NEW ORLEANS — Elyse Stevens had a repute for taking over complicated medical instances. Individuals who’d been battling habit for many years. Continual-pain sufferers on excessive doses of opioids. Intercourse employees and folks dwelling on the road.
“Many of my patients are messy, the ones that don’t know if they want to stop using drugs or not,” stated Stevens, a main care and habit drugs physician.
Whereas different docs averted these sufferers, Stevens — who was conversant in the town from her time in medical faculty at Tulane College — sought them out. She usually attended 6 a.m. breakfasts for homeless individuals, volunteered at a homeless shelter clinic on Saturdays, and, on Monday evenings, visited an deserted Household Greenback retailer the place advocates distributed provides to individuals who use medication.
One such night about 4 years in the past, Charmyra Harrell arrived there limping, her proper leg swollen and coated in sores. Emergency room docs had repeatedly dismissed her, so she eased the ache with road medication, Harrell stated.
Stevens cleaned her sores on Mondays for months till lastly persuading Harrell to go to the clinic at College Medical Middle New Orleans. There, Stevens found Harrell had diabetes and most cancers.
She agreed to prescribe Harrell ache remedy — an choice many docs would robotically dismiss for concern {that a} affected person with a historical past of habit would misuse it.
However Stevens was assured Harrell might maintain up her finish of the deal.
“She told me, ‘You cannot do drugs and do your pain meds,’” Harrell recounted on a Monday night in October. So, “I’m no longer on cocaine.”
Stevens’ method to affected person care has gained her awards and nominations in drugs, group service, and humanism. As an alternative of seeing sufferers in binaries — addicted or sober, with a constructive or detrimental drug take a look at — she measures progress on a spectrum. Are they showering every day, cooking with their households, utilizing much less fentanyl than the day earlier than?
However not everybody agrees with this versatile method that prioritizes working with sufferers on their targets, even when abstinence isn’t one in all them. And it got here to a head in the summertime of 2024.
“The same things I was high-fived for thousands of times — suddenly that was bad,” Stevens stated.
Versatile Care or Slippery Slope?
Greater than 80% of Individuals who want substance use remedy don’t obtain it, nationwide knowledge reveals. Obstacles abound: excessive prices, lack of transportation, clinic hours which are incompatible with jobs, concern of being mistreated.
Some docs had been making an attempt to ease the method for years. Covid-19 accelerated that development. Telehealth appointments, fewer urine drug assessments, and medicine refills that last more grew to become the norm.
The consequence?
“Patients did OK and we actually reached more people,” stated Brian Hurley, speedy previous president of the American Society of Habit Medication. The group helps persevering with versatile practices, comparable to serving to sufferers keep away from withdrawal signs by prescribing higher-than-traditional doses of habit remedy and specializing in restoration targets apart from abstinence.
However some docs want conventional approaches that vary from zero tolerance for sufferers utilizing unlawful medication to setting stiff penalties for individuals who don’t meet their docs’ expectations. For instance, a affected person who assessments constructive for road medication whereas getting outpatient care can be discharged and instructed to go to residential rehab. Proponents of this technique concern loosening restrictions may very well be a slippery slope that finally harms sufferers. They are saying persevering with to prescribe painkillers, for instance, to individuals utilizing illicit substances long-term might normalize drug use and hamper the objective of getting individuals off unlawful medication.
Progress needs to be greater than conserving sufferers in care, stated Keith Humphreys, a Stanford psychologist, who has handled and researched habit for many years and helps involuntary remedy.
“If you give addicted people lots of drugs, they like it, and they may come back,” he stated. “But that doesn’t mean that that is promoting their health over time.”
Versatile practices additionally are likely to align with hurt discount, a divisive method that proponents say retains individuals who use medication secure and that critics — together with the Trump administration — say allows unlawful drug use.
The controversy isn’t just philosophical. For Stevens and her sufferers, it got here to bear on the streets of New Orleans.
‘Unconventional’ Prescribing
In the summertime of 2024, supervisors began questioning Stevens’ method.
In emails reviewed by KFF Well being Information, they expressed issues about her prescribing too many ache drugs, a mixture of opioids and different managed substances to the identical sufferers, and excessive doses of buprenorphine, a medicine thought of the gold customary to deal with opioid habit.
Supervisors nervous Stevens wasn’t doing sufficient urine drug assessments and stored treating sufferers who used illicit medication as an alternative of referring them to larger ranges of care.
“Her prescribing pattern appears unconventional compared to the local standard of care,” the hospital’s chief medical officer on the time wrote to Stevens’ supervisor, Benjamin Springgate. “Note that this is the only standard of care which would likely be considered should a legal concern arise.”
Springgate forwarded that e mail to Stevens and inspired her to refer extra sufferers to methadone clinics, intensive outpatient care, and inpatient rehab.
Stevens understood the overall observe however couldn’t reconcile it with the fact her sufferers confronted. How would somebody dwelling in a tent, afraid of dropping their possessions, trek to a methadone clinic every day?
Stevens despatched her supervisors dozens of analysis research and nationwide remedy pointers backing her versatile method. She defined that if she stopped prescribing the drugs of concern, sufferers may depart the well being system, however they wouldn’t disappear.
“They just wouldn’t be getting care and perhaps they’d be dead,” she stated in an interview with KFF Well being Information.
Each College Medical Middle and LSU Well being New Orleans, which employs physicians on the hospital, declined repeated requests for interviews. They didn’t reply to detailed questions on habit remedy or Stevens’ practices.
As an alternative, they offered a joint assertion from Richard DiCarlo, dean of the LSU Well being New Orleans Faculty of Medication, and Jeffrey Elder, chief medical officer of College Medical Middle New Orleans.
“We are not at liberty to comment publicly on internal personnel issues,” they wrote.
“We recognize that addiction is a serious public health problem, and that addiction treatment is a challenge for the healthcare industry,” they stated. “We remain dedicated to expanding access to treatment, while upholding the highest standard of care and safety for all patients.”
Not Black-and-White
KFF Well being Information shared the complaints towards Stevens and the responses she’d written for supervisors with two habit drugs docs exterior of Louisiana, who had no affiliation with Stevens. Each discovered her practices to be inside the bounds of regular habit care, particularly for complicated sufferers.
Stephen Loyd, an habit drugs physician and the president of Tennessee’s medical licensing board, stated docs operating tablet mills sometimes have sparse affected person notes that record a chief grievance of ache. However Stevens’ notes detailed sufferers’ life circumstances and the intricate choices she was making with them.
“To me, that’s the big difference,” Loyd stated.
Some individuals assume the “only good answer is no opioids,” comparable to oxycodone or hydrocodone, for any sufferers, stated Cara Poland, an habit drugs physician and affiliate professor at Michigan State College. However sufferers may have them — typically for issues like most cancers ache — or require months to decrease their doses safely, she stated. “It’s not as black-and-white as people outside our field want it to be.”
Humphreys, the Stanford psychologist, had a distinct take. He didn’t evaluation Stevens’ case however stated, as a basic observe, there are dangers to prescribing painkillers long-term, particularly for sufferers utilizing immediately’s deadly road medication too.
Overprescribing fueled the opioid disaster, he stated. “It’s not going to go away if we do that again.”
‘The Thing That Kills People’
After months of rigidity, Stevens’ supervisors instructed her on March 10 to cease coming to work. The hospital was conducting a evaluation of her practices, they stated in an e mail considered by KFF Well being Information.
In a single day, a whole bunch of her sufferers had been moved to different suppliers.
Luka Bair had been seeing Stevens for 3 years and was secure on every day buprenorphine.
After Stevens’ departure, Bair was left with out remedy for 3 days. The withdrawal signs had been extreme — headache, nausea, muscle cramps.
“I was just in physical hell,” stated Bair, who works for the Nationwide Hurt Discount Coalition and makes use of they/them pronouns.
Though Bair ultimately bought a refill, Springgate, Stevens’ supervisor, didn’t wish to proceed the routine long-term. As an alternative, Springgate referred Bair to extra intensive and residential applications, citing Bair’s intermittent use of different medication, together with benzodiazepines and cocaine, as markers of excessive danger. Bair “requires a higher level of care than our clinic reasonably can offer,” Springgate wrote in affected person portal notes reviewed by KFF Well being Information.
However Bair stated every day attendance at these applications was incompatible with their full-time job. They left the clinic, with 30 days to discover a new physician or run out of remedy once more.
“This is the thing that kills people,” stated Bair, who ultimately discovered one other physician keen to prescribe.
Springgate didn’t reply to repeated calls and emails requesting remark.
College Medical Middle and LSU Well being New Orleans didn’t reply questions on discharging Stevens’ sufferers.
‘Reckless Behavior’
A few month after Stevens was instructed to remain dwelling, Haley Beavers Khoury, a medical scholar who labored along with her, had collected almost 100 letters from different college students, docs, sufferers, and homelessness service suppliers calling for Stevens’ return.
One scholar wrote, “Make no mistake — some of her patients will die without her.” A nun from the Daughters of Charity, which ran the hospital’s earlier incarnation, referred to as Stevens a “lifeline” for susceptible sufferers.
Beavers Khoury stated she despatched the letters to about 10 individuals in hospital and medical faculty management. Most didn’t reply.
In Could, the hospital’s evaluation committee decided Stevens’ practices fell “outside of the acceptable community standards” and constituted “reckless behavior,” in line with a letter despatched to Stevens.
The hospital didn’t reply KFF Well being Information’ questions on the way it reached this conclusion or if it recognized any affected person hurt.
In the meantime, Stevens had secured a job at one other New Orleans hospital. However as a result of her resignation got here amid the continuing investigation, College Medical Middle stated it was required to tell the state’s medical licensing board.
The medical board started its personal investigation — a growth that ultimately price Stevens the opposite job provide.
In presenting her facet to the medical board, Stevens repeated many arguments she’d made earlier than. Sure, she was prescribing highly effective drugs. No, she wasn’t making medical choices primarily based on urine drug assessments. However nationwide habit organizations supported such practices and promoted tailoring care to sufferers’ circumstances, she stated. Her response included a 10-page bibliography with 98 citations.
Legal responsibility
The board’s investigation into Stevens is ongoing. Its web site reveals no motion taken towards her license as of late December.
The board declined to touch upon each Stevens’ case and its definition of applicable habit remedy.
In October, Stevens moved to the Virgin Islands to work in inner drugs at a neighborhood hospital. She stated she’s grateful for the welcoming locals and the monetary stability to assist herself and her mother and father.
Nevertheless it hurts to think about her former sufferers in New Orleans.
Earlier than leaving, Stevens packed away handwritten letters from a number of of them — one was 15 pages lengthy, written in alternating inexperienced and purple marker — during which they shared childhood traumas and small successes that they had whereas in remedy along with her.
Stevens doesn’t know what occurred to these sufferers after she left.
She believes the scrutiny of her practices facilities on legal responsibility greater than affected person security.
However, she stated, “liability is in abandoning people too.”
