One night earlier in November, James Hagan arrived in Penn Presbyterian Medical Center’s emergency room, straight from the streets of Kensington. The toll of living rough — and more than two decades of on-and-off heroin use — was wearing on him. He was severely dehydrated, entering withdrawal, but he managed to get the El to West Philadelphia, and the hospital.
Within 20 minutes of arriving in the ER, he said, he was on buprenorphine, the opioid-replacement drug that curbs cravings and withdrawal symptoms. The doctors in the ER, he said, let him rest — but they also alerted the staff at the addiction treatment unit upstairs. Within hours, Nicole O’Donnell, a certified recovery specialist who has known Hagan for years, was at his bedside.
“OK, Jimmy,” she said. “What are we going to do?”
For people in active addiction, the decision to enter treatment can be a difficult one, even when their drug use lands them in the emergency room. The fear of painful withdrawal can send someone back to the streets. So can the stigma and shame associated with addiction.
Even the most well-meaning doctors can find it hard to persuade someone in their ER to enter treatment. (And not all are well-meaning. Drug users have reported in surveys that the fear of being treated with disdain or disgust keeps them out of hospitals and away from the care they need.)
Certified recovery specialists like O’Donnell — people who once struggled with addictions themselves and now use their experiences to help others to enter treatment — are aiming to change those perceptions.
The approach is working: Since Penn Medicine’s peer recovery program launched last winter with help from federal funds, seven in 10 of the emergency department’s patients with opioid use disorder have stuck with treatment for at least 30 days, the hospital says. About 200 patients with addiction go through the emergency room each month.
“Peer support is huge for the patients. The side effect we weren’t anticipating was that it was also a huge support to the doctors,” said Julie Dees, the director of behavioral health at Presbyterian. “They have embraced the peer specialists as really members of the team, because they’ve been through it.”
Peer specialists have been employed for years in the behavioral health fields and are becoming increasingly common figures in area hospitals and treatment programs. Across town from Presbyterian, Temple University’s health system has also staffed several ERs and its office-based opioid treatment program with peer specialists from the local recovery organization PRO-ACT.
Penn Medicine’s program employs three peer specialists who work throughout its three Philadelphia hospitals and crisis response center. The specialists go to ER bays and hospital rooms, deployed using an algorithm that checks electronic medical records for symptoms and medication to identify people with addiction.
The hospital also worked to get nearly all of its emergency doctors licensed to prescribe buprenorphine. Although any doctor with a Drug Enforcement Administration license can prescribe the opioid painkillers that can spark addiction, federal law requires special training to prescribe a potential remedy.
Sometimes, a bedside buprenorphine prescription can be enough to get patients started on treatment. It can ease patients’ withdrawal pain, so they are willing to hear from someone like O’Donnell, rather than leaving the hospital in search of drugs.
O’Donnell says she can accomplish neither goal unless she can build trust with her patients in addiction. “It’s about accepting people exactly where they are,” she said. For patients who aren’t ready to enter treatment, she offers doses of Narcan, instructions on how to avoid overdoses, or just a friendly conversation.
At 40, she has been in recovery from an opioid use disorder for nearly 11 years. She got involved in addiction outreach five years ago, after her sister died of an opioid overdose.
“I just needed to do something,” she said. “Two weeks after she passed, I was in Kensington, handing out coats. I wanted to be there for [people in addiction] in a way that maybe people weren’t for my sister.”
O’Donnell worked in Kensington, at the heart of Philadelphia’s drug crisis, with the outreach organization Angels in Motion while earning her peer specialist certification. A year and a half ago, she took the job at Presbyterian.
The job, O’Donnell said, is not limited to the hospital.
She and her colleagues are regularly in Kensington, looking for former patients or offering help to people thinking of entering treatment. Hagan, 42, who’s been in and out of treatment — and the Presbyterian ER — for some time, first met O’Donnell at a warming center for homeless people on a freezing day in the neighborhood two years ago.
“Even when we don’t want help,” Hagan said, “they’re always there.”
Another patient, Devin Kloss, 33, reached out to O’Donnell last winter after his parents, who both work at the hospital, heard about the peer program and hoped she might help. Kloss’ addiction had almost cost him his life, several times over: He had overdosed seven times in 2018. He started off 2019 with a breathing tube at Methodist Hospital in South Philadelphia after another overdose.
He told friends he had been beaten up: He was too ashamed to admit what had actually landed him in the hospital.
Months later, he hit a breaking point. “It was my birthday, I was homeless, and it was like, 10 degrees out,” he said. He had been walking for hours, shaking off a bad reaction to a questionable bag of heroin, trying to stay awake. At 7 a.m., he called O’Donnell. She brought him to Presbyterian within 40 minutes, Kloss said, where doctors found that his frantic walking had worn away the skin on the bottom of his feet.
Eventually, he entered inpatient and then outpatient treatment at Presbyterian. Even after a relapse over the summer, O’Donnell and her colleagues stayed in touch with him, he said. When he ran into them just after buying drugs in Kensington, they didn’t act disappointed, he said. They just offered him a dose of Narcan, the overdose-reversing drug, in case he needed it.
A few weeks later, Kloss was back in the hospital’s inpatient program, where he’s still receiving treatment. “I went to a shelter, I woke up, and my first thought was to call Nicole. I was just like, I can’t keep doing this. I got on the train, I came here, and I slept in the stairwell until people showed up,” he said. “It’s about how personal the experience is here. It’s hard to keep people like us engaged. You have to speak the language.”
Hagan, who’s been in inpatient treatment at Presbyterian since the beginning of November, has relapsed several times since he first got to know O’Donnell. “I have a hard time saying I need help,” he said. But he’s stayed in touch with O’Donnell through it all, made sure to carry Narcan, and even saved friends from overdoses. The staff at Presbyterian know him by name.