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NEW YORK — Dr. Zehra Siddiqui was appointed to be the medical director of Ryan Health’s Chelsea-Clinton branch last year. Within weeks, she was on the front lines of fighting one of the largest crises facing the U.S. health care system today — opioid addiction.
In 2018, Ryan Health rolled out a comprehensive opioid addiction treatment program, which patients can access during a routine check-up, as opposed to going to a dedicated facility.
“We want to remove all the barriers to treatment,” said Siddiqui.
Drug overdoses led to the deaths of more than 70,000 people across the United States in 2017, and more than 68 percent of those deaths involved a prescription or illicit opioid drug. Community health centers, such as Ryan Health, care for the most vulnerable people who are dealing with drug abuse, just as they care for the most vulnerable people in general.
“Primary care, or places where it’s easier to access that people go more often, you have a better chance of doing addiction treatment, because people are more likely to see their primary doctor,” Siddiqui said.
The Hell’s Kitchen-based clinic (which is named for the neighborhood) serves a marginalized community somewhat hidden amidst a rapidly gentrifying area that now boasts trendy restaurants and tony apartments. Nevertheless, the area, which gained fame as the setting of “Taxi Driver” and “Daredevil,” is still home to many long-time residents in rent-controlled apartments, as well as people who are experiencing homelessness, or who are otherwise vulnerable.
“We’re not treating anyone different than we were [them] treating before. These are the patients we were treating before… but now we are screening all our patients for addictions,” Siddiqui said, referring to patients age 18 and older. Despite being located in an expensive part of the city, about 80 percent of Ryan Health’s patients earn an income below the poverty line. Ten percent are homeless. The system has close to 206,000 patient encounters per year.
Ryan Health, which has several locations throughout Manhattan as well as mobile clinics and in-school centers, debuted their opioid treatment program last year. The program followed the 2016 passage of the national Comprehensive Addiction and Recovery Act, which expanded the ability to prescribe pharmaceuticals which treat opioid addiction, such as buprenorphine — the active ingredient in suboxone — to nurse practitioners and physician assistants after they complete 24 hours of specialized training.
An earlier federal law, the 2000 Drug Addiction Treatment Act, allowed for physicians to prescribe buprenorphine after eight hours of training. All providers have caps on how many patients they can treat, ranging from 30 to 100 in the first year. A coalition of 22 states, led by New York, is calling on the U.S. Department of Health and Human Services to drop these requirements entirely, which would greatly expand the health care system’s capacity to treat opioid addiction.
One Patient at a Time
Ryan has treated 35 patients in its opioid treatment program to date. One of them is Rene, who asked that his last name be withheld, given the sensitivity of his health condition.
“Over a year ago, I decided I didn’t want to do it (opioids) anymore. I thought I could quit on my own, but it was really hard,” he said.
“I thought I could do it on my own and found all these people who had done it, but I couldn’t, it was pretty much impossible.”
Rene said he did research online to both find strategies to quit and then to find treatment centers, but did not succeed on either front, owing to the many contradictory facts online and the labyrinth nature of the U.S. medical system, respectively. As an employee at a hotel, he was also unable to take a chunk of time off work, and was uncomfortable sharing his addiction with those close to him.
Siddiqui said Rene’s experience is typical for many of her patients dealing with addiction.
“The health care system is confusing in general,” she said, noting that a search for addiction treatment will often result in private treatment centers, in addition to the fact that costs are rarely clear for patients.
She added that there is another differentiating factor when it comes to opioid addiction treatment beyond these pervasive issues.
“People don’t want to be labeled. There’s no stigma in getting treatment here (at Ryan Health),” she said.
Rene said he first heard about Ryan Health from a friend who suggested he go to get an HIV test.
“I went to Ryan (Health) for a few years. So I asked the doctor if he could direct me in the right direction to get off the pills, and he said they were going to be starting a program. I was like, ‘Of course, I definitely want do it’,” Rene said.
Patients must be in the withdrawal process for pharmaceutical treatment to be effective. Ryan’s program involves patients doing the actual induction — starting the treatment — at home, in coordination with Siddiqui and her team, and then coming back a week later to continue coordinating care. Patients receive calls in the intervening time to check up on them and note the amount of suboxone they used.
Rene said the program has worked for him.
“There were a couple hiccups, but it’s good now. I’m on the medication and will hopefully wean off that. I just needed guidance and some medication involved and someone to keep up and check in on me, someone I could call when I felt urges or when I had a question,” he said.
The multi-provider approach is a staple of Ryan Health’s program, which includes a physician, nurses, and behavioral health staff, who implement modalities such as eye movement desensitization and reprocessing to care for trauma.
They will also send staff members to walk with patients across the street to the pharmacy to make sure there are no unexpected challenges, such as a high co-pay, with prescriptions. If any problems do emerge, the staff members will go back with the patient to help them with costs via grant programs and other available resources. As a Federally Qualified Health Center, Ryan offers a means-based sliding scale fee structure, in addition to Medicaid, Medicare, and private insurance payment options.
Making sure patients have what they need extends all the way to the top of the clinic as well.
“I think a part of me is a social worker too. I do the doctor thing half the time, and I’m also being a social worker, helping them (patients) find where to get food or low-cost groceries or how to help get free activities for their kids,” Siddiqui said.
In assessing what she feels should be done to fight the opioid crisis better, Siddiqui said that more education is needed amongst her peers to reduce the fear of treating those afflicted with addiction
“There’s a lot of hesitancy to treat people with addiction, seeing them as high risk,” she said. Siddiqui also believes that more providers should be allowed to treat addiction and that programs should have a focus on treating people, “where they’re at,” all in a bid to reduce barriers to care.
The accessibility at Ryan played a crucial role in Rene’s experience. He said that in addition to the pharmaceuticals and other kinds of easily quantifiable care, he felt that his health care providers gave him something more.
“It felt like they’re like my own personal concierge doctors. It’s really nice to have that in person,” he said. “It definitely matters, especially in big cities. You want feel at home. These big cities can be cold.”
Since 2009, Direct Relief has provided more than $130,000 in medical aid to Ryan Health, and more than $60,000 worth of overdose-reversing naloxone to health centers across New York.