I can’t lose everything,” Paul Reithlinghshoefer told his mother when he relapsed back to using heroin in early 2017. Feeling suicidal, Paul was admitted to the psychiatric inpatient unit at Adventist Behavioral Health Hospital in Rockville, Maryland.
The company website states: “If you or a loved one need close attention for a mental health condition, inpatient care at Adventist can help. Find specialized treatment in safe, healing environments … This level of care away from the stress of daily life can help you recover more quickly.”
Paul hoped that a brief hospitalization would help him recover from the relapse and improve his mental health. It was not to be. After about a week, Paul was discharged from Adventist—a week earlier than planned. He used heroin again and died from an overdose on April 9. The autopsy revealed the presence of fentanyl. He was 34.
Tragedies like this have been endured by tens of thousands of families in the course of our utter failure to address the US overdose crisis. But a key element of Paul’s story is the alleged—though disputed—reason for his early discharge from care.
Paul said it was because he smoked a cigarette on the unit. His mother, Jessie Dunleavy, told Filter that her son called her and said, “I’m coming home. I got kicked out of the program for smoking.” Hospital documents obtained by Filter confirm that he was discharged on March 14, 2017, but don’t state why.
Smoking is not allowed anywhere inside Adventist or on its grounds—the campus is totally “smoke-free.” Vaping is included in this ban, and “leaving the nursing units to use tobacco/smoking products is prohibited.” I received a copy of the smoking policy confirming this from Tina Bergeron Sheesley, Adventist’s director of public relations and marketing.
Sheesley told Filter that Paul was not discharged for smoking. She wouldn’t say why he was discharged, citing privacy laws. Clinical staff at Adventist confirmed, she said, that no patient would ever be discharged for violating the smoking ban. When I asked what the consequences, in that case, would be, Sheesley replied: “Our behavioral health caregivers remind any patients who are found with tobacco products of our no-smoking policy. As I mentioned previously, we would not discharge patients from our program for violating the policy.”
Intake staff I spoke with said that when patients are admitted, their belongings are searched and any cigarettes or vapes are confiscated. Tobacco products—a term used by Adventist and others to include nicotine products that don’t contain tobacco—are considered “contraband,” despite being legal. Staff claimed that cigarettes could never get on the unit because all visitors’ bags are thoroughly searched.
According to Lisa, Paul thought he could have a few quick drags in the bathroom, undetected.
So where did Paul allegedly get the cigarettes? From Lisa,* a close friend who visited him.
“Paul asked me to bring him a pack of cigarettes,” Lisa told Filter, “The cigarettes were on the inside of my coat pocket and when we hugged I passed the pack to him.” It was easy, she said.
Paul was a pack-a-day smoker when he could afford it. Nicotine eased his anxiety. According to Lisa, he thought he could have a few quick drags in the bathroom, undetected. He had learned how to smoke without getting caught when he was in jail. The trick, he told his mother, was “to blow the smoke into the toilet bowl.”
Paul also told Lisa that he had been discharged from Adventist for getting caught smoking, she said. “I felt horrible, that it was my fault because I gave him the cigarettes.”
Paul replied, “I’m sorry, it’s not your fault.”
When he died a few weeks later, Lisa continued to blame herself, believing that if Paul had completed treatment, he might not have relapsed.
Smoking and Vaping Bans Are a Barrier to Care
It has not been possible to prove whether or not Paul was discharged for this reason. But the allegations raise a wider issue that should be of great concern to harm reductionists.
The barriers to obtaining drug treatment or mental healthcare in the US are many. We can now add smoking bans—even outdoors, and even including vaping, which is safer than smoking by orders of magnitude—to the list of obstacles.
Increasingly, inpatient treatment programs are imposing these bans, with designated outdoor smoking areas being eliminated. In Philadelphia, as Brooke Feldman reported for Filter earlier this year, all publicly funded drug treatment programs now prohibit patients from leaving the facility to smoke or vape outside.
People who are addicted to cigarettes have lower quit rates than those addicted to any other drug, and high rates of relapse when they try to quit. What’s more, people who use illicit drugs and people with mental health issues have very high rates of smoking and low rates of quitting. Vaping, which is included in many treatment-facility bans, has been shown to be about twice as effective as nicotine patches or gums in helping people quit cigarettes.
So how realistic is it to expect daily smokers to quit cold turkey, while simultaneously addressing other addictions and the mental health issues that may have led them to use nicotine in the first place?
In this grim reality, treatment programs shouldn’t be implementing any barriers to access and retention.
Treatment-facility smoking and vaping bans, enforced in the name of patient health, make it harder for people to enter drug treatment and to stay in treatment. And this at a time when the prevalence of fentanyl in the supply makes using street drugs more dangerous than ever before.
In this grim reality, treatment programs shouldn’t be implementing any barriers to access and retention. And that means providing a space for people to smoke, or to vape. Outright bans punish the most vulnerable groups of smokers.
Far better options exist to protect patients’ health. In one mental health hospital in England that was going smoke-free, staff implemented a program to offer low-cost vaping products to all patients who smoked, with vaping permitted on the grounds. (The program was led by Louise Ross, who spoke with Filter about her work.)
Systemic Failures and a Mother’s Advocacy
Whatever the truth about Paul Reithlinghshoefer’s discharge, his struggle will resonate with many families.
As a child he was diagnosed with a learning disability and a language impairment. Student life was difficult—he was taunted by his peers. In his 20, Paul was diagnosed with an unspecified mood disorder, anxiety and OCD.
Paul used cocaine and marijuana when he was younger. At 27 he started injecting heroin. When he sought help, he entered the dysfunctional and often punishing world of drug treatment.
Jessie Dunleavy explained how Paul was bounced from one drug treatment program to another—at least seven in total. He went through insurance coverage nightmares, incarceration, homelessness, mental health courts, and doctors and drug counselors who shamed him when he relapsed.
Jessie tried to navigate these complicated care systems for her son, but said, “I was ignorant about treatment for heroin addiction. We didn’t know about methadone or Suboxone [buprenorphine].” These two medications are the gold standard of treatment for opioid use disorder, but stigma and barriers have prevented their wider use.
Jessie said of the dysfunctional drug treatment system, “There is so much stupidity.”
Like thousands of others, Paul got caught up in the so-called “Florida Shuffle.” A treatment program he attended in Maryland sent him on to another in Naples, Florida. There, he was prescribed buprenorphine for the first time; he told Jessie that the medication stopped the cravings and that he felt better. But when he was discharged from the program, he didn’t receive an ongoing Suboxone prescription. This failure—a denial of appropriate treatment that should be considered medical malpractice—is common.
As Paul got older, Jessie said, the gaps between his relapses got longer. In spite of mostly ineffective drug treatment, he was gradually getting better—most people with addiction do, on their own, given enough time.
Paul cobbled together a life. He had a job delivering sandwiches on his bike for Jimmy John’s that he loved. He wrote poetry. He was able to move into an apartment, had friends, traveled, dated and became a father. And he had a loving and supportive mother.
Before he died, Paul told Jessie, “If we can find me Suboxone, I’ll be okay.” But finding a provider to prescribe the life-saving medication was difficult. So instead of picking up an FDA-approved medication at the pharmacy, Paul sold his laptop and used the money to buy heroin on the street.
Paul’s tragic death turned his mother into a fierce harm reduction advocate, activist and champion of medication-assisted treatment. She has now written numerous op-eds on subjects ranging from stigma to barriers to drug treatment. She is a member of the Maryland Harm Reduction Action Network and the Annapolis Substance Abuse Coalition.
Jessie said of the dysfunctional drug treatment system, “There is so much stupidity.” Her mission is now to challenge that.
* Name has been changed to protect the source’s privacy at her request.
Photographs courtesy of Jessie Dunleavy