Inside Saint Francis Memorial Hospital’s frenetic emergency room, near San Francisco’s Tenderloin neighborhood, Dr. Joanne Sun quickly scans the medical record of her fourth overdose patient of the day.
“It seems to me that people are mainly overdosing on fentanyl,” said Sun, the hospital’s emergency department director. “A lot of times they don't even realize that what they bought off the street was fentanyl. Their intent was actually to do crystal or cocaine.”
Fentanyl is a synthetic opioid that’s up to 100 times stronger than morphine, and is now commonly mixed in street drugs.
“I think the pandemic has made everything worse in terms of mental health,” Sun said. “And unfortunately, drugs are going to be a crutch.”
Almost on cue, an older Black man with bloodshot eyes is wheeled through the ambulance bay. He says he intended to smoke crack, but overdosed after unknowingly inhaling fentanyl.
Black people who use drugs in San Francisco are nearly six times more likely than people of other races there to die of accidental overdoses, according to data recently compiled by The San Francisco Chronicle.
That discrepancy can be directly attributed to structural racism, according to the city’s Department of Public Health. “Among the effects of structural racism are years of unjust drug policies that punish rather than offer care, unaffordable housing, poverty, inequitable access to effective treatments for opioid use disorder, and discriminatory practices in the healthcare system,” a department spokesperson said in an email.
San Francisco has one of the nation’s highest overdose rates, with a related death rate more than triple those in Los Angeles and New York. To put that in context, nearly three times as many people in this city died from drug overdoses than from COVID-19 last year.
For decades, authorities have punished people who do drugs, even as the statistics have overwhelmingly demonstrated that such an approach is simply not effective in stemming drug use.
More than 93,000 people in the United States died from drug overdoses last year — an average of about 250 people a day — the highest one-year death toll on record. That includes the most deaths to date from overdoses of synthetic opioids, like fentanyl, as well as stimulants, like cocaine.
The dire situation is pushing policymakers to switch gears and increasingly recognize addiction as a disease requiring medical attention that should be treated in hospitals rather than jails.
“I see us as a bridge,” said Sun. “I definitely see us as a stabilizer. That's first and foremost. We make sure you’re stable. But then I also think of us as a bridge towards social services.”
Treating addiction in hospitals, however, is actually still rare and relatively new. Historically, ER docs have not dispensed evidence-based treatment designed to relieve opioid withdrawal symptoms. Until a few years ago, standard practice was to offer patients something to settle their nerves or relieve diarrhea. And then once stabilized, patients were often sent on their way.
“Essentially you would get handed a piece of paper, and that was your referral to your treatment and good luck,” said Christian Hailozian, a substance use navigator at Highland Hospital in Oakland. “That was essentially it: 'Please don't come back to the emergency department.' That was kind of the way that patients were treated.”
It was an approach that yielded overburdened ERs with revolving doors.
California Bridge, a statewide program developed in 2018, is designed to break this cycle by medically treating opioid withdrawal symptoms inside the ER rather than sending patients elsewhere for treatment, and losing that rare opportunity for face-to-face contact.
“The program creates a seamless continuum of care from the acute ER crisis to outpatient treatment,” said Dr. Andrew Herring, the medical director of Highland’s substance use disorder treatment program. “When you’re dealing with something as tenuous as treatment for opioid use disorder, it’s really the difference between life and death.”
The program, which started as a pilot at eight hospitals across the state, performed so well that the state invested another $20 million last fall to expand the model.
“Patients with addiction come into the ED,” said Skye Christensen, a spokesperson for the program. “They are going to show up there. But how they're treated and whether or not they're provided with ongoing care is central to whether they come back requiring more in-depth hospital resources.”
On a recent morning, a woman named Sonia arrived at Highland’s ER, her nose running and clothes drenched with sweat. (Her last name is not being used because of the stigma of addiction.)
“I've been sick, throwing up from both ends,” Sonia said, her voice shaky. “Last night I blacked out playing bingo.”
An ER doctor quickly determined she was in opioid withdrawal and dispensed a low dose of buprenorphine, also known by the brand name Suboxone. Almost immediately, Sonia brightened up.
The small white pills, one of three medications approved in the U.S. to treat opioid addiction, work by easing withdrawal symptoms and cravings for 24 to 48 hours, a crucial window meant to demonstrate to patients that kicking their habit is possible.
“[Buprenorphine] lowers mortality risk by about 50%,” said Dr. Monish Ullal, an internal medicine and substance use expert at Highland. “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 medications, like buprenorphine, in the ER are twice as likely to remain in treatment a month later than those who only receive treatment referrals. Despite that rate of efficacy, only 3% of ER doctors in the U.S. are trained to dispense the drug, according to a 2020 Yale School of Medicine survey.
One reason for the slow adoption: Many patients and doctors are skeptical of an opioid alternative that may have to be taken on a daily basis.
“Patients will ask, ‘How long am I going to stay on this medication?’” said Ullal. “‘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 the buprenorphine, too.’”
But that’s the case for treating many diseases, Ullal counters, like high cholesterol or high blood pressure.
“People will start taking those medicines and not bat an eye when they take it for the rest of their lives because there's benefit from the medicines and the benefits outweigh the risks,” he said. “And I would say it’s the same thing with this medication.”
Ullal says adopting this approach is treating a substance use disorder for what it is: a brain disease that requires specific medication. And now, California Bridge is training ER doctors across the state to dispense buprenorphine on demand.
A man named Drew, one of Highland’s more regular overdose patients, credits opioid alternatives like buprenorphine and methadone for saving his life. The 36-year-old, with a shaved head and a long scar across his nose, has injected heroin and ingested methamphetamine for 18 years. He says he lives on the streets and has long been estranged from his family — his mom intermittently calls jails and hospitals in Alameda County to make sure he’s still alive.
“I'm not going to lie. I would have definitely stayed using drugs. I wouldn't see the point or put myself through the withdrawals,” said Drew, who recently enrolled in an in-patient substance use program. “The option of buprenorphine is helping a lot of people like me get off drugs. Because it's pure hell for me. I experience withdrawals for like forever.”
The road to recovery is long and fraught, and it often takes a very dedicated person to help those who use drugs break their addiction — the reason why each patient in the California Bridge program is assigned a substance use navigator to help ensure a transfer to long-term treatment after they leave the ER.
Nearly 40% of hospitals across the state are now staffed with a navigator, and the program has a goal of staffing every acute-care hospital with one by 2025.
“Just letting them know it's OK,” said Hailozian, the substance use navigator from Highland. “We got you. That extra kind of hand-holding that these patients need to really start that journey of recovery. You have a disease, we're here to help you.”
Hailozian offers various forms of assistance, from helping a patient get signed up for health insurance to filling a prescription or connecting them to a treatment facility.
Monique Randolph, a substance use navigator at St. Francis Hospital, notes that the personal connection is key.
“I want somebody to be able to walk in that door and not feel alone,” she said. “And not feel judged and kind of know, ‘Hey, I can relate.’”
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