We owe our existence to the mesolimbic pathway, the part of our brain that rewards us for activities such as eating and having sex, tasks essential to the survival of our species. The gratification begins when tiny electrical bursts fire deep in the midbrain, travel along the conductive coatings of our neurons, and ultimately release molecules of the neurotransmitter dopamine, which leap from the branching ends of our neurons like squirrels springing between trees. These signals propagate out into the brain, encoding a simple yet overpowering command: “That felt good. Do it again.”
That pathway is “the part of the brain that we share with every other animal,” says Dr. Terry Horton, chief of addiction medicine at Christiana Care Health System. “It’s also the part of the brain that every substance of abuse can hijack.” When the primitive impulses selected by evolution take over, they give the rational, decision-making regions of the cortex little chance of influencing behavior. Nancy Reagan’s advice of “Just Say No” has no efficacy when one is in the throes of addiction.
Nor, to recall another campaign of that time, does the brain on drugs have any similarity to an egg sizzling in a hot pan. The interactions that take place are subtle and complex. “When drugs are misused in a vulnerable individual, a change can occur,” Horton explains. “It’s almost as if a switch has been flipped.” At this point, the brain changes chemically, structurally and functionally. That’s when a person can develop “compulsive drug seeking, use and craving, despite harmful consequences,” says Horton. “And that’s what we call addiction.” It is, first and foremost, a medical condition, a chronic brain disorder.
Horton is a profoundly compassionate doctor, but his understanding of addiction is grounded in science and medicine. Horton began his career in his native Delaware, completing many rotations as a medical student at Christiana Care in the 1980s. He had planned to pursue a practice in allergy and immunology, but “lost the flame for the topic,” he remembers. He ended up taking a position at St. Vincent’s Prison Health in New York City, and a year later became the chief physician for the Manhattan Detention Complex, or as it is colloquially known, The Tombs. “It wasn’t what my mom had in mind, but it was really remarkable,” Horton recalls of his time there. He then moved on to become the medical director, and later vice president, of Phoenix House, at the time one of the largest residential addiction treatment providers in the world.
His experience has taught him that addiction carries devastating repercussions for not only those who suffer from it directly, but also for entire communities where it takes hold. Horton refers to the extensive fallout of addiction as “concentric circles of damage.” There can be injury to the brain, physical injury, organ damage, emotional and psychological trauma, anxiety, depression, missed social opportunities in education and job training, the loss of friends and the destruction of families.
Consequently, those who suffer from opioid addiction want nothing more than to “Just Say No,” but almost invariably they lack the medical attention that makes such a decision likely or practicable. Providing such attention is the mission of Project Engage, an early intervention and substance abuse treatment program begun in 2008 at Christiana Care Health System under Horton’s guidance.
This clinical pathway to recovery grew out of a program designed to address the safety issue of alcohol withdrawal among hospital admissions. Taking advantage of hospitals’ status as aggregators of people with substance abuse disorders, Project Engage screens for and identifies patients who are suffering from addictions of all kinds. Team members then address the immediate medical needs of patients, engage them through the intervention of trained engagement specialists and guide them into recovery with social workers.
Project Engage relies heavily on its engagement specialists—counselors who carry a unique set of skills in their figurative black bag. They are trained in early intervention, and perhaps more importantly, they too have suffered from addiction. Not only do these specialists perform the essential work of earning a patient’s trust, but they also break through the stigma surrounding disorders of substance abuse, reforming and improving the culture of the hospital. They teach doctors and nurses to see someone struggling with addiction as a medical patient rather than someone who simply lacks character or a moral compass. Horton calls engagement specialists “recovery ambassadors.”
Project Engage has been implemented in both Christiana and Wilmington hospitals’ emergency departments, Christiana’s patient care units, Christiana Care’s primary care practices, and Christiana Care’s women’s and children’s services. The program has also branched out into the community and is currently launching Project Engage for Construction, a program involving 20 construction companies in an effort to address the high levels of addiction within the industry.
It goes without saying, but certainly bears emphasizing, that Project Engage saves the healthcare system enormous expenditures through diminishing the concentric circles of damage to which addiction gives rise. And these savings are no less substantial with respect to social services and the criminal justice system, particularly at a time when the opioid epidemic has grown into a perfect storm, the result of overprescribed analgesics, cheap heroin and the emergence on the streets of powerful drugs like fentanyl. Every addiction that is treated prevents an exponential increase in costly services.
The opioid epidemic has created an unprecedented challenge to the healthcare industry, but bright spots are shining through. Oddly enough, it is the terrible nature of opioid withdrawal that has provided Horton and his team with some leverage. Project Engage launched a new clinical pathway this past May that seeks to identify those in withdrawal and capitalize on this critical moment. “Withdrawal is such a primal misery,” says Horton, “that it overwhelms everything else.” That moment of vulnerability provides Project Engage with a latchkey into the otherwise defensive world of someone who suffers from a drug abuse disorder.
Both Christiana and Wilmington hospitals now screen all admissions for opioid addiction and, if warranted, for opioid withdrawal. That effort has produced incredible results. From a study group of 86 individuals who were identified as suffering from opiate withdrawal upon admission to the hospital, 53 agreed to accept treatment. Of those, three-quarters showed up for their first appointment at a provider in their community. Perhaps more significant is the fact that three-quarters of those individuals were continuing in treatment after a month. “These are unheard of numbers,” says Horton. “They’re shocking.” The statistics are still more impressive if one remembers that the patients in question entered the hospital for reasons other than addiction.
The motivation to enter comprehensive recovery lies in the pain a person suffers because of a disorder. Horton’s insight into this simple fact is due less to medical training and more to his sensitivity to the experiences of his patients, as well as to the precarious nature of living in the world that all people share. “I was once taught by one of my patients,” recalls Horton, “that all of humanity walks along the edge of a cliff. It’s just that those in recovery walk right up against the very edge.”
The opioid epidemic has reached into every corner of American life. Delaware saw 228 deaths in 2015, up from 172 in 2012. The good news is that treatment methods continue to improve, and help is available.
Anyone within the Christiana Care Health System can access Project Engage, including through a primary provider. Also, any pregnant woman can call Project Engage to receive treatment. Soon, that option will be available to employees of companies participating in Project Engage for Construction. For others, Horton suggests going online to the website of the Delaware Division of Substance Abuse and Mental Health. He recommends also Attack Addiction and the Caron Foundation as excellent resources.
The crisis of opioid addiction requires a new understanding—addiction is often characterized as a crime, not an illness. Science provides a needed perspective that allows the problem to be more fully understood as a neurological condition, while compassionate practitioners like Horton understand what is needed in the design and implementation of clinical pathways to lasting recovery.
“I am learning every day from my patients,” says Horton. “The people who are the most vulnerable have the most to teach us about our humanity.”
He retells a story of a patient, a 60-year-old woman. He asked her a standard question used to gain therapeutic traction with those seeking recovery: “What do you miss about your life that you don’t have because of drugs?”
“What I really want,” she replied, “is to just wake up one morning and have a cup of coffee with my husband.”
She went into recovery, as did her husband. With the first $40 they saved, they bought a new coffee maker. For Christmas, a relative gave them “His” and “Hers” coffee cups. “This couple taught me to enjoy my cup of coffee with my wife,” says Horton.
The lessons are not all personal, and he credits these instructive encounters directly for much of his education in addiction medicine. “There’s great value in understanding and attending to these patients. It helps us to become better doctors,” says Horton.
The opioid epidemic continues to claim lives, and it seems difficult to find information in the news that is not cold comfort. But Project Engage offers hope and healing, and providers like Horton demonstrate that good medicine depends both on a thoughtful application of science and a conscious commitment to compassion.