This story was initially revealed by KFF Well being Information.

NEW ORLEANS — Elyse Stevens had a fame for taking up complicated medical instances. Individuals who’d been battling dependancy for many years. Power-pain sufferers on excessive doses of opioids. Intercourse staff and folks dwelling on the road.

“A lot of my sufferers are messy, those that don’t know in the event that they wish to cease utilizing medication or not,” mentioned Stevens, a main care and dependancy drugs physician.

Whereas different medical doctors averted these sufferers, Stevens — who was conversant in town from her time in medical college at Tulane College — sought them out. She often attended 6 a.m. breakfasts for homeless folks, volunteered at a homeless shelter clinic on Saturdays, and, on Monday evenings, visited an deserted Household Greenback retailer the place advocates distributed provides to individuals who use medication.

One such night about 4 years in the past, Charmyra Harrell arrived there limping, her proper leg swollen and coated in sores. Emergency room medical doctors had repeatedly dismissed her, so she eased the ache with road medication, Harrell mentioned.

Stevens cleaned her sores on Mondays for months till lastly persuading Harrell to go to the clinic at College Medical Heart New Orleans. There, Stevens found Harrell had diabetes and most cancers.

She agreed to prescribe Harrell ache remedy — an possibility many medical doctors would robotically dismiss for concern {that a} affected person with a historical past of dependancy would misuse it.

However Stevens was assured Harrell might maintain up her finish of the deal.

“She instructed me, ‘You can’t do medication and do your ache meds,’” Harrell recounted on a Monday night in October. So, “I’m not on cocaine.”

Stevens’ strategy to affected person care has gained her awards and nominations in drugs, group service, and humanism. As an alternative of seeing sufferers in binaries — addicted or sober, with a optimistic or destructive drug check — she measures progress on a spectrum. Are they showering day by day, cooking with their households, utilizing much less fentanyl than the day earlier than?

However not everybody agrees with this versatile strategy that prioritizes working with sufferers on their targets, even when abstinence isn’t certainly one of them. And it got here to a head in the summertime of 2024.

“The identical issues I used to be high-fived for hundreds of instances — all of a sudden that was dangerous,” Stevens mentioned.

Versatile Care or Slippery Slope?

Greater than 80% of People who want substance use therapy don’t obtain it, nationwide knowledge exhibits. Obstacles abound: excessive prices, lack of transportation, clinic hours which can be incompatible with jobs, concern of being mistreated.

Some medical doctors had been making an attempt to ease the method for years. Covid-19 accelerated that development. Telehealth appointments, fewer urine drug exams, and medicine refills that last more turned the norm.

The end result?

“Sufferers did OK and we truly reached extra folks,” mentioned Brian Hurley, quick previous president of the American Society of Dependancy Medication. The group helps persevering with versatile practices, equivalent to serving to sufferers keep away from withdrawal signs by prescribing higher-than-traditional doses of dependancy remedy and specializing in restoration targets apart from abstinence.

However some medical doctors favor conventional approaches that vary from zero tolerance for sufferers utilizing unlawful medication to setting stiff penalties for individuals who don’t meet their medical doctors’ expectations. For instance, a affected person who exams optimistic for road medication whereas getting outpatient care could be discharged and instructed to go to residential rehab. Proponents of this methodology concern loosening restrictions could possibly be a slippery slope that in the end harms sufferers. They are saying persevering with to prescribe painkillers, for instance, to folks utilizing illicit substances long-term might normalize drug use and hamper the aim of getting folks off unlawful medication.

Progress ought to be greater than retaining sufferers in care, mentioned Keith Humphreys, a Stanford psychologist, who has handled and researched dependancy for many years and helps involuntary therapy.

“When you give addicted folks numerous medication, they prefer it, and so they might come again,” he mentioned. “However that doesn’t imply that that’s selling their well being over time.”

Versatile practices additionally are inclined to align with hurt discount, a divisive strategy that proponents say retains individuals who use medication protected and that critics — together with the Trump administration — say allows unlawful drug use.

The controversy isn’t just philosophical. For Stevens and her sufferers, it got here to bear on the streets of New Orleans.

‘Unconventional’ Prescribing

In the summertime of 2024, supervisors began questioning Stevens’ strategy.

In emails reviewed by KFF Well being Information, they expressed issues about her prescribing too many ache capsules, a mixture of opioids and different managed substances to the identical sufferers, and excessive doses of buprenorphine, a drugs thought of the gold commonplace to deal with opioid dependancy.

Supervisors nervous Stevens wasn’t doing sufficient urine drug exams and stored treating sufferers who used illicit medication as a substitute of referring them to larger ranges of care.

“Her prescribing sample seems unconventional in comparison with the native commonplace of care,” the hospital’s chief medical officer on the time wrote to Stevens’ supervisor, Benjamin Springgate. “Word that that is the one commonplace of care which might seemingly be thought of ought to a authorized concern come up.”

Springgate forwarded that electronic mail to Stevens and inspired her to refer extra sufferers to methadone clinics, intensive outpatient care, and inpatient rehab.

Stevens understood the final follow however couldn’t reconcile it with the truth her sufferers confronted. How would somebody dwelling in a tent, terrified of shedding their possessions, trek to a methadone clinic day by day?

Stevens despatched her supervisors dozens of analysis research and nationwide therapy pointers backing her versatile strategy. She defined that if she stopped prescribing the drugs of concern, sufferers would possibly depart the well being system, however they wouldn’t disappear.

“They simply wouldn’t be getting care and maybe they’d be useless,” she mentioned in an interview with KFF Well being Information.

Each College Medical Heart and LSU Well being New Orleans, which employs physicians on the hospital, declined repeated requests for interviews. They didn’t reply to detailed questions on dependancy therapy or Stevens’ practices.

As an alternative, they offered a joint assertion from Richard DiCarlo, dean of the LSU Well being New Orleans Faculty of Medication, and Jeffrey Elder, chief medical officer of College Medical Heart New Orleans.

“We aren’t at liberty to remark publicly on inner personnel points,” they wrote.

“We acknowledge that dependancy is a severe public well being drawback, and that dependancy therapy is a problem for the healthcare trade,” they mentioned. “We stay devoted to increasing entry to therapy, whereas upholding the very best commonplace of care and security for all sufferers.”

Not Black-and-White

KFF Well being Information shared the complaints towards Stevens and the responses she’d written for supervisors with two dependancy drugs medical doctors outdoors of Louisiana, who had no affiliation with Stevens. Each discovered her practices to be throughout the bounds of regular dependancy care, particularly for complicated sufferers.

Stephen Loyd, an dependancy drugs physician and the president of Tennessee’s medical licensing board, mentioned medical doctors operating tablet mills usually have sparse affected person notes that listing a chief grievance of ache. However Stevens’ notes detailed sufferers’ life circumstances and the intricate selections she was making with them.

“To me, that’s the massive distinction,” Loyd mentioned.

Some folks assume the “solely good reply isn’t any opioids,” equivalent to oxycodone or hydrocodone, for any sufferers, mentioned Cara Poland, an dependancy drugs physician and affiliate professor at Michigan State College. However sufferers might have them — generally for issues like most cancers ache — or require months to decrease their doses safely, she mentioned. “It’s not as black-and-white as folks outdoors our discipline need it to be.”

Humphreys, the Stanford psychologist, had a unique take. He didn’t evaluation Stevens’ case however mentioned, as a common follow, there are dangers to prescribing painkillers long-term, particularly for sufferers utilizing at this time’s deadly road medication too.

Overprescribing fueled the opioid disaster, he mentioned. “It’s not going to go away if we try this once more.”

‘The Factor That Kills Individuals’

After months of pressure, Stevens’ supervisors instructed her on March 10 to cease coming to work. The hospital was conducting a evaluation of her practices, they mentioned in an electronic mail considered by KFF Well being Information.

In a single day, a whole lot of her sufferers had been moved to different suppliers.

Luka Bair had been seeing Stevens for 3 years and was steady on day by day buprenorphine.

After Stevens’ departure, Bair was left with out remedy for 3 days. The withdrawal signs had been extreme — headache, nausea, muscle cramps.

“I used to be simply in bodily hell,” mentioned Bair, who works for the Nationwide Hurt Discount Coalition and makes use of they/them pronouns.

Though Bair ultimately acquired a refill, Springgate, Stevens’ supervisor, didn’t wish to proceed the routine long-term. As an alternative, Springgate referred Bair to extra intensive and residential applications, citing Bair’s intermittent use of different medication, together with benzodiazepines and cocaine, as markers of excessive threat. Bair “requires the next stage of care than our clinic fairly can supply,” Springgate wrote in affected person portal notes reviewed by KFF Well being Information.

However Bair mentioned day by day attendance at these applications was incompatible with their full-time job. They left the clinic, with 30 days to discover a new physician or run out of remedy once more.

“That is the factor that kills folks,” mentioned Bair, who ultimately discovered one other physician keen to prescribe.

Springgate didn’t reply to repeated calls and emails requesting remark.

College Medical Heart and LSU Well being New Orleans didn’t reply questions on discharging Stevens’ sufferers.

‘Reckless Habits’

A few month after Stevens was instructed to remain residence, Haley Beavers Khoury, a medical scholar who labored along with her, had collected practically 100 letters from different college students, medical doctors, sufferers, and homelessness service suppliers calling for Stevens’ return.

One scholar wrote, “Make no mistake — a few of her sufferers will die with out her.” A nun from the Daughters of Charity, which ran the hospital’s earlier incarnation, referred to as Stevens a “lifeline” for susceptible sufferers.

Beavers Khoury mentioned she despatched the letters to about 10 folks in hospital and medical college management. Most didn’t reply.

In Might, the hospital’s evaluation committee decided Stevens’ practices fell “outdoors of the appropriate group requirements” and constituted “reckless conduct,” in line with a letter despatched to Stevens.

The hospital didn’t reply KFF Well being Information’ questions on the way it reached this conclusion or if it recognized any affected person hurt.

In the meantime, Stevens had secured a job at one other New Orleans hospital. However as a result of her resignation got here amid the continued investigation, College Medical Heart mentioned it was required to tell the state’s medical licensing board.

The medical board started its personal investigation — a growth that ultimately price Stevens the opposite job supply.

In presenting her facet to the medical board, Stevens repeated many arguments she’d made earlier than. Sure, she was prescribing highly effective drugs. No, she wasn’t making medical selections based mostly on urine drug exams. However nationwide dependancy organizations supported such practices and promoted tailoring care to sufferers’ circumstances, she mentioned. Her response included a 10-page bibliography with 98 citations.

Legal responsibility

The board’s investigation into Stevens is ongoing. Its web site exhibits no motion taken towards her license as of late December.

The board declined to touch upon each Stevens’ case and its definition of applicable dependancy therapy.

In October, Stevens moved to the Virgin Islands to work in inner drugs at an area hospital. She mentioned she’s grateful for the welcoming locals and the monetary stability to assist herself and her dad and mom.

But it surely hurts to consider her former sufferers in New Orleans.

Earlier than leaving, Stevens packed away handwritten letters from a number of of them — one was 15 pages lengthy, written in alternating inexperienced and purple marker — through which they shared childhood traumas and small successes that they had whereas in therapy along with her.

Stevens doesn’t know what occurred to these sufferers after she left.

She believes the scrutiny of her practices facilities on legal responsibility greater than affected person security.

However, she mentioned, “legal responsibility is in abandoning folks too.”

KFF Well being Information is a nationwide newsroom that produces in-depth journalism about well being points and is among the core working applications at KFF—an unbiased supply of well being coverage analysis, polling, and journalism. Study extra about KFF.

Associated