ 245,310.50 38.5%
Collaborative outreach to community, particularly higher risk
populations, between behavioral health professionals and law
enforcement to provide resources aimed at harm reduction and
prevention $ 176,471.85 27.7%
HARM REDUCTION TOTAL $ 636,734.97
48
Treatment
Substance use treatment is a pivotal point in an individual
addressing their SUD, and it is vital that the resources be
available and accessible for those who are seeking these
services. There are multiple entry points to treatment, including
through harm reduction services, recovery services in the case
of recurrence of SUD, and many in between. The offered
programs need to take all potential pathways into
consideration.
Existing Programs and Services
Participants discussed a number of existing treatment-related
programs and services. Participants spoke particularly highly of
the services provided by Duffy Health Center, including its use
of an integrated model, incorporation of harm reduction
resources, and the Moms Do Care program. Other resources discussed included Gosnold Behavioral
Health; Community Health Center of Cape Cod; Yarmouth Comprehensive Treatment Center; Outer
Cape Health Services; and mobile clinics (e.g., the previous CHART (Community Harm Reduction and
Treatment) team partnership between Duffy Health Center, the Community Health Center of Cape
Cod, and the AIDS Support Group of Cape Cod).
Several participants shared that there are private treatment facilities opening in Barnstable County
but expressed concerns about access for people who cannot afford to pay for services.
“[There are] private facilities who are sprouting up and only taking private insurance and
actually pulling some shady business to draw patients into treatment programs and selling the
world to individuals. [I’m] hopeful that [their] hearts are in the right place. There is at least one to
two in Falmouth, Mashpee, and Bourne areas.”
Barriers to Accessing Existing Services
Participants described a number of barriers to accessing and benefiting from existing treatment
resources. The most frequently reported barriers included lack of transportation; lack of affordable
and low-barrier housing while in treatment; and challenges navigating insurance coverage. As
one participant shared:
“There needs to be some type of transportation when someone is trying to get treatment. I’ve
gotten beds before, but I can’t even get there. So maybe some type of program where if you’re
trying to get a bed, say it’s in Fall River or New Bedford, it would probably be huge. Then it’s not
a huge fight trying to get in - it’s already a huge fight with yourself.”
Related to transportation, participants discussed the “huge commitment” required to obtain MOUD
from treatment centers on a daily basis and the need to work on “loosening restrictions.”
Participants also described the challenges involved in providing treatment to unhoused and
unsheltered individuals:
Treatment Programs
Community Health Center of
Cape Cod
Duffy Health Center
Gosnold Behavioral Health
Outer Cape Health Services
Yarmouth Comprehensive
Treatment Center
49
“[It’s] very hard to treat people not housed [who] are very transient. [The] continuity of care is
really challenging.”
Another participant discussed how a lack of affordable housing compelled a client who is in treatment
to live in an environment where other people are still actively using substances:
“Housing that is available is very expensive, and there’s not a lot of housing here in general. It’s
not cheap to be on the Cape; a lot of people are either on vacation or retired here. You have the
haves and have nots. Housing down here has always been a challenge. I can think of a client off
the top of my head who’s living in a house where they’re all using crack, but she has nowhere
else to go.”
Participants reported lack of awareness regarding what resources exist and how to navigate them as
another barrier to accessing treatment. As one participant expressed:
“If people would know… you know, there is help out there instead of putting a needle in your
arm. I’m seeing people walk into the clinic just a mess. And within months they’re going in the
right direction.”
Another participant described the need to compile resources in one place:
“[We need] resources in one place. Let’s streamline it so parents, loved ones, and addicts can
navigate [the] system. Let’s think about streamlining resources. Another big thing is navigating
insurance companies.”
Needed Programs and Services
Many participants reported that there are not enough beds or treatment facilities available.
Participants also shared that there are not enough long-term treatment options or methadone
clinics and other MOUD treatment options (described in further detail in the harm reduction section
above). One participant explained the effect these gaps can have on individuals who are seeking
treatment:
“Even though [in] our programs we really work hard for same day initiation of treatment, there
aren’t a lot of opportunities for folks struggling with active use if they walked into [somewhere]
using right now at this moment and wanted treatment to start. [We] need a bridge, [an] easy
access clinic. Someone should walk in and be able to find options [and be] referred to whoever is
the right choice… Even though we desire hospitals to be that linkage if that is where they are
at… hopefully they would not get to that level. Can we figure out a way that they don’t need to
get into [the] hospital system?”
Another participant echoed the need for more beds, particularly for people who do not have private
insurance:
“A big thing is getting beds in detox. The sober living is not enough; it seems like if you don’t have
a private insurance, there’s not enough sober houses. [There are] not enough houses and beds
and [there are] people with MassHealth coming straight out of holding. I turn down gentlemen
every day—at least five people—because there’s no beds out here. If you don’t have private
insurance, it’s tough out here.”
50
Participants also reported that there are not enough treatment options tailored to the needs of
specific populations, including young people; women with young children; and people who are
exiting jail. One participant explained the lack of options for youth under 18, including the need for
services that are not provided virtually:
“[There are] substance use programs at [the] Outer Cape but not for those under 18. And just
because you’re 18 you’re not an adult. That transitional period, there is absolutely nothing on
[the] Outer Cape; [there’s] more as you get to [the] Mashpee Falmouth area. I know [Cape Cod
Healthcare] is getting ready to launch another [partial hospitalization program] [but it’s] still
more virtual based. Substance use disorder is already isolating – I find it counterproductive to
stick them in their bedroom and have them log onto Zoom for five hours a day.”
Another participant also described the need to address isolation when designing treatment services
for youth:
“If an adult comes in and they have substance use disorder, I would connect [them] with [a]
recovery coach, meet with harm reduction, and refer them to Alcoholics Anonymous. Everyone
knows peer models work. We don’t have that freedom with teens. So, it’s hard due to
confidentiality and you want to protect the student. It’s isolating for them to think they are the
only ones.”
Several participants described the closure of Emerson House’s program for women and children as a
major loss:
“[I’d] rather see treatment be less money driven and more driven by needs. What happened to
Emerson is just a tragedy. [It was] just an amazing program and [it] worked for so many
women.”
Many participants also spoke of the need for more dual diagnosis treatment services as well as a
broader need to acknowledge and address the intersections between substance use and mental
health. As one participant explained:
“Those two things [mental health and substance use] overlap very often. [I’m] not sure [if] it’s
[the] chicken or egg – just those two things coexisting [is] difficult. [It’s] hard to admit that you
are dealing with one or both of those things. Add that onto the lack of sober homes and long-
term treatment facilities. [There’s] not enough of dual diagnosis. When seeing people [in]
treatment in Emerson House, that is what people are experiencing. They feel like the only way to
feel better is to use drugs and alcohol. It works sometimes but it tends to just make things much
worse. [We need to] have the proper dual diagnosis with people.”
Another participant described the consequences of inadequate substance use and mental health
services, particularly for young people:
“[The] biggest piece is [the] tie between substance use and mental health and access to services
for those kids. People [are] talking about we gotta go to McLean or Children’s. [There are] just no
beds for kids and there never had been. Kids [are] locked up in [a] detention unit [when] they
needed a bed. Lock up isn’t the place for them. A judge looking at someone saying I have no bed,
51
[I] will send them to jail. You see that on [the] adult and juvenile level; there [are] just no beds.
Sometimes [jail is] quicker than detox… Now they are back home in [an] environment [that was]
not safe for them in [the] first place. [When] kids [are] using substances, there is stuff going on at
home and [they] are just self-medicating at that point.”
Cost of Substance Use Treatment
The primary cost data for treatment was provided by three health care centers in the county: Duffy
Health Center, Cape Cod Health Care (CCHC), and Outer Cape Health Services (OCHS). BSAS provided
admissions for Barnstable County that were then combined with the average costs reported by the
National Center for Drug Abuse Statistics (NCDAS) for the state of Massachusetts. The Barnstable
County Sheriff’s Office provided the cost of SUD treatment for incarcerated individuals and those who
are in pretrial.
Table 7 presents the overall estimated cost of treatment. It is estimated that more than $45 million is
spent on substance use treatment activities in Barnstable County. The majority of cost provided came
from DPH-funded BSAS admissions. This cost figure is based on admissions data from BSAS and
NCDAS estimates an average cost of $12,500 per 30-day admission for substance use treatment
nationally.20 Not all health care centers in Barnstable County submitted cost data, therefore the cost
of inpatient and outpatient care provided by local health care facilities is underestimated. These
costs, alongside the cost of the other domains, are further discussed in a later section of this report;
see Appendix C for full details of these estimates.
Table 7. Estimated Costs of Treatment Activities
TOTAL % OF TOTAL
Treatment
Local health care facility expenditures (inpatient +
outpatient) for substance use treatment services $ 7,398,325.80 16.3%
DPH-funded substance use treatment programs $ 37,675,000.00 82.8%
Substance use treatment costs for inmates $ 432,374.68 1.0%
TREATMENT TOTAL $ 45,505,700.48
52
Recovery
When talking about the recovery, individuals often noted there is no one path, or even only a couple
“right” paths, to enter or remain in recovery. Each person’s journey will look different and for offered
services to be effective for the recovery community, they need to understand the importance of
offering a variety of services and resources. One common thread in many people’s recovery is the
need for a support system who understands their recovery experiences.
Existing Programs and Services
Overall, participants shared that there is a strong recovery
community in Barnstable County but that more services are
always needed. Participants discussed several key recovery
resources and services, including WellStrong, PIER Recovery
Support Center, Recovery Without Walls, Refuge Recovery,
Foundations Group Recovery Centers, Herren Project recovery
support services, Alcoholics Anonymous (AA) and Narcotics
Anonymous (NA) meetings, and sober homes. Other recovery
support services discussed in relation to other domains that
also provide recovery services include B Free Wellness and
Recovery Build Alternative Peer Group (APG). Participants also
described the benefits of support services for the parents and
families of people using substances, including Parents Support
Parents and Learn 2 Cope. One participant shared:
“The recovery community on the Cape is really strong. I think the
way all the pieces interact together; treatment centers coordinate
well with sober houses. Those are excellent, there are [a] number
of them.”
Many participants described community, connection, and
support, including peer recovery support services and
recovery coaches, as critical components of recovery. As one
participant summarized:
“Isolation is the worst thing for somebody in recovery. It’s relapse,
it’s death, it’s the complete opposite of what recovery is, because
recovery is connection.”
This participant went on to explain:
“Coaching has made a huge difference for some people—just having that one person walk
alongside you in the beginning. Even making a phone call in the beginning of your recovery,
setting up a doctor’s appointment, it’s scary. I know that maybe doesn’t make sense for someone
who doesn’t understand, but it is. But that’s one example of what can happen when the peer-to-
peer support is there. People thrive off of community.”
Recovery Programs
AA & NA meetings
B Free Wellness
FIRST Steps Together
Foundations Group Recovery
Centers
Herren Project
Learn2Cope
Parents Supporting Parents
PIER Recovery Support Center
Recovery Build APG
Recovery Without Walls
Refuge Recovery
Sober homes
WellStrong
53
Participants also discussed the importance of physical spaces where people in recovery can be in
community together, have “something to do outside of work”, and “feel like they’re giving back,”
especially as they transition out of treatment. A number of participants spoke highly of WellStrong, a
fitness and wellness community for people in recovery that “provide[s] [a] safe space for people in
recovery to walk in, be themselves, feel comfortable, [and] have a place where, if they’re struggling,
[they can] ask for help.” As one participant shared:
“The beautiful thing about WellStrong is [that its] doors are open every day. [You can] come hang
out [and] grab a cup of coffee.”
A number of participants described the importance of wellness services, activities, and programs
for people in recovery, including meditation, yoga and fitness, and art therapy.
“[The] wellness portion is huge... Incorporating things that you didn’t before. We currently
partner with Sharing Kindness and offer [a] grief support 5-week program for young adults. The
longer you’re in recovery, the more loss you experience because, unfortunately, a lot of people
don’t grasp [or] hold onto recovery. We don’t have coping skills to deal with it.”
Another participant shared:
“[We dive] deep into [the] ways we can continue to support [our members] because you never
know what that ‘aha’ moment is for someone – it can be art, music, or walking for different
people. [You] never know what someone needs for healing.”
Participants also shared that there are many “different pathways to recovery,” that different
people will benefit from different approaches, and that abstinence is not the only option; a couple of
participants stated that their organizations do not offer or directly work with 12 step programs.
“It took me a little while to be like, it’s okay if I have a friend who decides she doesn’t want to go
to meetings, but she wants to go be a yoga instructor and that’s what’s healing for her. That’s
her journey, that’s her path, we’re not all the same and that’s okay.”
This participant went on to describe the importance of recognizing that people in recovery know what
they need and do not need to be told what is best for them:
“[We need] to have places where there are these options and people can choose whether or not
it’s for them. We’re an intelligent group emotionally, which is very much undermined. We talk
about feelings all the time, we’re very emotionally aware of our needs for each other. It’s just
being heard and being provided the space. We’re told what we need a lot. That’s why I
appreciate the time to be able to say what we need.”
Barriers to Accessing Existing Services
The most frequently discussed barriers to accessing recovery services included lack of insurance
coverage and difficulty navigating the insurance system; and lack of transportation, especially
for the many people in recovery who do not have drivers’ licenses. Describing issues with insurance
coverage, one participant shared:
54
“It seems like if you don’t have private insurance, there’s not enough sober houses…if you don’t
have private insurance, it’s tough out here.”
Another participant described the challenges they have faced trying to get insurance to cover needed
services for a family member:
“Two years later I’m still having a hard time navigating what services are available. [It] took
almost 1.5 years to get to therapy. [It’s] so hard to navigate [the] system between insurance
companies. One system tells you one thing, and another tells you another.”
Transportation was also described as a key barrier to accessing existing services:
“A lot of people don’t have licenses who are in recovery and transportation is so difficult – a lot of
meetings and things [are] so hard for people to get to.”
Transportation is really the number one barrier. A lot of people would love to come to WellStrong
but they can’t get there… WellStrong offers so many amazing things… There’s so much interest
and [the] number one thing that holds people back is transportation for sure.”
Several participants described additional barriers to accessing services, including a lack of
awareness about existing resources; and difficulty navigating existing resources, including for
parents and family members who are supporting their loved ones in seeking recovery services. As one
participant shared:
“There is just a lack of places for people to access this knowledge… [they] need a platform to
look. They don’t know about different therapies, [Eye Movement Desensitization and
Reprocessing], [Rapid Transformational Therapy]. We’re out there but it’s getting that
information to people in recovery.”
Describing the difficulty of navigating existing resources, another participant shared:
“[You] have to jump through hoops to get care. It’s a difficult task for anyone; [they’re] going
through trauma as it is and [then] trying to get… help on top of that.”
Needed Programs and Services
Overall, participants emphasized the need for more of the services described above, including sober
homes, peer recovery support services, wellness resources, recovery centers, and support services for
the parents and families of people using substances. Many participants shared that there is a need for
more housing for people in recovery, particularly sober homes for people who do not have private
insurance. One participant characterized the housing situation as follows:
“[It] always comes back to housing. Unless we correct that, [there is] no point in trying to correct
anything else… We should have established links [to] congregate housing that… [there are] no
homes there for us.”
While many participants spoke about the need for more sober homes, a couple also shared that there
is a need for more regulation to ensure that all sober homes provide high quality services. As one
participant shared:
55
“[I] feel like [sober house managers and owners] should have to check in monthly [and show
that] they [are] providing certain services… [Because] anyone [can] open [a] house, a lot turn to
flophouses. A lot of people [in recovery] say [that the sober homes] allow you do everything, [but
if you] do one thing [they] don’t like, they kick you out. There need to be more restrictions on
recovery homes [so] not just anyone can open [one].”
Another participant described the need for additional supportive housing as people transition out of
sober homes:
“I see so many people relapse in that transition. I’m not sure that people transitioning out of
sober living are really ready to go take on apartment. Sometimes they [live with] roommates
[who are] not ready to be roommates to someone in recovery. I think grad houses are [an]
amazing transition but [there are] not tons of them. I do see that time as a very dangerous time
for recovery and [the need for] supports around that.”
One participant highlighted how the lack of affordable housing can disrupt the important networks of
support that people build while they are in recovery:
“Once people live in sober living [and have an] established network, it’s difficult for them to stay
on the Cape. Affordable housing is hard to find.”
Several participants shared that there are not enough recovery services for parents of young
children, particularly mothers.
“[There’s] a lot of need for women with children. [There are] hardly any services. Even fathers
too… a lot of times [parents] have to leave [their] kids in not great situations when they go into
recovery, so that’s difficult.”
As described in the treatment section, the closure of Emerson House’s program for women and
children was seen as major loss. A couple of participants highlighted that the opportunity for service
providers to make more money was behind the closure of this and other programs. One participant
shared:
“[We need to] push for nice houses with moms for kids. [The] only thing they had was Emerson
House and that’s closed now. There [are] no halfway houses anymore. [You can] get one of those
beds [at] Emerson TSS or [you’re] back on the street. [Halfway houses were] a big thing in this
community and that’s gone.”
Another participant shared their perceptions regarding the financial motives underlying the closure of
Emerson House and other programs:
“A lot of reason these six houses were closed [is that organization] wanted to switch to [a] mental
health and addiction model. When management… shifted over the years, [the] client became
less important; [they] looked at [the] client as [a] cost. Primarily, [they] can get much more
money by billing as mental health and CSS [Clinical Stabilization Services].”
56
Other participants discussed the need for navigators who can connect individuals in recovery and
their loved ones to needed services and supports. One participant shared that existing resources
are not adequate:
“[The] state has [the] [Mass]Options program where you can call and get some help.
MassOptions [is] mediocre, [and] we have 211… which is too complicated. Where is the person or
persons who can walk you through this... That is what we need for this kind of thing. Anyone
should be able to access it.”
A couple of participants shared that navigation services should work to break down silos and address
all the needs that individuals in recovery have, including insurance, transportation, housing, food
assistance, mental health services, and support services for their loved ones.
Cost of Substance Use Recovery
Programs provided costs to support recovery, including those for recovery coaching programs,
programs to support sober home placement, and other recovery supports (e.g., peer groups, classes,
recovery navigation, etc.). Data were provided from Duffy, WellStrong, Parents Supporting Parents,
and RecoveryBuild APG.
Table 8 presents the overall estimated cost of treatment. It is estimated that more than $1.3 million is
spent on substance use recovery activities in Barnstable County. More than half of the reported costs
were for other recovery supports (57.1%); over a third (38.9%) were for recovery coaching programs.
These costs, alongside the cost of the other domains, are further discussed in a later section of this
report; see Appendix C full for details of these estimates.
Table 8. Estimated Costs of Recovery Activities
TOTAL % OF TOTAL
Recovery
Recovery coaching programs $ 514,267.00 38.9%
Support for sober home placement $ 53,650.00 4.1%
Other recovery support programs $ 755,293.00 57.1%
RECOVERY TOTAL $ 1,323,210.00
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Resource Inventory
A goal of this assessment was to identify the available substance use resources in Barnstable County.
Many of the organizations that provide these resources have been mentioned throughout this report;
this section further describes the specific services they provide (see Appendix B for further detail).
While this inventory captures many of the services available to Barnstable County communities, it is
not an exhaustive list and is intended as a dynamic tool to be updated on an ongoing basis.
Within prevention resources, most have a focus on
overall prevention through activities around
mindfulness, emotional regulation, and health
behaviors as a path to prevent substance use, as
well as other physical and mental health issues.
Others focus on prevention through recovery work
with parents of young people, which focus both
specifically on substance use as well as these
overall healthy behaviors.
Harm reduction services tend to focus on the
following resources: needle/syringe exchanges,
Narcan distribution and education, and
fentanyl test strip distribution and education.
There are also programs in the county that
focus on mobile harm reduction bringing
resources directly to where the higher risk
populations are.
The most commonly used treatment services for
SUD include inpatient services providing more
intensive care, outpatient services, programs
offering MAT including MOUD for opioid use
disorder, and detox programs.
As previously discussed, there is no one path to or
in recovery. However, there are some commonly
offered services including group meetings and
peer support groups, recovery coaching, and
holistic health services such as mindfulness.
Types of Recovery Activities
Group Meetings & Peer Support
Recovery Coaching
Holistic Health & Mindfulness
Types of Prevention Activities
Holistic, Health Behaviors, Emotional
Regulation, Etc.
Substance Use Specific
Prevention through Recovery
Types of Harm Reduction Activities
Syringe/Needle Exchange
Narcan Distribution & Education
Fentanyl Test Strip Distribution & Education
Mobile Harm Reduction
Types of Treatment Activities
Inpatient
Outpatient
Medically Assisted Treatment (MAT)
Detox
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Two types of services that cut across these
domains are support services for family, friends,
and loved ones of someone with SUD disorder and
grief support for individuals who have lost
someone to SUD.
As indicated in the resource inventory, many organizations and programs address needs in more than
one of the domains discussed. Throughout the conversations with community members and
stakeholders, several participants described the need for more coordination and collaboration
across agencies offering similar or related services. One participant emphasized that the
importance of this collaboration is to help the people in their community who need these services:
“I feel like finding a way to bridge services together and have a healthy communication system.
Professionally and personally, I have seen a competition type thing and that bothers me. It is
about the person that needs to [be] served… If there’s something we can create, remembering
why we’re doing this and who we are doing it for.”
Another participant talked about this in the context of their own organization and its leadership:
“I don’t know if collaborating or championing service with other agencies has been discussed in
our leadership, but [I] agree [that we need] to partner to get services [to] everyone.”
Types of Other Activities
Family Support
Grief Support
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Cost of Substance Use in Barnstable County
This section presents a deeper analysis of the cost data discussed in previous sections. In some cases,
data from programs were able to be allocated to a certain substance; not all programs were able to
provide this level of detail. See Appendix C for full details of these estimates.
Using the cost data provided for this assessment, the estimated cost of substance use in Barnstable
County is $48,333,708.77. The vast majority of this cost is focused on treatment (93.5%). All other
domains represent less than 5% of the reported costs (Table 9).
Table 9. Estimated Cost Barnstable County Substance Use Assessments, 2022
TOTAL COST % OF TOTAL COST
Domain
Prevention $1,189,438.00 2.4%
Harm Reduction $ 636,734.97 1.3%
Treatment $ 45,505,700.48 93.5%
Recovery $ 1,323,210.00 2.7%
A detailed breakdown of the indicators related to specific programs and activities in each domain are
presented in Table 10. Provided prevention costs were relatively evenly distributed between youth-
focused prevention activities (51.3%) and school suspension diversion programs (48.7%). While
representing only 2.5% of the total cost, these activities have the potential to result in over $21 million
in savings based on estimates that every $1 spent on school-based prevention programs could save
$18.21
Harm reduction services represent just 1.3% of these costs but investment in these services has
immense potential to save both costs and lives. One study found that harm reduction efforts save
$100-$1,000 per HIV infection averted22; another estimated needle exchange programs save $23-71
dollars per person engaged.23 Harm reduction efforts, such as naloxone and testing strips, are directly
aimed at preventing overdose deaths24; in Barnstable County, there were 514 overdose deaths
between 2015 and 2021. The largest cost provided for harm reduction was for naloxone distribution
and education (38.5%), followed by costs related to outreach efforts conducted in collaboration with
law enforcement (27.7%), and managing needle exchange programs (25.0%). Most of the harm
reduction cost data collected are aimed at addressing opioid use and its related effects. For the
outreach activities, data could not be disaggregated by substance as they aim to reach a wide range of
populations in the community.
The treatment provided at state-funded treatment programs comprises the largest percentage of the
cost data received (82.8%). Local health care providers contribute the next largest portion (16.3%); it
is important to note that multiple local providers did not provide cost data for their treatment services
and therefore this number is likely an underestimate. The treatment provided in correctional facilities
is a newer indicator developed in response to changes in substance use policy and contributes 1.0% of
the estimated treatment costs. Most data for treatment could be disaggregated by substance. Alcohol
costs represent almost half (49.4%) of the treatment costs and opioids account for just under a third
of the treatment costs (31.9%).
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Recovery costs also represent a small percentage of reported costs (2.7%). One study found that a
program focused on recovery may have similar costs to traditional clinical approaches to substance
use but led to more positive outcomes for individuals to maintain long-term recovery such as more
days in recovery and fewer substance used-related problems experienced.25 Recovery as its own
domain allowed for further detail in the cost of different recovery supports. Other recovery support
services such as support groups (peer groups, grief and loss groups, AA/NA) account for more than half
(57.1%) of the recovery costs. In some cases, these costs could be broken out by alcohol compared to
other substances. Alcohol represents 16.5% of the costs; however, almost half (45.8%) could not
specify a substance.
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Table 10. Full Matrix of Estimated Cost of Substance Use in Barnstable County
COST BREAKDOWN
TOTAL % OF TOTAL Alcohol Marijuana Opioids Other Substances Unspecified Substance
Prevention
Youth-focused prevention activities & engagement $ 610,438.00 1.3% -- -- -- -- --
School suspension diversion programs $ 579,000.00 1.2% -- -- -- -- --
PREVENTION SUBTOTAL $ 1,189,438.00 2.5%
Harm Reduction
Programming that manages community-based collection
and disposal of excess prescription drugs $ 3,256.18 0.01% -- -- $ 3,256.18 -- --
Programming to manage community-based syringe and
needle exchange $ 158,994.60 0.3% -- -- $ 158,994.60 -- --
Programming to manage appropriate community-based
syringe and needle disposal $ 52,701.84 0.1% -- -- $ 52,701.84 -- --
Collaborative outreach to community, particularly higher
risk populations, between behavioral health professionals
and law enforcement to provide resources aimed at harm
reduction and prevention $ 176,471.85 0.4% -- -- -- -- $ 176,471.85
Programming providing education and naloxone to prevent
death from opioid overdose $ 245,310.50 0.5% -- -- $ 245,310.50 -- --
HARM REDUCTION SUBTOTAL $ 636,734.97 1.3%
Treatment
Local health care facility expenditures (inpatient +
outpatient) for substance use treatment services $ 7,398,325.80 15.2% $ 3,242,262.77 $ 92,629.01 $ 304,837.56 $ 1,128,596.46 $ 2,630,000.00
DPH-funded substance use treatment programs $ 37,675,000.00 77.4% $ 19,250,000.00 $ 637,500.00 $ 14,225,000.00 $ 3,562,500.00 --
Substance use treatment costs for inmates $ 432,374.68 0.9% -- -- -- -- $ 432,374.68
TREATMENT SUBTOTAL $ 45,073,325.80 93.5%
Recovery
Other recovery support programs $755,293 1.6% $ 63,525.00 -- -- $ 128,975.00 $ 562,793.00
Recovery coaching programs $514,267 1.1% $ 155,463.00 -- -- $ 315,637.00 $ 43,167.00
Support for sober home placement $53,650 0.1% -- -- -- --
RECOVERY SUBTOTAL $ 1,323,210.00 2.7%
TOTAL COST $ 48,222,708.77 -- 46.1% 1.5% 29.9% 10.6% 7.5%
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Direct comparison of total costs in 2014 and 2022 is not possible due to major methodological
changes across assessments, including the splitting of treatment and recovery into separate domains
and the removal of law enforcement as a domain. However, after subtracting law enforcement costs
from the 2014 total, the 2014 and 2022 totals are similar ($53,184,000 and $48,333,708.77,
respectively; Table 11). Still, comparisons should be made with caution as the data available and
received in each year varies.
Table 11. Estimated Cost Barnstable County Substance Use Assessments, 2014 and 2022
2022 TOTAL 2014 TOTAL
Domain
Prevention $1,189,438.00 $1,010,000.00
Harm Reduction $ 636,734.97 $707,000.00
Treatment $ 45,505,700.48 $51,467,000.001
Recovery $ 1,323,210.00 --
TOTAL $48,333,708.77 $53,184,000.00
1Recovery was not a separate domain in the 2014 assessment and are combined within this number. The regrouping of
treatment and recovery is in recognition of the importance of recovery as its own part of the substance use service field.
NOTE: Law enforcement cost data from 2014 is not shown in alignment with new domains. The removal of law enforcement –
the largest percentage of the 2014 assessment cost estimates, in part due to the inclusion of a large portion of police budgets
– is in response to the understanding that there are other more effective ways to address substance use in communities and
treating SUD as a public health issue rather than a criminal issue.
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KEY FINDINGS AND INITIAL RECOMMENDATIONS
This section summarizes the key findings of this assessment, overall and by domain, including some
initial recommendations based on suggestions from assessment participants.
Overall
This assessment is one step in the work to address substance use in Barnstable County; the process
highlights the potential impact of regular, ongoing data collection and assessment of the substance
use needs and costs in the county to inform and improve the services available and how they are
delivered. To continue to utilize community perspectives and data to drive decisions regarding
substance use services in the county the following should be considered:
Conduct an assessment of this nature every 3 to 5 years with the goal of understanding both
ongoing needs and emerging trends related to substance use.
o Timing of assessments should be based on the timeframe of the current action plan,
with the aim of having an updated assessment started and/or complete before the
action plan is to be revisited.
Engage with key stakeholders to emphasize the importance of this work, and their
contribution to it, to the community to facilitate this type of regular data collection.
o Some examples include engaging with school systems and leadership about the value
of data collection (e.g., YRBS) and substance use prevention programs to the wider
community, working with healthcare providers to provide standardized cost data,
coordinating with all municipalities to report data on local efforts around substance
use services, etc.
Conduct additional community engaged assessment work, with specific populations and
topics of focus, to gain a deeper understanding of needs and trends identified as well as fill
any gaps in knowledge.
o Efforts should be made to explore the impact of, and needs related to, substance use
specific to different populations, e.g., geographic areas, different racial and ethnic
groups, age groups (e.g., youth, older adults), caregivers, homeless or housing
instable, etc.
o Information should be gathered regarding the intangible costs of substance use (e.g.,
lost time at work/school, job loss, loss of productivity, etc.). These data are quantified
at the national level rather than locally but are often not directly applicable to the
unique aspects of regions like Barnstable County.
These assessments should aim to guide decision-making and action planning from an evidence-
informed perspective, which includes but is not limited to evidence-based practice or research as the
only form of evidence.26 Evidence-informed approaches consider other information that “affects
existing beliefs… about the significant features of the problem under study and how it might be
solved or mitigated;” in other words, it takes the perspectives of those with direct and lived
experience as valuable contributions to understanding how to approach solutions.27 SAMHSA also
recognizes the challenges faced in implementing evidence-based practices in under-resourced
populations.28 With an evidence-informed approach, decision-makers ensure both research and
community expertise and experience are integrated to create more equitable and inclusive action.
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The results quantify that the estimated cost is primarily attributable to treatment services; however,
investments in the other domains have great potential to positively impact quality of life and result in
cost savings. Perspectives from service providers, community members, and other key stakeholders
emphasized the importance of the services in all four domains. Individuals highlighted the
effectiveness of services being provided by local organizations; however, they were also clear that
there are needed services and supports for each domain as well as those that are cross cutting.
Furthermore, there are two main perceptions of substance use in the county – the growing awareness
of the complex impact of substance use and those who deny that substance use is an issue in the
community. These perceptions need to be fully understood to effectively address barriers, such as
stigma, and effectively deliver services equitably across different geographies and populations.
Based on the perspectives of community members, the following should be considered when
planning future actions to address substance use overall:
There is a need to understand and integrate the impact that social determinants of health –
particularly housing, transportation, and insurance – have on accessing resources when
developing and implementing substance use services.
To help ease access to existing resources, it is important to create awareness of these
resources – using different avenues of communication – as well as assistance in navigating
and selecting appropriate resources.
o Ideally, this navigation would have a person-to-person component (e.g., navigators)
as even resource inventories can be challenging for individuals – including those with
SUD and their loved ones – who may not know what services they need.
Cross collaboration and coordination between organizations and across domains are critical
to ensure those with SUD are able to get the needed services at each stage of their journey.
Ultimately, there needs to be more services across different geographies given some of the
barriers to access, such as transportation. Even if these services are available in Barnstable
County, they may not be accessible to those living in certain municipalities.
Prevention
Prevention efforts in the county reach far beyond (and in some cases before) prevention of substance
use. These efforts contribute a small portion to the cost of substance use in the county and have the
potential to save almost half the amount reported by participating programs as being spent in the
county on harm reduction, treatment, and recovery. There is a need to expand and build on existing
successful programs.
Based on the perspectives of service providers, community members, and other key stakeholders the
following should be considered when planning future actions to provide prevention services:
Focus on holistic approaches to prevention as an effective form of substance use prevention,
including addressing co-occurring mental health and substance use and providing safe and
healthy outlets for youth to spend their time.
Provide these holistic services starting in early childhood (0-5 years) and consistently through
young adulthood to build and maintain these skills.
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Utilize non-traditional approaches to substance use prevention – not only providing
education on risks/abstinence, but also using approaches such as open and authentic
conversations about what people’s experiences have been and engaging parents, families,
and other adults connected to youth in these conversations.
Harm Reduction
These are lifesaving resources in themselves that also present important opportunities to connect
with people, provide them with support, and link them to other needed services. Harm reduction is
most successful when it is non-judgmental and respectful. Harm reduction contributes the lowest
amount to the overall cost of substance use in the county and a focus on these services could save
cost related to other domains such as treatment.
Based on the perspectives of service providers, community members, and other key stakeholders, the
following should be considered when planning future actions to provide harm reduction services:
Bring resources to where higher risk populations are to make them as low barrier as possible.
Address individual level and community level stigma impacting both the ability to bring new
harm reduction services to a community and access to existing harm reduction services.
o This work around reducing stigma will have far reaching impact, including opening up
the possibility of integrating harm reduction in work with youth and young adults.
Treatment
The current available treatment services are highly regarded; however, they are not able to meet the
full extent of the needs in the community including co-occurring substance use and mental health
concerns. Treatment services contribute the vast majority of the cost of substance use in the county;
alcohol and opioids are the primary substances driving the cost of treatment. There are growing
concerns among service providers and community members with lived experience about the closing
of effective programs and the affordability of substance use treatment due to the increasing number
of private facilities. Ultimately focusing on prevention, harm reduction, and recovery services while
continuing to fund affordable treatment services, could result in cost savings in the treatment
domain.
Based on the perspectives of service providers, community members, and other key stakeholders, the
following should be considered when planning future actions to provide treatment services:
Expand and build on existing long-term treatment options with a focus on specific
populations: youth, mothers with young children, those transitioning from the jail system.
Create more access to medication-assisted treatment (MAT), specifically those for opioid use
disorder such as Methadone.
Prioritize services for those with cooccurring mental health and substance use disorders.
Recovery
Barnstable County has a strong recovery community that supports individuals in their own paths of
recovery focusing on connection and supports from those with lived experience such as recovery
coaches. Recovery costs are a smaller portion of the total county cost and focus on providing diverse
support services to those at all points and journeys of recovery.
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Based on the perspectives of service providers, community members, and other key stakeholders, the
following should be considered when planning future actions to provide recovery services:
Establish more sober housing, specifically for those with public or no insurance as well as
parents with young children; emphasize integrating some form of regulation or monitoring of
the effectiveness of these homes to ensure they are providing the needed safe space for those
in recovery.
Expand support services focused on grief and loss, both for those with SUD and their families,
as well as services focused on holistic and diverse approaches to recovery.
Offer services to help those entering recovery navigate the available services as well as
provide support related to challenges such as transportation and insurance.
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ACKNOWLEDGEMENTS
The following section lists the individuals and organizations that contributed to this assessment. Each
provided invaluable input, data, and other key connections and resources to help understand
substance use in Barnstable County.
The members of the Regional Substance Addiction Council (RSAC) Prevention Workgroup served as
the Core Planning Group for this assessment providing their perspectives and input on the assessment
planning steps, initial and final results, and assessment report as well as connecting the assessment
team to key contact for further information (e.g., local level data, interviewee contacts).
Alicia Bryant
Barbara Dominic
Beth Griffin
Brianne Smith
Carilyn Rains
Gail Wilson
Jackie Chasey
Julia Bateman
Jordan, Joy
Kathe Medwin
Keith Gauley
Leila Maxwell
Mary Ellen Reed
Melissa Alves
Noel Sierra
Patty Mitrokostas
Rita Gonsalves
Ruth Provost
Shaun Cahill
Sheila House
Stacey Schakel
Stephanie Briody
Suzanne Hauptmann
Individuals from the following organizations, including community stakeholders, services providers,
and those with lived experience, participated in an interview to provide their insights, perspectives,
and experiences regarding substance use in Barnstable County.
ACCESS Hope
AIDS Support Group of Cape Cod
Al-Anon
Barnstable County Sheriff’s Department
Calmer Choice
Cape Cod Children's Place
Community Health Center of Cape Cod
Duffy Health Center
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Gosnold, School-based Counselor Program
Harwich Youth + Family Services
Health Imperatives
Learn 2 Cope
Monomoy Regional Middle School
Nauset Schools
One Shared Spirit
Parents Supporting Parents
Pier Recovery Center
Recovery Build APG
Recovery Research Institute
Recovery Without Walls
Wellstrong Inc.
Yarmouth Comprehensive Treatment Center
Yarmouth Police Department, Victim Service
Additionally, nine other community members shared their perspectives. A group of young people
focused on substance use prevention, individuals with experience accessing harm reduction services,
someone currently accessing treatment for substance use, and individuals who identify as in recovery.
The following organizations provided local level data describing services provided as well as related
cost information.
AIDS Support Group of Cape Cod
Access HOPE
Barnstable County Department of Human Services
Barnstable County Health Department
Barnstable County Sheriff's Office
Barnstable Police Department
Barnstable Police Dept
Barnstable Public Schools
Barnstable Town Health Department
Behavioral Health Innovators, Inc. (including RecoveryBuild Alternative Peer Group (APG) for
Teens and Positive Alternative to School Suspension (PASS) programs)
Boys & Girls Club of Cape Cod
Calmer Choice
Cape & Islands District Attorneys Office
Cape Cod Academy
Cape Cod Children's Place
Cape Cod Cooperative Extension | Barnstable County, Regional Government of Cape Cod
Cape Cod Healthcare
Cape Cod Parents Supporting Parents (PSP)
Center for Addiction Medicine, Massachusetts General Hospital
Chatham Fire Rescue
Community Planner, Barrett Planning Group, LLC.
Cotuit Fire Department
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Duffy Health Center
Harwich Fire Department
Harwich Health Dept
Mashpee DPW
Monomoy Regional Schools
Orleans Fire-Rescue
Outer Cape Health Services, Inc.
Sandwich Fire Department
Sharing Kindness, Inc.
Town of Barnstable - Health Division
Town of Chatham - Health Division
Wellfleet Police Department
WellStrong, Inc
Funding for this comprehensive assessment was granted to BCDHS through Part B of the MASSCall3
(MC3) grant from the Prevention Unit at the Department of Public Health’s (DPH) Bureau of Substance
Addiction Services (BSAS). Technical assistance and support were provided by DPH and BSAS staff
and consultants.
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APPENDICES
APPENDIX A: Discussion Guide
Barnstable County Substance Use Assessment
General Key Informant Interview Guide
Goals of the Key Informant Interview
To understand the perceptions of service providers, community members, and other
stakeholders in Barnstable County around substance use
To determine the challenges to and gaps in related services and programs
To identify opportunities for addressing community substance use needs more effectively
[NOTE: QUESTIONS FOR THE INTERVIEW GUIDE ARE INTENDED TO SERVE AS A GUIDE, NOT A SCRIPT.]
I. BACKGROUND
Hi, my name is __________ and I am with Health Resources in Action (HRiA), a non-profit public
health organization working with Barnstable County Department of Human Services. Thank you for
taking the time to speak with me today.
Barnstable County Department of Human Services is partnering with HRiA to conduct an assessment
to describe and understand the mortality, morbidity, and societal costs of substance use in the
County, the related needs and available resources, and how these needs are currently being
addressed and/or can be improved. As part of this process, we are having discussions like these with
service providers, community members, and other stakeholders in Barnstable County from a range
of different groups including those directly affected by substance use. We are interested in hearing
people’s feedback on the strengths and needs of the County and suggestions for the future.
We are conducting interviews and small group discussions with leaders in Barnstable County as well
as community members with lived experience to understand different people’s perspectives on
these issues. We greatly appreciate your feedback, insight, and honesty.
Our interview will last 60 minutes. After all of the interview and group discussions are completed,
we will be writing a summary report of the general themes that have emerged during the
discussions. We will not include any names or identifying information in that report. All names and
responses will remain confidential. Nothing sensitive nor personal that you say here will be
connected to directly to you in our report.
Any questions before we begin our introductions and discussion?
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II. THEIR AGENCY/ORGANIZATION (5 minutes)
[FOR SERVICE PROVIDERS & OTHER STAKEHOLDERS – skip for community members]
1. Tell me a bit about your organization. What is your organization’s mission/programs/services? What
communities do you work in? Who are the main clients/audiences for your programs?
a. What are some of the biggest challenges your organization faces in providing these
programs/services in the community?
III. COMMUNITY ISSUES (5 minutes)
2. How would you describe the community [your organization serves/you live in]?
a. What do you consider to be the community’s strongest assets? What are the most positive
aspects about the community/Barnstable County?
b. What are some of its biggest concerns/issues in general in the community? What challenges do
residents face day-to-day?
IV. PERCEPTIONS OF SUBSTANCE USE (10 minutes)
3. How big of an issue do you think substance use is in your community?
a. When I say that we are talking about “substance use” as a concern, what does that mean to
you? What issues come to mind when you hear that phrase?
b. What do you think are the most pressing substance use concerns in your community? [IF
NEEDED, PROBE ON SPECIFIC ISSUES SUCH AS OPIOID/HEROIN USE, MISUSE OF PRESCRIPTION
DRUGS, STIMULANTS, FENTANYL, OTHER DRUGS (COCAINE, ECSTASY), ALCOHOL, TOBACCO.]
4. In what ways has substance use affected your community?
a. What populations (age, race, ethnicity, gender, income/education, geographical etc.) do you see
as being most affected by this issue?
b. How supportive do you feel the larger community is of people who use substances and/or people
living with addiction, etc.? Why/why not? [PROBE ON ADDICTION AS A DISEASE, STIGMA]
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V. SUBSTANCE USE PREVENTION (15-20 minutes for primary domain, 5-7 minutes otherwise)
5. Let’s talk about prevention related to the substance use issues you mentioned. What programs,
services, and policies are you aware of in the community that currently focus on prevention of
substance use issues? [PROBE ON SPECIFIC SUBSTANCES, TARGET POPULATIONS, ETC.]
a. Tell me about these programs and services. What do you know about them? Who uses them?
b. How successful do you think these programs, services, or policies have been? What do you see
as the strengths of the substance use prevention programs, services, and policies in your
community? What should be changed/improved?
6. How available or accessible are these programs to the people who need them?
a. What challenges do residents in the community face in accessing substance use prevention
services? [PROBE FOR BARRIERS: INSURANCE ISSUES, LACK OF SERVICES, LACK OF
TRANSPORTATION, STIGMA, ETC.]
i. What do you think needs to happen in your community to help residents overcome or
address these challenges?
ii. Do you see opportunities currently out there that can be built upon to strengthen
substance use prevention in Barnstable County? For example, are there current
prevention-focused collaborations or initiatives that can be strengthened or expanded?
[PROBE FOR DETAIL]
7. What’s missing? What prevention programs, services or policies are currently not available that you
think should be? [PROBE ON SECONDARY AND TERTIARY PREVENTION, i.e., strategies to prevent the
negative consequences of substance use e.g., screening for alcoholism or use of Narcan to reverse
an opioid overdose?]
a. What do you think needs to be done to put these programs, services, or policies in place?
VI. SUBSTANCE USE HARM REDUCTION (15-20 minutes for primary domain, 5-7 minutes
otherwise)
8. Let’s talk about harm reduction related to the substance use issues you mentioned. What programs,
services, and policies are you aware of in the community that currently focus on harm reduction of
substance use issues? [PROBE ON SPECIFIC SUBSTANCES, TARGET POPULATIONS, ETC.]
a. Tell me about these programs and services. What do you know about them? Who uses them?
b. How successful do you think these programs, services, or policies have been? What do you see
as the strengths of the substance use harm reduction programs, services, and policies in your
community? What should be changed/improved?
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9. How available or accessible are these programs to the people who need them?
a. What challenges do residents in the community face in accessing substance use harm reduction
services? [PROBE FOR BARRIERS: INSURANCE ISSUES, LACK OF SERVICES, LACK OF
TRANSPORTATION, STIGMA, ETC.]
i. What do you think needs to happen in your community to help residents overcome or
address these challenges?
ii. Do you see opportunities currently out there that can be built upon to strengthen
substance use harm reduction in Barnstable County? For example, are there current
harm reduction-focused collaborations or initiatives that can be strengthened or
expanded? [PROBE FOR DETAIL]
10. What’s missing? What harm reduction programs, services or policies are currently not available that
you think should be?
a. What do you think needs to be done to put these programs, services, or policies in place?
VII. SUBSTANCE USE TREATMENT (15-20 minutes for primary domain, 5-7 minutes otherwise)
11. Let’s talk about treatment regarding a few of the substance use issues you mentioned. What
programs, services, and policies are you aware of in the community that currently focus on treating
substance use issues? [PROBE ON SPECIFIC SUBSTANCES, TARGET POPULATIONS, ETC.]
a. Tell me about these programs and services. What do you know about them? Who uses them?
b. How successful do you think these programs, services, or policies have been? What do you see
as the strengths of the substance use treatment programs, services and policies in your
community? What should be changed/improved?
12. How available or accessible are these programs to the people who need them?
a. What challenges do residents in your community face in accessing substance use treatment
services? [PROBE ON BARRIERS: INSURANCE ISSUES, LACK OF SERVICES AVAILABLE, LACK OF
TRANSPORTATION, STIGMA, ETC.]
i. What do you think needs to happen in your community to help residents overcome or
address these challenges?
ii. Do you see opportunities currently out there that can be built upon to strengthen
Barnstable County’s substance use treatment services? For example, are there current
collaborations or initiatives that can be strengthened or expanded? [PROBE FOR DETAIL]
74
13. What’s missing? What treatment programs, services or policies are currently not available that you
think should be?
a. What do you think needs to be done to put these programs, services, or policies in place?
VIII. SUBSTANCE USE RECOVERY (15-20 minutes for primary domain, 5-7 minutes otherwise)
14. Let’s talk about recovery regarding a few of the substance use issues you mentioned. What
programs, services, and policies are you aware of in the community that currently focus on helping
people in recovery? [PROBE ON SPECIFIC SUBSTANCES, TARGET POPULATIONS, ETC.]
a. Tell me about these programs and services. What do you know about them? Who uses them?
b. How successful do you think these programs, services, or policies have been? What do you see
as the strengths of the substance use recovery programs, services, and policies in your
community? What should be changed/improved?
15. How available or accessible are these programs to the people who need them?
a. What challenges do residents in your community face in accessing substance use recovery
services? [PROBE ON BARRIERS: INSURANCE ISSUES, LACK OF SERVICES AVAILABLE, LACK OF
TRANSPORTATION, STIGMA, ETC.]
i. What do you think needs to happen in your community to help residents overcome or
address these challenges?
ii. Do you see opportunities currently out there that can be built upon to strengthen
Barnstable County’s substance use recovery services? For example, are there current
collaborations or initiatives that can be strengthened or expanded? [PROBE FOR DETAIL]
16. What’s missing? What recovery programs, services or policies are currently not available that you
think should be?
a. What do you think needs to be done to put these programs, services, or policies in place?
IX. CLOSING (5 minutes)
17. Are you aware of any data sources regarding the impact of substance use in Barnstable County? If
so, would you be okay with us reaching out to you to see what we may be able to have access to for
this assessment?
18. I’d like you to think ahead about the future of your community. When you think about the
community 3-5 years from now, what is your vision specifically related to substance use in the
community?
a. What do you think needs to happen in the community to make this vision a reality?
75
Thank you so much for your time. That’s it for my questions. Is there anything else that you would like to
mention that we didn’t discuss today?
Just as a reminder, we will be writing a summary report of the general opinions that have come up
across all of the discussions we’re having with community leaders and residents. In that report, we
might provide some general information on what we discussed today, but we will not include any names
or identifying information. Your responses will be strictly confidential. In the report, nothing you said
here will be connected to your name or any identifying features about you.
Thank you again. Have a good day.
76
APPENDIX B: Resource Inventory
This is an image of a separate Excel document provided with the final report. This separate spreadsheet is intended to be updated on an ongoing basis as resources shift and expand in the
county.
Organization Town(s) Served Primary Domain Prevention Substance Use
Focused
Holistic
Approach/Healthy
Behavior Focused
Harm Reduction Fentanyl Test
Strips/Education
Mobile Harm
Reduction
Narcan Distribution Needle
Exchange/Disposal
Treatment Inpatient Outpatient MAT Detox Recovery Group Meeting Recovery Coaching Mindfulness Other Family Support Grief Support
ACCESS Hope Provincetown, Truro, Wellfleet, Eastham, Orleans, Brewster, Dennis, Bourne, Sandwich, Falmouth, Mashpee, Yarmouth, HyannisHarm Reduction x x x x x
AIDS Support Group of Cape Cod Provincetown, Hyannis, Martha's Vineyard, FalmouthHarm Reduction x x x x
Health Imperatives Hyannis Harm Reduction x x x
One Shared Spirit Mashpee Harm Reduction x x x x x
Nathan's Circle All towns Other x x
Boys and Girls Club of Cape Cod Mashpee Prevention x x x x
Calmer Choice All towns Prevention x x
Cape Cod Children's Place All towns Prevention x x x x x
School-based counselors All towns Prevention x
Sharing Kindness All towns Prevention x x x x
YMCA Barnstable Prevention x x
Youth Villages (Intercept and LifeSet) Raynham Prevention x x x
Positive Alternative to School Suspension (PASS)Barnstable Prevention x
Alcoholics Anonymous (AA) All towns Recovery x x
Al Anon Provincetown, Dennis, Barnstable, West Barnstable, Sagamore Beach, Mashpee, Falmouth, East FalmouthRecovery x x x x
B FREE Wellness Hyannis Recovery x x x x x
FIRST Steps Together All towns Recovery x x x x x x x
Learn 2 Cope Yarmouth Recovery x x x x
Massachusetts Organization for Addiction Recovery (MOAR)All towns (statewide) Recovery x x
Narcotics Anonymous (NA)Barnstable, Brewster, Cataumet, Falmouth, Forestdale, Harwich, Hyannis, Marstons Mills, Pocasset, YarmouthRecovery x x
Parents Supporting Parents Sandwich, all towns (virtual) Recovery x x x
PIER Recovery Center Hyannis Recovery x x x
Recovery Build APG South Dennis, Falmouth Recovery x x x x x
Recovery Research Institute -- Recovery x x
Recovery Without Walls West Falmouth Recovery x x x x x
Refuge Recovery Falmouth Recovery x x x
Wellstrong Inc. East Falmouth Recovery x x
Herren Project All towns Recovery x x
Foundations Group Recovery Centers Mashpee Recovery x x x x x
Cape Cod Comprehensive Treatment Center Opioid Use Disorder ProgramsYarmouth Treatment x x x
Cape Cod Health Care Hyannis, Falmouth, Harwich Treatment x x x
Clean Slate Centers Hyannis, Falmouth Treatment x x x
Column Health Hyannis Treatment x x x x
Community Health Center of Cape Cod Mashpee, Falmouth, Bourne, Sandwich, CentervilleTreatment x x x
Duffy Health Center Hyannis Treatment x x x x
Gosnold Falmouth, West Falmouth, CentervilleTreatment x x x x x
Outer Cape Health Services Harwich, Wellfleet, Provincetown Treatment x x x x x
Recovering Champions Falmouth Treatment x x x x x
77
APPENDIX C: Additional Cost Data Details
Below are further details of the cost data presented in this report, organized by domain.
Prevention
Calmer Choice provided cost information on implementing their programming in one school district
which they estimate reaches more than 1,300 students per district. The total estimated cost includes
mindfulness coaches, instructors, facilitators, classroom materials, and other costs (e.g., developing
curriculum, training, evaluation/assessment, etc.). On average based on previous implementation, the
full cost for implementation in one district is $545,938.
Sharing Kindness provided an estimated cost for implementing their peer-based family program
focusing on youth substance use prevention through grief support. Each family program costs
approximately $10,750 for an academic year. In 2022, they ran two programs and trained eight new
clinicians; with these additional resources, they aim to conduct six programs in 2023.
The Cape Cod PASS program provided the cost for operating its program in Centerville which includes
personnel expenses, equipment, supplies, and other costs. It costs $289,500 to operate one PASS
program; this will double in 2023-2024 as a second program is implemented.
Harm Reduction
For syringe and needle disposal, the majority of cost data was provided by CCCE. These data represent
efforts in 14 of the 15 municipalities in Barnstable County (Sandwich does not currently participate in
the program). Between January 1, 2022, and November 10, 2022, 348 50-pound boxes of needles and
syringes were picked up from 21 sites and 2,960 sharps containers were distributed to county
residents free of charge from 20 sites. Cost for this program through CCCE was $50,064.84 in 2022.
While these services are primarily supported by these CCCE funds, additional costs were provided by
two town fire departments (FD)/department of public works (DPW) as well as a police department
(PD). Mashpee DPW reported an average additional cost of $800 annually; Cotuit FD/DPW noted an
additional cost of $430 – these costs were for purchasing of the disposal containers and some staff
time. Barnstable PD reported an additional cost of $150 in fiscal year 2022, however they indicated
this was low and the costs have ranged up to $1,407 in the past.
For excess prescription drug disposal, the county funds kiosks at Barnstable County police stations.
CCCE had previously funded and managed this initiative and continues to advertise the program and
counsel residents on disposal opportunities, which equates to a cost of $612.18 on average annually.
Two PDs also provided their average cost per year: Wellfleet PD estimated $2,000 and Barnstable PD
reported a cost of $644.
One local PD, Barnstable, provided cost data related to their collaborative efforts in the community to
provide outreach and resources for behavioral health related needs. The department has both a
Component Grant for $51,300.59 to fund their Community Impact Unit (CIU) and provide outreach
and resources to the community for mental health and substance use needs; an additional
$14,570.40 funds the CIU’s work with the Overdose Response program. This PD also has a Co-
response Grant for $99,994 that embeds a clinician in a PD to address behavioral health needs. Lastly
this department provided costs for Section 35 and overdose response calls for a total of $10,606.86.
78
AIDS Support Group estimates it costs about $0.60 to provide one syringe; the 180,316 syringes in a
year cost a total $108,190. Using this same estimate, the 84,675 syringes distributed by ACCESS Hope
between March 2021 and March 2022 cost $50,805. Both these organizations as well as the Chatham
EMS provided cost for Narcan distribution. AIDS Support Group has a cost of $37 per dose and they
distributed 4,615 for a total cost of $170,755. Chatham EMS reported a slightly lower cost of $32.50
per dose and administers 8 doses for a total of $260. ACCESS Hope did not provide an estimated cost
per dose. Using the average of these two costs ($34.75) for the 2,138 kits distributed, ACCESS Hope’s
cost for March 2021-March 2022 was $74,296. These costs are likely underestimates as they do not
include staff time for this work.
Treatment
Duffy provided annual cost data for their OBAT program – $506,000 – as well as the cost of counseling
for those with substance use disorders - $400,000. CCHC provided the cost of emergency department
patient care related to substance use services from May through October 2022 as $3,862,325.80; they
have an additional cost for a registered nurse to do training and education with a cost of $94,918
annually. OCHS provided estimated annual costs for outpatient substance use care as $1,380,000
with additional estimated annual costs for training and community education at $1,250,000. Data
from some health centers could be categorized by substance and are displayed in a later section of
this report.
BSAS reported 3,014 admissions to its programs across Barnstable County in 2022. NCDAS estimates
an average cost of $12,500 per 30-day admission for substance use treatment nationally. Based on
these, the estimated cost of Barnstable County’s admissions to BSAS licensed programs is
$37,675,000. The Barnstable County Sheriff’s Office spent $432,374.68 on treating SUD in fiscal year
2022.
Recovery
Duffy provided cost data for their recovery coaching program at $415,100 annually. They also provide
other recovery supports through a recovery support navigator program with a cost of $192,960
annually.
WellStrong also provided recovery coaching costs from November 2021 through October 2022 at
$43,167. Additional recovery support services cost $247,793 in that time period and included
wellness, meetings, classes, and other related costs.
Parents Supporting Parents provided information on a scholarship program to help support
individuals’ transition out of treatment and into sober homes. In 2022, they distributed $53,650 in
scholarship funds to community members to find housing after treatment.
RecoveryBuild APG provided the estimated cost of maintaining their program at their Dennis and
Falmouth sites providing other recovery support services. These costs include the Family Therapist
and Youth Behavioral Health Specialist, peer mentors, and cost of activities, rent, and supplies. For
fiscal year 2024, they estimate running these two programs will cost $315,000, approximately
$157,500 per program.
79
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