Kathleen Creech knows who’s calling when her phone rings hours before the sun rises. It’s the call center from Project Relay, telling her that a patient suffering from a drug overdose has arrived at (or is on their way to) St. Barnabas Hospital. Receiving little information beyond the names of the patient and emergency medicine physician, she is expected to get to the hospital within an hour.
“The patient may not be conscious when I arrive, and so I might be the first person they see when they open their eyes,” she says. “I congratulate them on making it. Yes, they know why I’m there.”
As a wellness advocate with the New York City Department of Health and Mental Hygiene’s two-year-old Relay program, she fields these calls two overnights a week and on weekends. Like others in her position, she has personally lived in the shoes of these patients.
A TONE OF COMFORT
“I use a tone of comfort,” she says, in discussing how she speaks to them. “It’s important for them to hear a voice of trust and comfort, not judgment. They know I’m not selling anything. I try to reassure them that everything will be okay. Most of them are willing or have some kind of willingness to change.”
The emergency departments at St. Barnabas Hospital and other institutions in the Bronx command the front lines in the city’s ongoing war against the opioid crisis. Here, professionals like Dr. Howard Greller, an SBH emergency medicine physician and its director of Toxicology, witness first-hand the devastation caused by the drug addiction epidemic.
“This crisis impacts everyone, regardless of age, sex or background,” said Dr. Greller in August, in testimony he gave before the Joint New York State Senate Task Force on Opioids.
He specifically discussed two separate incidents – both involving infants who had been rushed to the hospital’s ER after ingesting opioids. “At SBH, we are addressing this with multiple interventions.”
St. Barnabas is the busiest site among the 12 hospitals presently involved in Relay. This is hardly surprising as the hospital sits in an area that has the city’s highest incidence of drug overdoses and overdose mortalities. While the number of drug overdose deaths decreased citywide in 2018 for the first time in eight years, that number actually increased in the Bronx by 29. According to the health department, the Crotona-Tremont and Hunts Point-Mott Haven neighborhoods have more than twice the citywide average of drug overdose rates. The use of fentanyl has become a huge problem because of its ubiquity in other drugs, as has the increase in the use of drugs like cocaine and methamphetamine.
Relay is a program targeted to those survivors of non-fatal opioid overdoses. Once revived with Narcan (naloxone), an opioid antagonist used to reverse opioid overdose, patients receive 24/7 access to wellness advocates like Creech, all with first-hand experience of substance use. Creech visits patients that first night – meetings may last anywhere from several minutes to the entire night. She may discuss with them such things as detox centers, homeless shelters, domestic violence or needle exchange. She dispenses a care bag that typically includes a toothbrush, toothpaste, a candy bar, a Metro card, a booklet on Relay, and a referral to detoxification. She may sit with a family member to put an arm around their shoulder and give them hope for the future.
Meanwhile, she says, “The patient is listening. You can see in their eyes that something clicks.”
She then hands the patient off to a colleague who will stay in close contact for the next 90 days. This may include accompanying them to detox and/or legal visits and boosting family members and friends in need of emotional support.
HARM REDUCTION
Relay employs a harm reduction strategy that is focused on the next steps of care. The hospital ER, explains Dr. Greller, is “a point of contact that encounters patients where they are most vulnerable and potentially responsive to taking the next step.” He and his team try to make a “warm handoff ” to Addiction Medicine services at the hospital for ongoing outpatient treatment.
The power of the Relay program, of course, resides with the wellness advocates. Creech says she changed her life 28 years ago and “hasn’t looked back since.” Although her drug of choice was different, she takes the tools she learned in her personal experiences to help others. “I can’t identify with the drug, but the pain I can relate to,” she says. “People in my circle were dying every day. I think about how many people would have survived if Narcan had been in existence back then. It’s the best thing since penicillin.”
Dr. Greller sees the benefits of Creech’s work all the time. “The shared experience with a peer advocate can build the bridge to care better than I can in my white coat,” he says. “The number of patients who have been engaged is significant.”
Since the program launched in January 2018 through November 2019, SBH has engaged 381 patients and distributed 694 naloxone kits to Relay patients and their friends and families. The program intends to have 15 hospitals in New York City enrolled by June 2020. According to Angela Jeffers, director of the Relay program, while “it is too early to measure long-term outcomes, one of the benefits at SBH indicates that we are reaching a population that is not being serviced by other service programs.”
Since January 2019, SBH has become involved in the state Department of Health’s Opioid Overdose Prevention Program (OOPP). Its goal is to distribute naloxone kits to people throughout the community. Dr. Greller and other medical professionals at SBH are responsible for “training the dispensers,” the dispensers being those in the community who receive the kits. “This includes teaching them what opioids are, what naloxone does, how to recognize if someone overdosed and the necessary steps to take,” says Dr. Greller. Close to 200 staff members at SBH have been trained to date, he says, with kits handed out to community members on a daily basis.
THE LANGUAGE OF ADDICTION
Dr. Greller stresses the importance in using “patient-centered” language when discussing opioid use disorders. This is something he says he works constantly on reinforcing with residents and staff. “If you talk about someone in bed 6 as a heroin addict, that dehumanizes them and labels them and so you may not think of that patient as a person with a story,” he says. “We wouldn’t stigmatize a patient with diabetes as an ‘insulin addict.’ If they eat too much sugar, we wouldn’t treat them punitively. Yet, we tend to do this with people with opioid disorders.”
He discusses this subject on a recent episode of The Dantastic Mr. Tox & Howard, a podcast he co-hosts. Featured is an interview with an old friend of his, Bill Kinkle, a former nurse and paramedic, who struggled for years with opioid use disorder that led to prison time and homelessness before he turned his life around.
“If you say ‘I have this 42-year-old drug addict, the images are different than a 42-year-old with a history of substance use disorder now in remission,” Kinkle says. “Compare ‘She’s an alcoholic, a drunk, she’ll never get clear or stay on the wagon,’ with ‘She’s a person with alcohol abuse disorder, who has a great chance for sustained recovery with appropriate care and treatment.’”
Adds Dr. Greller, “The way you speak about people influences your behavior consciously or unconsciously. People practicing healthcare need to understand this.”
As a physician at a hospital in the epicenter of the drug epidemic, he admits how challenging the effort can be – in terms of both combating the problem and getting people to view it in a different light. “Every day is a bit of a fight to make the appropriate changes needed to get people better,” he says. “I’ll settle for a little bit better every day. It takes time.
“It’s like steering an oil tanker. You’ve got to start turning miles before you get there.”
Governor Andrew M. Cuomo unveiled the second proposal of his 2020 State of the State agenda: legislation banning fentanyl analogs — a deadly synthetic opioid that is 50 to 100 times more potent than morphine — by making them subject to the same criminal sale or possession penalties as other controlled substances. The legislation will also empower the New York State Health Commissioner to ban any new fentanyl analogs that have been added to the federal schedule of controlled substances, allowing the State to deal with these deadly substances in real time rather than play catch up. The Governor will also propose a series of actions to expand access to medication-assisted treatment for opioid use disorder in hard to reach communities. Medication-assisted treatment entails using medications in combination with education and counseling to treat substance use disorders.
