Hospitals have many disease specialists, but often not for addiction. Now, that's changing

In late December of 2021, Marie noticed she was having more and more trouble breathing. On the morning of Dec. 28, she woke up gasping for air. Marie dialed 911.

“I was so scared,” said Marie, her voice rising, her hand clutching her chest at the memory. The voice in the 63-year-old's head said, “You’re going to die.”

At Salem Hospital, the staff treated Marie’s COPD, a chronic condition that includes emphysema and chronic bronchitis. A doctor checked in the next day and told Marie her oxygen levels looked good.

We’re not including Marie’s last name because she, like one in nine hospitalized patients, has a history of addiction to drugs or alcohol. Disclosing that can make it hard to find housing, a job and even medical care in hospitals where patients with an addiction may be shunned. But talking to the doctor that morning, Marie felt she didn’t have a choice.

“He said I could be released,” Marie recalled. “And I said, ‘I got to tell you something. I'm a heroin addict, and I'm, like, starting to be in heavy withdrawal. I can't literally move, please don't make me go.’ ”

At many hospitals in Massachusetts and across the country, Marie, while in the pain of withdrawal, would likely have been discharged. A hospital might send Marie on her way with referrals to a detox programs or places she could call for help.

Hospitals typically employ heart, lung, kidney and other specialists. But if your illness is an addiction or a condition related to drug or alcohol use, there are few hospitals where patients can see anyone who specializes in addiction medicine — even as overdose deaths reach record highs. And research shows the impact: an increased risk of fatal overdose within days or weeks after a hospital visit like Marie’s.

“They're left on their own to figure it out, which unfortunately usually means resuming use, because that's the only way to feel better,” said Liz Tadie, a nurse practitioner certified in addiction care.

Tadie launched a new approach at Salem Hospital, a member of the Mass General Brigham hospital network, using a federal grant that others in the hospital worked for several years to secure. Tadie started what’s known as an addiction consult service. In this case, that team included Tadie, three recovery coaches and a patient case manager.

So that day, when Marie said, “Please don’t make me go,” her doctor didn’t tell Marie she had to leave. He called Tadie. She tried methadone, which didn’t help Marie, then switched to buprenorphine, a medication that’s helping Marie manage her addiction to opioids. Marie says she turned to Tadie for lots of support and reassurance as well.

“Like, that I wasn't going to be left alone,” Marie said, “like that I wasn’t going to have to call a dealer ever again, that I could delete the number. I want to get back to my life. I just feel grateful.”

Tadie used success stories like Marie’s to help unravel decades of misinformation, discrimination and ignorance about patients with an addiction and their treatment options. Part of the problem, said Tadie, is that doctors, nurses and other clinicians get very little training in the physiology, medications and other aspects of treatment. And what they do get is often unhelpful.

“A lot of the facts are outdated,” Tadie said. “And people are training to use stigmatizing language — words like addict and substance abuse.”

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

“Sometimes I would recommend a dose and somebody would give pushback,” Tadie said. But “we got to know the hospital doctors and they, over time, were like, “OK, we can trust you. We’ll follow your recommendations.”

Other members of Tadie’s team have also wrestled with finding their place in the hospital hierarchy. David Cave, one of the recovery coaches at Salem Hospital, is often the first person to speak to someone who comes to the emergency room in withdrawal. He tries to help doctors and nurses understand what the person is going through and help navigate their care.

“I’m probably punching above my weight every time I try to talk to a clinician or doctor,” said Cave. “They don’t see letters after my name. It can be kind of tough."

But naming addiction as a specialty and hiring people with training in this disease is shifting the culture of Salem Hospital, according to Jean Monahan-Doherty, a social worker who’s referred patients to Tadie.

“There was finally some recognition across the entire institution that this was a complex medical disease that needed the attention of a specialist,” Monahan-Doherty said. “People are dying. This is a terminal illness unless it's treated.”

This approach to treating addiction is winning over some Salem Hospital employees, but not all.

“Some of the medical staff continue to see it as a moral issue,” Monahan-Doherty said. “Sometimes you hear an attitude of, ‘why are you putting all this effort into this patient? They're not going to get better.’ Well, how do we know? If a patient comes in with diabetes, we don't say, ‘OK, they've been taught once and it didn't work. So we're not going to offer them support again.’ ”

Even with some staff reservations, Tadie and her team have been overwhelmed many days with referrals. That’s the pattern at five Massachusetts hospitals that added addiction specialists in the past three years, funded through the federal HEALing Communities study.

“What starts as a trickle, becomes an active stream and at times, even a flood,” said Dr. Jeffrey Samet, leader of the Massachusetts portion of this national test of tools to reduce overdose deaths. Samet, who practices primary care at Boston Medical Center, says adding addiction specialists in hospitals is a key piece of the solution.

“You really do provide better care for patients and you make the care environment one that people are more satisfied working in,” Samet said.

Dr. Todd Kerensky, president of the Massachusetts Society of Addiction Medicine, sees patients who cry when they learn he specializes in addiction and wants to treat their disease, not shame them.

“It’s gut-wrenching to know there are a lot of institutions that don’t have this service,” said Kerensky. It’s not clear how many hospitals in Massachusetts have addiction experts on staff, but Kerensky says it’s a “distinct minority.”

There are several possible reasons. It’s a new field, so finding certified staff may be a hurdle. Some hospital leaders say they’re worried about losing money on addiction treatment. And others report not wanting to start treatment, because they aren’t sure where to send patients for outpatient or residential care after they are discharged from the hospital. Salem Hospital started what’s known as a bridge clinic where patients transition for outpatient care.

But Dr. Honora Englander, a national leader in addiction specialty programs, says hospitals that don’t have an addiction specialty team need to start one.

“People with substance use disorder are coming to our hospitals now,” said Englander, who directs an addiction care team at Oregon Health and Science University. “We can’t wait. We have to do better, and this is the time.”

Englander says the federal government could support the creation of more addiction consult services by offering financial incentives or penalties for hospitals that don’t embrace them. The Centers for Medicare and Medicaid Services could require that hospitals stock medications used to treat an addiction, and track what happens to patients hospitalized with a substance use disorder as CMS already does for other hospital readmissions.

At Salem Hospital, some staff are worried about the future of their program. Liz Tadie is moving to a new job at another hospital,  and the federal grant has ended. But Salem Hospital leaders say they are committed, and the service will continue.