FAR WEST TEXAS — Big Bend residents are no strangers to tackling problems posed by the physical isolation of their home turf. With no inpatient treatment or sober living options available within hundreds of miles, law enforcement, primary care physicians and supportive community members have to fill in the gaps. Many suffer in silence, facing additional hurdles like social stigma and legal fallout from crimes committed under the influence.
According to the National Institute of Mental Health, substance use disorder (SUD) is a treatable psychiatric illness. Diagnostic criteria includes whether or not the patient is able to control their substance use, how severely their use impacts their personal and professional lives, whether they take significant safety risks to use their substance of choice and if they have significant side effects if they stop using.
According to statistics from the Rural Health Information (RHI) Hub — an initiative of the federal Department of Health and Human Services — rates of substance abuse in remote communities are growing, outpacing urban areas in some categories like the use of methamphetamines and tobacco. “Though often perceived to be a problem of the inner city, substance use and misuse have long been prevalent in rural areas,” their website explains.
The RHI Hub has found that substance use in rural areas is correlated with low education attainment, poverty, unemployment, lack of access to healthcare, isolation and “a greater sense of stigma” — all of which impact mental health.
While the Big Bend is lucky to have relatively high graduation rates and a local university, the labor market in some pockets is suffering. Unemployment rates in Brewster and Jeff Davis counties are below average, but Presidio County’s current stats hover around 5.7%, well above the national average of 3.9%.
Social stigma — which can deter people from seeking treatment — is a much more abstract issue. In recent years, medical professionals have attempted to employ positive messaging and public education to help address these problems.
The National Institute on Drug Abuse (NIDA) advises providers to use “person-first” language to emphasize that addiction is a medical issue rather than one of morality or self-control. Rather than using terms like “tweaker” or “junkie,” the recommended language describes a “person with substance use disorder,” centering the patient rather than their drug of choice and underlying mental health issues.
But those in the know understand that words alone can’t cover the significant gaps in care. In the Big Bend and other rural areas, primary care physicians are often the first — and sometimes the only — point of contact for people hoping to get sober.
Dr. Adrian Billings, an expert at the Texas Tech University Health Sciences Center and former Big Bend clinician, said that the process is much different in remote areas. “In larger urban cities, specialists such as psychiatrists or addiction specialists would take care of this population,” he explained.
He said that some local providers might be able to prescribe suboxone and other medications intended to help kickstart the rehabilitation process, but other resources are scant: there are few social workers and substance use disorder counselors available to provide a holistic blueprint for treatment.
Apart from primary care providers, law enforcement are often the first to respond to addicts in crisis. Brewster County Sheriff Ronny Dodson has seen these scenarios unfold too many times to count.
While not every drug or alcohol-related crime is committed by a person with a substance use disorder, the two are often linked. Dodson said that there’s little his department can do to help folks whose criminal record is tied to their addiction. Instead, they have to wait for the courts to sort things out — it’s up to lawyers and judges to recommend or require treatment.
The best he and his deputies can do is study de-escalation tactics. He said that the training only goes so far to prepare law enforcement for the stress of dealing with someone under the influence. “You’ve got to calm them down, but sometimes it just doesn’t work,” he said. “You just never can tell what’s going to happen.”
If Dodson or a deputy arrests someone in active addiction, there are few local resources to help them sober up. He said that he’d had issues in the past with a lack of resources to help people detox from alcohol — the most life-threatening substance to detox from — and that many were left to suffer alone behind bars.
With nearly 40 years of law enforcement experience, Dodson thinks the issue is more complex than meets the eye. The type of substances cops have to look out for has changed over the years — PCP was a huge problem when he was first starting out, but fentanyl has started to creep into the supply in Brewster County in recent months.
Dodson doesn’t believe that Brewster County is especially afflicted, but does think that these issues are only getting more severe. He speculates that rapidly changing environmental and social conditions are to blame. “Mental health is a huge problem in the world right now,” he said.
Big Bend Regional Hospital District Executive Director JD Newsom has had his frustrations with the lack of a local safety net for people in active addiction. “There’s not a whole lot, and it’s something we’ve really struggled with,” he said. “Some of it’s systemic, and some of it’s that we’re in the middle of nowhere.”
Newsom gave the example of a disabled client who also abused alcohol to the point that it was compounding his pre-existing health issues. To provide better care, he wanted to place the client in a medically-supervised detox program so they could separate which health issues were related to his disability and which were related to his substance use disorder.
The process was much more aggravating than he anticipated. The emergency room at the Big Bend Regional Medical Center did not have the resources to treat the client, so they referred him to a rehab facility, where staff said they didn’t have the experience to treat someone with such a severe disability. He was eventually referred to a hospital in El Paso that also declined to help.
The client was eventually treated after he lost his housing, but the process was long and heartbreaking. “He’s alive and happy and healthy and so grateful for what we did,” Newsom said. “But the frustrating part was that there was a systemic failure to help this person.”
He thinks that part of the issue is that there isn’t enough data to track how serious these issues are in the Big Bend, particularly in the region’s remote unincorporated areas. In a place like Terlingua, professionals may never get a true sense of scale. “People go there to disappear,” he said. “We have no idea how significant of a problem it is. Maybe that’s just the nature of where we live and the people who’ve been out here historically.”
Despite Terlingua’s reputation as a rough and rowdy place, some locals dispute the idea that South Brewster County’s addiction problems are more severe. One member of the Terlingua chapter of Alcoholics Anonymous — who wishes to remain unnamed — said that her community wasn’t unique. “It’s not that people drink here more than anywhere else — people drink everywhere,” she said.
Alcoholics Anonymous (AA) is an organization aimed at providing support for people who want to become sober. Meetings are held around the world in dozens of languages and are even available online. The program provides a structure to help addicts find community and share their trials and tribulations with an understanding audience.
This Terlingua AA member explained that the organization provides long-term support that medical treatment alone can’t provide — a stint in rehab doesn’t provide a blueprint for how a person struggling with addiction should live their life. “It’s not just withdrawal from alcohol, it is learning how to navigate the world sober,” she explained. “When I was drinking, the answer was always to get drunk, whether I was sad, I was mad, I was happy. Then suddenly you take alcohol away — how do I handle that?”
She acknowledged that it could be particularly intimidating for people in rural areas to start going to meetings where they likely already knew everyone. “You are always welcome to come and sit down,” she wanted to impart to anyone interested in attending. “Whether you stay sober or drink, it’s none of my business. I’m not the alcohol police — I’ll still love you.”
South Brewster County meetings are held Thursday at 7:30 p.m. at the Big Bend Church in Study Butte. She wanted to emphasize that the meetings are not explicitly affiliated with the church and that anyone is welcome. “You don’t have to be sober to go to AA, you just have to have the desire.”
SUPPORT OPTIONS
PERMIACARE
Permiacare offers a number of services for people seeking help, from intensive inpatient care to outpatient support groups. Specific peer support groups are available for men, women and youth. Permiacare also offers a Co-Occurring Psychiatric and Substance Use Disorder (COPSD) program for folks whose substance use and other psychiatric conditions are entwined.
For a free screening to determine which state-funded services are right for you, call 1-844-420-3964. More information and an online screening are available at permiacare.org/substance-use-disorder-services.
ALIVIANE
El Paso-based Aliviane offers a wide array of services from telehealth screenings, outpatient and inpatient clinics, and support groups. The organization has also been working with the federal Rural Opioid Response Program in hopes of expanding their offerings to the greater Trans-Pecos region. For more information, visit aliviane.org or call 915-782-4000.
This story is part of a series on mental health in the Big Bend funded by the Presidio County Community Foundation.