Guest Blog: Walking Alongside Patients with Substance Use Disorders

*This piece is republished from the Colorado Psychiatric Society Autumn 2023 A Piece of Our Mind newsletter.

As part of our ongoing commitment to behavioral health, PRMS is pleased to feature Dr. Ashley Curry, Colorado Psychiatric Society member, psychiatrist, and addiction specialist, as a guest blogger this month. Dr. Curry introduces the Access Transformative Outreach Program (ATOP) at Denver Health and shares more about its impact on the community and patient improvement.

“In my early professional years, I was asking the question, ‘How can I treat, or cure, or change this person?’ Now I would phrase the question in this way: How can I provide a relationship which this person may use for his own personal growth?” -Carl Rogers

In August 2023, the Access Transformative Outreach Program (ATOP) at Denver Health celebrated one year of working with patients! ATOP is funded through a grant by Colorado Access, thanks to the initial support of Colorado Psychiatric Society (CPS) member Dr. Kim Nordstrom, to provide intensive case management to patients with primary substance use disorders who frequently use emergency, inpatient, and detoxification (“detox”) services. We are an interdisciplinary team comprised of a program supervisor, four case managers, a psychiatrist, a nurse, a peer recovery coach, and a care navigator. We function similarly to an assertive community treatment (ACT) team but focus exclusively on patients with severe substance use disorders. Some, but not all, are also diagnosed with what is traditionally described as severe and persistent mental illness (such as severe psychotic or mood disorders). Most of the patients we serve are experiencing homelessness.

Our work is community based. Since many of our patients do not have phones, our first contact typically takes place when they are utilizing services at Denver Health, for example, in the emergency department, inpatient setting, or detoxification center. After patients join the program (thus far, very few have declined our offer for services), we follow them into the community and meet them where they are at. I have done psychiatric visits in people’s homes, shelters, parks, and in detox. Some prefer to come see us in our office where they can access food, water, and clothing. We offer doughnuts and coffee three days a week. Our doors are open for drop-ins during business hours Monday through Friday.

Sobriety is not a requirement to work with ATOP. Patients do not have to be actively seeking substance use treatment. They are not required to meet with me (though most have). So, what is the goal of a program like ATOP? The program seeks to transform the way a patient accesses medical care - in short, fewer acute healthcare utilizations and more engagement with outpatient and preventative care. To do so, we must first transform the patient’s relationship with the medical system. Many of the patients we serve are wary of any medical providers. They have only received sporadic care throughout their lives. They have experienced discrimination in these settings. Without phones, permanent addresses, or access to transportation, they must overcome significant barriers to make and keep appointments. We do our best to eliminate and reduce these barriers. Above all, we build trust and a relationship with our patients (which often can extend to other clinics at Denver Health) and encourage them to seek care.

Working with a team like ATOP is one of the most difficult and rewarding jobs in medicine. Difficult because nothing is easy when a person is experiencing homelessness and struggling with substance use. Difficult because of the structural barriers that seem to keep our patients in the same patterns from which they want to break free. Difficult because close patient relationships come with the shared pain of relapse and loss. Rewarding because we build relationships with patients that are not possible in many traditional medical models. Rewarding because a patient success is shared and felt by the whole team. Rewarding because it feels good to show up for someone when they are not expecting anyone to show up. As the medical director on this team, I find I spend as much time thinking about my team members (“Is everyone okay?!?”) as I do about my patients. In the quote above, Carl Rogers, an American psychologist, speaks about his earlier self, which in many ways exemplifies a traditional medical approach to caring for patients.

As a team, we are in constant tension between the urge to treat and the need to take a step back and accompany a patient on their journey. When we feel like we are working harder than the patient it is often because, in that moment, our wish for them (however well intentioned) is not in line with what they desire for themselves.

As I reflect on a year of ATOP, I think about some of the milestones:

• A patient proudly reporting more consecutive days of sobriety than they have ever had
• A patient getting the keys to an apartment after years of homelessness
• A patient calling our office to check-in after weeks of trying to find them
• A patient walking into the office and stating, “I don’t want to use anymore.”

One of the best endorsements for our program is that people call to inquire about it. We have received calls from people in detox and even a security guard at the light rail station who was looking for services for a family member. One of our patients had given him our card and told him, “They work miracles.” We direct those who are not eligible for our program to other services. We take pride in being a team that is recommended by our patients.

What does the next year hold for ATOP? We will be working with Colorado Access to transition to a billing model that will allow us to keep doing what we do! We are working to adapt and update our eligibility criteria to allow for some real-time referrals within our own hospital system. We have a few of our 60 patient slots left to fill. We continue to celebrate (and be grateful for) each of our team members who do choose to do this work. And we will continue to walk along with our patients on their journey and cultivate relationships that allow them to grow and change.

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