“Not just a methadone clinic” – How ETS has flourished

Evergreen Treatment Services is located on Airport Way in Seattle’s SODO district, close to many of the homeless encampments along the busy I-5 corridor. It is an obscure building with a faded awning in the front. When I arrived at 3PM (after dosing hours), the inside of the building felt like a cold maze, with areas sectioned off with crowd dividers. I met with Michelle Peavy, a psychologist at ETS, who told me about the history of the program. It has been around for over 70 years and serves over 1300 clients, with more than 40% of those clients being homeless. It predominantly serves as a medication assisted treatment provider, handling both methadone and buprenorphine prescriptions. Clients can come in at various time day, check in, and line up to go into a small and private room where they receive their daily dose from a dispensing window. During check-in, a screen will tell them if they need to leave a urine sample or not. Michelle talks about how the program recently started prescribing buprenorphine and methadone regardless of whether the patient is using other medications or not. This approach is based upon the philosophy that it is better to have points of contact between provider and patient rather than none at all. The daily dispensing of medication is an intersection point that is a valuable opportunity to reach out to the individual and “check-in”.

There are also additional resources available for patients. There are psychologists on site that do peer-to-peer counseling, an approach that Michelle feels is more effective than group counseling. There are also weekly health clinics on-site, staffed by physicians from Harborview Medical Center. During these clinics, patients can be screen for HIV and hepatitis C. If positive, patients are hooked up to a treatment program and in the case of hepatitis, they can receive their weekly medications at the site.

An interesting resource ETS provides is their acupuncture room. Although Michelle is unsure if the approach is evidence-based to help with substance use, she believes that the quiet relaxing room provides a type of “getaway” from the chaotic lives that some of their patients have. Many patients report feeling decreased stress levels and less cravings with these treatments.

I appreciate that ETS provides something of a “one stop shop” for those who are on medication-assisted treatment programs. Their bare-bones building may not look like much, but that was their goal- to not stand out as a treatment facility, but to normalize it.

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Assisting mothers and babies: PCAP + Swedish Hospital’s Inpatient Addiction Program

Parent-Child Assistance Program (PCAP)

The Parent-Child Assistance Program was started in 1991 in the state of Washington as a pilot project to help substance-abusing mothers build healthier support systems and obtain resources that will enable them to maintain healthy independent lives. This is done through a “home visitation case-management model” in which mothers are paired with a case manager who will serve as their advocate. PCAP helps mothers obtain alcohol and drug treatment, stay in recovery, and work through issues related to their substance use. There are currently 12 sites in Washington with talks of expanding to 15 sites in July 2017. The King County site is one of the largest sites and I was grateful for the opportunity to meet with its site supervisor, Charlene (Lena) Takeuchi who has been with the program for over 18 years.

The KC site recently moved to a simple office building off Lake City’s busy Aurora Ave. As a result, the location is still working on unpacking and making it feel like home. Upon entering, there is a living room-like area filled with toys for all ages to welcome the families. There is a computer for mothers to use if they need to access any materials. It’s a simple setup where they meet with case managers to talk about their situation, but I imagine that most of the magic occurs during these interactions. The site’s most important possession is a whiteboard that shows where the case managers are for that day if they are out in the field and what vehicles they are using. Lena stresses the importance of having her case managers check in every couple of hours so she can make sure they are safe and accounted for.

Lena and I talked about the logistics of the program and the difficulties they have encountered. A lot of the women have significant trauma, either from family, friends, significant others, or the shame associated with substance abuse and pregnancy. This prevents them from seeking a lot of the care they need. She recalls a patient who was successfully enrolled in a treatment program at Swedish and on the day they had sent an advocate out to pick the patient up, the advocate was late. This led to the patient becoming worried and deciding to opt out of being admitted to rehab.

It was clear that PCAP has made an amazing amount of progress is gathering data about the role of traumatic events and substance abuse in pregnancy. This allows for continued funding as well as policy changes to help these mothers get the help they need.

 

Swedish OBGYN Chemically Using Pregnant Women’s Program – Ballard Campus

Swedish’s OBGYN treatment program specifically focuses on admitting pregnant women with substance use. It is led by Dr. Jim Walsh, an efficient yet compassionate and empathetic gentleman who entered the field of addiction by opportunity and chance. Having visited PCAP the day before, I was told that Dr. Walsh is an amazing presence in the field of OBGYN and addiction and is a valuable asset to the community.

The setup of the program is unique. For inpatient treatment, there are only a certain number of beds available. They prioritize women who are later in their gestational age and are at higher risk of having complications. During inpatient treatment, women eat together in a communal dining room, do several recovery classes together, and are given medication-assisted treatment. Dr. Walsh stresses the important of having medication-assisted treatment and points out the overwhelming evidence the shows that it works. He has seen countless times that simply believing in yourself (“having confidence”) is not enough because the stigma against those who abuse drugs during pregnancy is so strong that it often leads to isolation and relapse. He believes the program works because they take provide a supportive non-judgmental environment for women who are undergoing similar circumstances. This is particularly important in recovery groups when having someone who is not pregnant discussing their substance use disorder can make those who are pregnant feel more ashamed of their actions.

Swedish also has an outpatient drop-in clinic for those who are undergoing substance use but are not of high risk enough to be admitted. The clinic, located on Swedish’s First Hill, is open Tuesday afternoons and is fully staffed to provide treatment care. Here, women can learn about resources such as PCAP and look into addiction treatment programs that may be available to them in an outpatient setting.

When asking about how women find out about the Swedish program, Dr. Walsh talks about the close-knit community of women and the power of word of mouth. As someone who is interested in Family Medicine, OBGYN, and community health, I hope that this program at Swedish is still around when I am practicing so I can also recommend it to others.

Creating community at the RecoveryCafe

As Seattle’s hypergentrification continues, a plain brick building on the corner of Denny and Fairview sticks of like a sore thumb with it’s plain brick façade against a glass and steel building complexes. The RecoveryCafé serves as an oasis for the recovering addicts community in a city that is building a new wall every other second- physically and metaphorically. The café strives to be an “alternative community” that celebrates sobriety by providing community base, non-religious but spiritually-led care. Its format is similar to a community center where people who are in recovery can become “members”. As a member, you are served 2 meals a day buffet-style, a variety of classes ranging from yoga to painting, computer and phone access, and the opportunity to enroll in classes to learn how to be a barista or yoga instructor. The only requirement to continue membership is to attend a recovery group (Recovery Circles) once a week in which you discuss your progress on maintaining sobriety or path towards sobriety. Additionally, members are required to be sober during the time they spend at the facility.

I met with Carolyn, the program manager, who gave me a tour of the cafe. It is a bright and warm one level layout with certain areas designated as living room space(books and couches), a media center with computers and printers, and a café in the middle with tables surrounding it cafeteria-style. Off to the side is the kitchen where volunteers are using whatever they received that day from local food banks and restaurants to prepare over 200+ meals.

The RecoveryCafé focuses on creating a space that focuses on building community and support. Using the Recovery Oriented System of Care (ROSC) model, they acknowledge that the pathway to recovery is different from individual to individual but the common thread is that most people are unable to do it alone. Carolyn has been at the café long enough to know individuals on a first-name basis and their personal stories. She encourages sharing and support between everyone and states that an essential part of Recovery Circles is giving feedback to those around you. I attended an orientation session led by Jason, the Director of Operations, in which new members were given an introduction as to what the RecoveryCafé could do for them. Members at the table came from a variety of socioeconomic backgrounds, different stages of recovery, and different levels of familiarity with the RecoveryCafé. Post-orientation, I talked to Jason about his philosophy towards medicine and it boiled down to “building support so individuals can be self-advocates”. He has a history of substance use himself and brings personal experience to the table in understanding that recovery alone is an extremely difficult pathway. He hopes that the relationships made here will at least serve as a constant in the often chaotic lives of those who walk through their doors.

Seattle’s most valuable organization right now: DESC

DESC is an organization that started in 1979 and focuses on “providing effective and affordable solutions to homelessness for our communities most vulnerable single adults”. Their focus is on “housing first”, an evidence-based approach adopted by other programs around the nation as our homelessness crisis continues to get worse. They have four locations with over 400 emergency shelter beds, 11 supportive housing sites, and two that are currently in the works.  One of these, a staff supportive housing, is going to be located in Southeast Seattle and focus to provide a supportive services for homeless men and women living with disabilities.  This project is a partnership with Harborview Medical Center and will sent you are a round a assisted living facility in which there will be Healthcare Services on site for these individuals.  A portion of this housing will also be for those who need transitional housing after leaving the hospital with complex needs that a conventional residential care system is unable to accommodate.

In addition to housing, DESC provides a multitude of outreach and treatment programs for all those who walk through their doors.  They work with community health programs in bringing care to those that are most vulnerable in our communities. For example, there is currently supportive housing complex for those who have limited function due to severe schizophrenia. There also supportive housing for those undergoing substance use and co-occurring mental illness.

When I first reached out to Jaime Moss, the program director at DESC, he told me to swing by on Monday morning at 10:30am.  I later found out that the first Monday of the month is when everyone receives their monthly Social Security payments so it was a perfect chance for me to meet a lot of the individuals that frequent DESC’s services.  While waiting in the lobby for Jaime, I spoke with the gentleman who had been frequenting DESC services for several years now.  He has a case manager that helps him get access to overnight shelters and attends support groups at DESC for his heroin addiction. He expressed that the people at DESC treated him like he was “human”, especially with his addiction.

During my conversation with Jaime, we talked about his personal philosophy towards addiction treatment. He talked about the many traumas that those undergoing homelessness undergo through their lives including abuse, violence, racism, bigotry, and mental illness. He then delved into how society’s system of penalizing those for something they cannot control at time sonly exacerbated their distrust of those around them. DESC is a pioneer in trialing different types of approaches due to its expansive network of coverage. Addiction treatment is very individual based so his belief that having different types of approaches is key to adapting treatments and supporting the recovery process. For instance, a new program at DESC centers around allocating a portion of an individual’s SS benefits for alcohol use. What trends show is that normally, most of the money from Social Security is spent immediately on alcohol. This leads to the person panhandling or doing illegal activities later in the month to get money to sustain their habit. or panhandling for money to sustain their use. By having a person control the money, there is less binging and a more steady stabilization of alcohol intake. This has shown to be effective with several people who are now able to have more animated interactions with those around them including case managers are DESC. It is understandable that this approach could be paternalistic, but there is a clear understanding that nothing is done without the client’s knowledge and agreement.

Jaime stressed the importance of building relationships. One of the most difficult aspects of his job is reducing staff turnover due to inadequate compensation (pay is partly with Medicaid coverage) and burnout. When case managers work so closely with clients, it is the clients who suffer most when case managers leave since many of them have a history of loss and the system letting them down. Jaime has been at DESC for 9 years and is familiar with most people at DESC. He mitigates the effects these turnover rates have on clients by being transparent and honest in his conversations with them about why people leave. However, what he offers in return is a commitment that someone will be there no matter what, even if it’s not who they wanted. And that is essentially what DESC strives to do.

Hectic

You probably understand this by now: I’m terrible at keep promises to myself. As a result, a blog that I wanted to work on on a somewhat daily process gets left behind.
In my defense, sleep is very very high on my priority list and during surgery rotation, the mantra is: sleep when you can, eat when you can, study when you can.

I could call it the 3s of clinical rotations: sleep, slurp, study. (I’m also a huge fan of soup so slurp would be an appropriate food verb for me)

So to keep you posted I will put up a series of reflections that I did during my Drug Rehab elective 6 weeks ago and then do a post this weekend about my surgery rotation (6 weeks in 1000 words or less? sounds like a personal statement! speaking of personal statement, I need to work on that too for surgery haha)

In conclusion, shut up and listen.

I have 23 minutes until half past eleven at which point I should be attempting to adjust my sleeping schedule in prep for my impending doom. That is, my surgical rotation. Yay 4am wakeup time, yay sexy surgery. But I am pushing myself to put at least 30 minutes a day into this thing. Otherwise, how else am I going to commit.

21 days builds a habit right? Just kidding, studies have shown its actually 90+ days. Will I link said studies here? No, because I’m sure a quick Google search will yield many results. Also, I’ve only got 17 minutes left.

SO.

The current elective I am doing is officially called Detox and Rehab Program for Alcoholism and Drug Abuse. It is two weeks and at the Puget Sound Veterans Affair Hospital. Specifically in their Addiction Treatment Center. The setup is one week working on site and the second week doing “site visits” where I drive around town visiting different community programs that are focused on providing resources for those undergoing substance abuse.

It’s been one helluva two weeks with my last day being tomorrow. First of all, as part of my school’s new curriculum, we are able to do electives prior to our required set of clerkships. With my interests in Family Medicine and OBGYN and a focus on under served populations, I wanted to choose an elective that would reconnect me with people and why I wanted to do medicine in the first place. Having finished with Step 1 recently, I had felt a bit of disconnect with myself.  I felt a bit lost. I may discuss this a bit more in a later post, but for now, I just felt unsatisfied with going into medicine and I think it was mostly because I had not seen a patient since October nor had I really set foot into a clinical setting since January.

This clerkship puts me directly with patients who are going through something completely unimaginable to some people, including myself. My experience with substance use is limited to what I have learned in class and witnessed in the emergency room. And most of those experiences are not positive experiences. And some of those experiences are reinforced with an often jaded physician muttering about “yet another addict” and their drug seeking ways. We’re taught to be conscious of our actions and to be aware of possible intentions by patients. Pain is subjective and that makes it a double edge sword. CONSTANT VIGILANCE.  It’s terrible but understandable, especially with an opioid crisis occurring in the US.

But that frustrates me. Society often blames and shames, but does not name itself as a culprit in this game. Yes, I had to put in the last part of that sentence because it makes me feel like a poet (and know it.) but in isn’t it true? This revolving door is there because our quick judgement of people often leads to a vicious cycle of miscommunication and frustration that doesn’t help either physician nor patient. I sincerely do not believe that someone intended to spend all their lives bouncing in and out of shelters, succumbing to a drug, and often losing who they are during the process. Most of these patients have gone through significant traumas that are occasionally unfathomable to the majority of the population. I often wished my medical curriculum spent more time focused on adverse childhood events and approaches to policy reform on a variety of specialty levels (rather than just a family physician perspective) and helped their students understand. I often wish my colleagues also selected electives that did not simply nourish the clinical side of medicine, but the humane side as well.

Lesson learned: Listen and you will learn.

11:30

 

Numero uno! + VA Puget Sound’s Addiction Treatment Center

Welcome! I finally learned how to setup WordPress. It’s a lot different than what it use to be 3 years ago. The user interface has definitely gotten a lot fancier! This is also why I hardly update my phone since sometimes the layout changes and I get confused. Is my grandma side showing yet?

Anyways, it took me an hour to set this thing up and I’m due to be in clinic tomorrow early morning so keep tuned! In the meantime, here’s a writeup for the current elective rotation I am on right now. More details on the next post- enjoy!

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Memorable quotes:

  • “It was just a part of my routine”
  • “False relationships are hard on [substance] use”
  • “ We all have the same wheelbarrow, but we put different things into it”

The VA Puget Sound’s Addiction Treatment Center is a multi-resource avenue for veterans undergoing substance abuse and addiction. It is regarded in high esteem as a center of excellence for its compassionate and respectful care and patient advocacy. How patients get to the center depends on their circumstances. Some come in with their walls down, feeling defeated, and ready for change after having their lives “controlled” by their substance. Some come in with mild resistance, unsure and skeptical, referred by primary care providers and family members. And some come in more than familiar with the program after having multiple relapses but remaining optimistic that this time around, it will be different.

Every day is a busy one at the ATC. Without knowing the clinic’s location, one would walk by the entrance without a second thought. But upon entering, you are greeted by a bustling lobby filled with patients waiting to give urine samples, pick up their methadone, see their case manager or waiting for an admit. During admit days (Tuesdays and Thursdays), patients first meet with Nancy, a no-nonsense irrepressibly charming nurse that does the morning triage. During these 10-15 minutes, a brief history and physical is done and with some quick judgement based upon 30+ years of experience of working with this particular population of patients, she formulates a treatment outline. The morning then proceeds with an introduction to ATC, a tutorial on opioid rescue kits, a meeting with a social worker for a complete assessment of their substance use history, and then depending on the patient’s needs, a meeting with a medical professional to finalize their treatment plan. I had the opportunity to follow a gentleman for an entire morning as he and the team worked on a plan to help wean him off multiple substances and keep him in his stable housing. With a complicated history consisting of depression, PTSD, and chronic pain, there were multiple reasons for his substance use. The discussions were centered around what his goals were (e.g. to reach abstinence for a hip replacement) and what incremental steps were needed to reach that goal. Things at the ATC are done in a patient-centered manner.

On Mondays, Wednesdays, and Fridays, I sat in on the ATC’s Intensive Stabilization Services (ISS), an intensive outpatient program (IOP) consisting of three hour-long sessions per day, three days a week. Sessions consisted of checking in, a focus group, and an education hour. These sessions were facilitated by a rotating group of medical professionals, social workers, and a chaplain. They served as a support group to discuss life experiences and different techniques and strategies to help with the recovery process. At the end of the three week program, patients can opt to continue in a treatment facility or be discharged with outpatient follow-up.

The core amount of my time at ATC was spent attending ISS sessions. I appreciated how inclusive the group was to my presence. They were a jovial group with a broad variety of experiences. Some had been through ISS before and for some, it was their first time. In one hour chunks, I slowly understood the extent these addictive substances could penetrate the human psyche and the relentless control it had on the body and mind. In many ways, addiction is similar to depression: a diagnosis that never completely goes away.  However, I also witnessed the resilience of humans and the power of human connection during these sessions. Through generous listening and a rule of “no cross talk” and “I statements only”, patients shared stories of relapses and cravings and received feedback from others. There was always something said that could be related by another person. This leads to validation and feelings of “you are not alone”, a very simple but important concept in addiction treatment.

During my time at the ATC, my emotional capacity for empathy has grown ten-fold as I am given an opportunity to hear these intimate stories. I sat with the group during lunch one day and asked what they felt was most important to them in a physician-patient relationship. I also wanted to know how their interactions with the medical system have gone in the past. Positive experiences boiled down to several key factors: the physician’s ability to be non-judgmental, honest, and understanding. Many of them had past encounters where they felt let down, dismissed, or worse, shamed by the medical community. It was a candid conversation that reinforced my biggest takeaway from my experience at ATC- the only way to help others is to always keep your door open and be willing to listen.