Tactics: Andy Mendenhall Urges ‘Courageous Optimism’ Amid Behavioral Health Crisis

Central City Concern’s CEO talks about how his organization has responded to the pandemic, the escalating behavioral health crisis and what’s next.

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This July Andy Mendenhall celebrates one year as CEO of Central City Concern. Mendenhall, who comes from Phoenix originally, attended college at the University of Portland and medical school at Oregon Health & Science University. Board-certified in addiction medicine and family medicine, he co-founded an outpatient integrated substance-abuse treatment program called HealthWorks NW, which was acquired by Hazelden Betty Ford in 2012. 

Mendenhall joined CCC in 2017 as senior medical director for substance-use disorder services and became chief medical officer in 2018. He succeeded Rachel Solotaroff, who left the organization last summer after five years as CEO and 16 years total with the organization.

CCC was founded in 1979 as Burnside Consortium and tasked initially with addressing the prevalence of alcoholism in Portland’s Old Town area. The organization purchased and began managing multiple downtown hotels, and assumed management of Hooper Detoxification Stabilization Center in 1982. The organization now manages multiple addiction treatment centers, addiction clinics and affordable-housing buildings in Portland. 

This interview has been edited for space and clarity.

What is your agency seeing right now that it was not seeing when you started in 2017? 

Central City Concern is an agency that’s been around in the region for, now, 43 years. We provide health care, we provide housing and we provide employment services, and we’re serving upwards of 13,000 to 14,000 people annually. We know that about 75% of the folks that start receiving services here at Central City Concern step into our health-services programming through Hooper Detoxification Center, which has been around for decades and is located near the Rose Quarter. Hooper is a medically supervised withdrawal-management program where we’re serving more than 2,500 individuals annually. It’s a 24/7 program; we serve a ton of folks year-round. We help those individuals get medically stabilized and detoxified from opioids, from methamphetamine, from alcohol, from benzodiazepines and other substances. 

Half of the folks we serve at Hooper come in with a primary diagnosis of opioid-use disorder, and the vast majority of those individuals over the last two years have shifted from using heroin to using fentanyl. Most of those individuals have been smoking fentanyl, but now we’re starting to see a shift back toward injecting fentanyl. And many people report that they have a history of overdose. 

We also have thousands of people who we’re providing a housing resource to. We have about 3,500 people who live with us in our housing continuum. Some of those are folks who have permanent housing with us and some of those are folks who have transitional housing with us. We know that substance-use disorder is represented in the community of folks who live with us. We have, over the last 18 months, been very intentional about developing a zero-overdose strategic approach whereby we are providing wide access to naloxone, which is the medicine used to reverse opioid overdose. It doesn’t mean that there aren’t folks still experiencing overdose. But what it does mean is that all of our housing staff are trained to respond, which is a really significant investment for us. On the back end, the goal is to provide support and to hope to get folks to a place where they’re open to engaging in withdrawal management and, better yet, engaging in treatment.

Dr. Andy Mendenhall, CEO and president of Central City Concern (CCC) photographed in his office in the Old Town neighborhood of Northwest Portland. Photo by Jason E. Kaplan

Talking about that 40% of people who need acute mental health services, what are your thoughts on how the system is both addressing and not addressing the needs of people who are acutely mentally ill but not necessarily substance-affected?

We do not currently have a fully resourced or fully functional continuum of psychiatric care within the region, nor do we have a state mental hospital or mental health hospital system at the Oregon State Hospital that can fully meet the needs of the population of the state of Oregon. That is our truth. Our truth is that we know that there is a significant gap between the demand and the need and the availability of inpatient and residential beds. That has been exacerbated by the COVID pandemic, which had a significant impact in terms of creating isolation; folks with severe mental illness and substance-use disorders need a lot of contact. They need a lot of support and accountability. Many of those regular connections became disrupted.

During the same time period, there was a reduction in the behavioral health workforce, both in terms of psychiatric care and also in terms of substance-use disorders care. The Alcohol and Drug Policy Commission report from PSU and OHSU calculated that we were deficient 36,000 behavioral health care workers in the state of Oregon — in a prepandemic estimate. Central City Concern is one of several agencies in the region that is suffering from persistent vacancies among our behavioral health workforce. 

Then we layer in an inadequate system of care for higher levels of acute psychiatric care that’s been persistent for a long time; all of that is contributing to create the ecosystem that we live in within this region. It’s really difficult for me as a physician — and for me as a leader of the organization — to know that we’re providing housing to individuals who are challenged to take care of themselves: They lack capacity to make decisions and therefore might be deemed incompetent. Our current state commitment standards have a really high bar. I think it’s really important for us in the region and in the state to evaluate our commitment standards to lower that bar, to do a better job of caring for people who lack the capacity to make decisions in their own best interest. It’s a false flag of freedom to think that somebody who lacks capacity actually is making decisions — because again, they lack capacity to make decisions. Let’s not mistake that lack of capacity with freedom more broadly, especially when we’re talking about treatable psychiatric conditions. 

Policy-wise, what do you feel Central City needs from local governments? What are the things that you’re watching?

I think, most importantly, we’re really watching how we are working together. And I’m really encouraged that Central City Concern and other community-benefit organizations are able to participate in new and different ways with the Joint Office of Homelessness Services, with County Behavioral Health and with the city. I see a level of collaboration and partnership and commitment that is refreshing, is new and unique, and it gives me a great sense of optimism in terms of coordination of strategy. 

We are very hopeful that the Oregon Health Authority will engage in intentional design and strategy work to ensure that folks who need an inpatient level of psychiatric care and stabilization will have access to that resource. In addition, the Medicaid 1115 demonstration waiver is really exciting. It is the functionality that gives states discretionary spending opportunity for the Medicaid benefit. Oregon is one of five states in the country that has a housing benefit as part of the Medicaid waiver. We’re really hopeful that the Oregon Health Authority will see the 1115 Waiver as the opportunity that it is for this region and ensure that there is coordinated deployment of that benefit. It’s an opportunity for the very first time in Oregon for housing to be paid for as a benefit out of the Medicaid system. We know through some pilot work that that saves money and saves a lot of unnecessary spending and health care dollars related to the complications of being houseless. 

We talked about fentanyl. Another thing I hear is that the meth people are using now is different than the meth people were using 10, 20 years ago.

It’s a lot more potent, and it’s a lot cheaper. That is driving a lot of the behavioral health acuity that we see that is distressing for members of the community. And a more potent, more reinforcing drug is also harder for folks to quit. 

I need to emphasize that we have a behavioral health workforce crisis of unprecedented proportion. Folks have simply left the industry. Folks got tired. Folks, in particular, got tired of referring people to nowhere and trying to coordinate people to nowhere. That leads to a certain level of moral injury, emotional fatigue and burnout. It is absolutely critical that we have a statewide strategy for recruiting individuals into the behavioral health treatment continuum of all stripes: drug and alcohol counselors, peers, bachelor’s-level behavioral health folks, master’s-level behavioral health folks. It’s going to take time to build up that workforce, to meet the needs of the state. It is probably the most important part of how we actually get to having enough capacity to meet the community need. 

CCC is working in partnership with a variety of different parties to establish a learning academy. We’re supporting an apprenticeship program with our partners at AFSCME. And we are in a holding pattern right now regarding being able to have enough folks to do the supervision, to actually do the training of the next generation. It’s important for leaders to be courageously patient as we navigate this. I have good reason to be optimistic that the right leaders at the state, metro, city and county level levels and CCO levels are engaged, they’re communicating, they’re starting to row in the same direction. They’re really starting to see this as the public health issue and challenging crisis that it is, and also understand that this is complex and multilayered. The reason to be optimistic is that people are communicating and people are agreeing that we need to be grounded in good public health data in order to align strategies to solve these challenges for the state and for the region. 

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