Brugge lifted up one of the jars and gazed at it with reverence. Each jar holds samples of breast tissue donated by patients after they underwent a tissue biopsy or breast surgery — samples that may reveal a new way to prevent breast cancer.

Brugge and her research team have analyzed the cell structure of more than 100 samples.

Using high-powered microscopes and complex computer algorithms, they diagram each stage in the development of breast cancer: from the first sign of cell mutation to the formation of tiny clusters, well before they are large enough to be considered tumors.

Their quest is to prevent breast cancer, a disease that afflicts roughly 1 in 8 U.S. women over their lifetimes, as well as some men. Their ultimate goal is to relieve the pain, suffering, and risk of death that accompany this disease. And their painstaking work, unspooling across six years of a seven-year, , has yielded results.

In late 2024, Brugge and her colleagues in breast tissue that contain the genetic seeds of breast tumors.

And they discovered that these “seed cells” are surprisingly common. In fact, they are present in the normal, healthy tissue of every breast sample her lab has examined, Brugge said, including samples from patients who haven’t had breast cancer but have had surgery for other reasons, such as breast reduction or a biopsy that proved benign.

The next research challenge for Brugge’s lab is clear: Find ways to detect, isolate, and terminate the mutant cells before they can spread and form tumors.

“I’m excited about what we’re doing right now,” Brugge said. “I think we could make a difference, so I don’t want to stop.”

Work in Brugge’s lab slowed significantly last year. In April, her from the National Cancer Institute at the National Institutes of Health was frozen, along with virtually all other federal money awarded to Harvard researchers.

The Trump administration said it was withholding the funds of antisemitism on campus.

Some of Brugge’s lab staff lost federal fellowships that funded their work. Brugge told others funded through the NIH grant that she couldn’t guarantee their salaries. In all, Brugge lost seven of her 18 lab employees.

In September, the funding for the NIH grant was restored. But in the intervening months, the Trump administration said Brugge and other Harvard researchers for the next round of multiyear grants.

A federal judge , but Brugge had missed the deadline to apply for renewal. So her current funding will end in August.

Brugge scrambled to secure private funding from foundations and philanthropists. She was then able to reinstate two positions for at least a year — but job applicants are wary.

Across the United States, the future of federal funding for cancer research is uncertain.

President Donald Trump has proposed by nearly 40% in the 2026 fiscal year.

In a , the White House said the “NIH has broken the trust of the American people with wasteful spending, misleading information, risky research, and the promotion of dangerous ideologies that undermine public health.”

But Congress has other plans: The released on Jan. 20 that would set the NIH’s budget at $48.7 billion, $415 million more than in the 2025 fiscal year.

In the meantime, advocates such as with the are reminding lawmakers that the cancer death rate has declined — — due in part to federally funded research advances.

“But we still have an incredible ways to go before we can say that we’ve changed the trajectory of cancer,” Fleury said. “There are still cancer types that are fairly lethal, and there are still populations of people for whom their experience of cancer is vastly different from other groups.”

Reductions in research funding will have a direct impact on treatment options for patients, Fleury said. For example, a 10% cut to the NIH budget would eventually result in two fewer new drugs or treatments per year, according to from the nonpartisan Congressional Budget Office.

A recent study looked at drugs that were developed through NIH-funded research and approved by the Food and Drug Administration since 2000. More than half those drugs would probably if the NIH had been operating with a 40% smaller budget.

“We can’t say, ‘But for that grant, that [specific] drug would not have come into existence,’” said , a co-author of the study and a professor at the Massachusetts Institute of Technology. But fewer drugs would have made it to market, he said. “It makes us at least want to pause and say, ‘What are we doing here? Are we shooting ourselves in the foot?’”

Amid all the uncertainty, Brugge has trouble focusing on her goal of finding new ways to prevent breast cancer.

Nowadays, she spends about half her time searching for new sources of funding, managing her remaining employees’ anxieties, and monitoring the most recent news about Harvard, the Trump administration, and the NIH and other federal agencies that have experienced grant freezes, staff layoffs, and other disruptions.

She’d rather return her attention to her ongoing investigations, which she’s confident could eventually save lives.

The breakdown of Brugge’s lab highlights another problem: The U.S. is kneecapping the next generation of cancer researchers. Her employees included , postdocs, and graduate students. Of the seven who left the lab in 2025, one left the U.S., one took a job at a health care management company, four went back to school, and one is still looking for work.

One of Brugge’s former staffers, Y., is a computational biologist. She helped design and run a tool that analyzes millions of breast tissue cells from the samples in the pink-lidded jars.

Y. moved to Switzerland in October to begin a PhD program. ºÚÁϳԹÏÍø News and NPR are identifying her by her middle initial because she plans to return to the U.S. for scientific conferences and worries that speaking publicly about her experience could risk future visa approvals.

“I thought the U.S. would be a safe place for scientists to learn and grow,” said Y., who moved to Boston from abroad for Harvard’s master’s degree program in bioinformatics. “I really hope that those who have the opportunities to study this further can fill in those missing pieces in cancer research.”

Brugge is no longer accepting job applicants from outside the U.S., even if they are top candidates, because she can’t afford to pay the Trump administration’s on visas for some foreign researchers.

The Association of American Universities and the U.S. Chamber of Commerce have , claiming the fee is misguided and illegal. The Trump administration said the fee would and improve opportunities for Americans.

Brugge doubts work in her lab will ever return to normal.

“There’ll always be, now, this existential threat to the research,” Brugge said. “I will definitely be concerned because we don’t know what’s going to happen in the future that might trigger a similar kind of action.”

Brugge has thought about shutting down her lab. But she still employs staff members whose future scientific careers are tied to finishing some of the research. And when she looks at those pink-lidded jars, she still sees so much promise.

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MacDonald wanted to find a new doctor right away. She needed refills for her blood pressure medications and wanted to book a follow-up appointment after a breast cancer scare. 

She called 10 primary care practices near her home in Westwood, Massachusetts. None of the doctors, nurse practitioners, or physician assistants was taking new patients. A few offices told her that a doctor could see her in a year and a half or two years.

“I was just shocked by that, because we live in Boston and we’re supposed to have this great medical care,” said MacDonald, who is in her late 40s and has private health insurance. “I couldn’t get my mind around the fact that we didn’t have any doctors.”

The shortage of primary care providers is a , but it’s particularly acute in Massachusetts. The state’s primary care workforce is shrinking faster than in most states, according to a .

Some health networks, including the state’s largest hospital chain, , are turning to artificial intelligence for solutions.

In September, right when MacDonald was running out of blood pressure medications, MGB launched a new AI-supported program, . MacDonald had received a letter from MGB, telling her no primary care providers in the network were taking new patients for in-person care. At the bottom of the letter was a link to Care Connect.

MacDonald downloaded the app and requested a telehealth appointment with a doctor. She then spent about 10 minutes chatting with an AI agent about why she wanted to see a physician. Afterward, the AI tool sent a summary of the chat to a primary care doctor who could see MacDonald by video.

“I think I got an appointment the next day or two days later,” she said. “It was just such a difference from being told I had to wait two years.”

Round-the-Clock Convenience

MGB says the AI tool can handle patients seeking care for colds, nausea, rashes, sprains, and other common urgent care requests, as well as mild to moderate mental health concerns and issues related to chronic diseases. After the patient types in a description of the symptoms or problem, the AI tool sends a doctor a suggested diagnosis and treatment plan.

Care Connect employs 12 physicians to work with the AI. They log in remotely from around the U.S., and patients can get help round-the-clock, seven days a week.

Care Connect is one of many AI-based tools that hospitals, doctors, and administrative staff are testing for a range of routine medical tasks, including note-taking, reviewing diagnostic results, billing, and ordering supplies.

Proponents argue that these AI programs can help relieve staff burnout and worker shortages by reducing time spent on medical records, referrals, and other administrative tasks. But there’s debate about and to use AI to improve diagnoses. Critics worry that AI agents miss important details about overlapping medical conditions.

Critics also point out that AI tools can’t assess whether patients can afford follow-up care or get to that appointment. They have no insight into family dynamics or caretaking needs, things that primary physicians come to understand through long-term personal relationships.

Since her first foray on the app in September, MacDonald has used Care Connect at least three more times. Two of those interactions led to an eventual conversation with a remote doctor, but when she went online to book an appointment for travel-related shots, she interacted only with the AI chatbot before visiting the travel clinic.

MacDonald likes the convenience.

“I don’t have to leave work,” she said. “And I gained some peace of mind, knowing that I have a plan between now and me finding another in-person doctor.”

So while she hunted for that person, MacDonald planned to stay with Care Connect.

“This is a logical solution in the short term,” MacDonald said. “At the end of the day, it’s the patient who’s feeling the aftermath of all of the bigger things going on in health care.”

Scarcity and Burnout

Many factors contribute to the shortage of providers. Many primary care doctors, such as pediatricians, internists, and family medicine physicians, are dissatisfied with their pay. They earn about , on average, than specialists such as surgeons, cardiologists, and anesthesiologists. 

At the same time, their workload has been increasing. Primary care doctors days packed with complex patient visits, followed by evenings spent updating medical records and responding to patient messages.

When MacDonald signed onto Care Connect, she was one of 15,000 patients in the Mass General Brigham system without a primary care provider. That number has grown as primary care doctors have left MGB for rival hospital networks.

, a primary care physician at an MGB health center in Chelsea, Massachusetts, said she’s staying at MGB for now, but she’s grown frustrated with the system’s leaders.

“They don’t make any effort to ease the shortage,” said Rao, who is also part of an MBG’s primary care doctors. “They put their money into specialties. Primary care feels like a peripheral part of the system, when it really should be a central part.”

Last year, MGB pledged to spend $400 million over five years on primary care services — though that includes the multiyear contract with Care Connect.

“Care Connect is just one solution among many in this broader strategy to alleviate the primary care capacity crisis,” , MGB’s chief operating officer, said in an emailed statement. “Our investment supports retaining our current physicians as well as recruiting new ones.”

Walls said MGB has increased staffing support for primary care physicians, implemented other AI tools, and hired a new executive for primary care. Some of these changes are based on recommendations from their own primary care doctors.

But some of those doctors say they would like other changes, and salary increases in particular.

Walls would not disclose the exact amount MGB is spending on Care Connect.

Bridge to Better Care or a ‘Band-Aid’?

MGB has rolled out other AI tools, including one that can transcribe a doctor’s in-person conversations with patients. Rao isn’t using that tool. She worries that patient information could be leaked and medical privacy violated, and she doesn’t want her conversations with patients to be used to help develop the next generation of AI medical tools.

“What if they’re just using my interactions with patients to train their AI and boot me out of my job?” she said.

That’s not the goal, said , a primary care physician who manages the program for MGB. All decisions about patient care are still made by real doctors, she said.

“We are not replacing our in-person primary care,” she said. “It’s still important, and the majority of patients still have in-person primary care.”

But the fear among some primary care doctors at MGB is that Care Connect will gradually erode access to in-person primary care visits. Of the $400 million pledged by MGB for primary care, they want less spent on AI and more used to attract and increase pay for primary care staffers.

, an MGB internist who is also involved in the unionizing effort, said the use of Care Connect can only fill a gap. “That sounds like a band-aid for a broken system to me,” he said.

Expanding AI Tools

As of mid-December, the Care Connect doctors were each seeing 40 to 50 patients a day. By February, the MGB network plans to make Care Connect available to all Massachusetts and New Hampshire residents who have health insurance, and to hire more doctors to staff the program as needed. 

Patients can use the program like an urgent care service, Ireland said. They can also decide to make one of the remote doctors their permanent primary care provider.

“Some patients want in-person care,” Ireland said. “But I do believe there’s a subset of patients who will appreciate the 24-hour, seven-day-a-week model and choose to be a part of this.”

Care Connect isn’t for patients who need emergency care or a physical exam, she said. And patients who need tests or imaging are referred to the network’s clinics or labs.

But the remote doctors can manage some of the same routine issues that all primary care doctors do, Ireland said, including moderate respiratory infections, allergies, and chronic conditions such as diabetes, high cholesterol, and depression. 

says only immediate, not ongoing, health problems should be on that list. Lin is chief of primary care at the Stanford University School of Medicine and founded Stanford’s Healthcare AI Applied Research Team.

“In its current state, the safest use of this tool is for more urgent care issues,” Lin said. “Your upper respiratory tract infections. Your urinary tract infections. Your musculoskeletal injuries. Your rashes.”

For patients with multiple chronic conditions such as high blood pressure and diabetes — or for patients with especially serious conditions like heart disease or cancer — Lin said nothing beats a human who sees you regularly.

Still, Lin agrees that the chat summary generated after an AI encounter can help a physician be more efficient. For patients, Lin understands the practical appeal of a virtual option.

“I would rather these patients get care, if that care can be safe,” he said, “than not get care at all.”

The company that developed the AI platform for Care Connect, , contends the program is delivering safe, effective care to patients with complex, chronic ailments — many of whom have no other option besides a hospital emergency room.

“America’s got a big problem with health care, issues with cost, quality, and access,” said , the company’s CEO. “To solve it, you need to start with primary care, and you have to use technology and AI.”

In addition to Mass General Brigham, K Health partners with five other health networks, including the highly ranked and Los Angeles-based .

In a funded by K Health, Cedars-Sinai researchers compared several hundred diagnosis and treatment recommendations made by AI with those made by physicians.

The researchers found the AI to be slightly better at identifying “critical red flags” and recommending care based on clinical guidelines, though the physicians were better at adjusting their treatment recommendations as they spoke more with the patient.

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The result is a pilot effort called the Clean Power Prescription program. The initiative aims to help keep the lights on for roughly 80 patients with complex, chronic medical needs.

The program relies on 519 solar panels installed on the roof of one of the hospital’s office buildings. Half the energy generated by the panels helps power the medical center. The rest goes to patients who receive a monthly credit of about $50 on their utility bills.

Kiki Polk was among the first recipients. She has a history of Type 2 diabetes and high blood pressure.

On a warm fall day, Polk, who was nine months pregnant at the time, leaned into the air conditioning window unit in her living room.

“Oh my gosh, this feels so good, baby,” Polk crooned, swaying back and forth. “This is my best friend and my worst enemy.”

An enemy, because Polk can’t afford to run the AC. On cooler days, she has used a fan or opened a window instead. Polk knew the , including added stress on the pregnant person’s heart and potential risks to the fetus. She also has a teenage daughter who uses the AC in her bedroom — too much, according to her mom.

Polk got behind on her utility bill. , her electricity provider, worked with her on a payment plan. But the bills were still high for Polk, who works as a school bus and lunchroom monitor. She was surprised when staff at Boston Medical Center, where she was a patient, offered to help.

“I always think they’re only there for, you know, medical stuff,” Polk said, “not the personal financial stuff.”

Polk is on maternity leave now to care for her baby, the tiny Briana Moore.

Goldman, who is also BMC’s medical director of climate and sustainability, said hospital screening questionnaires show thousands of patients like Polk struggle to pay their utility bills.

“I had a conversation recently with someone who had a hospital bed at home,” Goldman said. “They were using so much energy because of the hospital bed that they were facing a utility shut-off.”

Goldman wrote a letter to the utility company requesting that the power stay on. Last year, she and her colleagues at Boston Medical Center wrote 1,674 letters to utility companies asking them to keep patients’ gas or electricity running. Goldman took that number to Bob Biggio, the hospital’s chief sustainability and real estate officer. He’d been counting on the solar panels to help the hospital shift to renewable energy, but sharing the power with patients felt as if it fit the health system’s mission.

“Boston Medical Center’s been focused on lower-income communities and trying to change their health outcomes for over 100 years,” Biggio said. “So this just seemed like the right thing to do.”

Standing on the roof amid the solar panels, Goldman pointed out a large vegetable garden one floor down.

“We’re actually growing food for our patients,” she said. “And, similarly, now we are producing electricity for our patients as a way to address all of the factors that can contribute to health outcomes.”

Many hospitals help patients sign up for electricity or heating assistance because research shows that not having them . Aparna Bole, a pediatrician and senior consultant in the Office of Climate Change and Health Equity at the federal Department of Health and Human Services, said these are common problems for low- and moderate-income patients. BMC’s approach to solving them may be the first of its kind, she said.

“To be able to connect those very patients with clean, renewable energy in such a way that reduces their utility bills is really groundbreaking,” Bole said.

Bole is using a on the solar credits program to show other hospitals how they might do something similar. Boston Medical Center officials estimate the project cost $1.6 million, and said 60% of the funding came from the federal Inflation Reduction Act. Biggio has already mapped plans for an additional $11 million in solar installations.

“Our goal is to scale this pilot and help a lot more patients,” he said.

The expansion he envisions would allow a tenfold increase in patients who could be served by the program, but it still would not meet the demand. For now, each patient in the pilot program receives assistance for just one year. Boston Medical Center is looking for partners who might want to share their solar energy with the hospital’s patients in exchange for a higher federal tax credit or reimbursement.

Eversource’s vice president for energy efficiency, Tilak Subrahmanian, said the pilot was a complex project to launch, but now that it’s in place, it could be expanded.

“If other institutions are willing to step up, we’ll figure it out,” Subrahmanian said, “because there is such a need.”

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Divo explains that boot-shaped inhalers, which represent of the U.S. market for asthma medication, save lives but also contribute to climate change. Each puff from an inhaler releases a hydrofluorocarbon gas that is as the most commonly known greenhouse gas, carbon dioxide.

“That absolutely never occurred to me,” said Rubinstein. “Especially, I mean, these are little, teeny things.”

So Divo has begun offering a more eco-friendly option to some patients with asthma and other lung diseases: a plastic, gray cylinder about the size and shape of a hockey puck that contains powdered medicine. Patients suck the powder into their lungs — no puff of gas required and no greenhouse gas emissions.

“You have the same medications, two different delivery systems,” Divo said.

Patients in the United States are prescribed roughly of what doctors call metered-dose inhalers each year, according to the most recently available data published in 2020. The cumulative amount of gas released is the equivalent of driving half a million gas-powered cars for a year. So, the benefits of moving to dry powder inhalers from gas inhalers could add up.

Hydrofluorocarbon gas contributes to climate change, which is creating more wildfire smoke, other types of air pollution, and longer allergy seasons. These conditions can make breathing more difficult — especially for people with asthma and chronic obstructive pulmonary disease, or COPD — and increase the use of inhalers.

Divo is one of a small but growing number of U.S. physicians determined to reverse what they see as an unhealthy cycle.

“There is only one planet and one human race,” Divo said. “We are creating our own problems and we need to do something.”

So Divo is working with patients like Rubinstein who may be willing to switch to dry powder inhalers. Rubinstein said no to the idea at first because the powder inhaler would have been more expensive. Then his insurer increased the copay on the metered-dose inhaler so Rubinstein decided to try the dry powder.

“For me, price is a big thing,” said Rubinstein, who has tracked health care and pharmaceutical spending in his professional roles for years. Inhaling the medicine using more of his own lung power was an adjustment. “The powder is a very strange thing, to blow powder into your mouth and lungs.”

But for Rubinstein, the new inhaler works and his asthma is under control. A recent study found that some patients in the who use dry powder inhalers have better asthma control while reducing greenhouse gas emissions. In Sweden, where the vast majority of , are lower .

Rubinstein is one of a small number of U.S. patients who have made the transition. Divo said that, for a variety of reasons, only about a quarter of his patients even consider switching. Dry powder inhalers are often more expensive than gas propellant inhalers. For some, dry powder isn’t a good option because not all asthma or COPD sufferers can get their medications in this form. And dry powder inhalers aren’t recommended for young children or elderly patients with diminished lung strength.

Also, some patients using dry powder inhalers worry that without the noise from the spray, they may not be receiving the proper dose. Other patients don’t like the taste powder inhalers can leave in their mouths.

Divo said his priority is making sure patients have an inhaler they are comfortable using and that they can afford. But, when appropriate, he’ll keep offering the dry powder option.

Advocacy groups for asthma and COPD patients support more conversations about the connection between inhalers and climate change.

“The climate crisis makes these individuals have a higher risk of exacerbation and worsening disease,” said , chief medical officer of the . “We don’t want medications to contribute to that.”

Rizzo said there is work being done to make metered-dose inhalers more climate-friendly. The United States and many other countries are , which are also used in refrigerators and air conditioners. It’s part of the global attempt to avoid the worst possible impacts of climate change. But inhaler manufacturers are from those requirements and can continue to use the gases while they explore new options.

Some have pledged to produce canisters with and to submit them for regulatory review by next year. It’s not clear when these inhalers might be available in pharmacies. Separately, the FDA is spending about $6 million on a of developing inhalers with a smaller carbon footprint.

Rizzo and other lung specialists worry these changes will translate into higher prices. That’s what happened in the early to mid-2000s when ozone-depleting chlorofluorocarbons (CFCs) of inhalers. Manufacturers changed the gas in metered-dose inhalers and the cost to patients . Today, many of those re-engineered inhalers remain expensive.

William Feldman, a pulmonologist and health policy researcher at Brigham and Women’s Hospital, said these dramatic price increases occur because manufacturers register updated inhalers as new products, even though they deliver medications already on the market. The manufacturers are then awarded patents, which prevent the production of competing generic medications for decades. The Federal Trade Commission says it is .

After the CFC ban, “manufacturers from the inhalers,” Feldman said of the re-engineered inhalers.

When inhaler costs went up, physicians say, patients cut back on puffs and suffered more asthma attacks. , medical director for climate and sustainability at Brigham and Women’s Hospital, is worried that’s about to happen again.

“While these new propellants are potentially a real positive development, there’s also a significant risk that we’re going to see patients and payers face significant cost hikes,” Furie said.

Some of the largest inhaler manufacturers, including GSK, are for allegedly inflating prices in the United States. Sydney Dodson-Nease told NPR and ºÚÁϳԹÏÍø News that the company has a strong record for keeping medicines accessible to patients but that it’s too early to comment on the price of the more environmentally sensitive inhalers the company is developing.

Developing affordable, effective, and climate-friendly inhalers will be important for hospitals as well as patients. The that hospitals looking to shrink their carbon footprint reduce inhaler emissions. Some hospital administrators see switching inhalers as low-hanging fruit on the list of climate-change improvements a hospital might make.

But , medical director of environmental stewardship at Providence, a hospital network in Oregon, said, “It’s not as easy as swapping inhalers.”

Chesebro said that even among metered-dose inhalers, the climate impact varies. So pharmacists should suggest the inhalers with the fewest greenhouse gas emissions. Insurers should also adjust reimbursements to favor climate-friendly alternatives, he said, and regulators could consider emissions when reviewing hospital performance.

, a family physician in Toronto, said clinicians can make a big difference with inhaler emissions by starting with the question: Does the patient in front of me really need one?

Green, who works on a project to make inhalers , said that a third of adults diagnosed with asthma may not have the disease.

“So that’s an easy place to start,” Green said. “Make sure the patient prescribed an inhaler is actually benefiting from it.”

Green said educating patients has a measurable effect. In her experience, patients are moved to learn that emissions from the approximately 200 puffs in one inhaler are in a gas-powered car. Some say switching to dry powder inhalers may be as beneficial for the climate as a patient .

One of the hospitals in Green’s health care network, , found that talking to patients about inhalers led to a significant decrease in the use of metered-dose devices. Over six months, the hospital went from 70% of patients using the puffers, to 30%.

Green said patients who switched to dry powder inhalers have largely stuck with them and appreciate using a device that is less likely to exacerbate environmental conditions that inflame asthma.

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A 17-year-old boy with shaggy blond hair stepped onto the scale at Tri-River Family Health Center in Uxbridge, Massachusetts.

After he was weighed, he headed for an exam room decorated with decals of planets and cartoon characters. A nurse checked his blood pressure. A pediatrician asked about school, home life, and his friendships.

This seemed like a routine teen checkup, the kind that happens in thousands of pediatric practices across the U.S. every day — until the doctor popped his next question.

“Any cravings for opioids at all?” asked . The patient shook his head.

“None, not at all?” Medina said again, to confirm.

“None,” said the boy named Sam, in a quiet but confident voice.

Only Sam’s first name is being used for this article because if his full name were publicized he could face discrimination in housing and job searches based on his prior drug use.

Medina was treating Sam for an addiction to opioids. He prescribed a medication called buprenorphine, which curbs cravings for the more dangerous and addictive opioid pills. Sam’s urine tests showed no signs of the Percocet or OxyContin pills he had been buying on Snapchat, the pills that fueled Sam’s addiction.

“What makes me really proud of you, Sam, is how committed you are to getting better,” said Medina, whose practice is part of .

The American Academy of Pediatrics addicted to opioids. But only 6% of pediatricians report ever doing do, according to .

In fact, buprenorphine prescriptions for adolescents as overdose deaths for 10- to 19-year-olds . These overdoses, combined with accidental opioid poisonings among young children, have become the for U.S. children.

“We’re really far from where we need to be and we’re far on a couple of different fronts,” said the chief of adolescent medicine at and a co-author of the study that surveyed pediatricians about addiction treatment.

That survey showed that many pediatricians don’t think they have the right training or personnel for this type of care — although Medina and other pediatricians who do manage patients with addiction say they haven’t had to hire any additional staff.

Some pediatricians responded to the survey by saying they don’t have enough patients to justify learning about this type of care, or don’t think it’s a pediatrician’s job.

“A lot of that has to do with training,” said , associate director for pediatric programs for the Yale Program in Addiction Medicine. “It’s seen as something that’s a very specialized area of medicine and, therefore, people are not exposed to it during routine medical training.”

Camenga and Hadland said medical schools and pediatric residency programs are working to add information to their curricula about substance use disorders, including how to discuss drug and alcohol use with children and teens.

But the curricula aren’t changing to help the number of young people struggling with an addiction, not to mention .

In a twisted, deadly development, drug use among adolescents has declined — but .

The main culprits are fake Xanax, Adderall, or Percocet pills laced with the powerful opioid fentanyl. Nearly deaths among 10- to 19-year-olds were traced to counterfeit pills.

“Fentanyl and counterfeit pills is really complicating our efforts to stop these overdoses,” said , the Centers for Disease Control and Prevention’s expert on adolescent addiction medicine and overdose prevention. “Many times these kids are overdosing without any awareness of what they’re taking.”

Terranella said pediatricians can help by stepping up screening for — and having conversations about — all types of drug use.

He also suggests pediatricians prescribe more naloxone, the nasal spray that can reverse an overdose. It’s available over the counter, but Terranella, who practices in Tucson, Arizona, believes a prescription may carry more weight with patients.

Back in the exam room, Sam was about to get his first shot of Sublocade, an injection form of buprenorphine that lasts 30 days. Sam is switching to the shots because he didn’t like the taste of Suboxone, oral strips of buprenorphine that he was supposed to dissolve under his tongue. He was spitting them out before he got a full dose.

Many doctors also prefer to prescribe the shots because patients don’t have to remember to take them every day. But the injection is painful. Sam was surprised when he learned that it would be injected into his belly over the course of 20-30 seconds.

“Is it almost done?” Sam asked, while a nurse coaches him to breathe deeply. When it was over, staffers joked out loud that even adults usually swear when they get the shot. Sam said he didn’t know that was allowed. He’s mostly worried about any residual soreness that might interfere with his evening plans.

“Do you think I can snowboard tonight?” Sam asked the doctor.

“I totally think you can snowboard tonight,” Medina answered reassuringly.

Sam was going with a new buddy. Making new friends and cutting ties with his former social circle of teens who use drugs has been one of the hardest things, Sam said, since he entered rehab 15 months ago.

“Surrounding yourself with the right people is definitely a big thing you want to focus on,” Sam said. “That would be my biggest piece of advice.”

For Sam, finding addiction treatment in a medical office jammed with puzzles, toys, and picture books has not been as odd as he thought it would be.

He mom, Julie, had accompanied him to this appointment. She said she’s grateful the family found a doctor who understands teens and substance use.

Before he started visiting the Tri-River Family Health Center, Sam had seven months of residential and outpatient treatment — without ever being offered buprenorphine to help control cravings and prevent relapse. residential programs for youth offer it. When Sam’s cravings for opioids returned, a counselor suggested Julie call Medina.

“Oh my gosh, I would have been having Sam here, like, two or three years ago,” Julie said. “Would it have changed the path? I don’t know, but it would have been a more appropriate level of care for him.”

Some parents and pediatricians worry about starting a teenager on buprenorphine, which can produce including long-term dependence. Pediatricians who prescribe the medication weigh the possible side effects against the threat of a fentanyl overdose.

“In this era, where young people are dying at truly unprecedented rates of opioid overdose, it’s really critical that we save lives,” said Hadland. “And we know that buprenorphine is a medication that saves lives.”

Addiction care can take a lot of time for a pediatrician. Sam and Medina text several times a week. Medina stresses that any exchange that Sam asks to be kept confidential is not shared.

Medina said treating substance use disorder is one of the most rewarding things he does.

“If we can take care of it,” he said, “We have produced an adult that will no longer have a lifetime of these challenges to worry about.”

This article is from a partnership that includes , , and ºÚÁϳԹÏÍø News.

This <a target="_blank" href="/mental-health/buprenorphine-children-teens-pediatricians-substance-use-disorder/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

An 80-plus-degree day is not sizzling by Phoenix standards. Even in Boston, it wasn’t high enough to trigger an official heat warning for the wider public.

But research has shown that those temperatures, coming so early in June, would likely drive up the number of heat-related hospital visits and deaths across the Boston region.

The targeted email alert the doctors and nurses at in Somerville, Massachusetts, got that day is part of a pilot project run by the nonprofit and Harvard University’s , known as C-CHANGE.

Medical clinicians based at 12 community-based clinics in seven states — California, Massachusetts, North Carolina, Oregon, Pennsylvania, Texas, and Wisconsin — are receiving these alerts.

At each location, the first email alert of the season was triggered when local temperatures reached the 90th percentile for that community. In a suburb of Portland, Oregon, that happened on May 14 during a springtime heat wave. In Houston, that occurred in early June.

A second email alert went out when forecasts indicated the thermometer would reach the 95th percentile. For Cambridge Health Alliance primary care physician Rebecca Rogers, that second alert arrived on July 6, when the high hit 87 degrees.

The emails remind Rogers and other clinicians to focus on patients who are particularly vulnerable to heat. That includes , , or patients with , , or .

Other at-risk groups include and people who can’t afford air conditioning, or who don’t have stable housing. Heat has been linked to complications as well.

“Heat can be dangerous to all of us,” said , director of health care solutions at C-CHANGE. “But the impacts are incredibly uneven based on who you are, where you live, and what type of resources you have.”

The pilot program aims to remind clinicians to start talking to patients about how to protect themselves on dangerously hot days, which are happening more frequently because of climate change. Heat is already the in the U.S. from weather-related hazards, Dresser said. Letting clinicians know when temperatures pose a particular threat to their patients could save lives.

“What we’re trying to say is, ‘You really need to go into heat mode now,'” said , vice president for science at Climate Central, with a recognition that “it’s going to be more dangerous for folks in your community who are more stressed.”

“This is not your grandmother’s heat,” said Ashley Ward, who directs the at Duke University. “The heat regime that we are seeing now is not what we experienced 10 or 20 years ago. So we have to accept that our environment has changed. This might very well be the coolest summer for the rest of our lives.”

The alerts bumped heat to the forefront of Rogers’ conversations with patients. She made time to ask each person whether they can cool off at home and at work.

That’s how she learned that one of her patients, Luciano Gomes, works in construction.

“If you were getting too hot at work and maybe starting to feel sick, do you know some things to look out for?” Rogers asked Gomes.

“No,” said Gomes slowly, shaking his head.

Rogers told Gomes about early signs of heat exhaustion: dizziness, weakness, or profuse sweating. She handed Gomes she’d printed out after receiving them  along with the email alerts.

They included information about how to avoid heat exhaustion and dehydration, as well as specific guidance for patients with asthma, chronic obstructive pulmonary disease (COPD), dementia, diabetes, multiple sclerosis, and mental health concerns.

Rogers pointed out a that ranges from pale yellow to dark gold. It’s a sort of hydration barometer, based on the color of one’s urine.

“So if your pee is dark like this during the day when you’re at work,” she told Gomes, “it probably means you need to drink more water.”

Gomes nodded. “This is more than you were expecting to talk about when you came to the doctor today, I think,” she said with a laugh.

During this visit, an interpreter translated the visit and information into Portuguese for Gomes, who is from Brazil and quite familiar with heat. But he now had questions for Rogers about the best ways to stay hydrated.

“Because here I’ve been addicted to soda,” Gomes told Rogers through the interpreter. “I’m trying to watch out for that and change to sparkling water. But I don’t have much knowledge on how much I can take of it.”

“As long as it doesn’t have sugar, it’s totally good,” Rogers said.

Now Rogers creates heat mitigation plans with each of her high-risk patients. But she still has medical questions that the research doesn’t yet address. For example: If patients take medications that make them urinate more often, could that lead to dehydration when it’s hot? Should she reduce their doses during the warmest weeks or months? And, if so, by how much? Research has yielded no firm answers to those questions.

Deidre Alessio, a nurse practitioner at Cambridge Health Alliance, also has received the email alerts. She has patients who sleep on the streets or in tents and search for places to cool off during the day.

“Getting these alerts makes me realize that I need to do more homework on the cities and towns where my patients live,” she said, “and help them find transportation to a cooling center.”

Most clinics and hospitals don’t have heat alerts built into electronic medical records, don’t filter patients based on heat vulnerability, and don’t have systems in place to send heat warnings to some or all of their patients.

“I would love to see health care institutions get the resources to staff the appropriate outreach,” said Gaurab Basu, a Cambridge Health Alliance physician who co-directs the Center for Health Equity Advocacy and Education at Cambridge Health Alliance. “But hospital systems are still really strained by covid and staffing issues.”

This pilot program is an excellent start and could benefit by including pharmacists, said Kristie Ebi, founding director of the at the University of Washington.

Ebi has studied heat early-warning systems for 25 years. She says one problem is that too many people don’t take heat warnings seriously. In a who experienced heat waves in four cities, only about half of residents took precautions to avoid harm to their health.

“We need more behavioral health research,” she said, “to really understand how to motivate people who don’t perceive themselves to be at risk, to take action.”

For Ebi and other researchers, the call to action is not just to protect individual health, but to address the root cause of rising temperatures: climate change.

“We’ll be dealing with increased exposure to heat for the rest of our lives,” said Dresser. “To address the factors that put people at risk during heat waves, we have to move away from fossil fuels so that climate change doesn’t get as bad as it could.”

This article is from a partnership that includes , , and ºÚÁϳԹÏÍø News.

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Clinicians who wanted to prescribe the medicine had to complete an eight-hour training. They could treat only a limited number of patients and had to keep special records. They were given a Drug Enforcement Administration registration number starting with X, a designation many doctors say made them a target for drug-enforcement audits.

“Just the process associated with taking care of our patients with a substance use disorder made us feel like, ‘Boy, this is dangerous stuff,'” said , who chairs an American Medical Association task force addressing substance use disorder.

“The science doesn’t support that but the rigamarole suggested that.”

That rigamarole is mostly gone. Congress eliminated what became known as the “X-waiver” in legislation President Joe Biden . Now begins what some addiction experts are calling a “truth serum moment.”

Were the X-waiver and the burdens that came with it the real reason only about 7% of clinicians in the U.S. were cleared to prescribe buprenorphine? Or were they an excuse that masked hesitation about treating addiction, if not outright disdain for these patients?

There’s great optimism among some leaders in the field that getting rid of the X-waiver will expand access to buprenorphine and reduce overdoses.  shows taking buprenorphine or methadone, another opioid agonist treatment, reduces the mortality risk for people with opioid dependence by 50%. The medication is an opioid that produces much weaker effects than heroin or fentanyl and reduces cravings for those deadlier drugs.

The nation’s drug czar, , said getting rid of the X-waiver would ultimately prevent millions of deaths.

“The impact of this will be felt for years to come,” Gupta said. “It is a true historic change that, frankly, I could only dream of being possible.”

Gupta and others envision obstetricians prescribing buprenorphine to their pregnant patients, infectious disease doctors adding it to their medical toolbox, and lots more patients starting buprenorphine when they come to emergency rooms, primary care clinics, and rehabilitation facilities.

We are “transforming the way we think to make every moment an opportunity to start this treatment and save someone’s life,” said , the medical director for substance use disorder at Mass General Brigham in Boston.

Wakeman said clinicians she has been contacting for the past decade are finally willing to consider treating patients with buprenorphine. Still, she knows stigma and discrimination could undermine efforts to help those who aren’t being served. In 2021, a national survey showed of people with opioid use disorder received medications such as buprenorphine and .

The test of whether clinicians will step up and if prescribing will become more widespread is underway in hospitals and clinics across the country as patients struggling with addiction queue up for treatment. A woman named Kim, 65, is among them.

Kim’s recent visit to the Greater New Bedford Community Health Center in southern Massachusetts began in an exam room with Jamie Simmons, a registered nurse who runs the center’s addiction treatment program but doesn’t have prescribing powers. KHN agreed to use only Kim’s first name to limit potential discrimination linked to her drug use.

Kim told Simmons that buprenorphine had helped her stay off heroin and avoid an overdose for nearly 20 years. Kim takes a medication called Suboxone, a combination of buprenorphine and naloxone, which comes in the form of thin, filmlike strips she dissolves under her tongue.

“It’s the best thing they could have ever come out with,” Kim said. “I don’t think I ever even had a desire to use heroin since I’ve been taking them.”

can produce mild euphoria and slow breathing but there’s a ceiling on the effects. Patients like Kim may develop a tolerance and not experience any effects.

“I don’t get high on Suboxones,” Kim said. “They just keep me normal.”

Still, many clinicians have been hesitant to use buprenorphine — known as a partial opioid agonist — to treat an addiction to more deadly forms of the drug.

Kim’s primary care doctor at the health center never applied for an X-waiver. So for years Kim bounced from one treatment program to another, seeking a prescription. During lapses in her access to buprenorphine, the cravings returned — an especially scary prospect after the powerful opioid fentanyl largely replaced heroin on the streets of Massachusetts, where Kim lives.

“I’ve seen so many people fall out in the last month,” Kim said, using a slang term for overdosing. “That stuff is so strong that within a couple minutes, boom.”

Because fentanyl can kill so quickly, the  and other medications to treat opioid use disorder have increased as deaths linked to even stronger types of fentanyl rise.

Buprenorphine is present in a  nationwide, 2.6%. Of those, 93% involved a mix of one or more other drugs, often benzodiazepines. Fentanyl is in  in Massachusetts.

“Bottom line is, fentanyl kills people, buprenorphine doesn’t,” Simmons said.

That reality added urgency to Kim’s health center visit because Kim took her last Suboxone before arriving; her latest prescription had run out.

Cravings for heroin could have returned in about a day if she didn’t get more Suboxone. Simmons confirmed the dose and told Kim that her primary care doctor might be willing to renew the prescription now that the X-waiver is not required. But Dr. Than Win had some concerns after reviewing Kim’s most recent urine test. It showed traces of cocaine, fentanyl, marijuana, and Xanax, and Win said she was worried about how the street drugs might interact with buprenorphine.

“I don’t want my patients to die from an overdose,” Win said. “But I’m not comfortable with the fentanyl and a lot of narcotics in the system.”

Kim was adamant that she did not intentionally ingest fentanyl, saying it might have been in the cocaine she said her roommate shares occasionally. Kim said she takes the Xanax to sleep. Her drug use presents complications that many primary care doctors don’t have experience managing. Some clinicians are apprehensive about using an opioid to treat an addiction to opioids, despite compelling evidence that doing so can save patients’ lives.

Win was worried about writing her first prescription for Suboxone. But she agreed to help Kim stay on the medication.

“I wanted to start with someone a little bit easier,” Win said. “It’s hard for me; that’s the reality and truth.”

About half of the providers at the Greater New Bedford health center had an X-waiver when it was still required. Attributing some of the resistance to having the waiver to stigma or misunderstanding about addiction, Simmons urged doctors to treat addiction as they would any other disease.

“You wouldn’t not treat a diabetic; you wouldn’t not treat a patient who is hypertensive,” Simmons said. “People can’t control that they formed an addiction to an opiate, alcohol, or a benzo.”

Searching for Solutions to Soften Stigma

Although the restrictions on buprenorphine prescribing are no longer in place, Mukkamala said the perception created by the X-waiver lingers.

“That legacy of elevating this to a level of scrutiny and caution —that needs to be sort of walked back,” Mukkamala said. “That’s going to come from education.”

Mukkamala sees promise in the next generation of doctors, nurse practitioners, and physician assistants coming out of schools that have added addiction training. The  and the  have online resources for clinicians who want to learn on their own.

Some of these resources may help fulfill a  for clinicians who prescribe buprenorphine and other controlled narcotics. It will take effect in June. The DEA has not issued details about the training.

But training alone may not shift behavior, as Rhode Island’s experience shows.

The number of Rhode Island practitioners approved to prescribe buprenorphine increased roughly threefold from 2016 to 2022 after the state said . Still, having the option to prescribe buprenorphine “didn’t open the floodgates” for patients in need of treatment, said , an addiction specialist who teaches at Brown University. From 2016 to 2022, when the number of qualified prescribers increased, the number of patients taking buprenorphine also increased, but by a much smaller percentage.

“It all comes back to stigma,” Rich said.

He said long-standing resistance among some providers to treating addiction is shifting as younger people enter medicine. But tackling the opioid crisis can’t wait for a generational change, he said. To expand buprenorphine access now, states could use pharmacists, partnered with doctors, to help manage the care of more patients with opioid use disorder, Rich’s .

Wakeman, at Mass General Brigham, said it might be time to hold clinicians who don’t provide addiction care accountable through quality measures tied to payments.

“We’re expected to care for patients with diabetes or to care for patients with heart attack in a certain way and the same should be true for patients with an opioid use disorder,” Wakeman said.

One quality measure to track could be how often prescribers start and continue buprenorphine treatment. Wakeman said it would help also if insurers reimbursed clinics for the cost of staff who aren’t traditional clinicians but are critical in addiction care, like recovery coaches and case managers.

Will Ending the X-Waiver Close Racial Gaps?

Wakeman and others are paying especially close attention to whether eliminating the X-waiver helps narrow racial gaps in buprenorphine treatment. The medication is  to white patients with private insurance or who can pay cash. But there are also stark differences by race at some health centers where most patients are on Medicaid and would seem to have equal access to the addiction treatment.

At the New Bedford health center, Black patients represent 15% of all patients but only 6% of those taking buprenorphine. For Hispanics, it is 30% to 23%. Most of the health center patients prescribed buprenorphine, 61%, are white, though white patients make up just 36% of patients overall.

, who co-authored a book on , said access to buprenorphine doesn’t guarantee that patients will benefit from it.

“People are not able to stay on a lifesaving medication unless the immense instability in housing, employment, social supports — the very fabric of their communities — is addressed,” Hansen said. “That’s where we fall incredibly short in the United States.”

Hansen said expanding access to buprenorphine has  among all drug users in France, including those with low incomes and immigrants. There, patients with opioid use disorder are seen in their communities and offered a wide range of social services.

“Removing the X-waiver,” Hansen said, “is not in itself going to revolutionize the opioid overdose crisis in our country. We would need to do much more.”

This article is part of a partnership that includes , , and KHN.

This <a target="_blank" href="/mental-health/some-roadblocks-to-lifesaving-addiction-treatment-are-gone-now-what/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

If you or someone you know may be considering suicide, contact the by dialing 988, or the by texting HOME to 741741.

It was around 2 a.m. when Carmen realized her 12-year-old daughter was in danger and needed help.

Haley wasn’t in her room — or anywhere else in the house. Carmen tracked Haley’s phone to a main street in their central Massachusetts community.

“She don’t know the danger that she was taking out there,” said Carmen, her voice choked with tears. “Walking in the middle of the night, anything can happen.”

Carmen picked up Haley, unharmed. But in those early morning hours, she learned about more potentially dangerous behavior — provocative photos her daughter had sent and plans to meet up with a boy in high school. She also remembered the time a few years back when Haley was bullied and said she wanted to die. Carmen asked KHN to withhold the family’s last name to protect Haley’s identity.

Carmen drove her daughter to a local hospital — the only place she knew to look for help in an emergency — where Haley ended up on a gurney, in a hallway, with other young people who’d also come with an urgent mental health problem. Haley spent the next three days like that. It was painful for her mother, who had to go home at times to care for Haley’s siblings.

“Leaving [her] in there for days, seeing all those kids, it was terrifying for me,” Carmen said.

That week last October, Haley was one of who went to a Massachusetts hospital ER in a mental health crisis, waiting days or even weeks for an opening in an adolescent psychiatric unit. The problem, known as “boarding,” has been across the country for more than a decade. And some hospitals have reported record numbers during the covid-19 pandemic.

“We see more and more mental health patients, unfortunately, languishing in emergency departments,” said , president of the American College of Emergency Physicians. “I’ve heard stories of not just weeks but months.”

But now a and are testing ways to provide urgent mental care outside the ER and reduce this strain on hospitals. Massachusetts has contracted with four agencies to provide intensive counseling at home through a program called . It’s an approach that could be a model for other states grappling with boarding. For Haley, so far, it’s a game changer.

To determine what’s best for each child, hospitals start with a psychological evaluation, like the one Haley had on her second day in the ER.

“I didn’t know if they were just going to send me home or put me in a really weird place,” she said. “It was, like, really nerve-wracking.”

DeAnna Pedro, a liaison between pediatrics and psychiatry at UMass Memorial Medical Center, reviewed Haley’s report and considered recommending time in a psychiatric unit.

“She was doing a lot of high-risk things,” Pedro said. “So there was a lot of thought given to: Would we need to go to something extreme like a psychiatric admission?”

But both Pedro and Haley’s parents worried about this option. It would be a dramatic change for a 12-year-old whose only experience with mental health care was with her school counselor. So instead Pedro contacted Youth Villages, a youth diversion agency Massachusetts hired during the pandemic. Haley’s family met with a supervisor right there in the ER.

Later, during the first home visit, there was a safety sweep.

“We look under rugs, we look behind picture frames, we look in the dirt of plants,” said Laura Polizoti, the counselor from Youth Villages assigned to Haley’s case. Youth Villages also provided window and door alarms that Haley’s parents could activate at night.

Counseling for Haley and her parents started right away. A key goal was to understand why Haley was sneaking out at night and taking inappropriately sexual pictures.

During a counseling session one afternoon in December, Polizoti focused on Haley’s anger at herself and her mom.

“Have you ever done an emotional thermometer before?” Polizoti asked, laying a large graphic of a thermometer on the table. It had blank lines for five emotions, from cool to hot.

“It can help you see where your feelings are at,” Polizoti explained. “Then we’ll come up with coping skills for each level.”

In the blank next to the bottom of the thermometer, Haley wrote “chill.” At the top, in the red zone, she wrote “infuriated.”

“Infuriated — that’s a good word,” Polizoti said. “So when you’re infuriated, how do you think you feel physically? What do you notice?”

Haley told Polizoti her palms get sweaty, she stops talking, and she makes “a weird face.” Haley scrunched up her nose and frowned to demonstrate. Polizoti laughed.

As the exercise unfolded, Polizoti asked Haley to think of ways to calm herself before irritation turns to anger. Haley suggested spending time alone, watching TV, playing with her siblings, or jumping on the family’s trampoline.

“That’s a good one, the trampoline,” said Polizoti. “Can we come up with one more?

“I could, like, talk with my mom?” Haley said.

“Awesome,” said Polizoti.

Initial numbers suggest this diversion program is working. The Massachusetts Department of Mental Health said that as of early February 536 young people, ages 4 to 18, had worked with one of the four agencies. A large majority, 82%, have not returned to an emergency room with a mental health concern; 92% have met their treatment goals, or were referred for additional treatment once stabilized by the initial diversion service.

Advocates for parents of children with mental health issues said the main complaint they hear is that hospitals don’t present the home care program option quickly enough, and that when they do, there is often a wait.

“We would love to have more opportunities to get these diversions with more families,” said Meri Viano, associate director at the . “We’ve seen in the data and heard from families that this has been a great program to get children in that next place to heal faster.”

And then there’s the relatively affordable cost: $8,522, on average, for the typical course of care. At Youth Villages, that pays for three 45- to 60-minute counseling sessions a week, in a patient’s home or other community setting, for three months. The savings are significant. One study of pediatric boarding at $219 an hour, or $5,256 for just one day. And that’s before the expense of a psychiatric hospital stay.

In Massachusetts, the diversion program seems to be relieving overburdened hospitals and staff. from the Massachusetts Health & Hospital Association shows youth ER boarding numbers dropped as more hospitals started referring families to home-based options. MHA said the numbers are hopeful.

Kang, with the American College of Emergency Physicians, is optimistic about mental health organizations like Youth Villages offering urgent care outside of hospitals, but said starting diversion programs isn’t easy. If state and local governments don’t take the lead, hospitals need to vet community mental health partners, create care agreements, and figure out how to pay for home-based services. All this while hospitals are overwhelmed by staffing shortages.

Making these kinds of systemic changes may require “getting past some inertia as well as some reluctance to say, ‘Is this really what we need to do?'” said Kang.

Some families hesitate to try diversion if their child takes psychiatric medications or they think the child should be prescribed those medicines. Youth Villages does not have prescribers on staff. Children who need medication see a psychiatrist or primary care doctor outside the program.

It’s not clear what percentage of children and teens who go to a hospital ER for mental care can be treated at home rather than in a psychiatric unit — home isn’t always a safe place for a patient. But in other cases, home care is the best option, said , Youth Villages’ executive director in Massachusetts and New Hampshire.

“Many of the mental health challenges that these children are facing are driven by factors in their natural environment: their school, their neighborhood, their peer system,” said Stone. “It’s our view that you really can’t work on addressing those factors with a child in a placement.”

Clinicians in psychiatric units do work on family and social issues, sometimes bringing family members into the hospital for sessions. There’s no data yet to compare the outcomes.

Some mental health advocates argue that the need for diversion will subside as Massachusetts launches a to improve mental health care. But for the time being, Carmen and other parents coping with a new mental health crisis will likely still head to an ER, where they may be offered intensive counseling at home.

“A lot of parents don’t know what the kids are going through because they don’t want to accept that your kids really need help,” Carmen said. “Hopefully this can help another family.”

This article is from a partnership that includes , , and .

This <a target="_blank" href="/health-industry/youth-mental-health-emergency-department-diversion-boarding-massachusetts/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

“I was so scared,” Marie said later, her hand clutched to her chest.

Marie, 63, was admitted to , north of Boston. The staff treated her chronic obstructive pulmonary disease, a lung condition. A doctor checked on Marie the next day, said her oxygen levels looked good, and told her she was ready for discharge.

We are not using Marie’s last name because she, like hospitalized patients, has a history of addiction to drugs or alcohol. Disclosing a diagnosis like that can make it hard to find housing, a job, and even medical care in hospitals, where patients with an addiction might be shunned.

But talking to the doctor that morning, Marie felt she had to reveal her other medical problem.

“‘I got to tell you something,’” Marie recalled saying. “‘I’m a heroin addict. And I’m, like, starting to be in heavy withdrawal. I can’t — literally — move. Please don’t make me go.’”

At many hospitals in Massachusetts and across the country, Marie would likely have been discharged anyway, still in the pain of withdrawal, perhaps with a list of local detox programs that might provide help.

Discharging a patient without specialized addiction care can mean losing a crucial opportunity to intervene and treat someone at the hospital. don’t have specialists who know how to treat addiction, and other clinicians might not know what to do.

Hospitals typically employ all sorts of providers who specialize in the heart, lungs, and kidneys. But for patients with an addiction or a condition related to drug or alcohol use, few hospitals have a clinician — whether that be a physician, nurse, therapist, or social worker — who specializes in addiction medicine.

That absence is striking at a time when overdose deaths in the U.S. have reached , and patients face an increased risk of fatal overdose in the days or weeks after being discharged from a hospital.

“They’re left on their own to figure it out, which unfortunately usually means resuming [drug] use because that’s the only way to feel better,” said Liz Tadie, a nurse practitioner .

In fall 2020, Tadie was hired to launch a new approach at Salem Hospital using $320,000 from a federal grant. Tadie put together what’s known as an “addiction consult service.” The team included Tadie, a patient case manager, and three recovery coaches, who drew on their experiences with addiction to advocate for patients and help them navigate treatment options.

After Marie asked her doctor to let her stay in the hospital, he called Tadie for a bedside consultation.

Tadie started by prescribing methadone, a medication to treat opioid addiction. Although many patients do well on that drug, it didn’t help Marie, so Tadie switched her to buprenorphine, with better results. After a few more days, Marie was discharged and continued taking buprenorphine.

Marie also continued seeing Tadie for outpatient treatment and turned to her for support and reassurance: “Like, that I wasn’t going to be left alone,” Marie said. “That I wasn’t going to have to call a dealer ever again, that I could delete the number. I want to get back to my life. I just feel grateful.”

Tadie helped spread the word among Salem’s clinical staff members about the expertise she offered and how it could help patients. Success stories like Marie’s helped make the case for addiction medicine — and helped unravel decades of misinformation, discrimination, and ignorance about patients with an addiction and their treatment options.

The small amount of training that doctors and nurses get is often unhelpful.

“A lot of the facts are outdated,” Tadie said. “And people are trained to use stigmatizing language, words like ‘addict’ and substance ‘abuse.’”

Tadie gently corrected doctors at Salem Hospital, who, for example, thought they weren’t allowed to start patients on methadone in the hospital.

“Sometimes I would recommend a dose and somebody would give pushback,” Tadie said. But “we got to know the hospital doctors, and they, over time, were like, ‘OK, we can trust you. We’ll follow your recommendations.’”

Other members of Tadie’s team have wrestled with finding their place in the hospital hierarchy.

David Cave, one of Salem’s recovery coaches, is often the first person to speak to patients who come to the emergency room in withdrawal. He tries to help the doctors and nurses understand what the patients are going through and to help the patients navigate their care. “I’m probably punching above my weight every time I try to talk to a clinician or doctor,” Cave said. “They don’t see letters after my name. It can be kind of tough.”

Naming addiction as a specialty, and hiring people with specific training, is shifting the culture of Salem Hospital, said social worker Jean Monahan-Doherty. “There was finally some recognition across the entire institution that this was a complex medical disease that needed the attention of a specialist,” Monahan-Doherty said. “People are dying. This is a terminal illness unless it’s treated.”

This approach to treating addiction is winning over some Salem Hospital employees — but not all.

“Sometimes you hear an attitude of, ‘Why are you putting all this effort into this patient? They’re not going to get better.’ Well, how do we know?” Monahan Doherty said. “If a patient comes in with diabetes, we don’t say, ‘OK, they’ve been taught once and it didn’t work, so we’re not going to offer them support again.’”

Despite lingering reservations among some Salem clinicians, the demand for addiction services is high. Many days, Tadie and her team have been overwhelmed with referrals.

Four other Massachusetts hospitals added addiction specialists in the past three years using federal funding from the . The project is paying for a wide range of strategies across several states to help determine the most effective ways to reduce drug overdose deaths. They include mobile treatment clinics; street outreach teams; distribution of naloxone, a medicine that can reverse an opioid overdose; rides to treatment sites; and multilingual public awareness campaigns.

It’s a new field, so finding staff members with the right certifications may be a challenge. Some hospital leaders say they’re worried about the costs of addiction treatment and fear they’ll lose money on the efforts. Some doctors report not wanting to initiate a medication treatment while patients are in the hospital because they don’t know where to refer patients after they’ve been discharged, whether that be to outpatient follow-up care or a residential program. To address follow-up care, Salem Hospital started what’s known as a “bridge clinic,” which offers outpatient care.

Dr. Honora Englander, a national leader in addiction specialty programs, said the federal government could support the creation of more addiction consult services by offering financial incentives — or penalties for hospitals that don’t embrace them.

At Salem Hospital, some staffers worry about the program’s future. Tadie is starting a new job at another hospital, and the federal grant ended June 30. But Salem Hospital leaders say they are committed to continuing the program and the service will continue.

This story is part of a partnership that includes ,  and KHN.

This <a target="_blank" href="/health-industry/hospitals-have-been-slow-to-bring-on-addiction-specialists/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Drilling down from national rates, the picture varies widely at the regional level, and from state to state. For example, Massachusetts and most states in the Northeast reached or exceeded 70% (for adults, age 18 and older) in June. Tennessee and most Southern states have vaccination rates between 50% and 60%, and administration rates are slowing down.

Local variations in demand for the vaccines and in-state strategies for marketing and distributing the shots help explain the range.

In Massachusetts, for example, residents overwhelmed phone lines and appointment websites as soon as vaccines became available. The state began opening mass vaccination sites in January to meet demand. At Gillette Stadium in Foxborough, the home field of the New England Patriots, Jumbotron screens flashed updates and speakers blasted instructions to people arriving for a shot. When demand peaked in March, as many as 8,000 residents a day snaked through lines to a waiting syringe. Registered nurse Francesca Trombino delivered jab after jab at Fenway Park and then at the Hynes Convention Center in Boston for five months.

“I still hold a lot of interactions very dear to my heart,” she said, reflecting on those months in late June. “I had so many people cry, just out of pure shock, just being able to feel free.”

Heading into the long Fourth of July weekend, more than 82% of Massachusetts adults had received at least one shot. That number doesn’t surprise many public health experts because residents generally have embraced vaccination recommendations in the past, and Massachusetts regularly registers some of the highest rates for pediatric and influenza inoculations in the country. In Tennessee, where only 52% of adults are at least partially vaccinated against covid, nurses sit waiting. In some of the state’s rural counties, only 30% of residents have been vaccinated.

“Our first couple weeks we had people booked, then after that we had people start no-showing,” said Kirstie Allen, who coordinates covid vaccinations at the federally subsidized clinic in Linden, Tennessee. “We had a waiting list, the people on the waiting list didn’t want to come. It’s gradually just gotten worse.”

Allen is down to offering the vaccine just one day a week, and she aims to sign up at least 10 patients to avoid wasting doses in the multi-use Moderna vial.

Allen has witnessed plenty of vague skepticism in her town of 1,200 people. And she can sympathize. Despite administering the shots, the mother and licensed practical nurse has not yet been vaccinated and said she’s waiting for more research results to be released, and to see how everyone does over time.

“I’m one of those people who are unsure at the moment about getting it,” she said, adding she wouldn’t get her kids vaccinated yet either.

This wait-and-see attitude is especially common among white, rural conservatives in the South, according to in recent months. After an initial surge of interest, demand for vaccinations waned, and states like Tennessee held mass vaccination events only in the most densely populated cities.

Having Reached the 70% Goal, Massachusetts Adopts Targeted Strategy

In Massachusetts, with fewer than 20% of adults still unvaccinated, the state is closing its high-volume vaccine clinics and focusing on specific demographic groups and communities with low vaccination rates.

“As these [big] sites come to their mission complete, we need to keep pushing harder into the neighborhoods,” said Rodrigo Martinez, “into those locations that really need it.”

Martinez is with CIC Health, a company that moved from managing mass vaccination sites to running small outdoor clinics at supermarkets where shoppers who got a shot . That hyperlocal approach is part of a growing effort in Massachusetts to bring vaccines to residents, especially those in low-income and minority communities where the virus spread quickly and vaccination rates remain low.

Massachusetts has targeted 20 such cities including Brockton, south of Boston. It’s a diverse city of essential workers, a group that has been hit hard during the pandemic. First-dose vaccination rates are especially low for Latinos, at 39%, and Blacks, 41% (for all ages, not just adults).

The hyperlocal approach was on display in Brockton on a Sunday in late June, when the city, with assistance from the state, hosted a mobile vaccine clinic at a popular park. A , retrofitted to hold vaccination stations, idled near tents offering free food, music, legal advice for immigrants and health insurance enrollment assistance.

This particular neighborhood in Brockton features residents who speak Portuguese, Spanish, English and Haitian Creole.

“Bienvenue! Welcome!” shouted Isabel Lopez, a vaccine ambassador, as she moved from one cluster of families to another, urging them to go grab a free hamburger, hot dog — and a vaccine.

“We are here, bringing the communities together, to make this a fun day and also a creative way to get people vaccinated,” Lopez said.

Near the soccer field, Lopez scored a big win. She persuaded five hesitant members of one household to go to the bus and at least talk with a nurse there. A half-hour later, all five had received their first shots. Lenin Gomez said afterward that he had had doubts about the vaccine but was persuaded when the nurse stressed the need to protect the children living in Gomez’s home.

“If I’m not fully protected, who will take care of the little ones?” Gomez said. “That’s what opened my mind to getting vaccinated.”

When Gomez gets his second dose in a few weeks, he can enter himself in a statewide lottery that will give away five $1 million prizes for anyone who’s vaccinated. Massachusetts Gov. Charlie Baker said he hopes these jackpots will entice hesitant residents to roll up their sleeves.

Hefty Financial Incentives Are Less Common in the South

In the states that need most to boost vaccination rates, there’s little interest in creative financial incentives. Tennessee has . In Alabama, the NAACP funded a for $1,000 prizes aimed at millennials and Gen Zers.

Overall, the daily vaccination rate across the South has slowed, worrying health officials who are watching the explosive growth and spread of the delta variant in several parts of the U.S. But some Southern residents continue to come around to the idea. In Lobelville, Tennessee, 57-year-old Laurel Grant was initially hesitant to get the shot because of possible side effects.

“But everybody I know has done real good, just maybe a little fever or a little tiredness,” she said.

So Grant got her own shot in June, at a local pharmacy. It helped that the Pilot Flying J truck stop where she works to employees who got fully vaccinated.

“There’s a few down there at work who are like, ‘I’m not going to get it,'” Grant said, “I’m like, ‘Yes, you are. You gotta go, like it or not.'”

Converts like Grant are being seen as the best kind of evangelist for this next phase of vaccinating latecomers. Tennessee’s health department has started to release online. But the marketing efforts are beginning to annoy some Republican state lawmakers convinced the state is trying too hard. They’re .

A recent hearing in the Tennessee state legislature included threats of disbanding Tennessee’s health department. State Rep. Iris Rudder, along with other GOP lawmakers, brandished printouts of social media ads produced by state health officials. They featured smiling kids with adhesive bandages on their shoulders.

“It’s not your business to target children. It’s your business to inform the parent that their child is eligible for the vaccination,” she told health department officials at the hearing in June. “So I would encourage you, before our next meeting, to get things like this off your website.”

This criticism was mostly directed at the state’s health commissioner, Dr. , who responded at the hearing by saying the state is not “whispering to kids” or trying to get them vaccinated behind the backs of their parents. She said she’s not going to back off when it comes to vaccination outreach.

Piercey also said she doesn’t think the risk level in Tennessee is as dire as the low vaccination rates suggest. Tennessee had a of covid cases during the winter. That means at least 850,000 people — based on positive test results — are walking around with some level of natural immunity. Piercey said those residents are partially compensating for low vaccination rates.

“Yes, I want everybody who wants a vaccine to get it,” she said. “But what I really want at the end of the day is for this pandemic to go away. I want to minimize cases and eliminate hospitalizations and deaths, and we’re pretty close to getting there.”

The outlook is less rosy in neighboring Arkansas. The state escaped the worst of the winter outbreaks. Now it is trying to stop flare-ups of illness caused by the more contagious delta variant. Gov. Asa Hutchinson told ” that if nothing else will inspire Southerners to get vaccinated, “reality will.”

This story is part of a partnership that includes , , and KHN.

This <a target="_blank" href="/public-health/covid-vaccinations-biden-goal-70-percent-southern-rates-lag/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Brugge lifted up one of the jars and gazed at it with reverence. Each jar holds samples of breast tissue donated by patients after they underwent a tissue biopsy or breast surgery — samples that may reveal a new way to prevent breast cancer.

Brugge and her research team have analyzed the cell structure of more than 100 samples.

Using high-powered microscopes and complex computer algorithms, they diagram each stage in the development of breast cancer: from the first sign of cell mutation to the formation of tiny clusters, well before they are large enough to be considered tumors.

Their quest is to prevent breast cancer, a disease that afflicts roughly 1 in 8 U.S. women over their lifetimes, as well as some men. Their ultimate goal is to relieve the pain, suffering, and risk of death that accompany this disease. And their painstaking work, unspooling across six years of a seven-year, , has yielded results.

In late 2024, Brugge and her colleagues in breast tissue that contain the genetic seeds of breast tumors.

And they discovered that these “seed cells” are surprisingly common. In fact, they are present in the normal, healthy tissue of every breast sample her lab has examined, Brugge said, including samples from patients who haven’t had breast cancer but have had surgery for other reasons, such as breast reduction or a biopsy that proved benign.

The next research challenge for Brugge’s lab is clear: Find ways to detect, isolate, and terminate the mutant cells before they can spread and form tumors.

“I’m excited about what we’re doing right now,” Brugge said. “I think we could make a difference, so I don’t want to stop.”

Work in Brugge’s lab slowed significantly last year. In April, her from the National Cancer Institute at the National Institutes of Health was frozen, along with virtually all other federal money awarded to Harvard researchers.

The Trump administration said it was withholding the funds of antisemitism on campus.

Some of Brugge’s lab staff lost federal fellowships that funded their work. Brugge told others funded through the NIH grant that she couldn’t guarantee their salaries. In all, Brugge lost seven of her 18 lab employees.

In September, the funding for the NIH grant was restored. But in the intervening months, the Trump administration said Brugge and other Harvard researchers for the next round of multiyear grants.

A federal judge , but Brugge had missed the deadline to apply for renewal. So her current funding will end in August.

Brugge scrambled to secure private funding from foundations and philanthropists. She was then able to reinstate two positions for at least a year — but job applicants are wary.

Across the United States, the future of federal funding for cancer research is uncertain.

President Donald Trump has proposed by nearly 40% in the 2026 fiscal year.

In a , the White House said the “NIH has broken the trust of the American people with wasteful spending, misleading information, risky research, and the promotion of dangerous ideologies that undermine public health.”

But Congress has other plans: The released on Jan. 20 that would set the NIH’s budget at $48.7 billion, $415 million more than in the 2025 fiscal year.

In the meantime, advocates such as with the are reminding lawmakers that the cancer death rate has declined — — due in part to federally funded research advances.

“But we still have an incredible ways to go before we can say that we’ve changed the trajectory of cancer,” Fleury said. “There are still cancer types that are fairly lethal, and there are still populations of people for whom their experience of cancer is vastly different from other groups.”

Reductions in research funding will have a direct impact on treatment options for patients, Fleury said. For example, a 10% cut to the NIH budget would eventually result in two fewer new drugs or treatments per year, according to from the nonpartisan Congressional Budget Office.

A recent study looked at drugs that were developed through NIH-funded research and approved by the Food and Drug Administration since 2000. More than half those drugs would probably if the NIH had been operating with a 40% smaller budget.

“We can’t say, ‘But for that grant, that [specific] drug would not have come into existence,’” said , a co-author of the study and a professor at the Massachusetts Institute of Technology. But fewer drugs would have made it to market, he said. “It makes us at least want to pause and say, ‘What are we doing here? Are we shooting ourselves in the foot?’”

Amid all the uncertainty, Brugge has trouble focusing on her goal of finding new ways to prevent breast cancer.

Nowadays, she spends about half her time searching for new sources of funding, managing her remaining employees’ anxieties, and monitoring the most recent news about Harvard, the Trump administration, and the NIH and other federal agencies that have experienced grant freezes, staff layoffs, and other disruptions.

She’d rather return her attention to her ongoing investigations, which she’s confident could eventually save lives.

The breakdown of Brugge’s lab highlights another problem: The U.S. is kneecapping the next generation of cancer researchers. Her employees included , postdocs, and graduate students. Of the seven who left the lab in 2025, one left the U.S., one took a job at a health care management company, four went back to school, and one is still looking for work.

One of Brugge’s former staffers, Y., is a computational biologist. She helped design and run a tool that analyzes millions of breast tissue cells from the samples in the pink-lidded jars.

Y. moved to Switzerland in October to begin a PhD program. ºÚÁϳԹÏÍø News and NPR are identifying her by her middle initial because she plans to return to the U.S. for scientific conferences and worries that speaking publicly about her experience could risk future visa approvals.

“I thought the U.S. would be a safe place for scientists to learn and grow,” said Y., who moved to Boston from abroad for Harvard’s master’s degree program in bioinformatics. “I really hope that those who have the opportunities to study this further can fill in those missing pieces in cancer research.”

Brugge is no longer accepting job applicants from outside the U.S., even if they are top candidates, because she can’t afford to pay the Trump administration’s on visas for some foreign researchers.

The Association of American Universities and the U.S. Chamber of Commerce have , claiming the fee is misguided and illegal. The Trump administration said the fee would and improve opportunities for Americans.

Brugge doubts work in her lab will ever return to normal.

“There’ll always be, now, this existential threat to the research,” Brugge said. “I will definitely be concerned because we don’t know what’s going to happen in the future that might trigger a similar kind of action.”

Brugge has thought about shutting down her lab. But she still employs staff members whose future scientific careers are tied to finishing some of the research. And when she looks at those pink-lidded jars, she still sees so much promise.

This article is from a partnership that includes , , and ºÚÁϳԹÏÍø News.

This <a target="_blank" href="/health-industry/nih-grant-freeze-breast-cancer-research-slowed-harvard-lab/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

MacDonald wanted to find a new doctor right away. She needed refills for her blood pressure medications and wanted to book a follow-up appointment after a breast cancer scare. 

She called 10 primary care practices near her home in Westwood, Massachusetts. None of the doctors, nurse practitioners, or physician assistants was taking new patients. A few offices told her that a doctor could see her in a year and a half or two years.

“I was just shocked by that, because we live in Boston and we’re supposed to have this great medical care,” said MacDonald, who is in her late 40s and has private health insurance. “I couldn’t get my mind around the fact that we didn’t have any doctors.”

The shortage of primary care providers is a , but it’s particularly acute in Massachusetts. The state’s primary care workforce is shrinking faster than in most states, according to a .

Some health networks, including the state’s largest hospital chain, , are turning to artificial intelligence for solutions.

In September, right when MacDonald was running out of blood pressure medications, MGB launched a new AI-supported program, . MacDonald had received a letter from MGB, telling her no primary care providers in the network were taking new patients for in-person care. At the bottom of the letter was a link to Care Connect.

MacDonald downloaded the app and requested a telehealth appointment with a doctor. She then spent about 10 minutes chatting with an AI agent about why she wanted to see a physician. Afterward, the AI tool sent a summary of the chat to a primary care doctor who could see MacDonald by video.

“I think I got an appointment the next day or two days later,” she said. “It was just such a difference from being told I had to wait two years.”

Round-the-Clock Convenience

MGB says the AI tool can handle patients seeking care for colds, nausea, rashes, sprains, and other common urgent care requests, as well as mild to moderate mental health concerns and issues related to chronic diseases. After the patient types in a description of the symptoms or problem, the AI tool sends a doctor a suggested diagnosis and treatment plan.

Care Connect employs 12 physicians to work with the AI. They log in remotely from around the U.S., and patients can get help round-the-clock, seven days a week.

Care Connect is one of many AI-based tools that hospitals, doctors, and administrative staff are testing for a range of routine medical tasks, including note-taking, reviewing diagnostic results, billing, and ordering supplies.

Proponents argue that these AI programs can help relieve staff burnout and worker shortages by reducing time spent on medical records, referrals, and other administrative tasks. But there’s debate about and to use AI to improve diagnoses. Critics worry that AI agents miss important details about overlapping medical conditions.

Critics also point out that AI tools can’t assess whether patients can afford follow-up care or get to that appointment. They have no insight into family dynamics or caretaking needs, things that primary physicians come to understand through long-term personal relationships.

Since her first foray on the app in September, MacDonald has used Care Connect at least three more times. Two of those interactions led to an eventual conversation with a remote doctor, but when she went online to book an appointment for travel-related shots, she interacted only with the AI chatbot before visiting the travel clinic.

MacDonald likes the convenience.

“I don’t have to leave work,” she said. “And I gained some peace of mind, knowing that I have a plan between now and me finding another in-person doctor.”

So while she hunted for that person, MacDonald planned to stay with Care Connect.

“This is a logical solution in the short term,” MacDonald said. “At the end of the day, it’s the patient who’s feeling the aftermath of all of the bigger things going on in health care.”

Scarcity and Burnout

Many factors contribute to the shortage of providers. Many primary care doctors, such as pediatricians, internists, and family medicine physicians, are dissatisfied with their pay. They earn about , on average, than specialists such as surgeons, cardiologists, and anesthesiologists. 

At the same time, their workload has been increasing. Primary care doctors days packed with complex patient visits, followed by evenings spent updating medical records and responding to patient messages.

When MacDonald signed onto Care Connect, she was one of 15,000 patients in the Mass General Brigham system without a primary care provider. That number has grown as primary care doctors have left MGB for rival hospital networks.

, a primary care physician at an MGB health center in Chelsea, Massachusetts, said she’s staying at MGB for now, but she’s grown frustrated with the system’s leaders.

“They don’t make any effort to ease the shortage,” said Rao, who is also part of an MBG’s primary care doctors. “They put their money into specialties. Primary care feels like a peripheral part of the system, when it really should be a central part.”

Last year, MGB pledged to spend $400 million over five years on primary care services — though that includes the multiyear contract with Care Connect.

“Care Connect is just one solution among many in this broader strategy to alleviate the primary care capacity crisis,” , MGB’s chief operating officer, said in an emailed statement. “Our investment supports retaining our current physicians as well as recruiting new ones.”

Walls said MGB has increased staffing support for primary care physicians, implemented other AI tools, and hired a new executive for primary care. Some of these changes are based on recommendations from their own primary care doctors.

But some of those doctors say they would like other changes, and salary increases in particular.

Walls would not disclose the exact amount MGB is spending on Care Connect.

Bridge to Better Care or a ‘Band-Aid’?

MGB has rolled out other AI tools, including one that can transcribe a doctor’s in-person conversations with patients. Rao isn’t using that tool. She worries that patient information could be leaked and medical privacy violated, and she doesn’t want her conversations with patients to be used to help develop the next generation of AI medical tools.

“What if they’re just using my interactions with patients to train their AI and boot me out of my job?” she said.

That’s not the goal, said , a primary care physician who manages the program for MGB. All decisions about patient care are still made by real doctors, she said.

“We are not replacing our in-person primary care,” she said. “It’s still important, and the majority of patients still have in-person primary care.”

But the fear among some primary care doctors at MGB is that Care Connect will gradually erode access to in-person primary care visits. Of the $400 million pledged by MGB for primary care, they want less spent on AI and more used to attract and increase pay for primary care staffers.

, an MGB internist who is also involved in the unionizing effort, said the use of Care Connect can only fill a gap. “That sounds like a band-aid for a broken system to me,” he said.

Expanding AI Tools

As of mid-December, the Care Connect doctors were each seeing 40 to 50 patients a day. By February, the MGB network plans to make Care Connect available to all Massachusetts and New Hampshire residents who have health insurance, and to hire more doctors to staff the program as needed. 

Patients can use the program like an urgent care service, Ireland said. They can also decide to make one of the remote doctors their permanent primary care provider.

“Some patients want in-person care,” Ireland said. “But I do believe there’s a subset of patients who will appreciate the 24-hour, seven-day-a-week model and choose to be a part of this.”

Care Connect isn’t for patients who need emergency care or a physical exam, she said. And patients who need tests or imaging are referred to the network’s clinics or labs.

But the remote doctors can manage some of the same routine issues that all primary care doctors do, Ireland said, including moderate respiratory infections, allergies, and chronic conditions such as diabetes, high cholesterol, and depression. 

says only immediate, not ongoing, health problems should be on that list. Lin is chief of primary care at the Stanford University School of Medicine and founded Stanford’s Healthcare AI Applied Research Team.

“In its current state, the safest use of this tool is for more urgent care issues,” Lin said. “Your upper respiratory tract infections. Your urinary tract infections. Your musculoskeletal injuries. Your rashes.”

For patients with multiple chronic conditions such as high blood pressure and diabetes — or for patients with especially serious conditions like heart disease or cancer — Lin said nothing beats a human who sees you regularly.

Still, Lin agrees that the chat summary generated after an AI encounter can help a physician be more efficient. For patients, Lin understands the practical appeal of a virtual option.

“I would rather these patients get care, if that care can be safe,” he said, “than not get care at all.”

The company that developed the AI platform for Care Connect, , contends the program is delivering safe, effective care to patients with complex, chronic ailments — many of whom have no other option besides a hospital emergency room.

“America’s got a big problem with health care, issues with cost, quality, and access,” said , the company’s CEO. “To solve it, you need to start with primary care, and you have to use technology and AI.”

In addition to Mass General Brigham, K Health partners with five other health networks, including the highly ranked and Los Angeles-based .

In a funded by K Health, Cedars-Sinai researchers compared several hundred diagnosis and treatment recommendations made by AI with those made by physicians.

The researchers found the AI to be slightly better at identifying “critical red flags” and recommending care based on clinical guidelines, though the physicians were better at adjusting their treatment recommendations as they spoke more with the patient.

This article is from a partnership that includes , , and ºÚÁϳԹÏÍø News.

This <a target="_blank" href="/news/ai-primary-care-doctors-shortages-massachusetts-mass-general-brigham/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

The result is a pilot effort called the Clean Power Prescription program. The initiative aims to help keep the lights on for roughly 80 patients with complex, chronic medical needs.

The program relies on 519 solar panels installed on the roof of one of the hospital’s office buildings. Half the energy generated by the panels helps power the medical center. The rest goes to patients who receive a monthly credit of about $50 on their utility bills.

Kiki Polk was among the first recipients. She has a history of Type 2 diabetes and high blood pressure.

On a warm fall day, Polk, who was nine months pregnant at the time, leaned into the air conditioning window unit in her living room.

“Oh my gosh, this feels so good, baby,” Polk crooned, swaying back and forth. “This is my best friend and my worst enemy.”

An enemy, because Polk can’t afford to run the AC. On cooler days, she has used a fan or opened a window instead. Polk knew the , including added stress on the pregnant person’s heart and potential risks to the fetus. She also has a teenage daughter who uses the AC in her bedroom — too much, according to her mom.

Polk got behind on her utility bill. , her electricity provider, worked with her on a payment plan. But the bills were still high for Polk, who works as a school bus and lunchroom monitor. She was surprised when staff at Boston Medical Center, where she was a patient, offered to help.

“I always think they’re only there for, you know, medical stuff,” Polk said, “not the personal financial stuff.”

Polk is on maternity leave now to care for her baby, the tiny Briana Moore.

Goldman, who is also BMC’s medical director of climate and sustainability, said hospital screening questionnaires show thousands of patients like Polk struggle to pay their utility bills.

“I had a conversation recently with someone who had a hospital bed at home,” Goldman said. “They were using so much energy because of the hospital bed that they were facing a utility shut-off.”

Goldman wrote a letter to the utility company requesting that the power stay on. Last year, she and her colleagues at Boston Medical Center wrote 1,674 letters to utility companies asking them to keep patients’ gas or electricity running. Goldman took that number to Bob Biggio, the hospital’s chief sustainability and real estate officer. He’d been counting on the solar panels to help the hospital shift to renewable energy, but sharing the power with patients felt as if it fit the health system’s mission.

“Boston Medical Center’s been focused on lower-income communities and trying to change their health outcomes for over 100 years,” Biggio said. “So this just seemed like the right thing to do.”

Standing on the roof amid the solar panels, Goldman pointed out a large vegetable garden one floor down.

“We’re actually growing food for our patients,” she said. “And, similarly, now we are producing electricity for our patients as a way to address all of the factors that can contribute to health outcomes.”

Many hospitals help patients sign up for electricity or heating assistance because research shows that not having them . Aparna Bole, a pediatrician and senior consultant in the Office of Climate Change and Health Equity at the federal Department of Health and Human Services, said these are common problems for low- and moderate-income patients. BMC’s approach to solving them may be the first of its kind, she said.

“To be able to connect those very patients with clean, renewable energy in such a way that reduces their utility bills is really groundbreaking,” Bole said.

Bole is using a on the solar credits program to show other hospitals how they might do something similar. Boston Medical Center officials estimate the project cost $1.6 million, and said 60% of the funding came from the federal Inflation Reduction Act. Biggio has already mapped plans for an additional $11 million in solar installations.

“Our goal is to scale this pilot and help a lot more patients,” he said.

The expansion he envisions would allow a tenfold increase in patients who could be served by the program, but it still would not meet the demand. For now, each patient in the pilot program receives assistance for just one year. Boston Medical Center is looking for partners who might want to share their solar energy with the hospital’s patients in exchange for a higher federal tax credit or reimbursement.

Eversource’s vice president for energy efficiency, Tilak Subrahmanian, said the pilot was a complex project to launch, but now that it’s in place, it could be expanded.

“If other institutions are willing to step up, we’ll figure it out,” Subrahmanian said, “because there is such a need.”

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Divo explains that boot-shaped inhalers, which represent of the U.S. market for asthma medication, save lives but also contribute to climate change. Each puff from an inhaler releases a hydrofluorocarbon gas that is as the most commonly known greenhouse gas, carbon dioxide.

“That absolutely never occurred to me,” said Rubinstein. “Especially, I mean, these are little, teeny things.”

So Divo has begun offering a more eco-friendly option to some patients with asthma and other lung diseases: a plastic, gray cylinder about the size and shape of a hockey puck that contains powdered medicine. Patients suck the powder into their lungs — no puff of gas required and no greenhouse gas emissions.

“You have the same medications, two different delivery systems,” Divo said.

Patients in the United States are prescribed roughly of what doctors call metered-dose inhalers each year, according to the most recently available data published in 2020. The cumulative amount of gas released is the equivalent of driving half a million gas-powered cars for a year. So, the benefits of moving to dry powder inhalers from gas inhalers could add up.

Hydrofluorocarbon gas contributes to climate change, which is creating more wildfire smoke, other types of air pollution, and longer allergy seasons. These conditions can make breathing more difficult — especially for people with asthma and chronic obstructive pulmonary disease, or COPD — and increase the use of inhalers.

Divo is one of a small but growing number of U.S. physicians determined to reverse what they see as an unhealthy cycle.

“There is only one planet and one human race,” Divo said. “We are creating our own problems and we need to do something.”

So Divo is working with patients like Rubinstein who may be willing to switch to dry powder inhalers. Rubinstein said no to the idea at first because the powder inhaler would have been more expensive. Then his insurer increased the copay on the metered-dose inhaler so Rubinstein decided to try the dry powder.

“For me, price is a big thing,” said Rubinstein, who has tracked health care and pharmaceutical spending in his professional roles for years. Inhaling the medicine using more of his own lung power was an adjustment. “The powder is a very strange thing, to blow powder into your mouth and lungs.”

But for Rubinstein, the new inhaler works and his asthma is under control. A recent study found that some patients in the who use dry powder inhalers have better asthma control while reducing greenhouse gas emissions. In Sweden, where the vast majority of , are lower .

Rubinstein is one of a small number of U.S. patients who have made the transition. Divo said that, for a variety of reasons, only about a quarter of his patients even consider switching. Dry powder inhalers are often more expensive than gas propellant inhalers. For some, dry powder isn’t a good option because not all asthma or COPD sufferers can get their medications in this form. And dry powder inhalers aren’t recommended for young children or elderly patients with diminished lung strength.

Also, some patients using dry powder inhalers worry that without the noise from the spray, they may not be receiving the proper dose. Other patients don’t like the taste powder inhalers can leave in their mouths.

Divo said his priority is making sure patients have an inhaler they are comfortable using and that they can afford. But, when appropriate, he’ll keep offering the dry powder option.

Advocacy groups for asthma and COPD patients support more conversations about the connection between inhalers and climate change.

“The climate crisis makes these individuals have a higher risk of exacerbation and worsening disease,” said , chief medical officer of the . “We don’t want medications to contribute to that.”

Rizzo said there is work being done to make metered-dose inhalers more climate-friendly. The United States and many other countries are , which are also used in refrigerators and air conditioners. It’s part of the global attempt to avoid the worst possible impacts of climate change. But inhaler manufacturers are from those requirements and can continue to use the gases while they explore new options.

Some have pledged to produce canisters with and to submit them for regulatory review by next year. It’s not clear when these inhalers might be available in pharmacies. Separately, the FDA is spending about $6 million on a of developing inhalers with a smaller carbon footprint.

Rizzo and other lung specialists worry these changes will translate into higher prices. That’s what happened in the early to mid-2000s when ozone-depleting chlorofluorocarbons (CFCs) of inhalers. Manufacturers changed the gas in metered-dose inhalers and the cost to patients . Today, many of those re-engineered inhalers remain expensive.

William Feldman, a pulmonologist and health policy researcher at Brigham and Women’s Hospital, said these dramatic price increases occur because manufacturers register updated inhalers as new products, even though they deliver medications already on the market. The manufacturers are then awarded patents, which prevent the production of competing generic medications for decades. The Federal Trade Commission says it is .

After the CFC ban, “manufacturers from the inhalers,” Feldman said of the re-engineered inhalers.

When inhaler costs went up, physicians say, patients cut back on puffs and suffered more asthma attacks. , medical director for climate and sustainability at Brigham and Women’s Hospital, is worried that’s about to happen again.

“While these new propellants are potentially a real positive development, there’s also a significant risk that we’re going to see patients and payers face significant cost hikes,” Furie said.

Some of the largest inhaler manufacturers, including GSK, are for allegedly inflating prices in the United States. Sydney Dodson-Nease told NPR and ºÚÁϳԹÏÍø News that the company has a strong record for keeping medicines accessible to patients but that it’s too early to comment on the price of the more environmentally sensitive inhalers the company is developing.

Developing affordable, effective, and climate-friendly inhalers will be important for hospitals as well as patients. The that hospitals looking to shrink their carbon footprint reduce inhaler emissions. Some hospital administrators see switching inhalers as low-hanging fruit on the list of climate-change improvements a hospital might make.

But , medical director of environmental stewardship at Providence, a hospital network in Oregon, said, “It’s not as easy as swapping inhalers.”

Chesebro said that even among metered-dose inhalers, the climate impact varies. So pharmacists should suggest the inhalers with the fewest greenhouse gas emissions. Insurers should also adjust reimbursements to favor climate-friendly alternatives, he said, and regulators could consider emissions when reviewing hospital performance.

, a family physician in Toronto, said clinicians can make a big difference with inhaler emissions by starting with the question: Does the patient in front of me really need one?

Green, who works on a project to make inhalers , said that a third of adults diagnosed with asthma may not have the disease.

“So that’s an easy place to start,” Green said. “Make sure the patient prescribed an inhaler is actually benefiting from it.”

Green said educating patients has a measurable effect. In her experience, patients are moved to learn that emissions from the approximately 200 puffs in one inhaler are in a gas-powered car. Some say switching to dry powder inhalers may be as beneficial for the climate as a patient .

One of the hospitals in Green’s health care network, , found that talking to patients about inhalers led to a significant decrease in the use of metered-dose devices. Over six months, the hospital went from 70% of patients using the puffers, to 30%.

Green said patients who switched to dry powder inhalers have largely stuck with them and appreciate using a device that is less likely to exacerbate environmental conditions that inflame asthma.

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A 17-year-old boy with shaggy blond hair stepped onto the scale at Tri-River Family Health Center in Uxbridge, Massachusetts.

After he was weighed, he headed for an exam room decorated with decals of planets and cartoon characters. A nurse checked his blood pressure. A pediatrician asked about school, home life, and his friendships.

This seemed like a routine teen checkup, the kind that happens in thousands of pediatric practices across the U.S. every day — until the doctor popped his next question.

“Any cravings for opioids at all?” asked . The patient shook his head.

“None, not at all?” Medina said again, to confirm.

“None,” said the boy named Sam, in a quiet but confident voice.

Only Sam’s first name is being used for this article because if his full name were publicized he could face discrimination in housing and job searches based on his prior drug use.

Medina was treating Sam for an addiction to opioids. He prescribed a medication called buprenorphine, which curbs cravings for the more dangerous and addictive opioid pills. Sam’s urine tests showed no signs of the Percocet or OxyContin pills he had been buying on Snapchat, the pills that fueled Sam’s addiction.

“What makes me really proud of you, Sam, is how committed you are to getting better,” said Medina, whose practice is part of .

The American Academy of Pediatrics addicted to opioids. But only 6% of pediatricians report ever doing do, according to .

In fact, buprenorphine prescriptions for adolescents as overdose deaths for 10- to 19-year-olds . These overdoses, combined with accidental opioid poisonings among young children, have become the for U.S. children.

“We’re really far from where we need to be and we’re far on a couple of different fronts,” said the chief of adolescent medicine at and a co-author of the study that surveyed pediatricians about addiction treatment.

That survey showed that many pediatricians don’t think they have the right training or personnel for this type of care — although Medina and other pediatricians who do manage patients with addiction say they haven’t had to hire any additional staff.

Some pediatricians responded to the survey by saying they don’t have enough patients to justify learning about this type of care, or don’t think it’s a pediatrician’s job.

“A lot of that has to do with training,” said , associate director for pediatric programs for the Yale Program in Addiction Medicine. “It’s seen as something that’s a very specialized area of medicine and, therefore, people are not exposed to it during routine medical training.”

Camenga and Hadland said medical schools and pediatric residency programs are working to add information to their curricula about substance use disorders, including how to discuss drug and alcohol use with children and teens.

But the curricula aren’t changing to help the number of young people struggling with an addiction, not to mention .

In a twisted, deadly development, drug use among adolescents has declined — but .

The main culprits are fake Xanax, Adderall, or Percocet pills laced with the powerful opioid fentanyl. Nearly deaths among 10- to 19-year-olds were traced to counterfeit pills.

“Fentanyl and counterfeit pills is really complicating our efforts to stop these overdoses,” said , the Centers for Disease Control and Prevention’s expert on adolescent addiction medicine and overdose prevention. “Many times these kids are overdosing without any awareness of what they’re taking.”

Terranella said pediatricians can help by stepping up screening for — and having conversations about — all types of drug use.

He also suggests pediatricians prescribe more naloxone, the nasal spray that can reverse an overdose. It’s available over the counter, but Terranella, who practices in Tucson, Arizona, believes a prescription may carry more weight with patients.

Back in the exam room, Sam was about to get his first shot of Sublocade, an injection form of buprenorphine that lasts 30 days. Sam is switching to the shots because he didn’t like the taste of Suboxone, oral strips of buprenorphine that he was supposed to dissolve under his tongue. He was spitting them out before he got a full dose.

Many doctors also prefer to prescribe the shots because patients don’t have to remember to take them every day. But the injection is painful. Sam was surprised when he learned that it would be injected into his belly over the course of 20-30 seconds.

“Is it almost done?” Sam asked, while a nurse coaches him to breathe deeply. When it was over, staffers joked out loud that even adults usually swear when they get the shot. Sam said he didn’t know that was allowed. He’s mostly worried about any residual soreness that might interfere with his evening plans.

“Do you think I can snowboard tonight?” Sam asked the doctor.

“I totally think you can snowboard tonight,” Medina answered reassuringly.

Sam was going with a new buddy. Making new friends and cutting ties with his former social circle of teens who use drugs has been one of the hardest things, Sam said, since he entered rehab 15 months ago.

“Surrounding yourself with the right people is definitely a big thing you want to focus on,” Sam said. “That would be my biggest piece of advice.”

For Sam, finding addiction treatment in a medical office jammed with puzzles, toys, and picture books has not been as odd as he thought it would be.

He mom, Julie, had accompanied him to this appointment. She said she’s grateful the family found a doctor who understands teens and substance use.

Before he started visiting the Tri-River Family Health Center, Sam had seven months of residential and outpatient treatment — without ever being offered buprenorphine to help control cravings and prevent relapse. residential programs for youth offer it. When Sam’s cravings for opioids returned, a counselor suggested Julie call Medina.

“Oh my gosh, I would have been having Sam here, like, two or three years ago,” Julie said. “Would it have changed the path? I don’t know, but it would have been a more appropriate level of care for him.”

Some parents and pediatricians worry about starting a teenager on buprenorphine, which can produce including long-term dependence. Pediatricians who prescribe the medication weigh the possible side effects against the threat of a fentanyl overdose.

“In this era, where young people are dying at truly unprecedented rates of opioid overdose, it’s really critical that we save lives,” said Hadland. “And we know that buprenorphine is a medication that saves lives.”

Addiction care can take a lot of time for a pediatrician. Sam and Medina text several times a week. Medina stresses that any exchange that Sam asks to be kept confidential is not shared.

Medina said treating substance use disorder is one of the most rewarding things he does.

“If we can take care of it,” he said, “We have produced an adult that will no longer have a lifetime of these challenges to worry about.”

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An 80-plus-degree day is not sizzling by Phoenix standards. Even in Boston, it wasn’t high enough to trigger an official heat warning for the wider public.

But research has shown that those temperatures, coming so early in June, would likely drive up the number of heat-related hospital visits and deaths across the Boston region.

The targeted email alert the doctors and nurses at in Somerville, Massachusetts, got that day is part of a pilot project run by the nonprofit and Harvard University’s , known as C-CHANGE.

Medical clinicians based at 12 community-based clinics in seven states — California, Massachusetts, North Carolina, Oregon, Pennsylvania, Texas, and Wisconsin — are receiving these alerts.

At each location, the first email alert of the season was triggered when local temperatures reached the 90th percentile for that community. In a suburb of Portland, Oregon, that happened on May 14 during a springtime heat wave. In Houston, that occurred in early June.

A second email alert went out when forecasts indicated the thermometer would reach the 95th percentile. For Cambridge Health Alliance primary care physician Rebecca Rogers, that second alert arrived on July 6, when the high hit 87 degrees.

The emails remind Rogers and other clinicians to focus on patients who are particularly vulnerable to heat. That includes , , or patients with , , or .

Other at-risk groups include and people who can’t afford air conditioning, or who don’t have stable housing. Heat has been linked to complications as well.

“Heat can be dangerous to all of us,” said , director of health care solutions at C-CHANGE. “But the impacts are incredibly uneven based on who you are, where you live, and what type of resources you have.”

The pilot program aims to remind clinicians to start talking to patients about how to protect themselves on dangerously hot days, which are happening more frequently because of climate change. Heat is already the in the U.S. from weather-related hazards, Dresser said. Letting clinicians know when temperatures pose a particular threat to their patients could save lives.

“What we’re trying to say is, ‘You really need to go into heat mode now,'” said , vice president for science at Climate Central, with a recognition that “it’s going to be more dangerous for folks in your community who are more stressed.”

“This is not your grandmother’s heat,” said Ashley Ward, who directs the at Duke University. “The heat regime that we are seeing now is not what we experienced 10 or 20 years ago. So we have to accept that our environment has changed. This might very well be the coolest summer for the rest of our lives.”

The alerts bumped heat to the forefront of Rogers’ conversations with patients. She made time to ask each person whether they can cool off at home and at work.

That’s how she learned that one of her patients, Luciano Gomes, works in construction.

“If you were getting too hot at work and maybe starting to feel sick, do you know some things to look out for?” Rogers asked Gomes.

“No,” said Gomes slowly, shaking his head.

Rogers told Gomes about early signs of heat exhaustion: dizziness, weakness, or profuse sweating. She handed Gomes she’d printed out after receiving them  along with the email alerts.

They included information about how to avoid heat exhaustion and dehydration, as well as specific guidance for patients with asthma, chronic obstructive pulmonary disease (COPD), dementia, diabetes, multiple sclerosis, and mental health concerns.

Rogers pointed out a that ranges from pale yellow to dark gold. It’s a sort of hydration barometer, based on the color of one’s urine.

“So if your pee is dark like this during the day when you’re at work,” she told Gomes, “it probably means you need to drink more water.”

Gomes nodded. “This is more than you were expecting to talk about when you came to the doctor today, I think,” she said with a laugh.

During this visit, an interpreter translated the visit and information into Portuguese for Gomes, who is from Brazil and quite familiar with heat. But he now had questions for Rogers about the best ways to stay hydrated.

“Because here I’ve been addicted to soda,” Gomes told Rogers through the interpreter. “I’m trying to watch out for that and change to sparkling water. But I don’t have much knowledge on how much I can take of it.”

“As long as it doesn’t have sugar, it’s totally good,” Rogers said.

Now Rogers creates heat mitigation plans with each of her high-risk patients. But she still has medical questions that the research doesn’t yet address. For example: If patients take medications that make them urinate more often, could that lead to dehydration when it’s hot? Should she reduce their doses during the warmest weeks or months? And, if so, by how much? Research has yielded no firm answers to those questions.

Deidre Alessio, a nurse practitioner at Cambridge Health Alliance, also has received the email alerts. She has patients who sleep on the streets or in tents and search for places to cool off during the day.

“Getting these alerts makes me realize that I need to do more homework on the cities and towns where my patients live,” she said, “and help them find transportation to a cooling center.”

Most clinics and hospitals don’t have heat alerts built into electronic medical records, don’t filter patients based on heat vulnerability, and don’t have systems in place to send heat warnings to some or all of their patients.

“I would love to see health care institutions get the resources to staff the appropriate outreach,” said Gaurab Basu, a Cambridge Health Alliance physician who co-directs the Center for Health Equity Advocacy and Education at Cambridge Health Alliance. “But hospital systems are still really strained by covid and staffing issues.”

This pilot program is an excellent start and could benefit by including pharmacists, said Kristie Ebi, founding director of the at the University of Washington.

Ebi has studied heat early-warning systems for 25 years. She says one problem is that too many people don’t take heat warnings seriously. In a who experienced heat waves in four cities, only about half of residents took precautions to avoid harm to their health.

“We need more behavioral health research,” she said, “to really understand how to motivate people who don’t perceive themselves to be at risk, to take action.”

For Ebi and other researchers, the call to action is not just to protect individual health, but to address the root cause of rising temperatures: climate change.

“We’ll be dealing with increased exposure to heat for the rest of our lives,” said Dresser. “To address the factors that put people at risk during heat waves, we have to move away from fossil fuels so that climate change doesn’t get as bad as it could.”

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Clinicians who wanted to prescribe the medicine had to complete an eight-hour training. They could treat only a limited number of patients and had to keep special records. They were given a Drug Enforcement Administration registration number starting with X, a designation many doctors say made them a target for drug-enforcement audits.

“Just the process associated with taking care of our patients with a substance use disorder made us feel like, ‘Boy, this is dangerous stuff,'” said , who chairs an American Medical Association task force addressing substance use disorder.

“The science doesn’t support that but the rigamarole suggested that.”

That rigamarole is mostly gone. Congress eliminated what became known as the “X-waiver” in legislation President Joe Biden . Now begins what some addiction experts are calling a “truth serum moment.”

Were the X-waiver and the burdens that came with it the real reason only about 7% of clinicians in the U.S. were cleared to prescribe buprenorphine? Or were they an excuse that masked hesitation about treating addiction, if not outright disdain for these patients?

There’s great optimism among some leaders in the field that getting rid of the X-waiver will expand access to buprenorphine and reduce overdoses.  shows taking buprenorphine or methadone, another opioid agonist treatment, reduces the mortality risk for people with opioid dependence by 50%. The medication is an opioid that produces much weaker effects than heroin or fentanyl and reduces cravings for those deadlier drugs.

The nation’s drug czar, , said getting rid of the X-waiver would ultimately prevent millions of deaths.

“The impact of this will be felt for years to come,” Gupta said. “It is a true historic change that, frankly, I could only dream of being possible.”

Gupta and others envision obstetricians prescribing buprenorphine to their pregnant patients, infectious disease doctors adding it to their medical toolbox, and lots more patients starting buprenorphine when they come to emergency rooms, primary care clinics, and rehabilitation facilities.

We are “transforming the way we think to make every moment an opportunity to start this treatment and save someone’s life,” said , the medical director for substance use disorder at Mass General Brigham in Boston.

Wakeman said clinicians she has been contacting for the past decade are finally willing to consider treating patients with buprenorphine. Still, she knows stigma and discrimination could undermine efforts to help those who aren’t being served. In 2021, a national survey showed of people with opioid use disorder received medications such as buprenorphine and .

The test of whether clinicians will step up and if prescribing will become more widespread is underway in hospitals and clinics across the country as patients struggling with addiction queue up for treatment. A woman named Kim, 65, is among them.

Kim’s recent visit to the Greater New Bedford Community Health Center in southern Massachusetts began in an exam room with Jamie Simmons, a registered nurse who runs the center’s addiction treatment program but doesn’t have prescribing powers. KHN agreed to use only Kim’s first name to limit potential discrimination linked to her drug use.

Kim told Simmons that buprenorphine had helped her stay off heroin and avoid an overdose for nearly 20 years. Kim takes a medication called Suboxone, a combination of buprenorphine and naloxone, which comes in the form of thin, filmlike strips she dissolves under her tongue.

“It’s the best thing they could have ever come out with,” Kim said. “I don’t think I ever even had a desire to use heroin since I’ve been taking them.”

can produce mild euphoria and slow breathing but there’s a ceiling on the effects. Patients like Kim may develop a tolerance and not experience any effects.

“I don’t get high on Suboxones,” Kim said. “They just keep me normal.”

Still, many clinicians have been hesitant to use buprenorphine — known as a partial opioid agonist — to treat an addiction to more deadly forms of the drug.

Kim’s primary care doctor at the health center never applied for an X-waiver. So for years Kim bounced from one treatment program to another, seeking a prescription. During lapses in her access to buprenorphine, the cravings returned — an especially scary prospect after the powerful opioid fentanyl largely replaced heroin on the streets of Massachusetts, where Kim lives.

“I’ve seen so many people fall out in the last month,” Kim said, using a slang term for overdosing. “That stuff is so strong that within a couple minutes, boom.”

Because fentanyl can kill so quickly, the  and other medications to treat opioid use disorder have increased as deaths linked to even stronger types of fentanyl rise.

Buprenorphine is present in a  nationwide, 2.6%. Of those, 93% involved a mix of one or more other drugs, often benzodiazepines. Fentanyl is in  in Massachusetts.

“Bottom line is, fentanyl kills people, buprenorphine doesn’t,” Simmons said.

That reality added urgency to Kim’s health center visit because Kim took her last Suboxone before arriving; her latest prescription had run out.

Cravings for heroin could have returned in about a day if she didn’t get more Suboxone. Simmons confirmed the dose and told Kim that her primary care doctor might be willing to renew the prescription now that the X-waiver is not required. But Dr. Than Win had some concerns after reviewing Kim’s most recent urine test. It showed traces of cocaine, fentanyl, marijuana, and Xanax, and Win said she was worried about how the street drugs might interact with buprenorphine.

“I don’t want my patients to die from an overdose,” Win said. “But I’m not comfortable with the fentanyl and a lot of narcotics in the system.”

Kim was adamant that she did not intentionally ingest fentanyl, saying it might have been in the cocaine she said her roommate shares occasionally. Kim said she takes the Xanax to sleep. Her drug use presents complications that many primary care doctors don’t have experience managing. Some clinicians are apprehensive about using an opioid to treat an addiction to opioids, despite compelling evidence that doing so can save patients’ lives.

Win was worried about writing her first prescription for Suboxone. But she agreed to help Kim stay on the medication.

“I wanted to start with someone a little bit easier,” Win said. “It’s hard for me; that’s the reality and truth.”

About half of the providers at the Greater New Bedford health center had an X-waiver when it was still required. Attributing some of the resistance to having the waiver to stigma or misunderstanding about addiction, Simmons urged doctors to treat addiction as they would any other disease.

“You wouldn’t not treat a diabetic; you wouldn’t not treat a patient who is hypertensive,” Simmons said. “People can’t control that they formed an addiction to an opiate, alcohol, or a benzo.”

Searching for Solutions to Soften Stigma

Although the restrictions on buprenorphine prescribing are no longer in place, Mukkamala said the perception created by the X-waiver lingers.

“That legacy of elevating this to a level of scrutiny and caution —that needs to be sort of walked back,” Mukkamala said. “That’s going to come from education.”

Mukkamala sees promise in the next generation of doctors, nurse practitioners, and physician assistants coming out of schools that have added addiction training. The  and the  have online resources for clinicians who want to learn on their own.

Some of these resources may help fulfill a  for clinicians who prescribe buprenorphine and other controlled narcotics. It will take effect in June. The DEA has not issued details about the training.

But training alone may not shift behavior, as Rhode Island’s experience shows.

The number of Rhode Island practitioners approved to prescribe buprenorphine increased roughly threefold from 2016 to 2022 after the state said . Still, having the option to prescribe buprenorphine “didn’t open the floodgates” for patients in need of treatment, said , an addiction specialist who teaches at Brown University. From 2016 to 2022, when the number of qualified prescribers increased, the number of patients taking buprenorphine also increased, but by a much smaller percentage.

“It all comes back to stigma,” Rich said.

He said long-standing resistance among some providers to treating addiction is shifting as younger people enter medicine. But tackling the opioid crisis can’t wait for a generational change, he said. To expand buprenorphine access now, states could use pharmacists, partnered with doctors, to help manage the care of more patients with opioid use disorder, Rich’s .

Wakeman, at Mass General Brigham, said it might be time to hold clinicians who don’t provide addiction care accountable through quality measures tied to payments.

“We’re expected to care for patients with diabetes or to care for patients with heart attack in a certain way and the same should be true for patients with an opioid use disorder,” Wakeman said.

One quality measure to track could be how often prescribers start and continue buprenorphine treatment. Wakeman said it would help also if insurers reimbursed clinics for the cost of staff who aren’t traditional clinicians but are critical in addiction care, like recovery coaches and case managers.

Will Ending the X-Waiver Close Racial Gaps?

Wakeman and others are paying especially close attention to whether eliminating the X-waiver helps narrow racial gaps in buprenorphine treatment. The medication is  to white patients with private insurance or who can pay cash. But there are also stark differences by race at some health centers where most patients are on Medicaid and would seem to have equal access to the addiction treatment.

At the New Bedford health center, Black patients represent 15% of all patients but only 6% of those taking buprenorphine. For Hispanics, it is 30% to 23%. Most of the health center patients prescribed buprenorphine, 61%, are white, though white patients make up just 36% of patients overall.

, who co-authored a book on , said access to buprenorphine doesn’t guarantee that patients will benefit from it.

“People are not able to stay on a lifesaving medication unless the immense instability in housing, employment, social supports — the very fabric of their communities — is addressed,” Hansen said. “That’s where we fall incredibly short in the United States.”

Hansen said expanding access to buprenorphine has  among all drug users in France, including those with low incomes and immigrants. There, patients with opioid use disorder are seen in their communities and offered a wide range of social services.

“Removing the X-waiver,” Hansen said, “is not in itself going to revolutionize the opioid overdose crisis in our country. We would need to do much more.”

This article is part of a partnership that includes , , and KHN.

This <a target="_blank" href="/mental-health/some-roadblocks-to-lifesaving-addiction-treatment-are-gone-now-what/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

If you or someone you know may be considering suicide, contact the by dialing 988, or the by texting HOME to 741741.

It was around 2 a.m. when Carmen realized her 12-year-old daughter was in danger and needed help.

Haley wasn’t in her room — or anywhere else in the house. Carmen tracked Haley’s phone to a main street in their central Massachusetts community.

“She don’t know the danger that she was taking out there,” said Carmen, her voice choked with tears. “Walking in the middle of the night, anything can happen.”

Carmen picked up Haley, unharmed. But in those early morning hours, she learned about more potentially dangerous behavior — provocative photos her daughter had sent and plans to meet up with a boy in high school. She also remembered the time a few years back when Haley was bullied and said she wanted to die. Carmen asked KHN to withhold the family’s last name to protect Haley’s identity.

Carmen drove her daughter to a local hospital — the only place she knew to look for help in an emergency — where Haley ended up on a gurney, in a hallway, with other young people who’d also come with an urgent mental health problem. Haley spent the next three days like that. It was painful for her mother, who had to go home at times to care for Haley’s siblings.

“Leaving [her] in there for days, seeing all those kids, it was terrifying for me,” Carmen said.

That week last October, Haley was one of who went to a Massachusetts hospital ER in a mental health crisis, waiting days or even weeks for an opening in an adolescent psychiatric unit. The problem, known as “boarding,” has been across the country for more than a decade. And some hospitals have reported record numbers during the covid-19 pandemic.

“We see more and more mental health patients, unfortunately, languishing in emergency departments,” said , president of the American College of Emergency Physicians. “I’ve heard stories of not just weeks but months.”

But now a and are testing ways to provide urgent mental care outside the ER and reduce this strain on hospitals. Massachusetts has contracted with four agencies to provide intensive counseling at home through a program called . It’s an approach that could be a model for other states grappling with boarding. For Haley, so far, it’s a game changer.

To determine what’s best for each child, hospitals start with a psychological evaluation, like the one Haley had on her second day in the ER.

“I didn’t know if they were just going to send me home or put me in a really weird place,” she said. “It was, like, really nerve-wracking.”

DeAnna Pedro, a liaison between pediatrics and psychiatry at UMass Memorial Medical Center, reviewed Haley’s report and considered recommending time in a psychiatric unit.

“She was doing a lot of high-risk things,” Pedro said. “So there was a lot of thought given to: Would we need to go to something extreme like a psychiatric admission?”

But both Pedro and Haley’s parents worried about this option. It would be a dramatic change for a 12-year-old whose only experience with mental health care was with her school counselor. So instead Pedro contacted Youth Villages, a youth diversion agency Massachusetts hired during the pandemic. Haley’s family met with a supervisor right there in the ER.

Later, during the first home visit, there was a safety sweep.

“We look under rugs, we look behind picture frames, we look in the dirt of plants,” said Laura Polizoti, the counselor from Youth Villages assigned to Haley’s case. Youth Villages also provided window and door alarms that Haley’s parents could activate at night.

Counseling for Haley and her parents started right away. A key goal was to understand why Haley was sneaking out at night and taking inappropriately sexual pictures.

During a counseling session one afternoon in December, Polizoti focused on Haley’s anger at herself and her mom.

“Have you ever done an emotional thermometer before?” Polizoti asked, laying a large graphic of a thermometer on the table. It had blank lines for five emotions, from cool to hot.

“It can help you see where your feelings are at,” Polizoti explained. “Then we’ll come up with coping skills for each level.”

In the blank next to the bottom of the thermometer, Haley wrote “chill.” At the top, in the red zone, she wrote “infuriated.”

“Infuriated — that’s a good word,” Polizoti said. “So when you’re infuriated, how do you think you feel physically? What do you notice?”

Haley told Polizoti her palms get sweaty, she stops talking, and she makes “a weird face.” Haley scrunched up her nose and frowned to demonstrate. Polizoti laughed.

As the exercise unfolded, Polizoti asked Haley to think of ways to calm herself before irritation turns to anger. Haley suggested spending time alone, watching TV, playing with her siblings, or jumping on the family’s trampoline.

“That’s a good one, the trampoline,” said Polizoti. “Can we come up with one more?

“I could, like, talk with my mom?” Haley said.

“Awesome,” said Polizoti.

Initial numbers suggest this diversion program is working. The Massachusetts Department of Mental Health said that as of early February 536 young people, ages 4 to 18, had worked with one of the four agencies. A large majority, 82%, have not returned to an emergency room with a mental health concern; 92% have met their treatment goals, or were referred for additional treatment once stabilized by the initial diversion service.

Advocates for parents of children with mental health issues said the main complaint they hear is that hospitals don’t present the home care program option quickly enough, and that when they do, there is often a wait.

“We would love to have more opportunities to get these diversions with more families,” said Meri Viano, associate director at the . “We’ve seen in the data and heard from families that this has been a great program to get children in that next place to heal faster.”

And then there’s the relatively affordable cost: $8,522, on average, for the typical course of care. At Youth Villages, that pays for three 45- to 60-minute counseling sessions a week, in a patient’s home or other community setting, for three months. The savings are significant. One study of pediatric boarding at $219 an hour, or $5,256 for just one day. And that’s before the expense of a psychiatric hospital stay.

In Massachusetts, the diversion program seems to be relieving overburdened hospitals and staff. from the Massachusetts Health & Hospital Association shows youth ER boarding numbers dropped as more hospitals started referring families to home-based options. MHA said the numbers are hopeful.

Kang, with the American College of Emergency Physicians, is optimistic about mental health organizations like Youth Villages offering urgent care outside of hospitals, but said starting diversion programs isn’t easy. If state and local governments don’t take the lead, hospitals need to vet community mental health partners, create care agreements, and figure out how to pay for home-based services. All this while hospitals are overwhelmed by staffing shortages.

Making these kinds of systemic changes may require “getting past some inertia as well as some reluctance to say, ‘Is this really what we need to do?'” said Kang.

Some families hesitate to try diversion if their child takes psychiatric medications or they think the child should be prescribed those medicines. Youth Villages does not have prescribers on staff. Children who need medication see a psychiatrist or primary care doctor outside the program.

It’s not clear what percentage of children and teens who go to a hospital ER for mental care can be treated at home rather than in a psychiatric unit — home isn’t always a safe place for a patient. But in other cases, home care is the best option, said , Youth Villages’ executive director in Massachusetts and New Hampshire.

“Many of the mental health challenges that these children are facing are driven by factors in their natural environment: their school, their neighborhood, their peer system,” said Stone. “It’s our view that you really can’t work on addressing those factors with a child in a placement.”

Clinicians in psychiatric units do work on family and social issues, sometimes bringing family members into the hospital for sessions. There’s no data yet to compare the outcomes.

Some mental health advocates argue that the need for diversion will subside as Massachusetts launches a to improve mental health care. But for the time being, Carmen and other parents coping with a new mental health crisis will likely still head to an ER, where they may be offered intensive counseling at home.

“A lot of parents don’t know what the kids are going through because they don’t want to accept that your kids really need help,” Carmen said. “Hopefully this can help another family.”

This article is from a partnership that includes , , and .

This <a target="_blank" href="/health-industry/youth-mental-health-emergency-department-diversion-boarding-massachusetts/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

“I was so scared,” Marie said later, her hand clutched to her chest.

Marie, 63, was admitted to , north of Boston. The staff treated her chronic obstructive pulmonary disease, a lung condition. A doctor checked on Marie the next day, said her oxygen levels looked good, and told her she was ready for discharge.

We are not using Marie’s last name because she, like hospitalized patients, has a history of addiction to drugs or alcohol. Disclosing a diagnosis like that can make it hard to find housing, a job, and even medical care in hospitals, where patients with an addiction might be shunned.

But talking to the doctor that morning, Marie felt she had to reveal her other medical problem.

“‘I got to tell you something,’” Marie recalled saying. “‘I’m a heroin addict. And I’m, like, starting to be in heavy withdrawal. I can’t — literally — move. Please don’t make me go.’”

At many hospitals in Massachusetts and across the country, Marie would likely have been discharged anyway, still in the pain of withdrawal, perhaps with a list of local detox programs that might provide help.

Discharging a patient without specialized addiction care can mean losing a crucial opportunity to intervene and treat someone at the hospital. don’t have specialists who know how to treat addiction, and other clinicians might not know what to do.

Hospitals typically employ all sorts of providers who specialize in the heart, lungs, and kidneys. But for patients with an addiction or a condition related to drug or alcohol use, few hospitals have a clinician — whether that be a physician, nurse, therapist, or social worker — who specializes in addiction medicine.

That absence is striking at a time when overdose deaths in the U.S. have reached , and patients face an increased risk of fatal overdose in the days or weeks after being discharged from a hospital.

“They’re left on their own to figure it out, which unfortunately usually means resuming [drug] use because that’s the only way to feel better,” said Liz Tadie, a nurse practitioner .

In fall 2020, Tadie was hired to launch a new approach at Salem Hospital using $320,000 from a federal grant. Tadie put together what’s known as an “addiction consult service.” The team included Tadie, a patient case manager, and three recovery coaches, who drew on their experiences with addiction to advocate for patients and help them navigate treatment options.

After Marie asked her doctor to let her stay in the hospital, he called Tadie for a bedside consultation.

Tadie started by prescribing methadone, a medication to treat opioid addiction. Although many patients do well on that drug, it didn’t help Marie, so Tadie switched her to buprenorphine, with better results. After a few more days, Marie was discharged and continued taking buprenorphine.

Marie also continued seeing Tadie for outpatient treatment and turned to her for support and reassurance: “Like, that I wasn’t going to be left alone,” Marie said. “That I wasn’t going to have to call a dealer ever again, that I could delete the number. I want to get back to my life. I just feel grateful.”

Tadie helped spread the word among Salem’s clinical staff members about the expertise she offered and how it could help patients. Success stories like Marie’s helped make the case for addiction medicine — and helped unravel decades of misinformation, discrimination, and ignorance about patients with an addiction and their treatment options.

The small amount of training that doctors and nurses get is often unhelpful.

“A lot of the facts are outdated,” Tadie said. “And people are trained to use stigmatizing language, words like ‘addict’ and substance ‘abuse.’”

Tadie gently corrected doctors at Salem Hospital, who, for example, thought they weren’t allowed to start patients on methadone in the hospital.

“Sometimes I would recommend a dose and somebody would give pushback,” Tadie said. But “we got to know the hospital doctors, and they, over time, were like, ‘OK, we can trust you. We’ll follow your recommendations.’”

Other members of Tadie’s team have wrestled with finding their place in the hospital hierarchy.

David Cave, one of Salem’s recovery coaches, is often the first person to speak to patients who come to the emergency room in withdrawal. He tries to help the doctors and nurses understand what the patients are going through and to help the patients navigate their care. “I’m probably punching above my weight every time I try to talk to a clinician or doctor,” Cave said. “They don’t see letters after my name. It can be kind of tough.”

Naming addiction as a specialty, and hiring people with specific training, is shifting the culture of Salem Hospital, said social worker Jean Monahan-Doherty. “There was finally some recognition across the entire institution that this was a complex medical disease that needed the attention of a specialist,” Monahan-Doherty said. “People are dying. This is a terminal illness unless it’s treated.”

This approach to treating addiction is winning over some Salem Hospital employees — but not all.

“Sometimes you hear an attitude of, ‘Why are you putting all this effort into this patient? They’re not going to get better.’ Well, how do we know?” Monahan Doherty said. “If a patient comes in with diabetes, we don’t say, ‘OK, they’ve been taught once and it didn’t work, so we’re not going to offer them support again.’”

Despite lingering reservations among some Salem clinicians, the demand for addiction services is high. Many days, Tadie and her team have been overwhelmed with referrals.

Four other Massachusetts hospitals added addiction specialists in the past three years using federal funding from the . The project is paying for a wide range of strategies across several states to help determine the most effective ways to reduce drug overdose deaths. They include mobile treatment clinics; street outreach teams; distribution of naloxone, a medicine that can reverse an opioid overdose; rides to treatment sites; and multilingual public awareness campaigns.

It’s a new field, so finding staff members with the right certifications may be a challenge. Some hospital leaders say they’re worried about the costs of addiction treatment and fear they’ll lose money on the efforts. Some doctors report not wanting to initiate a medication treatment while patients are in the hospital because they don’t know where to refer patients after they’ve been discharged, whether that be to outpatient follow-up care or a residential program. To address follow-up care, Salem Hospital started what’s known as a “bridge clinic,” which offers outpatient care.

Dr. Honora Englander, a national leader in addiction specialty programs, said the federal government could support the creation of more addiction consult services by offering financial incentives — or penalties for hospitals that don’t embrace them.

At Salem Hospital, some staffers worry about the program’s future. Tadie is starting a new job at another hospital, and the federal grant ended June 30. But Salem Hospital leaders say they are committed to continuing the program and the service will continue.

This story is part of a partnership that includes ,  and KHN.

This <a target="_blank" href="/health-industry/hospitals-have-been-slow-to-bring-on-addiction-specialists/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">

Drilling down from national rates, the picture varies widely at the regional level, and from state to state. For example, Massachusetts and most states in the Northeast reached or exceeded 70% (for adults, age 18 and older) in June. Tennessee and most Southern states have vaccination rates between 50% and 60%, and administration rates are slowing down.

Local variations in demand for the vaccines and in-state strategies for marketing and distributing the shots help explain the range.

In Massachusetts, for example, residents overwhelmed phone lines and appointment websites as soon as vaccines became available. The state began opening mass vaccination sites in January to meet demand. At Gillette Stadium in Foxborough, the home field of the New England Patriots, Jumbotron screens flashed updates and speakers blasted instructions to people arriving for a shot. When demand peaked in March, as many as 8,000 residents a day snaked through lines to a waiting syringe. Registered nurse Francesca Trombino delivered jab after jab at Fenway Park and then at the Hynes Convention Center in Boston for five months.

“I still hold a lot of interactions very dear to my heart,” she said, reflecting on those months in late June. “I had so many people cry, just out of pure shock, just being able to feel free.”

Heading into the long Fourth of July weekend, more than 82% of Massachusetts adults had received at least one shot. That number doesn’t surprise many public health experts because residents generally have embraced vaccination recommendations in the past, and Massachusetts regularly registers some of the highest rates for pediatric and influenza inoculations in the country. In Tennessee, where only 52% of adults are at least partially vaccinated against covid, nurses sit waiting. In some of the state’s rural counties, only 30% of residents have been vaccinated.

“Our first couple weeks we had people booked, then after that we had people start no-showing,” said Kirstie Allen, who coordinates covid vaccinations at the federally subsidized clinic in Linden, Tennessee. “We had a waiting list, the people on the waiting list didn’t want to come. It’s gradually just gotten worse.”

Allen is down to offering the vaccine just one day a week, and she aims to sign up at least 10 patients to avoid wasting doses in the multi-use Moderna vial.

Allen has witnessed plenty of vague skepticism in her town of 1,200 people. And she can sympathize. Despite administering the shots, the mother and licensed practical nurse has not yet been vaccinated and said she’s waiting for more research results to be released, and to see how everyone does over time.

“I’m one of those people who are unsure at the moment about getting it,” she said, adding she wouldn’t get her kids vaccinated yet either.

This wait-and-see attitude is especially common among white, rural conservatives in the South, according to in recent months. After an initial surge of interest, demand for vaccinations waned, and states like Tennessee held mass vaccination events only in the most densely populated cities.

Having Reached the 70% Goal, Massachusetts Adopts Targeted Strategy

In Massachusetts, with fewer than 20% of adults still unvaccinated, the state is closing its high-volume vaccine clinics and focusing on specific demographic groups and communities with low vaccination rates.

“As these [big] sites come to their mission complete, we need to keep pushing harder into the neighborhoods,” said Rodrigo Martinez, “into those locations that really need it.”

Martinez is with CIC Health, a company that moved from managing mass vaccination sites to running small outdoor clinics at supermarkets where shoppers who got a shot . That hyperlocal approach is part of a growing effort in Massachusetts to bring vaccines to residents, especially those in low-income and minority communities where the virus spread quickly and vaccination rates remain low.

Massachusetts has targeted 20 such cities including Brockton, south of Boston. It’s a diverse city of essential workers, a group that has been hit hard during the pandemic. First-dose vaccination rates are especially low for Latinos, at 39%, and Blacks, 41% (for all ages, not just adults).

The hyperlocal approach was on display in Brockton on a Sunday in late June, when the city, with assistance from the state, hosted a mobile vaccine clinic at a popular park. A , retrofitted to hold vaccination stations, idled near tents offering free food, music, legal advice for immigrants and health insurance enrollment assistance.

This particular neighborhood in Brockton features residents who speak Portuguese, Spanish, English and Haitian Creole.

“Bienvenue! Welcome!” shouted Isabel Lopez, a vaccine ambassador, as she moved from one cluster of families to another, urging them to go grab a free hamburger, hot dog — and a vaccine.

“We are here, bringing the communities together, to make this a fun day and also a creative way to get people vaccinated,” Lopez said.

Near the soccer field, Lopez scored a big win. She persuaded five hesitant members of one household to go to the bus and at least talk with a nurse there. A half-hour later, all five had received their first shots. Lenin Gomez said afterward that he had had doubts about the vaccine but was persuaded when the nurse stressed the need to protect the children living in Gomez’s home.

“If I’m not fully protected, who will take care of the little ones?” Gomez said. “That’s what opened my mind to getting vaccinated.”

When Gomez gets his second dose in a few weeks, he can enter himself in a statewide lottery that will give away five $1 million prizes for anyone who’s vaccinated. Massachusetts Gov. Charlie Baker said he hopes these jackpots will entice hesitant residents to roll up their sleeves.

Hefty Financial Incentives Are Less Common in the South

In the states that need most to boost vaccination rates, there’s little interest in creative financial incentives. Tennessee has . In Alabama, the NAACP funded a for $1,000 prizes aimed at millennials and Gen Zers.

Overall, the daily vaccination rate across the South has slowed, worrying health officials who are watching the explosive growth and spread of the delta variant in several parts of the U.S. But some Southern residents continue to come around to the idea. In Lobelville, Tennessee, 57-year-old Laurel Grant was initially hesitant to get the shot because of possible side effects.

“But everybody I know has done real good, just maybe a little fever or a little tiredness,” she said.

So Grant got her own shot in June, at a local pharmacy. It helped that the Pilot Flying J truck stop where she works to employees who got fully vaccinated.

“There’s a few down there at work who are like, ‘I’m not going to get it,'” Grant said, “I’m like, ‘Yes, you are. You gotta go, like it or not.'”

Converts like Grant are being seen as the best kind of evangelist for this next phase of vaccinating latecomers. Tennessee’s health department has started to release online. But the marketing efforts are beginning to annoy some Republican state lawmakers convinced the state is trying too hard. They’re .

A recent hearing in the Tennessee state legislature included threats of disbanding Tennessee’s health department. State Rep. Iris Rudder, along with other GOP lawmakers, brandished printouts of social media ads produced by state health officials. They featured smiling kids with adhesive bandages on their shoulders.

“It’s not your business to target children. It’s your business to inform the parent that their child is eligible for the vaccination,” she told health department officials at the hearing in June. “So I would encourage you, before our next meeting, to get things like this off your website.”

This criticism was mostly directed at the state’s health commissioner, Dr. , who responded at the hearing by saying the state is not “whispering to kids” or trying to get them vaccinated behind the backs of their parents. She said she’s not going to back off when it comes to vaccination outreach.

Piercey also said she doesn’t think the risk level in Tennessee is as dire as the low vaccination rates suggest. Tennessee had a of covid cases during the winter. That means at least 850,000 people — based on positive test results — are walking around with some level of natural immunity. Piercey said those residents are partially compensating for low vaccination rates.

“Yes, I want everybody who wants a vaccine to get it,” she said. “But what I really want at the end of the day is for this pandemic to go away. I want to minimize cases and eliminate hospitalizations and deaths, and we’re pretty close to getting there.”

The outlook is less rosy in neighboring Arkansas. The state escaped the worst of the winter outbreaks. Now it is trying to stop flare-ups of illness caused by the more contagious delta variant. Gov. Asa Hutchinson told ” that if nothing else will inspire Southerners to get vaccinated, “reality will.”

This story is part of a partnership that includes , , and KHN.

This <a target="_blank" href="/public-health/covid-vaccinations-biden-goal-70-percent-southern-rates-lag/">article</a&gt; first appeared on <a target="_blank" href="">KFF Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150&quot; style="width:1em;height:1em;margin-left:10px;">