Bridging the Gaps

The addiction and overdose crisis in Philadelphia is an escalating public health emergency.

Beyond the sobering statistics (see callouts), the city’s healthcare system is often fragmented, with issues like housing, language, and transportation causing barriers to services.

Most overdose deaths involve opioids, usually illicitly manufactured fentanyl, a highly potent opioid that has replaced heroin as the most common drug involved in fatal overdoses. However, two major shifts have eclipsed the ongoing concerns about fentanyl: the marked rise in polysubstance overdose and the unexpected emergence of xylazine (also called tranq).

In January 2023, The New York Times focused on Philadelphia in a report on the rise of the use of xylazine, which in humans can cause severe circulatory changes with devastating effects on tissue, leading to painful open lesions, necrosis, and potentially limb loss. Now over a year later, it’s not unusual to have three or more patients suffering from the drug’s effects at any given time in the Jefferson Multidisciplinary Addiction Service (JAMS), Jefferson Health’s multidisciplinary inpatient consultation program. It’s also common in Jefferson’s clinics to see patients trying to navigate life on the street with new disabilities from losing limbs due to xylazine use.

As the region’s largest health system and safety net hospital for two-thirds of all Philadelphians—and with an institutional commitment to health equity—Jefferson is uniquely positioned to reimagine the standard of addiction care through a multi-pronged approach designed to holistically address the issue from every angle via both the health system and the university.

According to the National Library of Medicine, opioid use disorder affects over 16 million people worldwide and over 2.1 million in the United States. Addiction care was historically delivered in siloed drug and alcohol programs outside the standard medical system. However, hospital admissions for patients with associated medical conditions are at an all-time high. The system was not developed to support these otherwise younger and heathier patients with substance use disorder (SUD), leaving them extremely vulnerable to the challenges of acute hospitalization.

People who use drugs face withdrawal, stigma, and isolation while in the hospital, all of which increase their risk of leaving the hospital early before their treatment is complete. Upon discharge, many patients with SUD are unable to access care in a highly fragmented system, leaving people at risk for recurrence or death before even reaching the next site of care. Revisits and readmissions for persistent or worsening conditions are the rule rather than the exception. The JAMS program facilitates comprehensive and patient-centered addiction care. It guides patients and medical teams in addressing acute pain in patients undergoing withdrawal, starting lifesaving medications for opioid use disorder, and collaborating on discharge planning. The program begins in the emergency department with advanced withdrawal treatments and initial engagement with a certified recovery specialist while hospitalized.

In May 2023, Jefferson Health received a $1.5 million gift from the Sheller Family Foundation to establish the Stephen and Sandra Sheller Consult and Bridge Pilot Program. Made possible by the generosity of Stephen and Sandra Sheller, the gift greatly enhances the work of JAMS, functioning as a vital safe harbor for discharged patients to improve patient engagement and success starting in the earliest stages of medical and substance use stabilization and joining them in their ongoing journey of recovery initiation and active treatment.

The first of its kind in Philadelphia and a new model of care, this relationship-centered, personalized program serves as a critical intermediary between acute hospital treatment and ongoing outpatient substance use disorder treatment and programs for the most vulnerable and in-need patients.

The Bridge Program supports patients through all care transitions following hospitalization (subacute nursing facility, inpatient rehab, etc.), welcoming them into ongoing outpatient care via in-person and telehealth services through the Bridge clinical site. Bridge services include medication for opioid use disorder initiation/continuation, wound care, integrated primary care, HIV and hepatitis C screenings, treatment, prevention, and specialty follow-up.

“There are a lot of factors already working against people fighting substance use disorder, and care can become fragmented between what happens in and outside a hospital setting,” said Rebecca Jaffe, MD, associate professor of medicine and division director of Hospital Medicine. “The Sheller Bridge Program is about engaging the patient when and where they need help, weaving together an array of services and providers both at Jefferson and in the community.”

The Bridge Program connects the services of tertiary care hospitals, starting in emergency rooms, with community systems designed to address long-term medical, behavioral, and social needs such as housing, legal assistance, and food insecurity, facilitating a compassionate handoff and transition into the community.

Earlier this year, Jefferson received a $250,000 two-year Venture Grant from the Pew Charitable Trusts to support the Bridge program, enabling it to respond more quickly to emerging concerns and expand service reach to aid in post-discharge follow-up and recovery. The grant will also enhance the work of JAMS.

“Jefferson is grateful for the generosity of the Pew Charitable Trusts,” said Lara Carson Weinstein, MD, professor of family medicine and co-lead of the Center for Supportive Healthcare. “Their vision and leadership will enable the Stephen and Sandra Sheller Consult and Bridge Program to establish the gold standard in outpatient complex care for people who use drugs for the Philadelphia region, offering hope for marginalized populations whose needs are not well met by the existing systems.”

Many people who leave the hospital before their treatment is complete because of intolerable withdrawal symptoms find it difficult to re-access care because of stigma and siloed systems. The Bridge Program services are designed to better meet the complex mental, behavioral, and physical health needs of people with substance use disorders, building on treatment initiated during acute hospitalizations and improving patient engagement and success in recovery following discharge.

Certified recovery specialists provide critical patient engagement benefits and care for each patient, providing peer support and patient stabilization.

“Once we get the referral, I’m usually the first person to see them in the hospital,” says Bobbie Deo, a certified recovery specialist. “I introduce myself, my role in peer support, and then the Bridge Clinic.”

“To be a certified recovery specialist in Pennsylvania, you have to have lived experience,” she shares. “I completely understand the emotions people are going through, so I try to go in and relay that I’m here for them. Sometimes—most times—this population is ignored. I’m their advocate. I try to get them engaged and to know that they’re not alone. It is more meaningful for them to speak to someone who knows where they’ve been.”

Deo sums up the power of the Bridge Program. “I’ve gone into patients’ rooms, and you can literally see a brick wall around them—then I start talking about my experiences and my life, and through their body language you can just watch it literally fall in front of you,” she says. “They will start sitting in the seat and being more engaged and wanting to talk to me.”

Deo offers both empathy and an example for a way out. “Addiction is such a lonely and miserable place, and just to have somebody stick their hand out to say, ‘Hey, I know what you’re going through’—I wish I had had somebody to do that for me,” she says. “That’s why I take my job so seriously and I try so hard to help people—because I didn’t have anybody, and somehow, I was able to find my way out. If I can help somebody not struggle, why not?”

Researchers at Thomas Jefferson University are also focusing on addiction treatment in Philadelphia. Utilizing geographic information systems (GIS) mapping and focus groups, a new study made possible by a grant from the Pew Charitable Trusts, “Mapping the Opioid Use Disorder Crisis in Philadelphia,” has found that navigating the city’s drug treatment program offerings deters many people with opioid addiction from getting the care they need.

Study data was collected between November 2022 and August 2023, with the goal to provide insights into the factors that contribute to patient engagement, early exit from care, and retention. 

The research team used study findings to develop policy and practice recommendations around treatment access and retention with the goals of reducing overdose deaths in Philadelphia while supporting the development of a more just and equitable system of care. Study findings illustrated that individuals living with substance use describe several social determinants of health that create barriers to care, including transportation, housing, comorbid mental and physical health conditions, wounds, language issues, and childcare. In addition, there are distinct patterns of accessibility related to race/ethnicity, as most inpatient and outpatient facilities are in census tracts with high proportions of people who are non-Hispanic Black.

“We did several focus groups with people who have accessed the opioid use disorder treatment system in Philadelphia,” said Erin Kelly, assistant professor. “And while many had great experiences, many had experienced a lot of barriers both to getting into treatments and staying in treatment.”

In addition to its recommendations, study authors note that while it is also important to acknowledge the existence of numerous ongoing local and city-led initiatives designed to meet the needs of this rapidly evolving crisis, and that initiatives to coordinate services continue, significantly more resources and support are needed.

Still, Deo expresses optimism and real hope for the future. “Obviously the opioid epidemic is not going anywhere,” she says. “It’s getting extremely out of control, and so many times, people just slip through the cracks. I slipped through the cracks plenty of times. Our whole goal is to be there for the patient that doesn’t have anybody—and that’s so important—because that’s a lot of them. We’re going to make this something memorable, and I can’t wait. We’re growing every day, and this time next year, we’re going to be telling a whole different story.”