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Becker’s Healthcare Podcast
Dr. Dan Schatz, Medical Director of Addiction Services at NYC Health + Hospitals
00:19:14
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- [00:00]
A
Welcome everyone to the Beckers Healthcare podcast series. I'm Mariah Muhammad, writer and moderator with Becker's Healthcare. I'm thrilled to have with me today Dr. Dan Schatz, medical Director of Addiction Services in the Office of Behavioral Health at NYC Health and Hospitals. Doctor, welcome to the podcast. We're very excited to have you join us today to get us started. Would you mind please introducing yourself and telling us a bit about your background and organization?
- [00:24]
B
Sure. Thank you so much for having me today. I'm excited for the opportunity to talk to you about addiction in New York City Health and Hospital. I'm a primary care doctor, an internist, and an addiction medicine doctor. As you stated, I'm the medical director for addiction services for New York City Health and Hospital, which is the largest public health care system in the country. And we provide approximately 60% of behavioral health services in New York city, serving over 80,000 individuals across our 11 acute care facilities. In my particular role, I'm the clinical lead for addiction services, overseeing those 11 different sites which include addiction services in the outpatient setting, the emergency department, inpatient community. And then of course, addiction is not just isolated to the specialist, but we have to help all services across the health care system.
- [01:13]
A
Wonderful. Thank you so much for giving us that background. So jumping right into kind of mental health and addiction, what are some signs that someone is struggling with addiction? And say, if you do see these signs in a loved one or yourself, what should you do? Are there any next steps?
- [01:32]
B
Yeah, this is a very typical question that we hear all the time. And not to get overly technical, but I actually really like the diagnostic criteria that we use. It's from the DSM 5 criteria that these are kind of where we make the diagnoses of mental health and substance use. But the idea is that there's 11 different criteria, and if you meet two or more, then you have classified as having substance use disorder. The more criteria meet the, the higher your severity is. And these criteria, without jumping into the specifics, is really when you start seeing that the substance use is starting to affect you biologically. So you're having, you know, you're falling down, you're tripping, you have wounds or injuries, maybe socially, so you're giving up activities that you used to do. You're not interacting with your friends or family as much as you would like. And quite honestly, the question in itself means that there is a loved one who's concerned about it, which is one of the criteria. Has there been a loved one who has expressed concern about your substance use? So you're already meeting one criteria if you're already concerned about it. And then the third is psychologically, is that if you're feeling. If you're seeing a dependence and needing additional medication or additional substance to get the effect that you had before you have cravings and you're thinking about it, you're spending a lot of your time thinking about getting your substance or recovering from your substance. So if you see your loved one giving up and retreating kind of from their normal activities, this is where it should raise a flag. And of course, the diagnosis itself should be done by a professional. But you, as the loved one, should express that you're concerned and that you want to help and that you love them no matter what. Because this is always a journey and it's difficult and that you know that there's care that that's available, that's effective, that I'm sure we'll get to later in this conversation.
- [03:27]
A
Yes, absolutely. We'll definitely get there. And those are amazing steps that you shared. I personally am in New York City. I live in Brooklyn right now. So this is for me and the audience. But how do you access care and addiction services in yc?
- [03:44]
B
Yeah, again, being from New York City health and hospitals, I feel so fortunate and proud to be part of this large organization. So we have 11 acute care hospitals, but we also have many federally qualified health centers. So more like community health care. And we even have outreach into the community. So we are really committed to excellence and providing comprehensive personal care wherever you interact with our system. So if you interact with our system and you're struggling with addiction, we are training everyone to recognize, to screen for, and to refer to the addiction services at any of these facilities. So at all 11 of our acute care facilities, we absolutely have addiction services both in the outpatient and on the inpatient side. Behavioral health in general, that does have some knowledge and experience about addiction, has over 5,000 staff in the 11 hospitals and 30 community healthcare centers that I referenced before. And this does include both the emergency department, the inpatient and outpatient, and really excitingly into the community, too. We have programs that don't just stop at the four walls of our hospitals. And so, you know, the focus of what we try to do both in behavioral health and in health and hospitals and the addiction field at large is to provide high quality, low threshold care. So low threshold means I don't care if you have, if you're using benzos like Xanax and also opioids like Bent. We're going to treat whatever you're willing to treat. Right now, we're going to help you as much as we can. If you come into the emergency department, we'll get you care. If you just want to cut down, we'll help you get where you want to go as comfortably and safely as possible. We hope that by accepting you and saying our doors are always open, that you're ready, that allows for change to occur in addiction. It's really an exciting time because there is so much from opioid settlement dollars to increase focus from the city and the community on addiction services that there's a lot of innovation that's happening. So we have these consult teams, we have these vans that go into the community and help patients right there. Ultimately, if you or a loved one is suffering from an addiction or even just concerned about increasing use, Please come to one of our facilities. Everyone in our facility should know how to get you the care right away and to get you to the addiction services for ongoing expertise.
- [06:20]
A
Yes, yes, absolutely. Innovation in this space is definitely. Well, we need. I hope to see it continue to expand in this way. What are some of the most common challenges on the journey to recovery from substance use disorders? I know there are probably a ton of challenges.
- [06:39]
B
There are a lot of challenges. And at the same time, it's also. I realized the more and more I treat addiction, it's actually simple. Also, it's what we kind of all need, right? I break it down into three things, right? You need health and security. So a lot of our patients might be homeless, might have other complex medical care or psychosocial issues. And of course, those need to be addressed. That's kind of the standard medical care. And the whole person care is you need a house. If you don't have a house, it's really tough to deal with the addiction. But that's true for everybody. Whether you have an addiction or not. You need that safety and security. The second is you need connections. You need a sense of belonging. So a lot of our addiction services focus on providing community. What can we learn from each other? And this goes all different directions, from the patients to our staff, from our staff to the patients, and from the patients to each other. I'm really proud and excited about one of our growing workforce in health and hospitals and the addiction services is the use of peers. So people who have lived experiences, who now are working in the system saying, hey, I know what you've gone through. I've been there. I understand this. And they get to really align and provide allyship. So a lot of our Patients actually start in one of our services, realize that they really like helping others and supporting each other, go right to a new training academy that we have called Peer Academy that trains many peers. And after they get their serpa, which is their official licensure, then they come back, and now they're part of the team from the staff perspective. So in that sense, we really create a community. And this is important for individuals you might see out on the street or for friends or family even. Addiction is a very isolating activity. They're often ostracized or said, just, why can't you just say stop or no? What we need to understand is that they still crave connections to others. I'm sure you and many of your listeners have heard about the loneliest epidemic. It's acutely prevalent in these patients, and they seek that community. So if you're a loved one, even though I know it could be tough, I will tell you that the patients hold themselves out as saying, I don't want to burn that last bridge, but your love and your support is really part of the treatment and it's absolutely needed. So that was the second thing. So the first thing is medical and safety, and the second one is community. And the third one is a sense of purpose. I have treated hundreds and thousands of patients myself, although again, most of the time I'm overseen administratively. And so many of my patients are just looking for a purpose of something bigger and something bigger than themselves. And this is, again, this is true for us as well. And it's really tough for the original question, although I've gone far off topic here maybe, is that what is one of the challenges? And it's very hard for our patients who they've lost hope. They don't know what that next step is. It seems every step they take forward is two steps back. And every time there's a setback that makes their body crave the substance even more. And so really having that sense of purpose, whether that's in work that lots of our patients get purpose from, that, whether it's volunteering or being part of your church or community in that sense. So in some ways, it's really complex and it's harder for our patients, but it's also no different than what everyone else is experiencing.
- [10:25]
A
Yeah, yeah, absolutely. Thank you so much for sharing that. And throughout all these answers, you've given some responses to the next question that I'm going to ask you. But overall, how is NYC health and hospitals helping New Yorkers overcome these challenges?
- [10:42]
B
You know, addiction is highly Stigmatized from top to bottom for many decades. And I'm happy to have seen actually rapid change here in New York City health and hospitals. But across the city, the state and across the country, there really is a huge paradigm shift that's happening. So I'm so appreciative of the giant shoulders that we stand upon at this state to allow us to get here and also recognize that there's a long way to go. So we're committed to a cultural and clinical shift in our understanding and treatment of patients with substance use disorder. It was not uncommon back in the day that we would take care of a patient and say, oh, they're drug seeking, but actually they're not drug seeking. What they're looking for is relief. They're actually in physical and medical withdrawal. Their body is nauseated, in pain, not to mention the cravings for the substance as well. So it shifts from headbutting to, hey, this is a medical issue that we have tools for and that's really important. And that's a big shift. And one of the ways we're doing that is for our first ever system wide addiction workforce training program. And through this we're giving lots of videos and training to all of our staff throughout the system, in particular behavioral health staff. We're doing live actor simulation for all emergency department doctors that really do focus on this issue of stigma and treatment. Another thing that I think is really important is there's this belief that treatment might not work or they're just going to relapse anyways or they're going to cycle through our system. Well, I'm here to tell you that these medications for addiction, in particular for opioid use disorder, but also alcohol use disorder, are incredibly effective. They're life saving and they improve quality of life. They are more effective than almost any other intervention we do in a healthcare system. And yet relapse is still common. Just like relapse on smoking cessation and asthma, or exercise and diet with high blood pressure or diabetes. When someone relapses with diabetes and they've had an improvement with their sugar numbers and then they relapse and start eating their cake again. We don't yell at them and say that this is a moral failure. We just say, okay, what can we do? How do we get back on this and how do we provide the treatment that you need? We need to do that for addiction. Also that we need to focus that this is a journey, that it is a chronic relapsing disease, and that we are supportive of that. And we have medical interventions as well as behavioral interventions that are incredibly successful and meaningful. As the largest municipal healthcare system in the country and treating over 60% of behavioral health in our system, we actually see over tens of thousands of patients every year in the medical EDs for addiction. So what we like to say is not every patient's going to be ready for treatment right then, but we want to take advantage of every single opportunity. So in the emergency department we have a program called ED leads and we have peers and social workers who will come there and do what we call esper screening, brief intervention and referral to treatment. They communicate and are well integrated into the ED teams and generally ER teams, the physicians and the nurses and so they're well aware of each other and we take advantage of the moment and say, if you're not ready now, we'll get you next time. And we just kind of persistently have hope that the patients will engage at some point and if not, that they know that we're here and we're supportive of them. What patients need is to feel seen, have dignity. We want to reduce their risk even if we can't remove all of their risk and we want to start life saving treatment. What we really want to get across is that we want to earn the patient's respect and time. It takes a lot of time to interact with the healthcare system and so we want to make it meaningful and impactful. So what are the concrete issues that they need? What can we help them with today? Not some five or ten year goal. What, what do they need right now? Let's meet that, let's show them that we're here to support them and then we'll take, we'll take the next step together.
- [15:02]
A
Perfect. Addressing the stigma is definitely important and really helps people take the first step to getting help. Letting them know it, letting them know it is okay is essential, especially for addiction. What are some of the best approaches on training a workforce to provide trauma informed, patient centered care for their patients with substance use disorders?
- [15:27]
B
Yeah, great. There's a lot in that question. A lot of our patients do experience trauma. It's very common that a lot of these individuals with kind of more severe substance use disorder have experienced childhood trauma, which just kind of highlights that they, you know, a lot of these patients didn't choose to be addicted to whatever substance they had. They had a lot of risk factors and they had a lot of trauma and they use substances to forget about it for a little bit. But unfortunately, the more they use the kind of, the, the cycle kind of continues and creates more difficulties in their life which makes them use more substances and then becomes the biological dependence on the substance itself. So I really love the question and appreciate the time to take this again. Being in behavioral health, we have teams that work on trauma and domestic violence. So we have a full range of support. But we also have that system wide behavioral health training that we have a series of videos that we're creating and trainings that we explicitly talk about trauma. And really it gets to a lot of the stigma. And it's from the front desk all the way back to the physicians, right? If the front desk says, why are you acting up so much? It might be just because the patient has to go talk to their parole officer, they have to go talk to their housing person and they have to take care of their kid. And the fact that they've been waiting in the waiting room for 10 or 15 minutes is a lot to take. And so making sure everyone's aware and making sure that they're not taking it personally to be open and supportive and how to talk to the patient in a respectful and dignified way is really critical. And that's what a lot of our training is about. And this training is again, not just going to the physicians or the social workers or the nurses, it's to the front desk. Right? It's the entire team. And what we need is there's been a history of stigma put upon these patients. So we need a lot of positive experiences to earn their trust and to earn their confidence in us that we're going to provide treatment. So upon full implementation, we'll provide training to over 3,000 health and hospital staff to achieve the system wide culture change and facilitate additional treatment and care. And this includes both asynchronous and synchronous training. So we have a lot of videos that they can watch in training and material. But we also have a number of learning collaboratives as well as in person, kind of live actor simulation. So we have a pretty robust plan to address stigma. And I like to tell people that stigma is not just some software issue. It's the matter. It's a life or death issue. It means they either seek out care or they don't seek out care, because they don't. They're too scared to cross our four walls or a hospital. And the last piece I'll say is that's what makes me really excited that we're even going into the community. Crossing a door into a hospital is a threshold that some patients don't want to take and we want to meet them where they are. So we will go into the community to meet them. We'll take care of them virtually if we need to, whatever we can do to support the patient for what they're ready with.
- [18:52]
A
Absolutely. Thank you so much for those final thoughts. It's definitely been a very informative discussion. So again, I want to thank you so much for coming on Backwards healthcare, especially for the first time. I look forward to connecting with you again soon.
- [19:05]
B
Thank you so much for the opportunity and I really appreciate your thoughtful questions.
- [19:10]
A
Of course.