Breaking the Cycle of Addiction on our Streets

A beer bottle in a brown paper bag

We’ve all seen the signs of addiction in San Francisco. What is harder to identify is the cause. There are many related and overlapping factors that contribute to this problem: mental health, homelessness, poverty, physical and emotional abuse, hunger, and other stresses. The root causes are as varied as those who have a substance use disorder. This is why the work of the Addiction Care Team (ACT) at Zuckerberg San Francisco General (ZSFG) is invaluable.

The Addiction Care Team (ACT) is an innovative program at ZSFG that is sponsored by the San Francisco Health Plan, San Francisco General Hospital Foundation, and other philanthropy. ACT connects traditionally siloed medical care, addiction treatment, and community support to help address a patient’s Substance Use Disorder (SUD). ACT is staffed by a patient navigator, addiction medicine fellow, and a supervising physician that together provide a novel approach to addiction care. It is the second program of its type in a public hospital, and the first in such a racially and ethnically diverse population where patients use multiple substances and face complex social situations. Currently, ACT delivers SUD care only to patients on select hospital teams. Additional funding would expand capacity so ACT could be available to any patient.

Considering that at least 33% of patients hospitalized at ZSFG have a SUD and that many of these patients are unconnected to community care, the need is high and very urgent.

SUD occurs when people use alcohol and other drugs like opioids, methamphetamine, cocaine, benzodiazepines, or heroin despite harmful consequences. To add complexity, of those with SUD at ZSFG 48% are homeless and 40% have a mental illness. ACT addresses this complexity by working across disciplines to coordinate individually tailored, patient-centered care.

Hospitalization presents a unique opportunity. Patients reflect upon their own mortality and fragility and are highly motivated to make a change. “Oftentimes when we see patients, they have a moment of clarity. They are away from the situations where they were using. They may be sober for the first time in a while. We take the time to sit and have an honest conversation about what is happening in their lives and how we can help support them to meet their goals and needs,” says Marlene Martin, MD, Director of ACT.

ACT members are trained in motivational interviewing to guide these open conversations with patients. Gone is judgment about anyone’s choices. Gone is any implication that having a SUD is a person’s own failure. Gone is talking at patients and giving them a one-size-fits-all approach to overcoming addiction, often using scare tactics that don’t work. Instead, the team actively listens, reflects back what they hear, and notices language choices that indicate a patient’s desire for change, while recognizing the role other stressors and social situations play in a patient’s life that could be related to their disorder.

This manner of listening gets results because it puts the patient at the center. They dictate the plan. When their own motivations are reflected back, they feel heard. And because there is no judgment, they feel respected.

Very often there hasn’t been anyone to really listen or engage with the patient. With ACT, people have a trusted advocate during their hospitalization. “This is a very human interaction. We want to help, but that help must be consistent with what a patient desires,” adds Dr. Martin.

Not every patient is ready to stop using. ACT accepts that and provides harm reduction focused care. They support people cutting back if totally quitting isn’t yet a perceived option. With intravenous drug use, ACT shares how to inject safely to avoid infection and the availability of community syringe access programs to decrease risk of acquiring infections like HIV and Hepatitis C. This notion of “meeting patients where they are” can help to mitigate the complications from substance use—which is often the reason they have been hospitalized—while building rapport and engendering trust for the future.

For those patients who need and want residential treatment to deal with their disorder, ACT connects them with a program during hospitalization. In the past, this direct connection was not possible, so discharged patients had to get on a waitlist. During this waiting period, they went back to the streets, to the triggers of their use, lost motivation for treatment, or encountered barriers to accessing treatment. They often went back to using. Now individuals can go directly from ZSFG to residential treatment.

Over 65% of substance use disorder patients request help.

“Hospitalization is a brief moment in most of our patients’ lives. Our goal is to connect them to the support they need once they leave here so that they can thrive in the community,” says Dr. Martin. “That support can range from harm reduction to primary care linkage, from medication to reduce or stop alcohol or drug use to services like counseling, community case management, or residential treatment programs.”

ACT’s touchpoint