Asking people what they need: California caregivers trailblaze solutions for those dealing with addiction
And today we're bringing you a California report magazine special about a drug epidemic. That's been raging throughout the pandemic. More than 93,000 people died of a drug overdose nationwide last year, that means an average of 250 people dying. Every day. The country said some really grim records in 2020 more people died from opioids like fentanyl and stimulants like meth than ever before. KQBD health reporter. Leslie McClurg takes it from here.
San Francisco is a relatively small city compared to New York or Los Angeles, but surprisingly it's overdose. Death rate is three times higher than either New York or LA, nearly three times. As many people in San Francisco died from drugs than from COVID last year. And so I really wanted to see this problem. I visited a hospital near the Tenderloin.
Typically an overdose patient comes in from the community on an ambulance. You know, we get a ring down saying somebody was found, who's not breathing. Who's blue.
That's Dr. Joanne son. She's an ER, doctor at St. Francis Memorial
Hospital. It seems to me that there are mainly overdosing on fentanyl. A lot of times you don't even realize that what they bought off the street was fentanyl. Their intent was after you do crystal or a cocaine,
She says fentanyl is driving the crisis. It's a synthetic opioid. That's up to a hundred times stronger than morphine. It's now entrenched in street drugs. And that means more and more people are unknowingly buying contaminated drugs.
Hi, I'm Dr. Son. What happened the day that we were getting something else. And we got a little bit of fentanyl. And what were you trying to do? Smoke crack. Okay. Ah, okay.
How much for decades? The state has punished people who do drugs, but the war on drugs didn't work. And so in recent years, policymakers have been switching gears by recognizing addiction as a disease needing medical attention.
On today's show, we're going to hear from doctors from caregivers and people who are struggling with addiction, they're all involved in these two new statewide programs that are becoming models for the rest of the country.
I see us as a bridge. I definitely see us as a stabilizer. That's first and foremost, and that's every emergency department. We make sure that you're stable. But then I also think of us as a bridge toward social stuff.
Dr. Sun's hospital St. Francis is part of the first program. We're going to explore. It's called California bridge and it's all across the state from Redding to Fresno, to San Diego. It's pretty hard to believe, but treating addiction in a hospital is actually rare and quite new. So the program has a two-pronged approach. First, ER, docs are trained to dispense medication to treat opioid use,
And it definitely takes away any withdrawal symptoms you feel, which is the main motivator of trying to get a hit again.
Yeah. Historically, ER docs have not given out medicine to treat withdrawal. For example, when I visited St. Francis a patient there with a substance use disorder was in excruciating pain. He was riving on a gurney and he was so delirious. He had to be restrained by an EMT. In most hospitals across the country, the doctor might've given him something to settle his nerves or maybe something for his stomach. And then once he stabilized, he might've been just sent on his way. That was standard practice.
Essentially you would get handed a piece of
Paper and that was your referral to your treatment and good luck. That was essentially it.
That's Christian [inaudible], he's a substance use navigator with California
Bridge. Please don't come back to the emergency department, this kind of the way that patients were true.
And I imagine then that turns the whole system into a bit of a hamster wheel, right then patients are back on the streets and then they're back in the emergency room and back on the streets, that
Exactly they're going to crash land into your emergency department. Not because they want to, but because they almost have to
California bridge is designed to break the cycle by medically treating opioid withdrawal symptoms inside the ER, rather than sending these patients somewhere else. The other key component of the program is assigning each patient a care coordinator to make sure that there's a strong handoff to long-term treatment. Once they leave the ER,
Just letting them know we got you, we're going to try and do the most for you right now.
Christian can help in lots of different ways. Maybe he might help patient get signed up for insurance or fill a prescription or connect them to a treatment facility,
That extra kind of handholding that these patients need to really start that journey of recovery. And you have a disease we're here to help you.
The pilot program, which started three years ago at eight different hospitals, including this one, it worked so well that the state then invested another $20 million last fall to expand the California bridge model
Patient presents with mild opioid and benzo withdrawal system symptoms, irritability, tremor sweating last use fentanyl, crack cocaine,
And now 144 hospitals all across the state have a navigator. Someone like Christian. He works at Highland hospital in Oakland.
Welcome to Highland.
Highland is a huge hospital with a packed ER, Christian points to one of many posters, displaying a phone number.
This is the key to life.
It's the substance abuse hotline. And most hotlines connect you to a random operator. This one is extremely
It's connected to my phone. It's connected to all the patient navigators patients can call or text us.
We turn down a hallway and Christian opens a cabinet filled with fentanyl testing strips.
So narc hand, clean needle kits.
Narcan is a nasal spray. That's really easy to use and it can reverse an opioid overdose. Instantly. Usually patients have to go to the pharmacy to pick up Narcan on their way out of the hospital, but they often forget. And so Christian hands it directly to patients. He says that simple shift. It makes a pretty big difference. Yeah,
We, we give them out to every patient with substance disorder or they can request them. We can go see this patient in room 70.
We're going to meet a woman who just received an opioid withdrawal medication. And it's the cornerstone drug of the California bridge program.
Knock knock, Ms. Collins. Hi, are you okay?
Her full name is Sonya Collins. Rochelle. She's probably in her mid sixties. She slowly nods. And then she tries to push herself up on her elbows.
W would you, would you like me to raise the, raise the gurney on you
When she's elevated a little Sonya kind of straightens her headscarf, and then she pulls up her white bed sheet to reveal a really swollen ankle. She explains that she fell down recently and then she had to have surgery and then her doctor prescribed morphine for her pain. And then she ran out of it.
So you started getting nauseous and you start having a runny nose. Yeah. You had a seizure during bingo withdrawal symptoms, opioid withdrawals classic.
In the past, Sonia might've gotten saved Tums or maybe an anti-nausea medication to make her feel better. But today a doctor gives her a drug called buprenorphine. It's also known by the brand name, Suboxone,
You know, very similar to morphine. It's a lot safer though.
So almost immediately, Sonya brightens up the drug treated her withdrawal symptoms and it may have done even more
Than it was a really big intervention on reducing that person's risk.
That's Monique law. He's an internal medicine doctor at Highland and a substance abuse expert. He says giving Sonia buprenorphine could help avert a long-term addiction,
A huge proportion of patients that we meet here. You know, they were started by the healthcare system. They had a pain condition for which they've got prescribed oxycodone or Norco, hydrocodone, whatever it is. And then they developed dependence and their doctor continued it because that's what we told doctors to do for many, many years. And that was like supposed to be good care.
And the pharmaceutical industry told doctors, this was okay, drug companies, highly underplayed, how addictive these opioid medications were. And so patients would end up getting hooked and then they would run out of their payments.
And then they turn to heroin or buying pills on the street or offend Sonoma or what have you. And then we meet them. It's a really, really typical story, huge, huge proportion of our patients. That's exactly what happened
In Sonia's case. They caught her really early in the cycle. So she's not likely to go down that path and need long-term treatment. Instead she is prescribed a low dose of buprenorphine that she can slowly taper off.
And that's our number right there. Okay. So, and I'll write it down for you as well. Okay. I hope you feel better. I hope I feel,
Yeah. Sonya is a pretty unusual case because she'll likely recover pretty easily. Most of Christian's patients are a lot tougher because they often have to take an opioid alternative, something like buprenorphine or methadone for life.
Why'd you come here today. What can we help you with
My sobriety? You know, to get clean basically to just to get off for it for heroin and meth. Great
Drill is 36 years old and he lives on the streets. He often lands in the ER after an overdose. He's what some people might call a frequent flyer. We're only using his first name because of his illegal drug use. California bridge is pulling out all the stops to help him recover. This is methadone. A doctor delivers drew a couple of blue pills. He kind of winces as you choose, how important would you say that medication is to staying off drugs or
To be honest with you and I'm not going to lie now? I would've, um, definitely, um, stayed using drugs. I wouldn't see the point or like put myself through that, the withdrawals, you know, and feeling dope, sick. And, and I feel like, you know, the option of methadone or Suboxone is helping a lot of people get off the drug because it's pure health for me. I don't know about other people, but I, I experienced which is for like forever, forever, doesn't it? Yeah. So
Whose eyes kind of roll back as the methadone starts to hit and he slumps a little in his seat. Dr. Oola says, today is a success because every time that drew takes an opioid alternative, it means he's not injecting heroin. That's why medically assisted treatment is a key bridge tactic and part of a statewide push to make it way more widely available.
It lowers mortality risk by about 50%. There's very little in medicine that has that big of an impact on a person's chances of dying
Studies show that patients who receive opioid meds in the ER, are twice as likely to remain in treatment a month later, compared to someone who receives a referral. But what's crazy is that only 3% of ER, docs in the U S are trained to dispense them. Both patients and docs are skeptical of these opioid alternatives.
Patients will ask, how long am I going to stay on this medication? How soon can I get off? And then doctors are asking too, aren't you just replacing one drug for another, they're stuck on that buprenorphine to,
But Dr. argues that that's the case for a lot of diseases like high cholesterol or high blood pressure.
Sure. People will start those medicines and not bad in Iowa when they take it for the rest of their lives, because there's benefit from the medicines and the benefits outweigh the risks. And I would say, it's the same thing with this medication with buprenorphine,
He says, it's treating a substance use disorder for exactly what it is. A brain disease that requires specific medication. California bridge is training, ER, docs across the state to dispense it on demand. After visiting the ER, Kristen takes me downstairs to the bridge clinic. This is where a patient can start long-term treatment. And the clinic is right inside the hospital. And that's key because it's a lot easier for patients. If services are all in one place,
People who do drugs are often battling numerous health issues.
Now we can wrap around your care. We can get you into the HIV AIC clinic. We can treat your Hep C downstairs with your substance use disorder. Co concurrent
And social workers are available to help folks say, find housing or navigate a child custody case. And clinicians see about 800 patients a month who are addicted to everything from cocaine to opioids, to Xanax. I chat with a man. His name is Jose Martinez. He's sitting in the lobby while he's waiting for a therapy appointment.
I come here for peace of mind and to get my gears straightened out. Cause I got a couple of loose marbles up there.
He attends both individual and group sessions to improve his mental health and work with this trauma.
I grew up in, uh, south central, where Heights in LA. My mom got shot in the head. 1994 LA riots.
Jose says he often drinks a liter of vodka a day. He says, he's landed in the ER four times in the last six months. So the sooner that Jose turns his life around the sooner he'll stop using the ER, when he's in crisis,
I need help. I want help. He can't just do it alone. You need a whole team,
A team that believes in you, even when you're messing up over and over.
recovery is long and it's fraught. And it takes a really special person to help someone break their addiction. As I visited these different hospitals, I met someone whose story really sticks with me. She's a counselor at California bridge.
This is not a field that I thought of and my junior high school plan.
And before she had this job, she also struggled with addiction. And our goal now is to build patients up rather than,
And break them down. I want somebody to be able to walk in that door and not feel alone and not feel judged and kinda know, Hey, I can relate.
Her name is Monique Randolph. And she works at St. Francis. She's one of 144 substance use navigators all across the state. And people like Monique are really crucial in making California bridge work. They use the acronym Sutton.
I'm the third. And I love that name.
Monique tries to flip the script that people with addiction issues are so used to hearing from people in charge.
You know, when you're in jail, when you're in programs, when you're here at the hospital, they tell you, take your meds, follow up with the doctor, do this, do this. Don't do that. Don't do that in my role. It was how can I help you? Do you know, saying that to someone is life changing sometimes. How can I help you?
Sometimes she helps patients find a safe place to sleep, or maybe the number for a domestic violence clinic. Not everyone she meets is ready for change, but Monique always tries to leave the door open.
Here's my card. If at any time you change your mind,
The program's only staff from nine to five and Monique knows her patients need services at all hours, but she really tries to do all that she can with the time that she has,
I'm looking in the mirror at what I used to look like. And they're looking at me as a mirror of what they can become.
Occasionally Monique will share her story with a patient to build trust.
I snorted heroin every day, every day,
Monique sold drugs and she robbed stores all the support, her habits,
But deep down inside, I was just so rotten. My family didn't know for years, it was just my little dirty secret.
She tried to quit many times and there were stretches of sobriety, but they never really lasted. I'm like,
God just can't seem to get this
Together. Eventually she landed in federal prison for stealing and she left her five-year-old son behind.
When I came home from prison, I went to a halfway house for a little while and I got me a job, but I didn't have a home to come to.
Fortunately that's when she found a program for women and
Children and someone helped me and they didn't judge me, they didn't help me make short time goals for long-term success. And it's been 17 years. I'm not going back.
Monique has since dedicated our life to helping others overcome addiction. About 40% of hospitals across California have hired someone like Monique through the California bridge. And the goal is to enroll all remaining hospitals by 2025.
Okay, thank you. I'm still around. Okay.
The medications that are the cornerstone of the California bridge model are total game changers, but they only work for opioids, not stimulants like meth. There are no FDA approved medications for meth. And my colleague April Demboski covers health for the California report. And she's been following this for the last few years. So I wanted to bring her in here. Hey April. Hey Leslie. So can you kind of lay the landscape for us? What's the state of meth use in California. Meth is a huge problem. Last year, more people died from meth and cocaine overdoses than fentanyl and meth addiction can just ruin people's lives. And it runs up enormous costs, not only for the healthcare system, but also jails courts and foster care. And there's really no medication that can help these folks. Why is that? Meth is really different from opioids. We all have opioid receptors in our brains and medications like buprenorphine target those receptors to stave off cravings, but stimulants like meth and cocaine affect multiple parts of the brain.
There's just too many targets, right? Researchers have tested dozens and dozens of medications for meth, but they can't find one that really works. So then where does that leave folks who do math, if they want to get off the drug, it kind of leaves a lot of them in a place of why bother trying to stop. Wow. I was talking to Kelly Peiffer, she's an addiction doctor who now works for the state's department of healthcare services. That's the same department that runs the bridge program. And she told me that for people who use opioids, there's an awareness of medications like buprenorphine. There's this understanding that at some point I'm going to get help and cut back. But for meth users, it's the opposite. There's a lot of
Hopelessness in the community using stimulants, a lot less belief that treatment will help them.
That's really sad to hear. I mean, is there anything that can be done to help? Well, just like the bridge program, the state is now planning a massive investment in a new treatment for meth addiction. It's not a medication, it's a behavioral treatment and it's kind of unusual. The state wants to pay people who use drugs, not to use them. I wanted to understand better how this works. And so I talked to somebody who's been through the treatment. His name is Billy lemon. He lives in San Francisco and for 10 years he was deep into meth, both using it and selling it. At one point he was shipping pounds of drugs across state lines.
I would get bread bowls and I would hollow them out. I would lie in the inside of the sourdough with meth and then cover it back up and shrink, wrap the bread and then send loaves of bread with some accoutrement from fisherman's Wharf. So it looked like a care package to people in Boston. And then they would literally send me 15, $16,000 in twenties or hundreds via FedEx.
Billy was arrested three times. He spent time in jail, but that never motivated him to stop. He almost got put away in state prison and that scared him enough that he stopped selling methamphetamine, but he kept using to actually quit. He had to hit rock bottom.
You know, there was a suicide attempt at pier 23. It didn't happen that day.
That's when he begged a friend to help him get into rehab. And the day he went to the treatment center, he showed up with nothing but the clothes he was wearing and a backpack,
Zero money, literally zero money, not even a dollar. I didn't even have a cell phone
Earlier. Billy was walking by a park and threw his phone in the trash
'cause. I was, I had made the conscious decision to shut all those doors completely and an open new ones at whatever cost and however hard that was going to be. And it was hard.
Billy grew up in a family where no one talked about anything.
My dad drowned when I was five, my mom and I never talked about it until I was in college. She never even mentioned his name.
Suddenly he was in group therapy where he was expected to openly discuss his trauma and shame. And self-loathing,
It was, uh, yeah, it was hard.
But once he got a taste for talking about what was really going on, he was all in.
I kept telling myself to look at recovery, like a master's degree, like you're going back to school. He
Was like, he got addicted to recovery.
And so I was going to do rehab and I was going to do two 12 step meetings a day. And I was going to do outpatient treatment. At the same time.
Billy went to the San Francisco aids foundation to see what programs they had on offer. And they told him about a special treatment. They did they're called contingency management. Basically, if Billy stayed off drugs, they would pay him three times a week. He came in and peed in a cup. Every time he tested negative, the counselors would put $7 in his account.
And for somebody who had not had any legitimate money without committing felonies, that seemed like a cool thing.
After three months, those payments could add up to $300.
And so I was like, yes, yes. I want that for Billy.
It quickly became about more than just the money. It was about being told good job.
It was the first opportunity where I was like, I have, self-worth still, it's buried. This person sees it and is willing to give me $7 just to take care of myself. That was very motivating.
Now Billy could feel himself getting hooked on this, the legit dollars, the pat on the back.
And so once you get a little bit of a taste of that, um, for an addict, we want more of that, right? We want it all now.
And this is how contingency management works. The incentives aim to rewire the brain's reward system. So the person seeks the money or gift card to get a dopamine release instead of meth or Coke.
And you're like, oh, oh, oh, I can feel good without the daily use of that substance. Oh, I, maybe I should let me try and go one more week. And then all of a sudden you're at 90 days and you've actually, you've made a change,
But the treatment is controversial. Critics have scoffed at the idea of paying people, not to use drugs, calling it an ethical or a bribe. Most insurers don't cover it. Neither do state Medicaid programs. The feds generally forbid them from offering financial incentives, to patients as a protection against fraud and waste. And yet studies show contingency management works. It's not that different from an incentive program to lose weight or a gold star chart to get your kid to do their chores at the San Francisco program, Billy lemon did 82% of participants stopped using math or reduce their use. And this is why state Senator Scott Wiener sponsored a bill that would allow the state's Medicaid program to offer this treatment potentially reaching hundreds of thousands of low-income Californians. Wiener was actually surprised the bill passed the legislature with near unanimous votes.
The Republicans love it, which I didn't think they would, but they actually like it because there's an abstinence component to it, right? It's like we pay you money and you abstain from
The governor has the final say on the bill, but the state can still move forward. If they get the okay from the feds, California officials have already asked for permission to offer contingency management. And it looks like the Biden administration is going to say, yes, it will be expensive, but California's Dr. Kelly Peiffer says in the long run, the state will save money.
Hi, stimulant use means a lot of people involved in the criminal justice system instead of treatment. It means foster care placements. Instead of children's staying with family,
It ruins people's teeth and lands them in the hospital with heart attacks,
Which obviously not only devastating to the person and the family, but very expensive for our healthcare system.
Um, Piper says making contingency management more widely available, we'll make more people willing to seek treatment
Because people will see success stories. They'll see friends and family getting treatment and getting help and getting better
For Billy lemon contingency management was just what he needed to jumpstart his recovery and to stay the course and rehab. When he got his $300, he bought himself a cell phone because,
Uh, up until then breaking bad style is burner phones. Right? My number was never the same.
Now nine years later, he's still sober. And the number he got with the phone paid for with contingency management money is still his number.
It's a nice reminder of what making good decisions for yourself can turn into
We're. California is now with contingency management is not that different from where we were five years ago with buprenorphine, people were alarmed by the idea of treating drug addiction with another drug. But now thanks in part to the California bridge program. It's routine in California as contingency management rolls out over the next few years, maybe it won't seem so strange to pay people who use drugs not to use.
You've been listening to KQBD health reporters, April Demboski and Leslie McClurg in a California report magazine special on addiction.
Last year more than 93,000 people died of drug overdoses nationwide, more than 10,000 of them in California. The public health crisis, which has spiked during COVID, is taking a horrific toll on communities and cities across the state.
For decades the state's approach has been to punish people who do drugs. But it hasn't worked.
“It’s more than a failure, it has been incredibly harmful,” said Dr. Monish Ullal, internal medicine physician and associate medical director of the Bridge clinic at Highland Hospital. “I think the war on drugs is one of the most disappointing things that our country has done in the last 30 years.”
Now policymakers are switching gears by recognizing addiction as a disease needing medical attention. California is investing large amounts of money in new models of treatment for those dealing with substance addiction. Two new programs are showing promise and becoming models for the rest of the country.
Emergency rooms anchor recovery efforts
The first initiative is called CA Bridge, and its goal is to initiate treatment for patients with a substance use disorder in the emergency department. It may be hard to believe, but treating substance addiction within a hospital is a fairly recent strategy.
The program has a two-pronged approach. First, emergency medical physicians are trained to dispense medication to treat opioid use. Once a patient is stable, they are assigned a counselor or “substance use navigator” to ensure a strong hand-off to long-term treatment once they leave the ER.
“Just letting them know it's OK. We got you,” explained Christian Hailozian, a substance use navigator at Highland Hospital. “That extra kind of hand-holding that these patients need to really start that journey of recovery.”
The pilot program, which started at eight California hospitals, worked so well that the state invested another $20 million last fall to expand the California Bridge model. Now 144, or about 40% of hospitals across the state, have staffed a substance use navigator. The goal is to enroll all remaining hospitals by 2025.
The other big initiative is a new treatment for addiction to methamphetamine or cocaine. While there are three FDA-approved medications available to treat opioid use disorder — the cornerstone of the Bridge program — there are none for stimulants.
“There's a lot of hopelessness in the community using stimulants, a lot less belief that treatment will help them,” said Dr. Kelly Pfeifer, deputy director of behavioral health at the California Department of Health Care Services.
Meth-related overdoses have tripled nationwide in recent years, and treatment providers are desperate to find something that works.
Providers have landed on a behavioral treatment that studies show is highly effective, but has been only narrowly deployed: contingency management, an incentive therapy that uses money or prizes to encourage people who use drugs not to use them.
California is betting big on contingency management. Lawmakers passed a bill that would authorize the state’s Medi-Cal program to offer the treatment. It's awaiting Gov. Gavin Newsom's signature, and state health officials also have requested permission from the federal government to provide the therapy to hundreds of thousands of Californians in lower-income households.
Where to find support for substance abuse disorder
- If you are insured through Medi-Cal, you can access your county's substance abuse disorder county access line. The resources offered vary by county. Find the list of phone numbers here.
- Most California counties participate in the Drug Medi-Cal Organized Delivery System, a 2015 expansion that provides more alcohol and drug use services to people in need. Get more information on how to access treatment for an opioid addiction here.
- The San Francisco AIDS Foundation offers a variety of initiatives that center harm reduction to support those dealing with substance addiction. This includes support for cocaine and crack use, meth use and safe syringe disposal sites.
- Finding support for mental illness can sometimes be part of dealing with substance abuse. NAMI is the National Alliance on Mental Illness, and several counties have their own chapter. Find the closest one to you here.
- Providers wanting to learn how to make CA Bridge part of your work can learn more here.