Hospitals have been slow to bring in addiction specialists

In December, Marie, who lives in coastal Swampscott, Massachusetts, began having trouble breathing. Three days after Christmas, she woke up gasping for air and dialed 911.

“I was so scared,” Mary said later, clutching her arms to her chest.

Marie, 63, was admitted to Salem Hospital, north of Boston. Staff treated him for chronic obstructive pulmonary disease, a lung condition. A doctor checked Marie the next day, said her oxygen levels looked good, and told her she was ready for discharge.

We are not using Mary’s last name because she, like 1 in 9 people hospitalized, has a history of drug or alcohol addiction. Disclosing such a diagnosis can make it difficult to find housing, employment, and even medical care in hospitals, which may shun addicted patients.

But talking to the doctor that morning, Mary felt she had to disclose her other medical problem.

“‘I want to tell you something,'” Mary recalled. “‘I’m a heroin addict. And I’m starting to have, like, heavy withdrawal. I literally can’t move. Please don’t make me go.’

At many hospitals in Massachusetts and across the country, Marie would be discharged anyway, still in the throes of withdrawal, possibly with a list of local detox programs that could provide help.

Releasing a patient without specialized addiction care can mean missing an important opportunity to intervene and treat someone in hospital. Most hospitals don’t have specialists who know how to treat addiction, and other doctors may not know what to do.

Hospitals typically hire all kinds of providers who specialize in heart, lung, and kidney care. But for patients dealing with addiction or drug or alcohol use, very few hospitals have a physician — whether a physician, nurse, therapist or social worker — who specializes in addiction medicine.

This absence is striking at a time when overdose deaths in the United States are at record highs, and research shows that patients are at risk of fatal overdose in the days or weeks after being discharged from the hospital.

“They’re left on their own to figure it out, which unfortunately usually means starting over [drug] Use because it’s the only way to feel better,” says Liz Taddy, a nurse practitioner certified in addiction care.

In the fall of 2020, Taddy was hired to introduce a new procedure at Salem Hospital using $320,000 from a federal grant. Tadie has put together what is known as an “addiction counseling service”. The team included Teddy, a patient case manager, and three recovery coaches, who drew on their experiences with addiction to advocate for patients and help them navigate treatment options.

After Mary allows her doctor to stay her in the hospital, she calls Taddy for bedside consultation.

Tadie began with a prescription for methadone, a drug to treat opioid addiction. Although many patients do well with that medication, it didn’t help Mary, so Teddy switched her to buprenorphine, with better results. After a few more days, Marie was discharged and continued taking buprenorphine.

Mary also continued to see Taddy for outpatient treatment and turned to him for support and reassurance: “Like, I’m not going to be left alone,” Mary said. “I’m never going to call the dealer again, that I can delete the number. I want to get my life back. I just feel grateful.”

Tadie helped spread the word among Salem’s clinical staff members about the expertise she offered and how it could help patients. Success stories like Mary’s have helped the field of addiction medicine — and helped uncover decades of misinformation, discrimination and ignorance about addiction patients and their treatment options.

The little training that doctors and nurses receive is often unhelpful.

“A lot of information is out of date,” Tadie said. “And people are trained to use stigmatizing language, words like ‘addict’ and substance ‘abuse’.”

Tadie gradually corrected the doctors at Salem Hospital, who, for example, thought that their hospital was not allowed to start methadone patients.

“Sometimes I’ll recommend a dose and someone will give pushback,” Taddy says. But “we got to know the doctors at the hospital, and they said over time, ‘OK, we can trust you. We’ll follow your recommendations.’

Other members of Taddy’s team wrestled with their place in the hospital hierarchy.

David Cave, one of Salem’s recovery coaches, is often the first person to talk to patients who come to the emergency room during withdrawal. She strives to help doctors and nurses understand what patients are going through and help patients navigate their care. “Every time I try to talk to a therapist or doctor I’m probably punching above my weight,” says Cave. “They don’t see the letters after my name. It can be kind of hard.”

Designating addiction as a specialty, and hiring people with specific training, is changing the culture at Salem Hospital, said social worker Jeanne Monahan-Doherty. “Finally there was some recognition across the organization that this is a complex medical condition that requires the attention of a specialist,” Monahan-Doherty said. “People are dying. It is a terminal illness unless it is treated.”

One photo shows Liz Taddy and Jean Monahan-Doherty standing together inside a hospital.
Liz Taddy (left) was director of substance use disorder services at Salem Hospital North of Boston. Jean Monahan-Doherty (right), a social worker at the hospital, said, “Finally there was some recognition across the institution that this was a complex medical condition that required specialist attention.” Taddy is starting a job at another hospital, but Salem Hospital leaders say the program will continue.(Jesse Costa/WBUR)

This approach to addiction treatment is winning over some — but not all — employees at Salem Hospital.

“Sometimes you hear an attitude of, ‘Why are you putting so much effort into this patient? They’re not going to get better.’ Well, how do we know?” Dr. Monahan Doherty. “If a patient comes in with diabetes, we don’t say, ‘Well, they’ve been taught once and it didn’t work, so we’re not going to support them again.'”

Despite lingering reservations among some Salem physicians, demand for addiction services is high. For many days, Tadie and his team have been overwhelmed by referrals.

Four other Massachusetts hospitals have added addiction specialists in the past three years using federal funding from the Healing Communities Study. The project is funding a wide range of strategies across states to help determine the most effective ways to reduce drug overdose deaths. They include mobile treatment clinics; street campaign teams; dispensing naloxone, a drug that can reverse an opioid overdose; rides to treatment sites; and promoting multilingual public awareness.

This is a new field, so finding staff members with the right certifications can be a challenge. Some hospital leaders say they are concerned about the cost of addiction treatment and fear they will lose money on the effort. Some doctors report that patients are reluctant to start drug treatment during a hospital stay because they do not know where to refer patients after discharge, whether to outpatient follow-up care or a residential program. For follow-up care, Salem Hospital has started what it calls a “Bridge Clinic,” which provides outpatient care.

Dr. Honora Englander, a national leader in addiction specialty programs, said the federal government could help create more addiction counseling services by providing financial incentives — or penalties for hospitals that don’t embrace them.

At Salem Hospital, some staff are concerned about the program’s future. Tadie is starting a new job at another hospital, and the federal grant ends June 30 But Salem Hospital leaders say they are committed to continuing the program and the service will continue

This story is part of a partnership that includes WBURNPR and KHN.

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