Joey Wahler (Host): A look at substance abuse on this episode of Curating Care, a podcast brought to you by St. Clair, health expert care from people who care. I'm Joey Wahler. Well, September is National Recovery Month. When it started in 1989, the goal was promoting and supporting new evidence-based treatment and recovery practices, the nation's strong and proud recovery community, and the dedication of service providers and communities who make recovery in all its forms possible. With us are two St. Clair Hospital physicians aiming to increase public awareness surrounding substance use disorder treatment and recovery. Our guests indeed are Dr. Julia D'Alo, she's an emergency medicine physician at St. Clair Hospital, as well as Chief Medical Officer at Gateway Rehab; and Dr. Kristen Livesey, she's a physician hospitalist at St. Clair Hospital. Thanks to both of you for joining us.

Kristen Livesey, MD: Hi. Thanks for having us.

Julia D'Alo, MD: Really excited to be here.

Host: So first, for you, Dr. Livesey, how prevalent is substance abuse these days? Of course, we all hear about it practically our entire lives. But at the moment, how prevalent and have you noticed from your experience any trends or changes over the years, especially of course, since the pandemic?

Kristen Livesey, MD: I work as a hospitalist at St. Clair. I treat a variety of patients that are admitted. Sort of anecdotally, we have certainly seen a lot of changes through the pandemic. The pandemic impacted every aspect of our patients' lives. They've lost loved ones, lost jobs, they become more isolated, they have limited access to healthcare. And we've ultimately seen what is an epidemic inside the pandemic with a rise in substance use, a rise in substance use disorders, overdoses. We don't necessarily have the full picture yet. But some data at least from 2021 suggests that in the beginning of the pandemic, there was a 40% rise in opioid-related overdoses and a 30% increase in opioid-related deaths. And that's been fairly consistent with what I've experienced in the hospital setting and why it's so important and we're so grateful to talk about this today because it's really something that hits home for our community.

Host: Absolutely. So first for you, Dr. D'Alo, St. Clair Health has a partnership with Gateway Rehab, helping patients with substance use disorder to get treatment. So, can you tell us please a little bit about that relationship and what that process in a nutshell looks like for a patient?

Julia D'Alo, MD: Yeah. So, I mean, first a tiny bit of history, St. Clair Hospital recognized a critical need within the community and was determined to deepen its commitment to help people with substance use disorders. So Dr. Alan Yeated, St. Clair CMO Emeritus and member of the Board of Directors and Community Benefit Committee, formed a small work group and was tasked with finding a community partner and developing a program. So, a long process ensued and Gateway Rehab was the partner that St. Clair ultimately chose. So, months of collaboration between the two organizations resulted in the program that exists today. But the program inception was actually January 2019. It centers on and around a certified recovery specialist.

So, a certified recovery specialist is a person who is certified, so they are credentialed. They have personal lived experience with their own substance use disorder recovery. So, they are in long-term recovery themselves. They're able to offer insight into recovery process based on their own experiences. And because they've been right where that patient is at in that moment, they have this sort of unique perspective that allows them to function as a motivator, role model, advocate, mentor. So, the close collaboration between St. Clair and Gateway continues and the program improves and the community benefits as a result of that.

The process, for what it looks like for the patient, is really any patient throughout the St. Clair health footprint can benefit from the service by any staff member calling the CRS. So, 24 hours a day, they can call the CRS seven days a week and the certified recovery specialist will respond. So, any nurse, social worker, care coordinator, physician can make this call, and we have a full-time CRS named Jo who's housed at St. Clair Hospital. She wears a St. Clair badge, and although she's a Gateway employee, she's very much part of the St. Clair team. So, she responds to the request of the employee by seeing the patient. She arrives at the bedside of the patient. And she assesses, supports, motivates and helps in any way that she can. And then, she remains engaged with those inpatients by rounding on them on the inpatient units in the emergency department, the behavioral health unit, wherever she's needed. And she tries to keep people kind of on track with what their goals are. She tries to motivate them to enter into some level of treatment.

Host: And as you touched on, oftentimes it seems, doesn't it, that substance abusers who go on to treat others for that, they often make the best people in that field, don't they?

Julia D'Alo, MD: They do because they can really relate. I think what's sometimes hard is these patients with substance use disorders, they're very much misunderstood and they're sort of considered responsible for a lot of bad things that are happening in their lives. And they are. But there's a lot more to it. It's their disease that is really contributing to a lot of the behaviors. And because of that, even in a healthcare system, they can face a lot of stigma and they can have a lot of trouble relating to the healthcare provider. So, the CRS sort of can bridge that gap. They can talk to the healthcare provider and they can talk to the patient and they can try to get that patient ready and motivated for change and recovery.

Host: And just remind us, please, CRS stands for?

Julia D'Alo, MD: Certified recovery specialist.

Host: So back to you, Dr. Livesey. Why do you think it's important for substance use disorders to be treated in hospitalized patients?

Kristen Livesey, MD: We are incredibly grateful to have the partnership that we do with Gateway. The reason it's so important is, when a patient comes in with a substance use disorder, they're coming to the hospital for another reason. Maybe they have an infection, maybe they're withdrawing from a substance, and they're a very vulnerable, high-risk patient population. They're at higher risk of infections. They have a higher risk of death after leaving the hospital. So, any patient that comes into the hospital identified who has an opioid use disorder, they have a 10% risk of dying within the next year. And to sort of put that into perspective, that's pretty comparable to patients that have heart failure, that have been admitted with a heart attack. And for those patients, we're very structured. We have lot of evidence on what is the best practice medications that patients should be on when they have those medical diagnoses and what kind of followup do they need. And I'm not sure we think about opioid use disorders in the same way. It's important to identify those patients. It's important to provide treatments to them and leave the door open for ongoing medical care. If a patient is withdrawing from a substance and they're admitted for another reason, they have difficulty staying in the hospital because they feel terrible. They want to leave the hospital so they can go use and not feel miserable while they're here and we might not be able to treat them.

One of the analogies I think as helpful is sort of thinking about diabetes. So if a patient came in with an infection and they have diabetes and their diabetes was poorly controlled, we wouldn't really be able to fully treat that infection unless we gave that patient insulin. So, thinking about the patient that comes in with an opioid use disorder, if they come in with an infection, say an abscess from using IV drugs, if we just focus on the infection and just treat that infection without the reason they developed it, we're not ever going to be able to appropriately treat that patient.

Host: Gotcha. So obviously, it's a matter of wanting to seize this opportunity when the time is right to take care of everything that needs to be addressed under one roof.

Kristen Livesey, MD: And I think the other thing that's very important is sort of leaving the door open. That patient. That may not be the first or last time they make contact with a healthcare setting, and we want it to be a place where they feel welcomed, that they can receive care, and even if maybe they're not ready to initiate their road to recovery, at least if we create an environment where the patient feels safe, they might come back another time when they feel comfortable and ready for help.

Host: Right back to you, Dr. D'Alo. And I understand since your last community health needs assessment, you and yours have engaged with more than a thousand patients, with one-third of those entering treatment. So, tell us please about the success of this partnership since its inception.

Julia D'Alo, MD: Since the start of the program, the Gateway CRS has engaged with actually over 1,500 patients, with an average response time of eight minutes in the last quarter, meaning we pick up the phone, we call the CRS and they're at the bedside within eight minutes. And in the last quarter, we actually had 40% of patients who spoke with the CRS access some type of behavioral health treatment.

Most of that treatment is residential, like inpatient rehab or withdrawal management/detox. That's where we actually help people come off of the substances that they are dependent upon in a comfortable manner and then inpatient rehab being where they learn some life skills and ways to avoid ongoing drug use in the future. It shouldn't really be that interesting because the majority of these patients have alcohol use disorder, which is actually more prevalent in our society than actual opioid use disorder. And it also results in significant morbidity and, of course, there are more overall deaths from alcohol than even opioids. But we have captured a lot more people and helped them link them to treatment with the help of this program.

Host: Now, Dr. Livesey, I guess one thing that hasn't changed over the years is the stigma associated with substance use disorder, both among healthcare providers and patients as well. So, simply put, how do you address that?

Kristen Livesey, MD: I think it's a complicated question. So certainly, stigma is probably the number one barrier for patients to receive the help that they need. So, it's a challenge. We're certainly committed to trying to do what we can to manage stigma. And I think it's really thinking about the patient in front of you. And it's thinking about the language that we use and thinking about the human being separate from the medical diagnosis. So, there is a person in front of you that has a substance use disorder, rather than thinking of the person as an "addict." It's change in language and it's reframing, like I had mentioned, thinking about what is the reason the patient is here and what are the factors contributing to it that we can help with rather than just seeing them as that person with, substance use disorder.

We have ongoing education that we provide for nurses, for physicians, for our social workers. There's ongoing education in terms of grand rounds. We have informational videos. Dr. D'Alo and her team has been very helpful as well. Jo, her presence on campus is helpful as she is a person in recovery who has gone through this. And I think keeping the patient at the center of this is what helps and seeing a person who we know has gone through recovery takes it home and keeps the patient at the heart of all the efforts that we have.

Host: Well, you mentioned education there. And just to follow up on that, how about what steps are being taken to enhance education and training staff regarding substance use disorder overall? And of course, addiction management as well, how about that?

Kristen Livesey, MD: One of the things that we're really proud of, actually, is we looked at specifically our opioid withdrawal treatment pathway, so that's It's an area where we've been putting a lot of our efforts. So, we talk to local experts, we've involved our pharmacists, we've involved Dr. D'Alo, as a representative of Gateway in terms of how can we revamp the opioid withdrawal pathway that we have in the hospital. So, it's thinking about how we screen patients in a compassionate, appropriate manner. It's educating our nurses, our physicians on how to screen that patient for a use disorder, how to appropriately treat them for a use disorder. I think physicians, nurses, social workers all become more comfortable the more patients that they see engaging in the system and the more successes they see in terms of patients that have moved through their recovery.

Host: And then, in summary here, back to you, Dr. D'Alo, can you share maybe one example, please, of personal insight or perhaps an experience you've had that has helped shape your own personal approach to treating substance abuse over the years?

Julia D'Alo, MD: Now, I would say just generally speaking what I've learned is the very most important thing that I can do as a physician facing a person suffering with any disease, but specifically the disease of addiction is to show them love and compassion, you know, understanding of where they are in that moment. I always like sit close to them. I try to hold eye contact with them. You know, there's a lot of shame that comes with this disease and I find like if I can connect with them, they trust me and they'll listen to what I, say. I start by being light and friendly. I remind them that I'm on their side, that there's a better life waiting for them when they feel ready to pursue it. And I always remind them that recovery is very possible. They may have experienced some recovery in their own lives and some time of sobriety. But I acknowledge it takes a lot of work and I assure them that I can help separate them from their substance and keep them comfortable. We have the ability to do that in the hospital. We have the ability to do that at Gateway. And I just tell them that their life has value, that they matter, that they're worth it. And I tell them that we'll be with them through the whole process, and I find that this is more important than just about anything, you know, even a medication that I can offer. I mean, there are certainly medications that are very useful in the treatment of opioid use disorder and there are lots we can do for people. But I think the starting point is just telling them they need to start by the process of forgiving themselves. They need to kind of leave the shame behind and they need to start the journey, knowing that sometimes it's minute by minute or hour by hour. But in the end, it can add up to a lifetime of recovery and that's really the life they're meant to live.

Host: Indeed. Well that's very welcoming sounding, to say the very least. Do you want to maybe chime in on that, Dr. Livesey? How about from your standpoint?

Kristen Livesey, MD: I think from a personal perspective, I am passionate about this because probably over a decade ago, when I was a resident, one of the most impactful patients I had was a patient who walked in to my resident clinic that I saw during my first year. And I walked that patient through his recovery. He was ready at that time to engage. He had an alcohol use disorder. And I just saw his life change over the period of those three years. he was very fortunate. He had a supportive family that was involved. I can't take credit for him being ready at that time and changing, but I was there with ears. I was compassionate. I was someone who wasn't there to judge him and just leaving the door open is what helped him eventually achieve his recovery.

And I think to Dr. D'Alo's point, there's a lot of shame and stigma associated with use disorders. And, you know, it's not really our place to judge why that patient has a use disorder. I'm sure we don't understand half of what happened in that person's life that led them down the road of substance use, and just knowing that there's somebody here to listen and wants to help them and will be supportive on their journey.

Host: Yeah. It sounds like often what these patients need as much as anything from what the two of you are telling us is just for somebody to reach out and let them know that they care and that they're there to help and not to judge. So, congrats on doing that part of the job so well. Folks, we trust you're now more familiar with substance abuse recovery, Doctors D'Alo and Livesey, thanks so much again.

Kristen Livesey, MD: Thank you so much for having us. I appreciate it.

Julia D'Alo, MD: Thank you so much.

Host: And again, if you need more information, please visit stclair.org. Again, that's S-T-C-L-A-I-R.org. Now, if you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. And thanks again for listening to Curating Care, a podcast from St. Clair, health expert care from people who care.