Grantee Spotlight: Building Trust to Reduce Risk for Patients with Opioid Use DisorderApril 19, 2022
Starting in 2017, Thomas Jefferson University in Philadelphia has received funding from the state government to serve as an Opioid Use Disorder Center of Excellence, one of 45 in Pennsylvania. At these centers, staff offer not just treatment for opioid use disorder (OUD) but also attend to patients’ physical and mental health conditions and offer navigation and peer supports. A 2020 grant from FORE enabled Jefferson and its community partners to expand their model of holistic OUD treatment to more people and gather input from patients about what’s important to them. Based on their findings, the team recently created a series of videos to educate clinicians and other health care professionals about harm reduction, an evidence-based approach to reducing the risks of drug use. The videos illustrate practical strategies health care professionals can use to build trust with patients. We spoke with Lara Carson Weinstein, M.D., M.P.H., Dr.P.H., associate professor of family medicine and director of Jefferson’s addiction medicine fellowship, and Kelsey Smith, clinical research coordinator for Opioid Use Disorder Program Research, about their work.
Dr. Weinstein, how did you become interested in treating addiction?
Weinstein: I went into medicine looking for longitudinal relationships with people who have been marginalized or ignored. And in my pursuit of that, I found that many people used substances because of the trauma in their backgrounds or ongoing mental illness. So when the opportunity presented itself to start prescribing medications for opioid use disorder (MOUD) in 2016, I saw it as an opportunity to integrate an essential service into primary care.
You serve as medical director for two community-based OUD treatment programs. Can you tell us about them?
Weinstein: We partner with Project HOME and Pathways to Housing PA to provide integrated OUD treatment to people experiencing housing instability or homelessness, many who have psychiatric conditions along with substance use disorders. Project Home Healthcare Service, the health care arm of Project HOME, is a federally qualified health center. The largest site, the Stephan Klein Wellness Center, offers primary care, dental care, and behavioral services including substance use disorder treatment in North Philadelphia. Project HOME Health Services also offers MOUD services in the Hub of Hope drop-in center and clinic located in a train station. They just expanded their street medicine services; clinicians engage people in OUD treatment during periods of homelessness and connect them with ongoing services as they find housing. I’m the medical director of a Pathways to Housing PA clinic that’s run in partnership with Project HOME Health Services and Pathways to Housing PA and offers medical, behavioral health, substance use, and housing services. There’s a psychiatrist on site as well as peer social workers and housing supports. With FORE funding, we’ve been able to train more providers and expand capacity at all these clinics. We now have over 275 patients across these four sites.
What can you tell us about the people you’re serving?
Weinstein: We just completed a study looking at folks who accessed our services from March 2020 to March 2021. Their average age was 40, 63 percent were male, and 56 percent identified as Black or African American. We’re really glad that the Black community can access our services because traditionally buprenorphine has not been as widely available in Black communities as it has been for white patients.
How do you try to reduce barriers to OUD treatment and keep people engaged in care?
Weinstein: We don’t have any requirements for patients. We require ourselves to be the best trained we can be and the most available we can be for our patients. And we also require ourselves to learn how to partner with people who are in hard places and who are trying to get their needs met in ways that are survival-oriented and not necessarily effective in typical medical settings in. Our patients do not need insurance. They can have Medicaid or Medicare or be uninsured. And we have same-day or next-day access for appointments and can prescribe buprenorphine at the first visit, if appropriate. There’s no requirement for counseling, though nearly all patients take part.
What do you hear from patients about what they want from treatment?
Smith: We have a monthly patient advisory council at each of the sites, which is part of an effort to build long-term relationships with patients and gain feedback on our work. And then recently we did a pile-sorting study that started with semi-structured interviews with 15 patients. We asked, ‘What is important to you when you think of success in treatment and success in life?’ A typical success measure from the literature on OUD treatment is being tested for HIV or decreasing hospital or emergency department visits. Patients didn’t really mention those things. Instead, many of our patients mentioned things like being happy and connecting with family. Next, we asked 28 patients to sort and prioritize the themes identified in the interviews. There were three themes that everybody put in the high-importance category: optimism, being happy, and having a sense of self-worth; no physical dependence on substances; and being able to have stable housing and the trappings that come with that, like showering and being able to stay neat.
Along with trying to meet patients’ goals, you work to keep them safe by reducing the risks of using drugs. How receptive are your colleagues to this harm reduction approach?
Weinstein: Philly has been one of the epicenters of the overdose epidemic. So, people have learned that practical, compassionate approaches really are the only way we’re going to keep folks alive so that they can recover on their own terms. Over the last 18 months at Jefferson, we had 4,500 hospital admissions for medical problems for people with opioid use disorder. And those medical problems are related to not having access to clean works and to the adulteration of the unregulated drug supply. People are being poisoned. That piece of harm reduction is completely understood by people on the front lines. But as we expanded our OUD programs, we came up against stigma and preconceived notions about people who use drugs. At the same time, there’s also a lot of interest and questions from students and staff about how to connect with OUD patients.
You created videos with scripts that providers can follow to forge a stronger connection with patients? How did you develop them?
Smith: For a separate project, I was looking for curricula for medical students on how to work with patients who are sexual and gender minorities, and I found videos from the Fenway Institute and National LGBTQIA+ Health Education Center that modeled how to ask patients about their sexual orientation and gender identity. Seeing the videos and then discussing with Lara what she was seeing, it seemed clear there’s often a language barrier between providers and patients. We wanted to create videos to demonstrate how to have a good conversation and gain trust from your patients and show them that you’re there to support them.
We based the videos on things that we heard from patients, as well as things Lara and her colleagues have seen on a regular basis. One suggestion that came directly from the Patient Advisory Council was the blood draw video; people said: ‘There’s this weird tension when I have to explain to the phlebotomist that I have a history of injection drug use.’ Blood draws may be triggering for them, and it may be hard to find a vein. There’s a million different ways that it could go wrong or that a patient could be made to feel less than comfortable or welcome.
As we were writing these scripts, we were able to play them out for the patient groups and get people’s thoughts. One of our big questions about the video showing someone in active withdrawal in the clinic waiting room was: Is it too dramatic? Patients said no, ‘this is really how bad I would be feeling, this is how quickly it can go south, this is absolutely how quickly I would get security called on me.’
What’s your hope for how the videos will be used?
Weinstein: We want to educate people so they can be prepared for scenarios they’re almost certainly going to encounter in treating people with opioid use disorder. Someone’s going to go into active withdrawal in your waiting room. Someone’s going to have a urine screening result that was unexpected. Because then when it happens, you can say, ‘I got this, I saw this happen. I practiced this dialogue.’ We also wanted to make it clear that recovery is not linear. This means that people who are in treatment may still be using. Instead of a physician being shocked when reviewing a urine drug screen to learn that someone who is taking buprenorphine may occasionally be using fentanyl, we wanted to normalize that encounter — to take away judgment and instead create an opportunity to dig in: is the dose right? How’s the depression? How’s the anxiety? As the provider, every point of data, every encounter is a chance to learn.