When Jennifer came into the emergency room, she was hurting. What started as a sore spot had become an abscess and then a bacterial infection that would require seven to 10 days of treatment. That was time Jennifer did not have to spend at Dell Seton Medical Center, she thought. She was homeless, and she had been using heroin – that's how she got the infection, with a needle – and she was now in active withdrawal.
While she was in the ER, Jennifer was seen by a member of the hospital's "B-Team," who talked to her about how, once she was admitted, she could be given buprenorphine – a medication, also known as suboxone, that provides relief from the always harrowing and sometimes life-threatening symptoms of opioid withdrawal. She gave Jennifer her card. On that night, though, it wasn't going to happen – two hours later, Jennifer left the hospital "AMA," against medical advice, and went back to the streets where a fix could be found.
Two months later, Jennifer still had that card when she arrived back at Dell Seton, this time without the strength to leave. The infection had spread to her heart; she would end up spending seven weeks in intensive care. This time, she was admitted, and was given buprenorphine, and within two hours her withdrawal symptoms were gone.
She was still very, very sick, but not dopesick – rather, she was on a path to recovery, with the tools to stay on that path once she left the hospital, and eventually be able in sobriety to rebuild her life. As B-Team chaplain Evan Solice noted later, "She said, 'I've hit the end of my road, and I have to make a U-turn, if I get out of this hospital alive.' She had this really strong, fighting spirit."
One might think that it would be, if not routine, at least somewhat ordinary to administer buprenorphine to patients with opioid use disorders once they arrived at a hospital. But it's not. The Dell Seton and Dell Medical School B-Team – the B is for buprenorphine – is doing unique work that its members hope will change the way we treat people who need help at hospitals and clinics around the region, state, and nation. What seems like a simple practice – something that should be a common standard of care in a country experiencing an opioid crisis – actually necessitates a lot of big structural and cultural change.
"Jennifer" is not her real name, but her story is a real case that the B-Team included as part of its year-end report to Dell Med students and faculty. Her case illustrates multiple dimensions of the problem that Dell Med, and Dell Seton as a teaching hospital, feel a need to solve. As the B-Team describes it in its overview, "Patients with opioid use disorder (OUD) deserve the same dignity, autonomy and meaningful care afforded to patients with other medical diagnoses. Hospitalization represents a reachable moment and unique opportunity to start treatment for OUD, but at the vast majority of hospitals in the U.S., patients with OUD are typically offered little more than detoxification."
Dell Seton does not admit patients just to treat addiction – we have a largely separate health care system devoted to drug treatment and rehabilitation. But Dell Seton does admit patients whose opioid use disorders have made them sick in other ways, such as abscesses and infections spread by dirty needles. As the safety-net hospital in Travis County, it sees a number of such cases, often involving people experiencing homelessness, or with other mental and behavioral health diagnoses. In its first year as a pilot project, the B-Team recorded 122 consults with Dell Seton patients, of which 50 were started on buprenorphine.
Remember, this is just among people who are actually admitted – not seen in the emergency room, or kept in observation without admission, or there for non-inpatient services or for labor and delivery. So there are undoubtedly more patients with opioid problems than the B-Team has yet attempted to encounter, but even at that, you're looking at around one patient a week. That is more than other hospitals in Central Texas might see, and quite a bit less than you could expect to encounter in a hospital in a place like Ohio or West Virginia or New Hampshire.
Generally speaking, only a fraction of people who need treatment for drug problems actually receive it – the B-Team says in Texas, it's less than 10% – so encountering opioid users in the hospital for other reasons is a way to reach people who need help that they otherwise wouldn't or couldn't seek. (So is encountering them in jail.) At the same time, opioid use disorder is a real disease on its own terms – stated more formally, it's a "chronic relapsing-remitting medical disease and a risk factor for premature mortality – similar to conditions like diabetes," in the B-Team's words.
If you showed up at a hospital with a condition associated with diabetes – it could also, in fact, be a severe skin infection – you would receive treatment for that and you would of course also have your blood glucose levels tested and receive insulin or other medications as needed. Buprenorphine should be no different; it is the standard of care, just like insulin. But "I think that there's a huge cultural barrier within hospitals owning this as part of patient care," says Dr. Nick Christian, Dell Med resident physician on the B-Team.
Why? Sometimes it's simple – nobody at the hospital is licensed to administer buprenorphine. One of the many highly aggravating absurdities of America's response to the opioid epidemic is that getting this certification, known almost universally as an "X-waiver," requires a level of special training beyond that of any other medication, certainly beyond that needed to prescribe opioids. (Buprenorphine is a pill; administration is not a complicated medical procedure. It does show up on the street, but if you prepare it for injection the way users might other prescriptions like oxycodone, it could make your withdrawal symptoms worse.)
For M.D.s, it's an eight-hour course; for physician assistants, advance practice nurses and nurse practitioners, pharmacists, and others who carry a large share of the load in caring for patients with substance use disorders, the training is significantly longer. The B-Team is itself working to provide training to eligible prescribers and to advocate along with others on the front lines nationally for changes in these rules.
This layer of reflexive and now counterproductive caution is rather typical of the way our nation has traditionally reacted to addiction within the framework of health care. Any kind of medication-assisted treatment for substance use disorders runs into moralistic barriers that remain surprisingly robust – the belief that anything other than full and immediate abstinence (cold turkey) is simply enabling and prolonging, rather than managing and curing, the disease. That just adds another layer of torpor and inertia to change processes that, Christian says, are "just slowly adopted in the health care field. Even if a treatment is proven in studies, you probably wouldn't see people prescribing it routinely in the field until 10 years later."
Hospital care teams working on the front lines of today's broken health care system are not able, and certainly aren't often encouraged, to experiment. Medical centers have been strongly incentivized to reduce the length of stays and redirect patients to primary care providers. They look warily at the implications of starting long-term treatment for a condition that, for years, has been viewed and labeled as a mental illness and dealt with in a largely separate system that many providers who aren't specialists – physicians, nurses, social workers, chaplains, pharmacists, and others – have little exposure to in their training and even less in their day-to-day careers.
All of those factors working as a drag against change would still be present if the patient needing help was a bubbly Northwest Hills housewife with good insurance and a dark secret. The fact that many are more like Jennifer – experiencing homelessness, involved at first or secondhand with the criminal justice system (in her case, her boyfriend), and otherwise not being respectable – dumps another truckload of issues in between them and their care. These are patients who are unlikely to even come to the hospital if they can avoid it, unless and until their conditions become truly dire.
The B-Team describes this part of its work as "reducing stigma," or as chaplain Evan Solice puts it, "really just getting the other side of the story" from patients who would otherwise be stereotyped as noncompliant drug-seekers for whom actual pain management – associated with their conditions, or as a need after surgery – will be almost impossible. It can be hard to muster the appropriate amount of empathy for a patient whose belongings, and those of her family, need to be searched lest non-prescribed drugs be smuggled in, or who might be expected to leave abruptly and against medical advice. "Nurses are anxious, because these patients can be very difficult to care for," says Christian. "We can show that by treating them [with buprenorphine] they will be better patients."
Since Dell Seton is a teaching hospital, the cycle of changing the front-line culture is more rapid than elsewhere. "We have a new influx of nurses and residents every year," says social worker Rachel Holliman. "The goal is to make them comfortable reaching out to us." One goal of the B-Team moving forward is to develop a provider simulation "placing clinicians in the role of the patient experiencing addiction."
The culture change works both ways; the B-Team says patients are starting to know that Dell Seton will treat them differently and better than elsewhere. "Word is spreading on the street," says Holliman, "that they're going to get nonjudgmental care and also an opportunity to maybe move toward sobriety."
B-Team nurse Ken Giorgi says that in the past, or at other hospitals where he's worked, "patients would come in for medical treatment, and we'd send them out with a pamphlet, and maybe a list of some places they can go" to deal with their underlying addiction. "But that's it. And they already know that stuff, where to find meetings."
Giorgi says that "many patients are afraid to come to the hospital, because they don't think they'll be treated with respect, and they also won't be given pain medication for something that actually is really painful. We've really worked hard to change that thinking." Solice adds that the severity of withdrawal "is just not taken seriously" by even the most well-meaning providers who haven't seen it firsthand. "Something I learned talking with patients is they're not using heroin to get high; they say it was fun for the first two months but after that, all they're doing is ... trying to avoid withdrawal."
The transformation of health care delivery prompted by the Affordable Care Act and other public policy initiatives – and sure to continue as America continues to laboriously overhaul its health care system – has given hospitals like Dell Seton and schools like Dell Med a little bit of breathing room to be agents of cultural change. Christian says that for residents like himself, "when I have a patient that I'm worried about" who is using, or in withdrawal, "I am incentivized to ask more questions because I know that I have a way to treat it. Before, it was more like, the less I know the better, because even if I know, I can't do anything about it."
Of the 50 patients who were started on buprenorphine during the B-Team's first year, 45 were discharged with what the team calls a "warm handoff" to a follow-up appointment one week later with a licensed specialist (with an X-waiver) in medication-assisted therapy; 27 of those made it to those appointments, which is a better-than-average compliance rate. Both Dell Med and Dell Seton collaborate with the Central Texas providers who deliver the services that can help those patients sustain their recovery – the stuff we've talked about a lot as Austin's grappled with its homelessness crisis – and improve those percentages going forward.
Beyond Austin, the B-Team provides what both Dell Med and Dell Seton see as a promising model that's scalable and workable for other hospitals in other communities. "We don't have an addiction medicine specialty or program in place here" at Dell Seton, says Christian, "but we have a bunch of different people working in our different divisions of medicine who happen to care a lot about people that are experiencing addiction. As long as you have a heart and you have an X-waiver, you can make this program work."
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