To help patients with drug addiction, some hospitals are turning to people who've recovered from the disease themselves.
At Oregon Health & Science University (OHSU) in Portland, peer mentors who are in recovery from substance use disorder provide a fresh perspective to the rest of the Improving Addiction Care Team (IMPACT), which includes addiction medicine physicians and social workers, said hospitalist Honora Englander, MD, director of IMPACT.
For example, while training one peer mentor, Dr. Englander saw a patient who had overdosed on prescription opioids, ended up on extracorporeal membrane oxygenation in the ICU, and had been transferred to the general medicine floor. Dr. Englander wondered whether the overdose was unintentional and discussed it with the team.
The peer mentor explained to the team that during his own active use, he was depressed and suicidal, and there was a blurred line between wanting to relieve pain and wanting to die. “For him to educate the team in that way, and to then be able to connect with the patient about that, it was huge. And this was his first day,” said Dr. Englander, also an associate professor of medicine at OHSU.
While other hospitals have similar success stories, there are substantial challenges associated with integrating peers into inpatient care. Physicians and peer program directors shared their tips for doing this successfully.
The benefits of experience
Peers can use their personal experience with addiction to gain patients' trust in the often intimidating hospital setting.
Before RWJBarnabas Health in New Jersey launched its peer recovery program in 2016, doctors and nurses had little success encouraging patients who'd had overdoses reversed with naloxone to start treatment, said Angela Cicchino, a peer recovery specialist and supervisor of the program. Of some 200 people whose overdoses were reversed, one of them went to treatment and left the next day, she said, “So that wasn't working.”
That's due in part to the emotional distance between clinicians and patients, said Ms. Cicchino, and peer recovery specialists can fill in those gaps. “It's just one person speaking to another person that has been in the same exact position. . . . Basically, the recovery specialist is there to make a connection with that person,” she said.
The program, which is grant-funded by the New Jersey Department of Health, Division of Mental Health and Addiction Services, started in the ED and in 2018 expanded to be a 24/7 ED and inpatient program for all patients with substance use disorder, said Maninder A. Abraham, MD, MBA, system director for hospitalist services for RWJBarnabas Health. If someone is admitted and is diagnosed with a substance use disorder, a clinician can put in an order for a peer specialist, and “They are there within 15 minutes of us putting in the consult and are very much a part of the care team,” she said.
In the past, hospitalized patients with opioid use disorder were often resistant to addiction treatment, said Dr. Abraham, who is also section chief of hospital medicine at Saint Barnabas Medical Center in Livingston, N.J. But now, peers can connect with patients and convince them that buprenorphine will help. “These types of patients are more receptive to us with treatment,” she said.
In tandem with the peer recovery program, which has served more than 285,000 patients, the health system started an initiative to get its physicians waivered to prescribe buprenorphine. It began with ED physicians, 60% of whom were waivered right away, and is now in the process of getting hospitalists waivered as well, said Dr. Abraham. The aim is for the hospitalists to write discharge prescriptions for buprenorphine themselves, as most currently rely on an addiction medicine subspecialist or an ED physician to do so, said Dr. Abraham.
Peers can also lend a hand after discharge, which is a vulnerable time for people beginning treatment for opioid addiction. Peers at RWJBarnabas Health help make arrangements for patients' postdischarge transitions (e.g., to rehabilitation facilities), and they also host weekly All Recovery Meetings at the hospitals. The nondenominational support groups started with only a couple of people in recovery and their loved ones, and some have grown to welcome 40 to 50 attendees each week, said Ms. Cicchino.
Certified recovery specialists at Penn Presbyterian Medical Center in Philadelphia also help with discharge planning and long-term care coordination, said Julie Dees, MA, LPC, director of behavioral health. She directs Penn Medicine's Center for Opioid Recovery and Engagement (CORE), which provides comprehensive peer support for patients struggling with opioid use.
Before CORE launched in 2016, the ED typically responded to an overdose by getting the patient medically stable, and a social worker would provide a number to call to go into rehab or detox, said Ms. Dees. “The discharge instructions would say, ‘Please stop abusing drugs; it will lead to your death,’ and that was it,” she said. Now that peers consult in the ED about 500 times per year and more than 90% of ED physicians are waivered to prescribe buprenorphine, more patients are sticking with their recovery treatment of choice, Ms. Dees said.
“When meeting with a patient and starting them on buprenorphine, 68% are still in treatment at 30 days after discharge,” she said. “[That] is a really big deal for any sort of substance use treatment because most traditional substance use treatment is only about 5% to 10% effective.”
At OHSU, patients seen by IMPACT, including its peer mentors, had improved engagement with substance use disorder treatment after discharge, according to a propensity-matched study published in the December 2019 Journal of General Internal Medicine. More than a third of them (38.9%) entered posthospital substance use disorder treatment, compared to 23.3% of control patients.
In addition to connecting with patients at the bedside, peers participate in clinicians' daily huddles and weekly quality improvement meetings. They can serve as “cultural brokers,” improving trust and communication between patients and clinicians, said Dr. Englander. “I think having peers in hospital spaces can really transform the patient experience, which then, in turn, can affect the way that providers and patients interact,” she said.
In a qualitative study of IMPACT, also published in the December 2019 Journal of General Internal Medicine, clinicians reported that peers are able to translate hospital clinicians' recommendations and de-escalate crises, supporting patients to avoid leaving against medical advice and alleviating perceived discrimination from hospital staff.
In the study, one patient explained that the peer mentor was a good listener and didn't make judgments. Without the mentor, the patient would not have engaged with IMPACT. “If it wasn't for him, I wouldn't have talked to them,” the patient said. Similarly, an IMPACT clinician described how one dubious patient looked at the team and asked if anyone had ever used heroin before. A peer raised his hand, to the patient's surprise, which helped build trust.
While the value of peers comes from their lived experience of addiction and its consequences, as well as their distance from medical culture, these qualities can make it difficult to integrate them into hospital settings, said Dr. Englander. “I'm a real champion for peers in hospital settings,” she said. “And I also think it's really challenging.”
In the qualitative study, physicians and social workers recalled times when the peers' emotional identification with patients or lack of indoctrination in the hospital system made them feel like a peer was “fighting against the system.” Moreover, the peer model was generally confusing to physicians and nursing staff at first, said Dr. Englander.
“I think our first peers felt like folks were suspicious of them and didn't understand their role and at times questioned their credentials,” she said.
OHSU peers have ID badges but wear street clothes, Dr. Englander noted. In the study, one peer recalled that “Walking through the halls here in the beginning it was really hard. I dressed differently; I talked differently, so there was some people who obviously felt like I didn't belong.” Another peer said, “It's almost as if you have to be able to talk two languages” to speak with both patients and clinicians.
To help clear up any confusion, new peers now meet with nurse managers and are trained to introduce themselves to staff and explain their role before going in a patient's room, Dr. Englander said. The team also found that posting peer bios in staff bathrooms was helpful in introducing the peer role, she added.
RWJBarnabas Health had similar findings about integrating peers in the hospital. While no anxiety or confusion was reported by clinicians, they did require education about the peers, who wear a T-shirt that says “peer recovery specialist,” said Dr. Abraham.
“Everybody was really appreciative to get that extra help. . . . These patients can be really challenging, so any help we could get, we welcomed it,” she said. “But there needed to be education as to who [the peers] were and how they could help and how to call them.”
Another challenge of running a peer program is hiring the right people, said Ms. Dees. One needs a particular broad skill set to be an effective peer recovery specialist, from communicating with doctors about treatment recommendations to engaging with folks who aren't yet patients at a needle-exchange site, she said. “There's no easy way to write a job description for what we're looking for.”
Penn's peer specialists stay engaged with their patients for up to 12 months and will even go into the community if a patient is struggling with treatment or starts using again, Ms. Dees said. “Recovery is not a straight line. . . . It's not a shameful thing, and we want to make sure that if that happens, our patients know that they can reach out to us—or we're going to go looking for them,” she said.
A strong foundation in recovery is crucial for peers to be successful, Ms. Dees noted. To become a certified recovery specialist, one has to have a minimum of 18 months in recovery, she said. At RWJBarnabas Health, the program's more than 100 peer recovery specialists have all personally been in recovery for four years or more, said Ms. Cicchino.
Peers have experienced not only addiction but also its consequences. When starting IMPACT in 2015 at OHSU, which now has three full-time equivalent positions for peers, Dr. Englander needed to explain to hospital leadership the fact that peers “almost by definition would have a criminal record.” The hospital contracts with a community mental health and addictions association to hire its peers and perform background checks, she said.
“Turnover is an issue, both because of promotion or because things didn't work out. We've had both,” Dr. Englander said.
Yet another challenge is funding. IMPACT was able to make a business case for OHSU to fund the addiction medicine consult service (including peer salaries), based on length of stay and readmission reductions. On the other hand, the Penn and RWJBarnabas Health programs, which both targeted the ED, were funded by grants.
At Penn, three certified recovery specialists cover three Philadelphia EDs, so they can be stretched thin at times, said Ms. Dees. She added that because the work they do is not billable, the health system is working with the city and state to try to get reimbursement. That could make it easier to justify hiring more peers.
“I would love to hire more, and we're going to get to that point, but it's just not easy,” Ms. Dees said. “I think that if we were to try to close the program, there would be a lot of outrage, so I am very confident that the health system is going to find a way to make sure that we can keep going and going strong.”