Treat Addiction from

the Emergency room

season 2 Episode 6: Treating Addiction from the emergency room

Emergency rooms are the last safety net for the sickest, most marginalized people. People with addiction often end up in emergency departments following an overdose, during withdrawal, or with other health problems.

A new approach is linking people with addiction to drug treatment, instead of just sending them out the door when they’re well again. Two doctors, one emergency department, a social worker, and a person with addiction in recovery show how emergency rooms can become the gateway for people with addiction to access evidence-based drug treatment and other help they may need.

And how an accident with a broken hypodermic needle in her neck led to one woman's recovery from heroin.

TRANSCRIPT

TRANSCRIPT OF FINDING FIXES: SEASON 2, EPISODE 6

(Click the play button at the top of this page to listen)

Anna Boiko-Weyrauch: This is Finding Fixes, season 2, episode 6. I’m Anna Boiko-Weyrauch. 

On this episode we’re in the deep end of the pool. 

If you haven’t listened to our earlier episodes, you might want to go back and do that first. 

In episode one of this season we talked about how the opioid epidemic is like a swimming pool. 

The first time you take an opioid you enter the shallow end. It’s pretty safe there. The more opioids you take, and the longer you take them for, the further down the length of the pool you go and the riskier it gets.

The folks in the deep end are in a really risky situation. They’re the ones addicted to opioids, and they’re at high risk of drowning. 

But, we can throw them a life preserver to help them swim to safety by providing drug treatment that works. 

On this episode, we hear the stories of two doctors, a social worker, and a person in recovery from heroin. They show how emergency rooms can be an entryway into addiction treatment. 

Quick warning, if you’re squeamish about needles, you might want to skip ahead a few minutes.

Justina Bauthues says she tried to get help. Dozens of times even. But the right kind of help was always out of reach.

Justina Bauthues: I used up all nine of my lives for sure. 

Boiko-Weyrauch: For eight years she was addicted to heroin. Justina was living in her car in Whatcom County, Washington, near the US-Canada border. 

Bauthues: I was stealing food. I was stealing items to sell for my drugs. I was in trouble with the law. As low as you could possibly get.

Boiko-Weyrauch: It left a mark.

Bauthues: I have scars like this all over my body.

Boiko-Weyrauch: She points to her right arm. 

Bauthues: A scar that starts from my wrist to my shoulder.

Boiko-Weyrauch: Injecting heroin with dirty needles gave her abscesses—infections with pockets of pus under the skin that had to be lanced. Abscesses are one way heroin marked her body with scars.

Bauthues: I have them up and down my legs as well.

Boiko-Weyrauch: And one on her neck. It’s pretty subtle, half way up on the right side, nestled in a crease. 

Bauthues: I was using in my jugular because I didn't have any—any other veins left. And the tip of the needle broke off in my neck. 

Boiko-Weyrauch: Justina says, it actually didn’t hurt. 

Bauthues: It didn't feel like anything. Because I like I—I was used to poking myself—I want to say a minimum of 100 times a day. Because of not having anywhere to shoot up. So I—I would dig for hours. 

Boiko-Weyrauch: Luckily, when it broke off, the needle tip missed her jugular and got lodged in the tissue. Justina didn’t go to the hospital right away. She didn’t want to. 

Bauthues: I didn't want to be shamed and because it was a shameful thing. 

Boiko-Weyrauch: Justina says the nurses would frown at her, judge her, there.

Bauthues: So, I actually tried myself to grab tweezers or I don't even know what I was thinking at the time but I attempted to take it out on my own which obviously didn't work and just made it angry and infected.

 Boiko-Weyrauch: Finally her boyfriend said enough is enough. He offered to drive her an hour away to a different hospital in a different county. Justina agreed. They went to the ER at Skagit Valley Hospital where Dr. Shawna Laursen was on duty.

Shawna Laursen: Honestly, I remember the triage nurse coming back and rolling her eyes like, ‘Oh my god. This woman's got a needle in her neck. Here, you do it, Shawna.’ And I'm like, ‘OK. I can do that.’ 

Boiko-Weyrauch: She understands why the nurse rolled her eyes. 

Laursen: You see addiction all the time and you see people with addiction at their very worst. Again and again and again and it's hard to—it's hard to not get a bit jaded and you know a needle in your neck is kind of a big deal.

Boiko-Weyrauch: Dr. Laursen calls that square inch of neck where the needle was “high value anatomy.” It’s filled with important veins, nerves and arteries. 

So Dr. Laursen got an x-ray done. She realized she couldn’t actually remove it herself—it was too risky

Laursen: You always think it's, ‘Oh, it's just going to take me five minutes’ and then two hours later it's like oh it took a whole lot more work than we thought it did because it just seems like it would be easy and it just slips in between tissue planes and you can't find it and then you have to dig through this and then you injure this.

Boiko-Weyrauch: This kind of high stakes, gory problem-solving is what attracted Dr. Laursen to emergency medicine in the first place. Still, she called for backup this time, brought in a surgeon. And she had a conversation with Justina. She knew that after the surgery, Justina would need painkillers. So, she went over Justina’s options with her. 

Laursen: This is the pain medicine that we give you after a surgical procedure. So here you go. However, this is going to be a whole lot better option. Why don’t you think about this?’ 

Boiko-Weyrauch: Meaning, Suboxone. Dr. Laursen suggested Suboxone because it's not only a pain killer, it is also a treatment medication to help people with opioid addiction.

Dr. Laursen was familiar with Suboxone because at the time she had a side job with a private network of addiction clinics, called Ideal Option. Since then, Dr. Laursen has left her job at the emergency department and become the medical director of Ideal Option. 

Back then though, for Justina in that visit to the ER, the way the doctor talked to her, made her feel respected. 

Bauthues: She was encouraging and she had told me I'm too beautiful to die this way and you know she gave me the option of the painkillers that I was gonna get for when I left after surgery and she had set up an appointment for me for aftercare and I had never experienced that before in any other hospital.

Boiko-Weyrauch: This visit to the ER was one of many times Justina and Dr. Laursen would meet. Justina kept going back to get Suboxone. About a dozen times actually. Finally Dr. Laursen convinced her to go to an addiction clinic like she was supposed to.

The connection between them is significant. It’s a significant part of Justina’s story and why she’s not using heroin or living on the streets anymore. Justina got more than medication from Dr. Laursen.

Bauthues: She showed me compassion and love and you know she's the one that pushed me towards getting help for myself for sure. 

Boiko-Weyrauch: What what did receiving that compassion teach you about yourself and caring for yourself?

Bauthues: That I am worth it. That I am worth living and worth the help that she had to offer. 

Boiko-Weyrauch: Because you didn't feel like you were worth it before?

Bauthues: Oh definitely not. I definitely thought of myself as a second-class person for sure. 

Boiko-Weyrauch: How do you think of yourself now?

Bauthues: I'm still learning who I am but I'm liking who I am.

Boiko-Weyrauch: Justina has moved far beyond heroin. When we talked in April 2019 she was rounding the corner on one year off drugs, and working to get her life back on track. In a little bit, we’ll hear the second part of her story and about what recovery is giving her back. 

Usually, patients don’t get help treating opioid addiction in the emergency room. That’s just not how most ERs are set up. Some hospitals are trying to change that, and to see an example, I went to Swedish Hospital in Edmonds, Washington, just north of Seattle. 

(hospital equipment beeping)

Gregg Miller: The sounds that you hear right now, those are very comforting sounds to me. That kind of like that repetitive ‘bing bing’ it's like the little Buddhist bell ringing like ‘I'm still alive. My heart's still beating. There's nothing bad going on.’ 

Boiko-Weyrauch: Gregg Miller is a doctor in this emergency department. He’s giving me a tour. 

The ER is a big open room, with waist-high cubicles and desks in clusters. On every side are rooms for patients with big sliding glass doors and curtains pulled shut. 

Dr. Miller shows me a big screen they use to track patients with what looks like a spreadsheet. It’s pretty busy today, with about 50 patients here. 

Miller: We're seeing somebody with a rapid heart rate. Elderly folks who are weak or dizzy. A stroke patient. One two three four five suicidal patients. One homicidal patient. 

Boiko-Weyrauch: Something you need to know about the emergency department, it’s not like what you see on TV. 

Miller: I think people think about the emergency department like you see on E.R., right? Like, you know, ‘code blue,’ like, ‘Dr. stat, come in here.’ and, you know, ‘This patient's dying.’ but those patients—where it's like the truly traumatic—like their heart has stopped and we shock them and we get them back to life like that's a handful of patients a day, if that. 

Boiko-Weyrauch: Instead, emergency rooms are the last safety net for the sickest, most marginalized people. 

Miller: The people that society has forgotten about, your old neighbor who lives alone and has nobody to care for her or the homeless guy who's out on the streets has no place to get shelter. Or folks who are struggling with behavioral health issues, depression, substance abuse.They're uninsured or underinsured. No clinic really wants to see them. Their families are either nonexistent or have kicked them out. So they've got nowhere else to go. 

Boiko-Weyrauch: Drugs or alcohol lead to a lot of emergency department visits. That’s why getting emergency departments involved with addiction treatment is promising. But they need more than doctors to make it work. 

(doctor talking softly)

In the middle of the emergency department is a small space with a cluster of desks. A doctor leans over the cubicle wall and tells a man at a computer about a new patient. A sixteen-year-old boy threatening suicide.

Doctor: ...history of depression, won't really say if he's had prior attempts.

Boiko-Weyrauch: The man at the computer is a mental health counselor. He takes down the information in an Excel spreadsheet.

Counselor/Doctor: OK, And that’s all I got. All right. Okay. Thanks.

Boiko-Weyrauch: Next, the counselor’s job is to assess the patient, see what he needs and if the hospital or somewhere else in the community can help. He’s one of a few people who work in this little cluster of counselors and social workers. 

Huynh Chhor leads the counseling and social worker team in the emergency department—or E.D. 

Huynh Chhor: We're positioned in the middle of the E.D. so that we can be close to the providers and the nurses. We want to be easily accessible to the team so that if they need our support we can be available to them any time. 

Boiko-Weyrauch: Huynh has been a social worker for nine years. Something always bothered her about the social worker’s job in the emergency department. 

People who overdosed or were withdrawing from drugs would come in, get help, feel better and leave. 

On their way out the door, the social workers would help…a little. They would print out a list of names, addresses, and phone numbers for detox, or drug treatment, or homeless shelters. The social workers would encourage the patients to call those places for help on their own. 

Chhor: I think we saw very quickly that it was ineffective. People kept coming back in the same situation presenting the same way. And I think the work became very disheartening. It was really hard to see people returning in the same condition and not being able to help them in the way that we knew they could be helped. But we didn't have the resources to really follow these individuals in the community. 

Boiko-Weyrauch: Also, Huynh says this is how emergency department social workers are taught: your job ends when the patient leaves. 

But she wanted more for patients. So did Gregg Miller, the emergency room doctor showing me around. Gregg and Huynh started working together, got some grants, and put programs in place in the ER to better help opioid addicted patients.

Chhor: Now we're really integrating substance use disorder treatment and interventions and assessment into our process so that everybody who wants to be seen by a social worker can be seen by one. And the connections that we're helping to make are not just to resources but people. People who can follow people throughout their recovery process no matter where they are. 

Boiko-Weyrauch: Huynh and her staff don’t just give out lists to addicted patients anymore. They make phone calls, make introductions to other people and organizations who can help patients get a bed at a drug treatment program, a ride, food, and even a place to stay.

If a patient wants it, doctors will prescribe opioid treatment medication in the ER, and then the social workers will make follow-up medical appointments, even the same day, at an addiction clinic. 

The social workers can even get the patients cell phones to stay in touch with their doctors.

The Swedish Edmonds Emergency Department is now basically the door into a bigger network of health care and service providers throughout the community that can help—if the patients decide to accept it. 

I saw the first part of that process when I was visiting the emergency department. 

Miller: Do you want to talk to a paramedic about…

Boiko-Weyrauch: Dr. Miller and I walked by a few paramedics

Miller: Hey can I ask you a favor? I'm one of ER docs. 

Boiko-Weyrauch: He asked if they would talk to me about the opioid epidemic

Paramedic: Oh we just brought one in. 

Miller: Oh, OK.

Boiko-Weyrauch: And they said, they just brought in a patient who had overdosed. 

Kristen Hammersmith: She was laying in some dirt and pretty pale gasping for air. Not conscious. Trying to breathe. But couldn't do it. 

Boiko-Weyrauch: Kristen Hammersmith is a firefighter EMT with South Snohomish County Fire. 

Hammersmith: We moved her out of the soft ground, put her on to the concrete. We got oxygen and a bag valve mask going, check for pulses first. Then once we realized we actually did have a pulse, we started breathing for her putting the oxygen in her body and then we got a chance we gave her some Narcan, and gave her an I.V. and some more Narcan and then she was breathing on her own. 

Boiko-Weyrauch: The EMT says it was the second overdose she responded to in less than five days. 

Boiko-Weyrauch: So the woman who came in what's going to happen to her next? 

Miller: Yeah. So she's going to be observed for a couple hours or and at least an hour. So we'll keep an eye on her—make sure that once the Narcan wears off she—she still stays awake. 

Boiko-Weyrauch: Once she’s totally awake, she’ll get a visit from a doctor, and then the social workers. They’ll talk to her about whether she’s interested in taking treatment medication and going to an addiction clinic when she leaves. The social workers will tell her what other help is available in the community. 

What happens next is totally up to her.

Miller: A lot of times this is not the patient that’s really is looking for help. The folks who have an acute overdose don't think they have a problem or just aren't ready to deal with the opiate issues. And so a lot of times they decline treatment and just kind of go on but you at least start the conversation. You know you let them know that there are options out there for them and that when they're ready, come on back we'll be happy to help you out. 

Boiko-Weyrauch: But once the patient leaves the ER, they’ll get a phone call from a social worker to check up on them even if they didn’t accept any help.

Dr. Miller is the first to say this is not the most effective way to get a lot of people into drug treatment. 

A few numbers. For the first eight months of 2019, the Swedish Edmonds Emergency Department helped over fifty people start taking Suboxone in the ER. After they left, over sixty percent of those patients showed up at their follow-up appointment at an outside clinic. That’s a few dozen people

For the patients who do start on medication in the ER, some research shows it can really help. 

In 2015, a study done at Yale looked at people who started taking Suboxone during an emergency room visit. The study found that 78 percent of these patients were still getting that drug treatment a month later. 

But back to this one hospital for a moment. For this group of doctors and social workers, it’s about opening the door. Huynh says even if it just helps one person, it’s worth it. 

Chhor: Even patients who are unwilling to accept additional resources will tell us, ‘I'm really grateful that you called.’ They'll tell us that it means a lot to know that there are people thinking about them people who care about them enough to do that. And so I think any step that we can take towards someone's recovery is worthwhile. And that phone call could be that one thing that they remember the next time to know that we're safe people and we're people who are willing and ready to help them, and when they need that help, they can come back. 

Boiko-Weyrauch: Before you said that the traditional way of doing things was very disheartening. How do you feel now about it?

Chhor: Very hopeful. And the—our team feels the same way. We’ll send each other emails and I just sent one to staff this morning because I made that phone call to assist one of the patients to get to her appointment and I said I haven't felt this way—like this good—in a long time. 

Boiko-Weyrauch: It’s a chance for her patients to change, and another chance at life. 

This program relies on its social workers. Dr. Miller said he knows small hospitals may not have such a large staff. So, he suggested I talk to someone from a company trying to fill the gap. 

Jonathan Ciampi is the CEO of Bright Heart Health. The company connects patients and doctors over video conferencing.

Jonathan Ciampi: Are you on a tablet, a P.C., or a— 

Boiko-Weyrauch: That’s how he and I spoke, too. It looks like Jon’s sitting in a conference room. But that’s a virtual backdrop, he changes it with a click.

Ciampi: So I can be in San Francisco. I can be in the snow. Wherever you want to be. 

Boiko-Weyrauch: Jon’s company is one of about half a dozen like it that use this kind of video conferencing for addiction treatment. Many accept insurance and medicaid. Bright Heart Health works with patients coming out of emergency departments in California and Washington state.

Ciampi: If you're in an emergency department and they connected you, you can literally go right to our website and connect to somebody who would talk to you just like this.

Boiko-Weyrauch: Patients on the addiction medication Suboxone have to check in with a doctor pretty frequently to get the meds. 

Jon says the online video platform makes it easier for patients to actually show up for the appointment. Patients can see a doctor outside of normal business hours. And they don’t have the hassle of going in somewhere, because they can do the appointment from home. 

Ciampi: People have the sense of security they’re in their, like right now you're sitting on your own couch you may have a cat or a dog that's personal to you that you really like to have around you, you still have that animal with you. You don't feel in any way a threat even though we may be talking about something that is highly stigmatized out in the in the normal world. 

Boiko-Weyrauch: As one example, Jon says Bright Heart Health is working with the Community Hospital of the Monterey Peninsula in California. So far, since 2018, 50 patients have been referred to Bright Heart Health and over 80 percent actually showed up for an appointment. Those numbers as of July 2019. Jon says, the company is trying to improve those results. 

(Announcement over hospital intercom)

Boiko-Weyrauch: Back to the Swedish Edmonds Emergency Room for a moment—we hear an alert

Hospital Intercom: Code STEMI

Boiko-Weyrauch: Dr. Gregg Miller says that means someone is having a life-threatening heart attack. A man wearing scrubs strides by. 

Miller: That's one of the cardiology team going over right now. 

Boiko-Weyrauch: He's kind of sauntering. I thought you said he was going to rush. 

Miller: That's fast. That's fast for the ER. You always want to make sure your heart rate is slower than the patient’s. If you show up and your heart rate is going faster than the patient’s you’re in no shape to actually make good decisions. 

Boiko-Weyrauch: Dr. Miller turns this emergency into a teachable moment about the opioid epidemic. 

Heart attacks kill far fewer people today than in past decades. This year, approximately 60,000 Americans will survive heart attacks that would have killed them in 1995.

Dr. Miller says so many people are surviving heart attacks because paramedics and hospitals have invested in coordinating their efforts, and average people are trained in CPR. 

Miller: So there's a really good chance that if somebody drops dead in a public area they're going to be resuscitated and survive. And hopefully we'll see that same effort with the opiate epidemic like somebody is going to drop from an opiate overdose. The community is going to be trained in Naloxone and they're going to have access to Naloxone they're going to call 9 11 the patients can come into the emergency department. We're going to be hooked up with this outpatient treatment network. We're going to be able to get those patients into treatment so that long-term they survive. It took a lot of resources and investment for us to get there with cardiac arrests and it's gonna take a lot of resources and investments which are already being made. And I think it's an exciting time we're at the beginning of that here and with the American opiate epidemic and hopefully it'll change. I mean I think things will get better. 

Boiko-Weyrauch: Next, we’re going back to Justina—who you heard from at the beginning of the episode—to see how connecting with compassionate people in the ER made all the difference. 

(dishes clattering)

 Laursen: All right. Are we going to eat first? 

Boiko-Weyrauch: Yes. We’re gonna eat first.

Laursen: OK. Good. 

Boiko-Weyrauch: I met Justina and Dr. Shawna Laursen at the doctor’s house for lunch. 

Dr. Laursen’s a nice person, but she’s also super busy—so this was the best way for her to squeeze in an interview. In between her shifts at the ER, she made us all baked potatoes. 

Laursen: I have to admit, I love butter, I love sour cream.

Bauthues: Oh, me too!

Boiko-Weyrauch: That’s where I interviewed Justina, too. Dr. Laursen’s house is half-way between Seattle, where I live and a small town on the US-Canada border where Justina is. 

In April 2019 when we met, Justina had been on Suboxone and off heroin for almost a year. 

Justina was still dealing with the consequences of her chaotic past. She recently got out of jail, serving time for stealing a Fitbit from a Best Buy. 

She was living in a motorhome parked in her parent’s driveway. Her parents were taking care of her 10-year-old son. They all shared the common spaces in the house and spent time as a family. 

Bauthues: I'm happy. I’m—I'm living a normal life. I have my family. I'm allowed in my family's home. I eat three meals a day. I can go shopping without having the—the thought of needing to steal something for my next fix. I'm just—I’m normal. 

Boiko-Weyrauch: At the time we met, Justina didn’t have her driver’s license, so her parents drove her down for the interview. 

Bauthues: I see Mom and Dad cruising up and down the street.

Boiko-Weyrauch: As we were talking, she spotted them waiting to pick her up. 

Bauthues: They're knocking. It's my parents. 

Laursen: Oh, oh! 

Justina: You want me to go grab them?

Laursen: Yeah, go ahead and have them—have them come on up.

Boiko-Weyrauch: Justina’s parents Lisa and Tom Hilton came in to say hello. They’ve been through a lot. 

Lisa Hilton: It's been very hard. Heartbreaking. And I'm going to get really emotional.

Boiko-Weyrauch: This is Lisa Hilton, Justina’s mother. She says Justina’s addiction has affected her in a lot of ways: sleepless nights, worse health, and what she calls a “hardening.”

L. Hilton: They judge my husband and I and they think, ‘Oh, what did you do as a parent to make your kid that way?’ You know and then you wonder yourself, ‘What have I done? You know, that made my daughter that way? Did I do something?’ And it—and so it hardens you. 

Boiko-Weyrauch: Now they’re rebuilding their relationship with their daughter. 

L. Hilton: Trying to put the pieces back together, trying to gain trust. I think things are looking brighter for us and her. 

Boiko-Weyrauch: She says her daughter is back again—now she sticks around. 

L. Hilton: I mean it used to be, ‘I have to go I have to go. I have to go.’ And yeah. So it's nice to see her smile. Yeah. Willingness to help out. Just having her there. 

Boiko-Weyrauch: Also, Tom chimes in, ‘hugs.’ They weren’t really a touchy-feely family before. Now they try to hug once a day.

Tom Hilton: We still have to work on a lot of that and we give a hug before we—we depart from each other and I think there's a lot to that and that stimulus from you know just just the physical contact and I tell you, ‘I love ya’ and we get more of that now. So it's great. (laughs)

Boiko-Weyrauch: Getting off drugs is not about hitting bottom. For Justina, it wasn’t that a needle got stuck in her neck, it’s who she met.

Dr. Shawna Laursen. An ER doctor, who well before she met Justina, embraced a personal mission not to get jaded. 

Laursen: I consciously sat down and I'm like, you know, ‘I give you’—speaking to myself—‘permission to spend all the time you need with at least one patient a day.’ To be completely compassionate and actually connect with them at a personal level because it's what I need as a physician. And I—and I started doing that and I definitely do that far more than one patient a day now, but it's a learning process and how to do that and how to still meet all of the other goals and requirements—when there's 20 people waiting, there's 20 people waiting and they don't really care that you're connecting with anybody. But if you don't do that, you lose your humanity and you lose why you want to be a doctor and you're not very effective.

Boiko-Weyrauch: Emergency departments at hospitals get the brunt of the hardest patients with the most intractable issues, such as mental illness and substance abuse. On this episode, we learned how a new approach is linking people to treatment, instead of just sending them out the door. 

For Justina, in the end, her injury connected her to resources to stop using drugs, and it connected her to people with a compassionate message, that she deserved to live. 

One final note: A few days before this story was released in November 2019, the union that represents many healthcare workers at Swedish hospitals voted to authorize a strike. That includes emergency room social workers.

As of November 17th, the union called SEIU had not announced when or if they would strike. The union and Swedish have been in contract negotiations since April 2019—which is after I visited the emergency department and recorded the interviews in this episode. As a reporter

for public radio station KUOW in Seattle, I covered the story of the strike vote for local audiences.

Next time on Finding Fixes:

A group of mothers who bonded over some tough experiences.

Henriët Schapelhouman: You realize that normal people don't have conversations like this and do not laugh about looking for their children in the middle of the night which would make us laugh some more. 

Boiko-Weyrauch: When your child is addicted to heroin and what you can do. 

Finding Fixes is a project of Investigate West, a nonprofit journalism organization working in the public interest. 

Financial support comes from the Philadelphia Foundation, Moccasin Lake Foundation, and listeners like you. And if you’d like to support this podcast, make a tax-deductible donation at FindingFixes.com. 

While you’re there, you can drop us a note or you can send us an email at fixes@findingfixes.com.

This episode was produced and reported by Nicolle Galteland and me, Anna Boiko-Weyrauch, and edited by Alisa Barba. Music by Jake Weholt.

Special thanks to everyone we talked to in this episode. And thank YOU so much for listening.

If you want help finding local drug treatment, support groups, or organizations in your community for yourself or someone else, you can call 1-800-662-HELP (4357) and speak with someone at the national helpline run by SAMHSA, the Substance Abuse and Mental Health Services Administration. It’s free, confidential, and open 24 hours a day/365 days a year, available in English and Spanish. More information here.