On a sunny morning in Chelsea, Mass., Raina MacMahon passes a fast food restaurant that brings back memories of drug addiction. “At night, this is where all the buying and selling happens,” says Raina who, with help from Massachusetts General Hospital, is working hard to keep her own heroin habit in the past.
Determined to help many more people like Raina, Massachusetts General Hospital has launched a major new initiative to prevent and treat alcohol and drug addiction. Chelsea, where Raina lives, is one of the communities where Mass General is trying to make an impact. It’s a tough challenge and Raina’s difficult journey from addiction to recovery reflects some of the pitfalls that may lie ahead. But thanks to the involvement of a compassionate addiction specialist and her MGH colleagues, Raina’s story is also one of possibility and hope.
Bright-eyed and cheerful now, Raina, 33, is celebrating her one-year anniversary in recovery from drug addiction that began when she was a teenage runaway. After a number of failed attempts, her journey to recovery started last year with an ambulance ride to Mass General for treatment of a life-threatening heart valve infection. There, she met Sarah E. Wakeman, MD, medical director for substance use disorders with Mass General’s Center for Community Health Improvement.
With Raina, “we were all thinking about her as a whole person and keeping her preferences in mind,” says Dr. Wakeman, who is helping lead the new MGH effort to identify and treat alcohol and drug addictions. Known as the Strategic Plan for Substance Use Disorders, the plan will ensure that patients are accompanied along the path to recovery with the most effective and empathetic treatments available.
Response to a Community Call
Mass General’s addiction treatment plan is born from a deep commitment to the communities it serves. In 2012, MGH conducted a community-wide survey of people in Chelsea, Charlestown and Revere, where its community health centers are located. The survey asked what they saw as the biggest health problems. Substance use was number one in all three communities. Alcohol and drug addiction increases crime, homelessness and many of the other problems in these communities.
In response, Mass General is dedicating $3.5 million over the next three years to develop a new model of care in which people with substance use disorders are identified and treated over the long term, says Timothy E. Wilens, MD, director of the MGH Center for Addiction Medicine and a leader of the initiative.
“Too often, substance use is seen as a moral issue and people who have addictions are treated as difficult patients,” Dr. Wilens says. “But addiction is a brain-based disease and requires a long-term care model of treatment like heart disease or diabetes.”
“This is a very important initiative,” says Joy Rosen, vice president for Behavioral Health at Mass General. “We are transforming how we care for patients with substance use disorders by building strong links between our Emergency Department, our inpatient and outpatient units, and quality community-based services. We are introducing innovative treatment models to improve access to care, smooth transitions and reduce relapse and readmissions.”
The need is dire. Among the states, Massachusetts has the highest rate of emergency department visits due to illicit drug use. Many of these visits are repeats—from people who are treated for addictions-related injury or disease and discharged but who never make it to the next step—an addictions recovery program. A few weeks later, like Raina, they are back in the emergency room with the same or a new condition. The patient isn’t getting better and the cost of care is growing.
The reasons for relapse include the power of addiction itself, as well as the associated shame, confusion, cost and lack of available resources.
The reasons for relapse include the power of addiction itself, as well as the associated shame, confusion, cost and lack of available resources. Research shows that ensuring a discharged patient immediately connects with an outpatient recovery program increases that patient’s chance to achieve sobriety. The hospital wants to make sure that happens.
Addiction is a Disease
At Mass General’s Chelsea HealthCare Center, for example, the new plan is already ramping up. Mary E. Lyons-Hunter, PsyD, is unit chief of Mental Health and Social Services. The patients at the health center are largely immigrants who come from an astonishing number of places, including Central America, Africa and Eastern Europe. Many live in overcrowded, dilapidated housing. Violence, drugs and homelessness are ongoing problems.
“In a very poor underserved community like Chelsea, we can’t ignore the reality that addiction is a disease that must be treated like any other long-term illness,” Dr. Lyons-Hunter says. “We can’t just say ‘Go to AA’ or ‘Go get clean.’”
The Chelsea center plans to beef up the existing addiction treatment program, provide staff training, increase patient screening and bring on a new recovery coach to connect patients to addictions services.
MGH centers in Charlestown and Revere are also bolstering their screening and addiction treatment programs. And in Boston, the main hospital has created an Addictions Consult Team (ACT) to respond when a patient in need of addiction treatment is identified. The hospital will also hire four additional recovery coaches to work in the community, with the homeless and in the emergency room, and plans to establish a discharge clinic to help patients who are leaving the hospital and need immediate support to stay in recovery.
A Harrowing Ordeal
Raina left home at age 15, after an explosive argument with her parents over her “stealing” the family car for a joy ride. Soon, she joined other street kids in Portland, Ore., and embraced the drug culture.
“I became one of those little homeless kids who was hitchhiking and hopping trains,” she recalls. Drinking and smoking pot, she soon progressed to using crystal meth and crack cocaine. Her first experience with heroin was while hanging out under a highway bridge in Seattle, Wash., where she allowed someone she met to inject it.
She moved to Florida at 19, got a job and temporarily stopped using drugs but drank heavily. Still looking for something better, she moved to Boston and rediscovered heroin. Soon she was homeless, living underground in the Harvard Square MBTA station and finding drugs for college students to support her own habit. She tried detox centers and methadone but always relapsed.
Strong Withdrawal Symptoms
One day, she began feeling ill. A high fever kicked in. “Everything in my body began to hurt,” she recalls. Raina went to the Mass General Emergency Department. She was admitted and learned she had endocarditis, a dangerous heart valve infection caused by bacteria introduced to her bloodstream when she injected drugs.
She went on methadone while in the hospital to help her quit heroin and then went to a rehabilitation hospital after her infection subsided. But discharged on a Friday, her cravings and withdrawal symptoms were so strong she couldn’t make it to her outpatient medical appointment Monday without using heroin.
Seven weeks later, she was back in the MGH Emergency Department with endocarditis again, facing the possibility of heart surgery.
This time, things went differently. She met Dr. Wakeman, a young woman near her own age who reassured her that her drug addiction was not her fault and that she could get better. Raina felt optimistic for the first time. Instead of methadone, Dr. Wakeman prescribed suboxone, which, like methadone, is a substitute for heroin but which can be prescribed from a doctor’s office so that Raina need not stand in daily lines outside a methadone clinic where, she says, people often sell drugs.
Treated with Respect
She received intravenous antibiotics in the hospital for the heart valve infection. Then Dr. Wakeman arranged for her to convalesce in a drug-free medical rehabilitation facility that Raina now fondly calls “the old folks’ home.” There, she happily played bingo with older women.
Nevertheless, Raina relapsed a few weeks later. Her endocarditis flared up again and an ambulance brought her back to Mass General.
“It was heartbreaking to me how I kept doing this to myself,” she recalls. “When I saw Dr. Wakeman, I cried.” The doctor reassured Raina that relapse is part of the disease and urged her to keep trying. She talked with her about the brain science of addiction and treated her with respect, not judgment.
Finding the right combination of treatment and support that would help Raina toward long-term recovery was crucial, Dr. Wakeman says. “Our approach is to address the kinds of conditions that make it difficult for an individual person to recover, and work to resolve them.”
With Dr. Wakeman’s guidance, Raina began attending 12-step recovery meetings in the hospital. Then she returned to the “old folks’ home” and attended the Intensive Outpatient Program at Mass General’s West End Clinic. The day she went home she went to a 12-step meeting.
Now, with a year of sobriety behind her, Raina has a better relationship with her family. As a member of the Chelsea Leadership Team, she meets with city officials, clergy, police and others committed to helping people get access to the social services they need. She also attends intensive outpatient sessions, sees a therapist and visits Dr. Wakeman at Mass General every few weeks. Her heart condition needs ongoing care.
Coloring all efforts to help people recover from addiction is the problem of stigma. Unlike other illnesses, addiction is often regarded as a self-inflicted problem, one that the addicted person chooses freely.
The result of such bias is that patients are often expected to bootstrap themselves out of addiction. Mass General’s plan aims to break that cycle of stigma and relapse by educating clinicians, patients and public about the need for a new, unbiased, long-term approach to recovery.
“Because of the fear, shame and the need for motivation along the way,” says John F. Kelly, PhD, founding director of MGH’s Recovery Research Institute, “people often need an extra helping hand to get them to the next stage of recovery.”
Dr. Wakeman says an entire team of programs and people, including the patient, worked to create a personalized, coordinated plan to help Raina through heart-valve treatment and detoxification, into rehabilitation, intensive outpatient therapy and finally home to a life of recovery in Chelsea. It’s a model that the hospital is working to put in place on a grand scale for each and every patient with a substance use disorder.
Through it all, Raina understood that this Mass General doctor believed in her ability to get better.
Compassion and Expertise
These days, Raina is active with Chelsea community groups and is talking openly about her addiction and recovery to help lessen the stigma and pave the way for people to freely seek the care they need.
Once so frustrated with healthcare clinicians that she stopped seeing them, Raina now says that finding a doctor who did not judge and offered the right combination of compassion and expertise was the key to her success. Dr. Wakeman shepherded her through the painful transition from heroin to healthful living. She helped Raina move directly into a safety net of recovery programs after leaving the hospital. Through it all, Raina understood that this Mass General doctor believed in her ability to get better.
“Dr. Wakeman saved my life,” she says.
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