When Marc Cherna came to Allegheny County 21 years ago, the area’s youth and family services were seen as “a national disgrace.”

The agency was besieged by scandals. The number of young people being removed from their homes and put in the system was “out of control,” and its budget was rife with problems, he said.

Cherna was brought in to rehabilitate. A year after his 1996 start date, Cherna created the county Department of Human Services by taking 32 departments and merging them into five. Residents told his team they would benefit from centralized services.

“We want to be able to tell our story once,” Cherna recalls their clients saying. “Because most people who we serve have multiple issues and multiple problems, we formed a department and started that road of integrating.”

Cherna is now the longest reigning executive in the country.

In a Nov. 6 Facebook Live interview with PublicSource, Cherna focused on the county’s No. 1 public health issue — the opioid crisis. Below are some key takeaways from our 45-minute discussion. You can view the whole interview in the video above.

On the progression and severity of the opioid epidemic:

It’s horrible. I mean it’s really an out-of-control epidemic right now and it’s probably going to get worse before it gets better.

And I’ve been in this business for almost 45 years so I’ve been doing this a long time. I ran a state system for 13 years before I came here to the county system. So, I’ve been through the crack epidemic. I’ve been through many of the other things, but the opiate epidemic has its own challenges that are different. The challenge with this is that, one, it affects everybody and, two, a lot of addictions are being generated by the pills more than anything else.

There are thousands of people who need treatment. It’s a question of, one, are they willing? And, two, can we get them a bed when they are? And oftentimes, somebody will be ready for treatment, but for a very short period of time. If you don’t get them right then when they’re ready, they’ll go out and get high — you’ve lost the opportunity. There’s not enough beds right now because the demand is so great. Being able to reach people when they need it and having treatment on demand is key.

We’ve always had heroin but it used to be a lot less potent. Sometimes people would overdose and die, but it’s nowhere near the way it is right now. We had 650 overdose deaths in 2016. But I think the more telling number is [there were 10 times as many reversals].

On Narcan (naloxone), an overdose-reversing medication:

We put so much Narcan out there, and the EMS folks have been great. We have been reversing a lot of overdoses, so people are staying alive. But if that wasn’t out there, you’d have 5,000 deaths. And that’s probably a low number.

I mean, I think addiction is such a nasty disease. I’ve seen it firsthand. It’s affected my family. It’s affected my friends. I don’t know anybody who hasn’t been affected. And if people could quit, they would. It gets past being fun very quickly. Usually people get addicted and they don’t even realize it and then they’re stuck. But, I’ve seen an awful lot of people get into recovery. So, there is a time when the lightbulb will go on for most people and you just got to keep them alive until then.

I’m a big proponent of Narcan to keep people alive and hope that maybe this time it will work for them.

On medication-assisted treatment:

One of the things that we are very much stressing is that all the evidence and research is showing that the most effective thing to do is medication-assisted treatment. It allows people to stabilize and get their life stable and then they can start to deal with things.

Methadone, Suboxone, Vivitrol shots, all of these things will take people from chasing the drug 24/7 to being able to get on with their lives and getting some stability in their lives. After a period of time, they can start to wean off of that.

A lot of people who are on methadone or Suboxone lead very productive lives. They have their daily dose and then they go to work and they raise their kids and they go to school.

Some people will say, ‘Well, that’s just another drug.’ And the response is: Well, if you’re a diabetic, you’re taking the drug. You’re taking insulin. This is a disease. It’s physical. It’s a health-related thing. It’s not something that people do out of choice.

On abstinence and 12-step programs, which employ a set of guiding principles designed to help with overcoming substance abuse:

Abstinence is fine if somebody could stay abstinent. And that’s a very difficult thing to do. There are some people who get into recovery, go to treatment or go to meetings, and they manage to never use again. But there’s so many people who have not been successful at that. They relapse. Things happen. Triggers happen.

This is a brain disease, so your brain is not thinking right. It’s not that you don’t want to stay abstinent.

I think we can do a lot better with stigma, and it always really bothers me the whole anonymity thing. Unfortunately, society’s stigma kind of does that, where you’re afraid that if you say that you have a problem, or that you have had a problem, then other folks will stigmatize you. It would be harder to get a job, it would be harder to socialize with people.

Then you have the 12-step programs, which really pride themselves on anonymity — Alcoholics Anonymous, Narcotics Anonymous. So people don’t come forward and say, ‘I’ve got a problem. I have this disease.’ I think if everybody stood up with who is affected, this would go away in a hurry.

On babies being born addicted and when children are removed from their homes:

If a parent is addicted or a parent is using drugs, the child will be born addicted and then has to go through withdrawal and it’s really a pretty horrible kind of thing. If somebody is a heroin addict and is pregnant then [Magee-Women’s Hospital of UPMC] and places like that will try to move them to methadone because it’s not quite as bad on their withdrawal. It’s medically managed in a different way. You’re controlling what’s going into your body. Methadone is a controlled substance. Whereas, if you’re on the street purchasing heroin, you don’t know if you’re getting heroin, or if you’re getting fentanyl or carfentanil.

If a child is born addicted, [the neonatal folks] will refer to Children and Youth and we have to do an investigation. It doesn’t mean we’re going to remove the child necessarily, but we have to go and see what’s going on and try to provide services, try to minimize any risk. A number of children do get referred and do end up getting placed.

[Cherna said that, officially, about 40 percent of children referred to the Office of Children, Youth and Families are because of the opioid epidemic. He believes the figure is actually closer to 60 to 65 percent and that those cases just aren’t being identified as opioid-related.]

Over 65 percent of the kids we place, we place with relatives. We try to keep it in the family. We certainly work on reunification, help mom, get them to treatment or whatever is needed so she can stabilize to get her child back.

We also leave a lot of kids in their home, if we can have other kinds of support. We do have a contract with the Children’s Institute, where anybody we get who’s born addicted, we refer to them for case management. They carry that family for five years. We work closely with Children’s Hospital. One of our addiction agencies, POWER, works in our offices. They have women in recovery who help engage the mom who has an issue.

On the national emergency declaration by President Donald Trump:

It’s a declaration, but there’s no money behind it. If it’s going to help us, there needs to be some resources that go with it. It would be nice if they changed some of their policies and some of the restrictive things around confidentiality, so you can better serve people and coordinate their services and their care. It’s a good first step. But then, what comes behind it? I’d like to see them really pushing harm reduction. And really pushing that this is a disease.

On how the Department of Human Services approaches rehabilitation of addicted individuals and their families:

We’re trying to be very aggressive in terms of treatment. We have [requests for proposals] out right now for drug treatments for entire families. A lot of times, one spouse or the other partner will not go in [for treatment] because they’re afraid they will lose their kids or they don’t want to break up the family. If they were able to go in together with the children, I think we’d be better off.

If you have a family and you can do this, then it’s a combination of funding. They’ll save money. It’s an investment because if they stay addicted, or you end up having to remove the children, that costs a lot of money for placement. If the parents are going in and out of treatment, if they’re ending up in homeless shelters, or high utilizers of other services, over time that costs a lot of money. If they have healthcare needs because they’re not treating their addiction, you’re paying for hospitalizations.

We’re doing an evidence-based, in-home, home-visiting type drug treatment program that the former White House recommended.

We’re looking at a one-stop engagement center for folks to come into and get assessed and try to get treatment.

On addiction treatment in the Allegheny County Jail and reentry programs to ease inmates’ transitions into the community:

We’re leaders in terms of providing services to folks in the county jail and coming out [through our jail reentry programs]. The majority of folks who are arrested go in because of addiction. If you can provide treatment, if you can provide resources, if you can provide intensive case management that stays with them, you hopefully can reduce [recidivism]. Right now, there’s this revolving door.

We’ve had a national evaluation by the Urban Institute [released in 2014], which has said we really are making a difference and that it saves money and it’s much better for public safety.

There is not [medication-assisted treatment at the jail] right now. There’s a little bit of Vivitrol starting. It’s $1,000 a shot, but if you can do that and you get people on track, then it’s money well spent. I’m certainly encouraging it. They should do more and more of that.

On the Department of Human Services’ workforce and funding:

We have about an $800 million budget, which is federal, state and county funds. We have 300 or so agencies on the contract, so our community-based providers are the ones doing the bulk of the work. We have about maybe 3,200 employees overall.

Unfortunately, the workforce, we can’t pay enough for it. It’s a really hard job. And they’re basically entry level in a lot of ways. We’re limited in that respect. It’s hard to get people who can qualify. It’s also so difficult that people leave. So how do you maintain that? We have a lot of trouble recruiting and retaining good staff going forward on this. And part of that is because of lack of funding.

On new programs that are not yet public:

The big piece we’re doing that we haven’t talked about yet is predictive analytics. We are further ahead than anybody in terms of how we share data and how we analyze data. We’ve really invested heavily in that. So you can figure out, where are the trends?

We have to think about suburban poverty because things don’t stay stable. So what a community needs today, five years from now may not be. Lawrenceville, for instance, you know with gentrification, there might have been a lot of needs 10 years ago in Lawrenceville. They may not need as many human services today. But someplace like Braddock or Clairton may be in worse shape today. Penn Hills is a growing area of need. So you have to shift resources to try to meet those needs, but unless you do the analytics, you don’t know that in advance.

We’re first in the nation on predictive analytics for looking at our child welfare. We screen out about 50 percent of our calls. When we took a look after coming up with a predicted analytics tool, [we asked]: Are we going out on the ones that are highest risk? Or, are we going out on the ones that are lower risk? Can we use our resources better that way?

By using predictive analytics as a screening tool, we can make sure we’re going out on the ones who have the highest likelihood that something adverse is going to happen down the road. So many cases are gray-area cases, so it’s a judgment call. It’s a better use of our resources to be more effective and hopefully keep kids more safe.

On hope:

Well, I’m hopeful because I see that we make progress in spite of all the challenges. Just using children and youth as an example, when I came here, there were 3,318 kids in care. Today, there are under 1,500. Almost 2,000 kids less are in care. They’re living in their homes. They’re doing well. When I came, we had 1,600 kids waiting to be adopted. Today, there’s no backlog.

We have specialty courts. We have mental health courts. We have drug courts. The services that are being provided are much higher quality. We have very few homeless, especially chronic homeless. We closed the institutions, the mental health institutions.

That said, we have plenty of problems. There’s always going to be the need to do more. When you look back 20 years ago or 10 years ago, we’ve come a long way.

I think the challenge in many other places is turnover is so great for the administrators that they never get that kind of thing — they never build those kind of long-standing relationships to actually do things.

It’s a community’s responsibility to help each other.

Correction (11/9/2017): A previous version of this story provided an incorrect budget figure for the Allegheny County Department of Human Services. Its budget is $800 million.

Brittany Hailer is a freelance journalist based in Pittsburgh. She can be reached at bhailer08@gmail.com.

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Brittany Hailer reported for PublicSource between 2017 and 2019.