EDITORS’ NOTE: On Tuesday, a daylong conference, “On the Front Lines of the Opioid Epidemic: 50 Years of Leadership and Innovation at Montefiore-Einstein,” will be held at Einstein and Montefiore. The event will feature guests as well as Einstein and Montefiore staff and faculty members and patients sharing insights about the opioid epidemic. In connection with the event, we invited Dr. Melissa Stein, medical director of the Division of Substance Abuse (DoSA) at Montefiore, to reflect on the program’s past and present.
DoSA and I both turned 50 this year. I can think of only one person who could have witnessed our parallel development―my father, a psychiatrist, who began his career at Einstein in the 1960s. He moved to another institution in the mid-70s and wasn’t involved in the early years of DoSA’s existence. (Fortunately, he was there for me.) His commitment to his patients and trainees served as a model for me in my own career at Einstein and Montefiore.
Change is a part of life, for people and for institutions. I was born in New York City and went to high school in the Bronx, then to college in Chicago, before returning home for medical school. I tried out different jobs, activities, and relationships before settling into my current home, job, and nuclear family. DoSA has also evolved over the same time span, trying out different projects, moving into new spaces, and creating new programs to meet our patients’ needs. It’s a process that I’ve cherished personally and professionally.
Meeting a Need
The Bronx of the 1960s led to the need for DoSA. Poverty increased and city services in the borough decreased, especially in the South Bronx. The opioid epidemic arrived in the form of heroin use, fueled by poverty and by limited treatment and support. A few private doctors in New York prescribed methadone to people addicted to heroin, but this treatment was unregulated, illegal, and available only to patients who could pay for it. Legitimate medication-assisted treatment (with methadone) for opioid addiction could be obtained only at one place in the country—the infamous Narcotic Farm, a federal treatment facility and prison in Lexington, Kentucky.
Fortunately, methadone treatment for opioid addiction was being investigated at Rockefeller University, where Dr. Vincent Dole saw good results. Dr. Joyce Lowinson, recently graduated from Einstein, worked with him for two years before completing her psychiatry residency. She so loved working with these challenging patients that, following her residency, she collaborated with colleagues to secure $10 million from the federal government to address heroin addiction.
When Dr. Lowinson returned to Einstein, Dr. Israel Zwerling, the chair of psychiatry, assigned her to start a methadone clinic. Finding an appropriate location for the clinic was difficult because of the stigma associated with addiction and treatment. Inspired by a friend who used a trailer as guest quarters at her country home, Dr. Lowinson asked if the clinic could be housed in a trailer on Bronx State Hospital grounds―and DoSA was born.
By the end of 1970, DoSA had 350 patients and one location. Eventually it expanded to nine clinics in four locations. By 2003, when I came to work at DoSA, there were more than 3,000 patients on methadone and 150 patients enrolled in two (nonmethadone) intensive drug-treatment programs. DoSA was the second-largest methadone clinic system in New York State; it stood out from other methadone programs in providing patient-centered care. It featured a unique peer-advocacy group focused on the growing problem of hepatitis C virus (HCV) infection among our patients. Primary medical care and psychiatry were also available at all sites, and DoSA offered treatment of HIV―the leading cause of death for our patients. Research projects included investigations related to HIV and HCV. Vocational services and programming for parents and families were available.
To see how far DoSA has come, one must consider its physical roots. My first office at DoSA was in “the Hubs,” a three-story building in the South Bronx, which housed three DoSA clinics. It was well located, easy to get to—and, structurally, a horror. Built in 1931, the building featured compromises such as a lovely marble staircase but no elevator. I loved looking out of my huge office window, but it wouldn’t close fully and I occasionally found small snowdrifts on the sill on winter mornings. There were electrical problems and persistent infestations. Patients who developed health problems that impaired their ability to climb stairs had their care transferred to our clinic on the ground floor, rather than being able to continue to see their familiar caregivers. Meanwhile, in the North Bronx, care was still being delivered in three dilapidated trailers on the grounds of Bronx State, which faced its own challenges.
We needed new―and better―spaces to provide patients with the services they needed and deserved. Community resistance to methadone programs had created huge barriers in finding an appropriate space for new clinics. We overcame these hurdles. In 2007 the Hubs moved less than a mile south, becoming the Port Morris Wellness Center. Now, across the street from a hot-dog factory and a residence for homeless people with HIV, we enjoy a clean, well-lit space. There’s room for large and small groups, a dedicated vocational area with computers for patient use, and ample space for storage of art, medical, and cleaning supplies. I’m proud to show our clinic to visitors and happy to be providing care in a comfortable facility that respects patients who have often been pushed into uncomfortable corners of the healthcare system. In 2009, the Waters Place Wellness Center was completed, replacing the trailers that made only the feral cats living beneath them happy.
Opioids: Past, Present, and Future
It’s been my privilege to teach medical trainees about taking care of patients who have addiction disorders, and, as part of the students’ training, to work to reduce the stigma attached to addiction. Recently we developed an addiction medicine fellowship at Montefiore. Teaching provides me with opportunities to think deeply about why I do what I do, to make changes and try new approaches, and to share with students the joy and satisfaction that my work has brought me. Our patients can be challenging to care for, and not all doctors are suited for this job. Most doctors enjoy feeling authority, and that feeling must be granted to them by the patients, who follow their advice and instructions. Our patients are less likely to adhere to our instructions for many reasons—complicated medical problems and histories of psychological and physical trauma—and they are less likely to trust doctors who work within a system in which many of them have been treated badly in the past. I wouldn’t say that I relish the challenge created by these problems, but I know that by using medical and interpersonal tools learned during my training, I am able to help my patients. I find deep satisfaction in witnessing their victories and gratitude. All doctors will at some point care for patients with substance use disorders and I am committed to helping mine to be as effective as possible.
I have been here long enough to see people and programs come and go. I have attended farewell gatherings (and two funerals) for wonderful colleagues. A research project that provided patients HIV medication with their methadone (“directly observed therapy”) started and finished, and we continue to provide that lifesaving service to our patients, some of whom I’m sure would not be alive if not for that project. Similarly, research projects looking at treatment of HCV not only saved our patients’ lives, but pushed the entire medical community to treat drug users. In recent years we have increased our art-related programming, giving our patients opportunities to express themselves not just in the usual talk-therapy sessions but through creative writing, visual arts, and even dance.
Ultimately, all this history and development is about the patients. They’re the most-constant part of my experience at DoSA. They are why we are all here, doing what we do every day. A few have been here since the early days of the program. Some leave and return after periods of abstinence, incarceration, or grave illness. In recent years we have watched as patients age, which has brought new challenges in providing both medical and addiction care. And the most-recent wave of the opioid epidemic has brought more young patients to the clinics. This surge has put DoSA back in the spotlight, with more people from different parts of the country wanting to learn about our historic efforts. Just as DoSA worked to adapt to the circumstances of its first patients, it will innovate to make the lives of its newest ones better. I look forward to seeing what changes and challenges we will face next.