Emergency room staff at St. Louis area hospitals are getting to know Kael Maness. When he walks in, they just say, “Room 10.”
The room number changes, but the scenario is usually the same: The room holds a patient brought back to life after a heroin overdose. Maness, 32, introduces himself and explains he works for a drug treatment program. He’s in recovery after abusing drugs for 15 years. He’s been sent to help.
“I’m not a (expletive) psychologist. I’m just an addict they’ve given an opportunity to,” Maness says. “I’m going to help you.”
Maness will point to a bright spot on his biceps among the sleeve of tattoos on his arm. It’s sky blue with the date 5-12-14. That’s how long he’s been clean.
“Once they know I’m an addict, they open up,” he said. “I know how to talk to them. They’re my people. They’re me.”
Over a year ago, health providers came up with a plan to try to stop a barrage of heroin overdoses landing in emergency rooms. It is now a regionwide project that involves sending “recovery coaches” like Maness to hospitals as living proof that addicts can get better.
Each month, about 75 patients agree to meet with a coach.
The recovery coaches quickly connect patients to outpatient addiction treatment programs. And emergency room doctors can administer drugs that can ease withdrawal symptoms right away and provide patients a short prescription until they get into treatment — a new approach in treating addiction.
Patients landing in emergency rooms after nearly losing their lives are likely to be the next casualties in the epidemic. They have angered their friends and family. They have lost hope.
“We might be the last person fighting for them,” Maness said, “the last person in their corner.”
Danyell McMiller, 42, a father of four, began using drugs a dozen years ago to cope with his younger brother’s death. The only future he saw for himself was on a street corner.
Maness met him in the emergency room at Barnes-Jewish Hospital one Friday in April and tried to convince him he could get better.
“It seemed way out of reach,” McMiller said, “like being the president.”
McMiller had to wait for his 8 a.m. appointment the following Monday at the Preferred Family Healthcare treatment clinic on Delmar Boulevard in St. Louis.
“I’m glad you showed up,” Maness told him as the two sat together recently in the clinic’s art room, where McMiller painted a picture for his sister-in-law’s birthday.
McMiller hadn’t used heroin in four months.
He was quick to respond: “I’m glad you showed up.”
All thanks to you
Friends bring them. Sometimes they get left in the driveway. Or they arrive by ambulance after paramedics rescued them with Narcan, the antidote that reverses an overdose.
Every day, five to 10 people who have overdosed on opioids such as painkillers and heroin come through the doors where Dr. Robert Poirier works at Barnes-Jewish Hospital, the city’s busiest emergency department.
But no emergency department is immune to the epidemic, which took the lives of 650 people in the St. Louis region in 2016, more than four times the number of opioid deaths in 2007.
Doctors knew they had to do something other than sending patients back onto the streets.
Patients would get a list of drug treatment programs, but it could be three weeks to three months — especially without insurance — to get into one.
More than a year ago, participants in the Behavioral Health Network of Greater St. Louis asked: “How can we work together to get this under control?” Poirier said. The network is a consortium of health providers, leaders, advocates and consumers who work together to address barriers to mental health services.
The network found a model in Rhode Island, where a drug treatment program sent a peer to meet patients in emergency rooms.
It also found research — a 2015 study from Yale that showed patients given medication in emergency rooms to reduce withdrawal symptoms were twice as likely than others to be in a treatment program 30 days later.
Yale New Haven Hospital emergency doctors initiate medication, connect patients to treatment and give them Narcan to take home.
Combining both approaches, project EPICC — Engaging Patients in Care Coordination — began a test run in December at Barnes-Jewish Hospital with a $500,000 state grant.
Two recovery coaches were on call to meet with a patient at any time and connect them to free care at two addiction treatment programs.
The project has exploded. Nine hospitals in the city and St. Louis, St. Charles and Jefferson counties now participate. Five coaches working with five treatment programs are on call.
The effort received another $550,000 grant for next year, which pays for the coaches as well as administrative costs to track outcomes. Treatment for Missouri residents referred through the project is covered through a statewide budget of $5 million a year for the next two years.
“Getting people into a situation that they did not know was possible for them has at least saved dozens of lives,” said Mike Bloodworth, program director at Preferred Family Healthcare and Maness’ boss. “That’s the best, hearing people say, ‘I would be dead now without this.’”
As Maness recently walked to his car in the parking lot of a treatment center in St. Louis, a man on the sidewalk yelled at him through a chain link fence, “Kael! Hey!”
Maness remembered helping the man get treatment and into a sober living house. The man said he was walking home from work. Maness asked how long he had been clean.
“One hundred and seventeen days!” he said, beaming. “All thanks to you, man!”
I don’t have a home
Maness grew up in Arkansas, under the shadow of an abusive and alcoholic father, he said. At age 12, his parents divorced, and his mom eventually moved the family to Fenton, where he attended Rockwood Summit High School.
His mom remarried, which he hated. He stayed away from home, hanging out with his older sister’s friends. He felt a void, and he filled it with danger and drugs.
A talented drummer, Maness played with the well-known punk band Opposites Attack. The lifestyle fueled his addiction. He was smoking K2, synthetic marijuana, and taking painkillers.
Two times, Maness tried to stop. He relapsed the first time after 70 days straight. His then-fiancée had brought him a bottle of whiskey. “It’s good to have you back,” she told him.
After the second time, he got a job driving a truck for FedEx and cut ties with old friends. But he gave in to the voice telling him he could handle one drink. He was fired after passing out in his truck with a K2 pipe in his hand.
Maness, who was living with his mom, pretended to continue leaving for work. But one day, she found him passed out in her living room. She warned him he would have to leave if it happened again. It happened again.
His car became his home. He and a friend used heroin, stealing and strong-arming people for cash. He broke into his parents’ house, even stealing from his little brother’s piggy bank.
On Christmas Eve, a cop banged on his car window and told him he had to go home. “I don’t have a home,” Maness answered.
The officer insisted he had to take him somewhere, so Maness directed him to his mom’s house. As they pulled up, Maness could see his family in the driveway, hugging and saying their goodbyes for the night.
“Can you please just keep going?” he asked. “Drop me at the end of the block?”
The officer obliged, and Maness ended up back at his car.
Maness would eventually make his way to his sister’s house, asking for gas money. “You look like you’re going to die,” she told him. “Why don’t you go back to treatment again?”
Dr. Corey Waller told emergency physicians at a recent symposium at Washington University School of Medicine on the opioid crisis that humans need three things to survive: food, water and dopamine.
Dopamine is the “feel-good” chemical in the brain. It’s what gets us out of bed in the morning.
When we feel the worst, dopamine levels in the brain hover at 40 nanograms per deciliter, Waller said. Sex and favorite foods can boost levels up to 94 nanograms. Heroin jolts levels to more than 900 nanograms. The spikes cause the body to stop producing dopamine naturally, Waller said. “It kills the nerves in the happy part of the brain.”
Going without the drug is like going days without food or water. One will eventually do anything to get it, he said. “Motivation to get that drug is through the roof.”
Medications such as buprenorphine and methadone can block the euphoric effects of illegal drugs while also normalizing brain chemistry, which can take months.
Methadone can only be administered through a methadone clinic, but doctors can prescribe buprenorphine after completing training and earning a federal waiver.
Yet only eight emergency departments in the country have doctors treating addicts with buprenorphine, Waller said.
The slow adoption of medication-assisted therapy is partly due to misconceptions that the drugs are just substitutes for the illegal versions. Yet evidence shows they are a safe way to overcome addiction, and reduce the need for expensive inpatient detoxification facilities with long wait lists.
Doctors have long treated opioid addiction as a moral failure rather than a disease, Waller said. Medication is used to treat chronic diseases such as depression and diabetes, and addiction should be no different.
“This is a preventable and treatable disease,” Waller told the auditorium full of physicians. “We have a real ability to help, and it’s only us standing in the way.”
Not all hospitals participating in project EPICC have emergency physicians trained to prescribe buprenorphine, but that is quickly changing. More recognize it is key in getting patients to the door of a treatment program.
Doctors had to get over fears of people seeking emergency care in order to get a prescription, Poirier said. Barnes-Jewish, which only had four doctors able to prescribe, will have 20 more by the end of this month, he said. “It’s a culture change.”
A statewide program is educating health providers on the importance of medication assisted treatment and providing the training for free.
Dr. Randall Williams, the new director of Missouri’s health department, lauds the approach.
“If someone comes in for an overdose, or they have a serious addiction, the brain is not thinking about anything else but doing it again,” Randall said. “If you can get (buprenorphine) in their system … it gives you an itty-bitty window to get hope in them.”
Until his sister said it, treatment hadn’t seemed like an option, Maness said. They found a spot in the third inpatient facility they called.
After the two-week program, Maness moved into a sober living house in south St. Louis, where he lived for nearly two years. For 10 months, he took medications to help him with withdrawal.
He got jobs doing peer support work at different treatment centers before ending up at Preferred Family Healthcare. He earned his drug counseling certification.
When the job as recovery coach became available, Bloodworth knew Maness would be perfect. “He’s like a recovery salesperson,” he said, “and that can be a tough sell.”
Five days before McMiller met Maness in the emergency room, McMiller had shown up high at his brother’s house. His brother yelled that McMiller must not care.
But he did. He loved his brother. He loved his children, his life. Seeing his older brother with tears in his eyes was a wake-up call.
“I thought I was only hurting myself. I thought that no one cared … but that was not the truth,” McMiller said. Maness convinced him to show up for treatment. There, McMiller learned to stop blaming himself for his younger brother’s death.
“Hurting myself wasn’t justifying anything,” McMiller said. “There’s nothing I could’ve done, nothing at all. So get yourself together, and live.”
Maness recently bought a house in south St. Louis County. He’s working on a college degree. Instead of filling the void in his life with drugs, he said, he’s filling it with helping others.
“I have a life today I didn’t know I wanted,” Maness said.
He understands addiction is a disease, one that often isn’t treated because of the crime, hurt and shame that comes along with it.
“But people change” he said. “It happens all the time. I see it every day.”
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