“Overdose! Atkinson Street!”
We grabbed the oxygen tank, AED, and emergency kit. We ushered our patients out of the clinic and ran past the metal detectors to the street. We ran to the cluster of outreach workers, police officers, and onlookers that the emergency had attracted.
I work as a physician in a shelter-based clinic in Boston, near the intersection of Massachusetts Avenue and Melnea Cass Boulevard, where a large encampment of people experiencing homelessness has emerged. Injection drug use in this area has picked up recently, and overdoses are not uncommon. When people need help, outreach workers and shelter staff run in and call for us.
The man before us that day was pale, nearly blue, rigid, and barely breathing. His pupils were pinpoint, and the oxygen saturation meter read 68% — very low and consistent with an overdose that had suppressed his drive to breathe.
A woman supported the upper half of his body to keep it off the wet asphalt as the outreach nurse and I did our initial assessment. It’s not uncommon for people to use drugs with friends or romantic partners, and they often have useful information about the patient.
As the nurse administered oxygen and I unwrapped the naloxone (Narcan), I asked the woman if she knew him. And she said, “Not personally, but we’re all family here.”
As we continued to administer oxygen, took another round of vitals (oxygen up to 98%), and waited for the Narcan to kick in and the ambulance to arrive, the woman gathered up his valuables and zipped them up into his jacket pockets.
He started breathing more deeply and his color returned. Soon, he sat up and was able to tell us his name and answer some questions. I asked him what happened, and he explained that he was a veteran with PTSD, and sometimes got really depressed and would use drugs. Before I could decide what question to ask next, the woman said what I should have said: “Thank you for your service.”
He declined to go to the emergency room with the EMTs, but he did accept a Narcan kit from us. As he walked off into the crowd, the woman said, “I’ll look out for him.” And after a pause, “I should have finished my nursing degree.”
“It’s never too late!” the outreach nurse and I said in unison. With healthcare provider burnout at an all-time high, healthcare providers like her — compassionate people who deeply understand or are part of the communities they’re serving — are exactly who we need.
Her comment reminded me of the time when I first started working as a physician and was helping out at a health fair. I was assigned to the Narcan training booth, having administered Narcan at most half-a-dozen times. A woman came up and asked for Narcan training. I asked her if she had ever used Narcan before and she said, “Yes, I’d guess a hundred times or so on friends who overdosed, but it’s always good to get a refresher.”
Too often in medicine there is a sense that we as physicians and other healthcare providers have all the answers and have to get our patients to do what we tell them to. That approach has not gotten us far with people who use drugs — overdoses have reached an all-time high at a time when life-saving medications exist, but patients aren’t getting them. The problem is we’re neglecting to embrace the knowledge and expertise of people who understand this community.
In my experience as a provider of healthcare to people who are homeless, there is a deep well of knowledge and compassion in the people we serve. The increasing prominence of peer recovery coaches in promoting recovery and preventing drug-related harms including overdose is a first step to incorporating this knowledge and compassion in healthcare settings. Beyond this, medicine and research can go further to incorporate the knowledge and skills of people who use drugs to prevent overdose and other drug-related harms. Rather than making a history of substance use a barrier to applying to become a nurse, doctor, or other healthcare provider, we should consider what strengths these individuals bring to the table related to their experience.
Unfortunately, we have a long way to go. I was recently connected to a college student with a 4.0 GPA and a 99th percentile MCAT score who wanted to apply to medical school. He had won research awards and was all-around very accomplished. Yet, he told me that six physicians had discouraged him from applying to medical school. Why? Because he had a history of substance use that had derailed him from the traditional college path for a bit. Since then, he had maintained sobriety, and not only that, had spent hundreds of hours mentoring peers to support their sobriety. His experiences will serve him tremendously in treating people with substance use disorder. Yet, physicians were discouraging him from applying or telling him to hide his history of substance use.
The skills, knowledge, and compassion necessary to address the overdose crisis exist in the community of people who use drugs. Historically, this group of people has been particularly marginalized by healthcare institutions. But people who use drugs are finally starting to demand a seat at the table where decisions are made around research and treatment of substance use disorders. Researchers, clinicians, and policymakers need to come up with creative ways to partner with this community to meaningfully incorporate lived and living experience in designing research and clinical programs.
In the face of one of the biggest health crises of our generation, it’s time to realize that “we’re all family here.”
Avik Chatterjee, MD, MPH, is a physician with the Boston Health Care for the Homeless Program, an assistant professor at Boston University School of Medicine, a lecturer at Harvard Medical School, and an associate epidemiologist in the Division of Global Health Equity at Brigham and Women’s Hospital.