ONTARIO — On a sunny September evening in 2021, Nathaniel Sean Stringer joined family and colleagues for a recovery celebration at a park in Ontario. To enthusiastic applause, he received an award for his service to those struggling with addiction.

Just weeks later, Stringer overdosed on fentanyl and died inside a grocery store. He was 35.

His death shows how fragile recovery from addiction can be — and his story highlights a major pressure point in Oregon’s expanding addiction care system at a pivotal time.

Before he died, Stringer exemplified a growing statewide trend. He worked for the Malheur County Health Department as a peer mentor. “Peers” are people in recovery from addiction who engage with people who use drugs, offering mentorship and resources while demonstrating by example that recovery is possible. There are about 1,900 peers who specialize in addiction in Oregon, typically earning about $18 to $24 an hour.

The peer model is an evidence-based approach that is increasingly used around the country.

Now, using money generated through Oregon’s 2020 drug decriminalization law, Measure 110, a state-appointed council is pouring money into hiring many more peers as part of a shift toward treating addiction as a health care issue. Increasingly, peers across Oregon are connecting with people in need through street outreach and working in addiction care, mental health or homeless services, hospitals and jails.

But without adequate funding for detox facilities for withdrawal management, residential treatment and recovery housing, people inside the system say the state’s burgeoning peer workforce amounts to a pipeline that often leads nowhere.

A recent analysis from Oregon Health & Science University showed Oregon’s addiction care system is half the size it should be to meet demand.

Stringer was hired before Measure 110 was implemented, and those close to him believe factors outside his job drove his relapse. What’s clear, however, is that while people in the peer mentor role are tasked with motivating people to seek treatment, they — like Stringer did — frequently grasp for resources that don’t exist when their clients are ready to quit using. The situation puts tremendous stress on the very people on which the system’s current expansion relies.

“I absolutely believe in peers, I believe that they are the best people to engage people who are using drugs into treatment,” said Sarah Poe, director of the Malheur County Health Department, where Stringer worked. But peers don’t themselves provide treatment, and without more services to connect people to, she said, “It’s really hard work for peers to show up and keep trying to push this boulder up a hill — when the hill keeps getting more steep.”

Peers bear the weight

Janie Gullickson fought through methamphetamine addiction before becoming the director of the state’s most prominent peer-run organization, the Mental Health & Addiction Association of Oregon. Her enthusiasm is infectious when she speaks about the strength and resiliency of the peers she represents. As one of Measure 110’s chief petitioners, she believes in the law and its role in “expanding addiction recovery services across the continuum.”

Working out of her nonprofit’s headquarters in Northeast Portland, Gullickson oversees training, supervision and support for peers around Oregon — including in state-supported programs like Stringer’s in Malheur County.

Gullickson said the recovery community in Oregon has seen an increase in relapses and overdoses during the pandemic, including among peers such as Stringer.

In the wake of Stringer’s death, the health authority began requiring more structure to supervisory support for peers in state-funded peer programs, though a state spokesperson denied any connection between the two.

And for county-based peer programs that wanted outside help, the state also provided supervision and support by contracting with Gullickson’s organization.

“Some had great, experienced peer supervisors and were already doing peer programs. But it was those ones that felt very isolated and didn’t have that infrastructure that we focused on,” Gullickson said. They also worked with Malheur County, where the peer supervisor had been Stringer and his replacement was a member of his team, she said.

According to a statewide assessment Gullickson’s nonprofit helped conduct in 2020, fewer than half of peers reported receiving supervision once a week or more. Some participants attributed high turnover to a lack of support, trauma and burnout.

But Gullickson said it’s important not to “other” peers by suggesting they need more supervision than other workers and suggested stigma may play a larger role than supervision in relapse.

“What we’ve seen sometimes is people won’t say, ‘Hey, I need help right now’ in the way that we would think people in recovery would be able to do,” she said. “But when they get in this profession, often then it’s like, ‘Oh, I’ve got to prove myself.’”

Before 2020, the state required peers have at least two years of recovery behind them before taking the 40- or 80-hour certification courses. To meet the demand for peers and behavioral health counselors, authorities lowered the requirement to one year.

Adding to the stress of their job, many peers also say the residential programs in Oregon need to offer longer stays and different approaches to increase their effectiveness.

Kevin Fitts, a peer and director of the Oregon Mental Health Consumers Association, told a crowd during the recent opening of Multnomah County’s Behavioral Health Resource Center that while the focus now is addressing the extreme shortages in behavioral health, the question that’s being neglected is whether the model for treatment is succeeding.

“Are we having beneficial outcomes for the consumer of the services? Got me!” Fitts said. “We have a system in crisis. … What is important is getting the services that these people need out on the street. Well, are these services meeting the needs? Are people moving forward?”

Dreams dashed in Ontario

On a Thursday morning in September, the smell of homemade meatloaf filled the air inside a mid-century brick church on the northwest side of Ontario.

Steven Wolf greeted patrons as they walked up to the back door. Wolf is a peer mentor, a job that Stringer recruited him into. The two graduated from drug court together before becoming peers.

Like most mornings, Anthony Caliendo, 52, was the first to show up. He’s experienced homelessness since July. He told The Lund Report he’s not interested in drug treatment. But Wolf said he helped Caliendo rely more on cannabis and less on meth — a harm reduction method employed by some peers.

Caliendo said Wolf is easy to talk to because he comes from a similar background. “He’s been hungry and spent his money on dope instead of food,” he said.

With no local year-round homeless shelter in the area, the church is the only place in Ontario where people can get a free meal. No longer operating as a house of worship, the building serves as a drop-in center run by a small nonprofit called Origins Faith Community, which is not religiously affiliated.

Staff at Origins saw Measure 110 as the opportunity they had been waiting for. They launched a peer program with Measure 110 funds, and hired Wolf as its first peer.

But as the state program unfolded, it became clear the robust local system Origins and other local providers had planned was not going to be possible.

Origins originally asked the Measure 110 council for $3.1 million. But the state wouldn’t fund the requested transportation services, new drop-in center, and the purchase of a 20-unit apartment building adjacent to the church.

Altruistic Recovery, an outpatient behavioral health clinic across town, requested $13 million to create a detox and residential treatment facility, but was also denied.

Of the $265 million in funds distributed through Measure 110 last year, $1.8 million went to Malheur County.

That money, locals lament, will fund only seven beds — slated for an apartment complex that a local nonprofit plans to purchase as housing for people living with co-occurring HIV and substance use disorder.

Origins, meanwhile, got $616,000 — less than 20% of what it hoped for.

Counselor Dana Rush, who left Origins following cuts made in November, said she thought Measure 110 was going to be different.

”That’s why we were so excited about it — that finally, we could really meet people where they were,” she said, her voice breaking as tears filled her eyes. “And then to watch all of the stuff unfold and go, ‘Oh my gosh, we’re not going to be able to do that. OK, give us just what you can so we can just get started. And maybe we can build what we can. And we’ll do what we can. And we’ll keep doing what we can until — dang it — we’re just gonna keep doing what we can do.’”

In memory of Nathaniel Sean Stringer, Four Rivers Healthy Community is raising funds for a scholarship to Treasure Valley Community College for people in recovery, as well as a memorial tree and bench.