Aneri Pattani
NEW ORLEANS — Elyse Stevens had a fame for taking over complicated medical circumstances. People who’d been battling dependancy for many years. Chronic-pain sufferers on excessive doses of opioids. Sex staff and other people residing 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 dependancy drugs physician.
While different docs prevented these sufferers, Stevens — who was aware of town from her time in medical college at Tulane University — sought them out. She usually attended 6 a.m. breakfasts for homeless folks, volunteered at a homeless shelter clinic on Saturdays, and, on Monday evenings, visited an deserted Family Dollar 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 lined 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 University Medical Center New Orleans. There, Stevens found Harrell had diabetes and most cancers.
She agreed to prescribe Harrell ache treatment — an choice many docs would routinely dismiss for worry {that a} affected person with a historical past of dependancy would misuse it.
But Stevens was assured Harrell may 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 received her awards and nominations in medicine, community service, and humanism. Instead of seeing sufferers in binaries — addicted or sober, with a constructive or unfavorable drug check — she measures progress on a spectrum. Are they showering day by day, cooking with their households, utilizing much less fentanyl than the day earlier than?
But not everybody agrees with this versatile method that prioritizes working with sufferers on their targets, even when abstinence isn’t considered one of 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.
Flexible Care or Slippery Slope?
More than 80% of Americans who want substance use therapy don’t obtain it, nationwide information reveals. Barriers abound: excessive prices, lack of transportation, clinic hours which can be incompatible with jobs, worry 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 drugs refills that last more turned the norm.
The consequence?
“Patients did OK and we actually reached more people,” stated Brian Hurley, fast previous president of the American Society of Addiction Medicine. The group helps persevering with versatile practices, equivalent to serving to sufferers keep away from withdrawal signs by prescribing higher-than-traditional doses of dependancy treatment and specializing in restoration targets other than abstinence.
But some docs desire conventional approaches that vary from zero tolerance for sufferers utilizing unlawful medication to setting stiff penalties for many 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 advised to go to residential rehab. Proponents of this methodology worry loosening restrictions might be a slippery slope that finally harms sufferers. They say persevering with to prescribe painkillers, for instance, to folks utilizing illicit substances long-term may normalize drug use and hamper the objective of getting folks off unlawful medication.
Progress ought to be greater than preserving sufferers in care, stated Keith Humphreys, a Stanford psychologist, who has handled and researched dependancy for many years and supports involuntary treatment.
“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.”
Flexible practices additionally are likely to align with hurt discount, a divisive method that proponents say retains individuals who use medication protected and that critics — including the Trump administration — say permits unlawful drug use.
The debate is not only philosophical. For Stevens and her sufferers, it got here to bear on the streets of New Orleans.
‘Unconventional’ Prescribing
In the summer season of 2024, supervisors began questioning Stevens’ method.
In emails reviewed by KFF Health News, they expressed considerations about her prescribing too many ache capsules, a mixture of opioids and different managed substances to the identical sufferers, and excessive doses of buprenorphine, a medicine thought of the gold standard to deal with opioid dependancy.
Supervisors apprehensive Stevens wasn’t doing sufficient urine drug assessments and saved 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 electronic mail to Stevens and inspired her to refer extra sufferers to methadone clinics, intensive outpatient care, and inpatient rehab.
Stevens understood the overall follow however couldn’t reconcile it with the truth her sufferers confronted. How would somebody residing in a tent, afraid of shedding their possessions, trek to a methadone clinic day by day?
Stevens despatched her supervisors dozens of research studies and national treatment guidelines 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 Health News.
Both University Medical Center and LSU Health New Orleans, which employs physicians on the hospital, declined repeated requests for interviews. They didn’t reply to detailed questions on dependancy therapy or Stevens’ practices.
Instead, they supplied a joint assertion from Richard DiCarlo, dean of the LSU Health New Orleans School of Medicine, and Jeffrey Elder, chief medical officer of University Medical Center 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 Health News shared the complaints in opposition to Stevens and the responses she’d written for supervisors with two dependancy drugs docs exterior of Louisiana, who had no affiliation with Stevens. Both discovered her practices to be throughout the bounds of regular dependancy care, particularly for complicated sufferers.
Stephen Loyd, an dependancy drugs physician and the president of Tennessee’s medical licensing board, stated docs operating capsule mills usually have sparse affected person notes that checklist a chief criticism of ache. But 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 folks assume the “only good answer is no opioids,” equivalent to oxycodone or hydrocodone, for any sufferers, stated Cara Poland, an dependancy drugs physician and affiliate professor at Michigan State University. But sufferers might have them — generally 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 special take. He didn’t evaluation Stevens’ case however stated, as a basic follow, there are dangers to prescribing painkillers long-term, particularly for sufferers utilizing at this time’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 stress, Stevens’ supervisors advised her on March 10 to cease coming to work. The hospital was conducting a evaluation of her practices, they stated in an electronic mail considered by KFF Health News.
Overnight, lots of of her sufferers have been moved to different suppliers.
Luka Bair had been seeing Stevens for 3 years and was steady on day by day buprenorphine.
After Stevens’ departure, Bair was left with out treatment for 3 days. The withdrawal signs have been extreme — headache, nausea, muscle cramps.
“I was just in physical hell,” stated Bair, who works for the National Harm Reduction Coalition and makes use of they/them pronouns.
Although Bair ultimately bought a refill, Springgate, Stevens’ supervisor, didn’t wish to proceed the routine long-term. Instead, 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 threat. Bair “requires a higher level of care than our clinic reasonably can offer,” Springgate wrote in affected person portal notes reviewed by KFF Health News.
But Bair stated day by 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 treatment once more.
“This is the thing that kills people,” stated Bair, who ultimately discovered one other physician prepared to prescribe.
Springgate didn’t reply to repeated calls and emails requesting remark.
University Medical Center and LSU Health New Orleans didn’t reply questions on discharging Stevens’ sufferers.
‘Reckless Behavior’
About a month after Stevens was advised to remain house, 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 previous incarnation, known as Stevens a “lifeline” for weak sufferers.
Beavers Khoury stated she despatched the letters to about 10 folks in hospital and medical college management. Most didn’t reply.
In May, 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 Health News’ questions on the way it reached this conclusion or if it recognized any affected person hurt.
Meanwhile, Stevens had secured a job at one other New Orleans hospital. But as a result of her resignation got here amid the continuing investigation, University Medical Center stated it was required to tell the state’s medical licensing board.
The medical board started its personal investigation — a improvement that ultimately price Stevens the opposite job provide.
In presenting her aspect to the medical board, Stevens repeated many arguments she’d made earlier than. Yes, she was prescribing highly effective drugs. No, she wasn’t making medical choices based mostly on urine drug assessments. But nationwide dependancy organizations supported such practices and promoted tailoring care to sufferers’ circumstances, she stated. Her response included a 10-page bibliography with 98 citations.
Liability
The board’s investigation into Stevens is ongoing. Its website reveals no motion taken in opposition to her license as of late December.
The board declined to touch upon each Stevens’ case and its definition of applicable dependancy therapy.
In October, Stevens moved to the Virgin Islands to work in inside drugs at an area hospital. She stated she’s grateful for the welcoming locals and the monetary stability to assist herself and her dad and mom.
But it hurts to consider her former sufferers in New Orleans.
Before 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 they’d whereas in therapy 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.
But, she stated, “liability is in abandoning people too.”
