By Emma Whitford
“The first time I did heroin was in Brooklyn House of Detention,” recalls Eric McIntire, sitting in a windowless conference room at Barnabas Health Medical Group in West Orange, New Jersey. His two iPhones, which ring loudly and often, are on the table in front of him.
A native of Tottenville, Staten Island, McIntire recalls candidly how in his teens and twenties he turned his mother’s quiet, dead-end block—“the white-picket-fence-type thing”—into a “high drug-traffic area with a lot of ridiculous activities going on.” A bullet once shattered his mother’s bedroom window, he says. Heroin helped McIntire come down from crack, and dealing drugs helped pay for both. “I thought I was the Scarface of the world,” he laughs. “Meanwhile I couldn’t make enough money to re-up.”
Stories like these come in handy for the gregarious 45-year-old father of three, now sober going on fifteen years. He’s the recovery support coordinator at RWJBarnabas Health Institute for Prevention and Recovery—part of New Jersey’s largest health and hospital system—and his job is to make a connection with opioid overdose patients and persuade them to get on the road to recovery. He supervises 60 other recovery specialists— each in recovery for at least four years—who are deployed at hospital emergency rooms in seven counties, trying to do the same thing.
When patients reach the ER due to an overdose, it’s a fateful moment. Traditionally, hospitals just stabilized such patients and discharged them, pigeonholing addiction as a behavioral disorder, not a medical one, and, therefore, not their concern.
But such patients’ prospects are dismal. Among those who shoot heroin, about half of overdose survivors will eventually die from another overdose, according to Adam Bisaga’s new book, Overcoming Opioid Addiction.
Though hospitals are powerless to force patients into drug treatment, and ideal treatment may not be geographically or financially available, some hospitals are now taking what steps they can. A growing number of systems now enlist the services of peer counselors, like McIntire. In 2016, the New Jersey Department of Health, inspired by a Rhode Island program called AnchorED, began offering counties $255,000 in grants to hire and train former addicts as recovery specialists. The program is now in 42 emergency rooms across all 21 New Jersey counties.
“We’re definitely in a moment,” says Suzanne Borys, an assistant director at New Jersey Mental Health and Addiction Services. In July 2016, the National Governors Association endorsed the use of peer counselors to try to cajole opioid users into recovery, and today there are such programs in Massachusetts, Ohio, and Delaware, too.
Taking advantage of the her state’s grants, Connie Greene, Vice President of the Institute for Prevention and Recovery at RWJBarnabas, incorporated recovery specialists into her system’s new Opioid Overdose Recovery Program. Two years earlier she’d noticed an increase in emergency room patients in Monmouth and Ocean Counties who’d been administered the anti-overdose drug Narcan. Emergency room staff expressed frustration with these patients, who were in withdrawal and often upset.
At that time, Greene recalls, “patients were given a brochure, which ended up in the garbage before the individual left the hospital.”
Sensitivity training for ER staff was also falling flat, she says, since doctors and nurses didn’t have time to develop a bedside connection.
Between 2014 and 2016, only one patient agreed to try a treatment program. “He got into detox but left the next day,” Greene recounts.
With the arrival of peer counselors, Greene says, the “magic” kicked in, and more patients could be reached.
McIntire meets patients lying in a hospital bed, less than an hour after they’ve been administered Narcan. In a sea of nurse scrubs and lab coats, he’s the guy in street clothes. Many patients are afraid. Two of the sentences he hears most often are, “Am I getting arrested?” and “When can I get out of here?”
“Another big one is, ‘You have no idea what I’m going through,’” McIntire adds. “And I’m like, ‘Oh no. I know exactly what you’re going through. Mind if I sit down for a couple minutes?’”
Some bedside scenarios are easier to navigate than others. Patients have spit at McIntire when he starts in with his “recovery bullshit,” he admits, and he’s seen people angrily rip IVs out of their arms, spurting blood. He says recovery specialists know to leave when a full-fledged argument seems inevitable. But they follow up regularly by phone for eight weeks, regardless of the patient’s bedside mood. Greene refers to the follow-up practice as “lovingly stalking.” Specialists make three calls or texts in the first week, including the morning after the overdose; three calls the second week, and two each for the next six.
McIntire’s team boasts a 95-percent “participation rate,” by which they mean that the patient engages in bedside conversation or followup telephone calls. Once the patient is cooperating to that degree, a clinical navigator, as they’re called, talks to the patient over the phone. Using criteria from the American Society of Addiction Medicine, the navigator recommends an individualized treatment plan, based on the patient’s interest in treatment, mental health, history, and living situation. Clinical navigators also assess patients’ financial needs and help them find programs with available spaces.
Among public health authorities there is a broad consensus that medication-assisted treatment (MAT) is the safest and most effective treatment for opioid addiction, running the least risk of relapse and subsequent fatal overdose. (Overdose after detox is particularly dangerous, because patients have lost their tolerance.) Ideally, MAT means long-term, often lifetime, treatment with either methadone, buprenorphine, or naltrexone, backed up with behavioral therapy and support groups.
But New Jersey hospital officials have found that the reality on the ground is challenging; such state-of-the-art programs are hard to come by, and patients and their families often don’t want them.
While medication-assisted treatment is the “gold standard,” Greene says, many patients still prefer inpatient detox. “Let’s just say the field is in a process of change,” she admits.
There’s a lingering stigma around MAT, according to Borys. “It’s one of the things we’ve been struggling with,” she says. “There’s a pervasive notion that detox is the answer. It’s been institutionalized.”
The program is too new to have yet compiled any recovery success metrics. New Jersey does keep track of patients’ decisions about what path to take after their initial bedside conversations with recovery specialists, though. Across the state, 22 percent of patients accepted either detox or medication-assisted treatment at bedside, according to Borys. Another 39 percent agreed to try a recovery group or meeting, she continues. Eighteen percent refused services altogether, although some of them later changed their mind during follow-up calls. Another 21 percent fell into a variety of other categories: patients who left the hospital without a formal discharge, or didn’t participate because they were incarcerated, or or didn’t participate because they were hospitalized long-term for an unrelated illness.
Meanwhile, overdose deaths continue to rise in New Jersey. According to the latest figures from the Centers for Disease Control and Prevention, 2,542 people fatally overdosed in the state during the 12-month period ending September 30, 2017—a 50.2 percent increase over the preceding 12-month stretch. (The 2017 figures are provisional, meaning they are likely underestimated.)
The year-over-year rise is the worst in the nation—striking for a state whose governor during that period, Chris Christie, was so associated with fighting the epidemic, and chaired the White House commission on combating the opioid crisis. One major factor is the influx of illicit fentanyl—the deadly synthetic opioid far stronger than heroin—which was associated with 818 overdose deaths in New Jersey in 2016, nearly double the 417 such deaths in 2015.
Against this tide, one of McIntire’s strategies is to invite patients to a peer-led recovery meeting, regardless of their recovery status. “Whether you’re in-and-out, you’re on medication, whatever,” he says. “Anybody’s welcome.”
He also gives out his phone number—to everyone. In addition to emergency room calls at all hours of the night, McIntire gets calls from former patients seeking help after a relapse.
“Once they’re in, they’re in,” he says. “They have my number. I’ll never change my number.”