Strung out in suburbia

Modern Healthcare - - NEWS - By Steven Ross John­son

DOWNERS GROVE, Ill.—It is Tues­day, and not a sin­gle bed is va­cant in the detox unit at Ad­vo­cate Good Sa­mar­i­tan Hos­pi­tal, lo­cated in this mid­dle-class sub­urb about 23 miles west of down­town Chicago. A group of nurses hud­dle around a work­sta­tion to dis­cuss the day’s care plan for each of the pa­tients in the 10 semi-pri­vate and pri­vate pa­tient rooms. While the unit looks like any other med­i­cal de­part­ment in the 333-bed fa­cil­ity, its en­try­way’s large wooden doors re­main locked 24 hours a day. A row of lock­ers in the hall­way out­side those doors adds an ex­tra mea­sure of se­cu­rity for pa­tients and providers.

“When vis­i­tors come, we lock up purses and coats,” said Karen Fer­gle, a chem­i­cal de­pen­dency re­source nurse in the unit. “No mat­ter where you would go at what­ever hos­pi­tal, you will find peo­ple who want to sneak

“When vis­i­tors come, we lock up purses and coats. No mat­ter where you would go at what­ever hos­pi­tal, you will find peo­ple who want to sneak stuff in. If you don’t think that then you need to be ed­u­cated about the dis­ease.”

Karen Fer­gle, shown in back at right in Ad­vo­cate Good Sa­mar­i­tan Hos­pi­tal’s detox unit

stuff in. If you don’t think that then you need to be ed­u­cated about the dis­ease.”

Since 2012, Good Sa­mar­i­tan has been the only fa­cil­ity within Ad­vo­cate Health Care’s 12 acute-care hos­pi­tal net­work with a unit ded­i­cated solely to sub­stance abuse detox­i­fi­ca­tion. All pa­tients who come to the detox unit ar­rive from the hos­pi­tal’s emer­gency de­part­ment, and stay an av­er­age of three days be­fore ei­ther mov­ing on to a treat­ment fa­cil­ity or be­ing dis­charged.

Fer­gle said the goal of the pro­gram is to help those who are at high risk of dy­ing from their sub­stance abuse by put­ting them in a place where they can con­nect with a treat­ment cen­ter af­ter they’ve been dis­charged.

The in­crease in heroin users com­ing to the hos­pi­tal re­flects cur­rent trends in drug abuse in the com­mu­nity. For the past sev­eral years, DuPage County, bet­ter known for its bed­room com­mu­ni­ties and con­ser­va­tive pol­i­tics than its drug prob­lem, has been strug­gling with a rise in opi­oid de­pen­dency. Heroin and fen­tanyl abuse were re­spon­si­ble for 78 over­dose deaths in 2016, a 53% in­crease over the pre­vi­ous year.

“It’s at epi­demic pro­por­tions right now,” said Dr. Dipul Pata­dia, chair­man of emer­gency medicine at Good Sa­mar­i­tan. “We’re see­ing a lot more pa­tients come into the ED be­cause of it and in stronger forms.”

Sim­i­lar sce­nar­ios have played out in sub­ur­ban com­mu­ni­ties across the coun­try. Over­doses from both pre­scrip­tion and il­le­gal opi­oids killed more than 183,000 Amer­i­cans be­tween 1999 and 2015, ac­cord­ing to the Cen­ters for Dis­ease Con­trol and Pre­ven­tion.

The drug cri­sis has grown ex­po­nen­tially in big city sub­urbs in re­cent years. Ar­eas once thought im­mune find them­selves sub­jected to the same so­ci­etal is­sues that were tra­di­tion­ally as­so­ci­ated with hol­lowed-out ur­ban cen­ters or eco­nom­i­cally dev­as­tated ex­urbs.

Such changes have caused a no­tice­able shift in at­ti­tudes about ad­dic­tion in those com­mu­ni­ties as res­i­dents have wit­nessed neigh­bors, friends and fam­ily mem­bers strug­gle with the dis­ease. The grow­ing preva­lence of ad­dic­tion within the na­tional con­scious­ness made the opi­oid cri­sis a top cam­paign is­sue of the 2016 pres­i­den­tial race. Both Demo­cratic nom­i­nee Hil­lary Clin­ton and Repub­li­can nom­i­nee Don­ald Trump called for com­mit­ting more re­sources to­ward in­creas­ing ac­cess to treat­ment.

Grow­ing de­mand to treat the opi­oid epi­demic as a pub­lic health is­sue in­stead of a crim­i­nal one led Congress last July to pass the Com­pre­hen­sive Ad­dic­tion and Re­cov­ery Act in a rare show of bi­par­ti­san­ship.

Prox­im­ity has also af­fected the way health­care providers serv­ing those sub­urbs have ap­proached ad­dic­tion is­sues.

“One of the most stig­ma­tiz­ing groups is the med­i­cal pro­fes­sion,” said Dr. Brian O’Con­nor, founder of Mid­dle­sex Re­cov­ery, a treat­ment cen­ter lo­cated about 9 miles north of Bos­ton.

An OB-GYN by train­ing, O’Con­nor be­gan work­ing in ad­dic­tion re­cov­ery when he dis­cov­ered in 2005 his son

was us­ing heroin. O’Con­nor got cer­ti­fied to pre­scribe the med­i­ca­tion-as­sisted treat­ments methadone and buprenor­phine af­ter a num­ber of his ob­stet­rics pa­tients be­gan hav­ing ad­dic­tion is­sues. “Be­cause it’s so per­va­sive, and it touches so many peo­ples’ lives, I think they see it from a dif­fer­ent per­spec­tive rather than think­ing it is some­body else’s prob­lem.”

O’Con­nor es­ti­mated up to 99% of the 1,000 pa­tients who visit his treat­ment cen­ter are white, mid­dle class, and from the Bos­ton sub­urbs. He said providers in these ar­eas have got­ten more ac­cus­tomed to deal­ing with is­sues re­lated to ad­dic­tion as the num­ber of pa­tients pre­sent­ing such prob­lems in­creased.

“It’s not new in sub­ur­ban ar­eas—it’s been present here, but it truly popped up in the ur­ban ar­eas first and then made its way here,” said Laura Bal­samini, di­rec­tor of phar­macy ser­vices for Sum­mit Med­i­cal Group, a large physi­cian-owned prac­tice in sub­ur­ban New Jer­sey. “Now we’re on a level play­ing ground, only they may have paved the way with some of the strate­gies on how to com­bat it prior to us, and now we’re catch­ing up.”

Sub­ur­ban providers have some ad­van­tages in treat­ing sub­stance abusers. Their pa­tients are gen­er­ally bet­ter ed­u­cated and more aware of the dan­gers posed by ad­dic­tion to pre­scrip­tion opi­oids. As a re­sult, ad­dicted sub­ur­ban­ites are more likely to re­cover than those in more im­pov­er­ished ar­eas where re­sources for treat­ment are scarcer and ad­her­ence to pro­gram treat­ment harder to achieve.

“Sub­ur­ban peo­ple on av­er­age have more re­sources to re­spond to the prob­lem than ru­ral peo­ple,” said Dr. Keith Humphreys, pro­fes­sor of psy­chi­a­try at Stan­ford Univer­sity’s School of Medicine and a for­mer se­nior pol­icy ad­viser to the White House Of­fice of Na­tional Drug Con­trol Pol­icy. “They tend to be more ed­u­cated, have bet­ter jobs and live closer to more health­care pro­fes­sion­als than ru­ral peo­ple. This ex­tra cap­i­tal makes them more likely to re­cover from their ad­dic­tion.”

But the stigma as­so­ci­ated with ad­dic­tion may still cause sub­ur­ban­ites to be­lieve that drug abuse is some­thing that hap­pens some­where else. “If they be­lieve that ad­dic­tion ‘can’t hap­pen here’, they will ne­glect to screen their pa­tients for sub­stance use as they should and re­spond ap­pro­pri­ately to ad­dic­tion when they de­tect it,” Humphreys said.

For a sub­ur­ban provider, such a be­lief could cause them to fail to es­tab­lish sys­tem mea­sures that would im­prove pre­ven­tion and treat­ment ef­forts. “A lot of hos­pi­tals could be do­ing a lot more and they’re not,” said An­drew Weiner, di­rec­tor of ad­dic­tion ser­vices at Lin­den Oaks Be­hav­ioral Health, the men­tal health and sub­stance abuse treat­ment arm of the Ed­ward­sElmhurst Health sys­tem in Naperville, which, like Ad­vo­cate Good Sa­mar­i­tan, is in DuPage County just west of Chicago.

Lin­den Oaks is de­vel­op­ing drug pre­ven­tion and treat­ment stan­dards for the sys­tem. Last year, Lin­den Oaks launched an opi­oid task force that fo­cused on chang­ing pre­scrib­ing habits, in­creas­ing ed­u­ca­tion on ad­dic­tion, re­or­ga­niz­ing a pain clinic and ex­pand­ing ad­dic­tion treat­ment re­sources.

The task force rec­om­mended physi­cians use the state’s pre­scrip­tion-drug-mon­i­tor­ing pro­gram. Lin­den Oaks in­cor­po­rated an alert sys­tem in a pa­tient’s elec­tronic med­i­cal record to let pre­scribers know if a pa­tient has a his­tory of seek­ing drugs. It also in­cluded a pre­scrip­tion for nalox­one, an over­dose-re­ver­sal drug, with ev­ery opi­oid pre­scrip­tion doc­tors wrote. “Treat­ing the af­flicted is one part of the epi­demic, but the other part is con­tain­ing the out­break,” Weiner said.

Only 15% of the pa­tients who come to the detox unit at Good Sa­mar­i­tan each month go on to get ad­dic­tion treat­ment, a statis­tic that is both frus­trat­ing and gives hope, Fer­gle said. The unit works closely with lo­cal re­ha­bil­i­ta­tion cen­ters and 12-step pro­grams, whose mem­bers vol­un­teer their time with vis­its to the hos­pi­tal at least once a week.

Pa­tients who refuse to go di­rectly into treat­ment from the detox unit are given the op­tion of work­ing with a com­mu­nity li­ai­son spe­cial­ist, who fol­lows up with phone calls and one-on-one vis­its af­ter dis­charge. The idea be­hind the pro­gram, ac­cord­ing to Royal Mayer, one of those spe­cial­ists, is to try to es­tab­lish a re­la­tion­ship of trust with the pa­tient that will hope­fully help per­suade them to seek treat­ment down the road.

“For me, it’s just like baby steps,” Mayer said. “This pop­u­la­tion is so dif­fi­cult that you just have to be pa­tient and keep giv­ing them chances.”

The pro­gram’s suc­cesses prompted the hos­pi­tal to in­crease the unit’s in­pa­tient beds to 14 by Oc­to­ber. The model has even caught the at­ten­tion of two other Ad­vo­cate hos­pi­tals, who are con­sid­er­ing de­vel­op­ing sim­i­lar units at their fa­cil­i­ties.

“It’s ex­cit­ing when you can get those suc­cess sto­ries,” Fer­gle said. “That’s life­sav­ing, get­ting peo­ple into treat­ment.”

“It’s not new in sub­ur­ban ar­eas—it’s been present here, but it truly popped up in the ur­ban ar­eas first and then made its way here.” Laura Bal­samini, di­rec­tor of phar­macy ser­vices for Sum­mit Med­i­cal Group

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