Hospitals have been slow to hire addiction specialists

Hospitals have been slow to hire addiction specialists

In December, Marie, who lives on the coast of Swampscott, Massachusetts, began having trouble breathing. Three days after Christmas, she woke up gasping for air and called 911.

“I was so scared,” Marie said later, clutching her hand to her chest.

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

We don't use Marie's last name because she, like 1 of 9 Hospital patient, has a history of drug or alcohol addiction. Disclosing such a diagnosis can make it difficult to find housing, a job and even medical care in hospitals where patients with an addiction may be shunned.

But when she spoke to the doctor that morning, Marie felt she had to disclose her other medical problem.

"'I have to tell you something,'" Marie recalled. "'I'm addicted to heroin. And I'm starting to withdraw badly. I can't move - literally. Please don't make me go.'"

In many hospitals in Massachusetts and across the country, Marie likely would have been discharged anyway, still feeling the pain of withdrawal, perhaps with a list of local detox programs that could help.

Discharging a patient without specialized addiction services can mean missing a crucial opportunity to intervene and treat someone in the hospital. Most hospitals have no specialists who know how to treat addiction, and other clinicians may not know what to do.

Hospitals typically employ all types of providers who specialize in the heart, lungs and kidneys. But for patients with an addiction or condition related to drug or alcohol use, few hospitals have a clinician — be it a doctor, nurse, therapist or social worker — who specializes in addiction medicine.

This absence is striking at a time when overdose deaths have peaked in the United States Record highs and Research shows Patients are at increased risk of fatal overdose in the days or weeks after discharge from a hospital.

"They're left alone to figure it out, which unfortunately usually means resuming [drug] use because it's the only way to feel better," said Liz Tadie, a nurse certified in addiction support.

In fall 2020, Tadie was hired to launch a new approach at Salem Hospital with $320,000 from a federal grant. Tadie has put together what she calls an “addiction counseling service.” The team included Tadie, 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 Marie asked her doctor to let her stay in the hospital, he called Tadie for a bedside consultation.

Tadie began prescribing methadone, a medication used to treat opioid addiction. Although many patients do well with this medication, it didn't help Marie, so Tadie switched her to buprenorphine, with better results. After a few more days, Marie was discharged and continued taking buprenorphine.

Marie continued to see Tadie for outpatient treatment and turned to her for support and reassurance: “For example, that I wouldn't be left alone,” Marie said. "That I would never have to call a dealer again, that I could delete the number. I want to get back to my life. I'm just grateful."

Tadie helped spread the word among Salem's clinical staff about the expertise she offered and how it could help patients. Success stories like Marie's have helped make the case for addiction medicine - and helped expose decades of misinformation, discrimination and ignorance about patients with addiction and their treatment options.

The little training that doctors and nurses receive is often not helpful.

“A lot of the facts are out of date,” Tadie said. "And people are trained to use stigmatizing language, words like 'addict' and 'substance' 'abuse'."

Tadie gently corrected the doctors at Salem Hospital who, for example, thought they weren't allowed to start patients on methadone in the hospital.

“Sometimes I would recommend a dose and someone would hit back,” Tadie said. But "we got to know the hospital doctors, and over time they said, 'Okay, we can trust you. We'll follow your recommendations.'"

Other members of Tadie's team have struggled to find their place in the hospital hierarchy.

David Cave, one of Salem's recovery coaches, is often the first to speak to patients who come to the emergency room in withdrawal. He tries to help doctors and nurses understand what patients are going through and help patients navigate their care. “I probably beat myself up about my weight every time I try to talk to a clinician or doctor,” Cave said. "You don't see any letters after my name. It can be quite difficult."

Designating addiction as a specialty and hiring people with specific training is changing Salem Hospital's culture, said social worker Jean Monahan-Doherty. “There was finally recognition throughout the facility that this is a complex medical illness that requires specialist attention,” Monahan-Doherty said. "People are dying. This is an incurable disease if it's not treated."

This approach to treating addiction appeals to some Salem Hospital employees — but not all.

“Sometimes you hear an attitude like, ‘Why are you putting all this effort into this patient? He’s not going to get better.’ Well, how do we know?” said Monahan Doherty. “When a patient comes to us with diabetes, we don't say, 'Okay, they were taught it once and it didn't work, so we're not going to offer them any more support.'"

Despite ongoing reservations among some Salem clinicians, demand for addiction services remains high. On many days Tadie and her team were overwhelmed with recommendations.

Four other hospitals in Massachusetts added addiction specialists in the last three years, receiving federal funding from the HEALing Communities study. The project funds a broad range of strategies across multiple states to help identify the most effective ways to reduce drug overdose deaths. These include mobile treatment clinics; road operations teams; distribution of naloxone, a drug that can reverse an opioid overdose; trips to treatment locations; and multilingual public awareness campaigns.

It's a new field, so finding employees with the right certifications can be challenging. Some hospital leaders say they are concerned about the cost of addiction treatment and fear they will lose money on the effort. Some physicians report that they do not want to initiate drug treatment while patients are in the hospital because they do not know where to refer patients after discharge, whether to outpatient follow-up care or an inpatient program. For aftercare, Salem Hospital has set up a so-called “bridge clinic” that offers outpatient care.

Dr. Honora Englander, a national director of addiction specialty programs, said the federal government could support the creation of more addiction counseling services by offering financial incentives - or penalties for hospitals that don't accept them.

At Salem Hospital, some employees are worried about the future of the program. Tadie is starting a new position at another hospital, and the federal grant ended June 30. However, 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 WBUR, NPR and KHN.

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