MacDonald quería encontrar un nuevo doctor de inmediato. Necesitaba que le renovaran la receta de sus medicamentos para la presión arterial y quería agendar una cita de seguimiento tras un susto por un posible cáncer de mama.

Llamó a diez  consultorios de atención primaria cerca de su casa en Westwood, Massachusetts. Ningún doctor, enfermero profesional ni asistente médico estaba aceptando nuevos pacientes. Algunas oficinas le dijeron que un profesional podría atenderla en un año y medio o tal vez en dos.

“Me sorprendió mucho, porque vivimos en Boston y se supone que tenemos una atención médica excelente”, dijo MacDonald, quien tiene poco más de 40 años y cuenta con seguro médico privado. “No podía creer que no hubiera doctores disponibles”.

La falta de médicos de atención primaria es , pero en Massachusetts se siente con más fuerza. Según , la cantidad de médicos de cabecera en el estado está disminuyendo más rápido que en la mayoría del país.

Algunas redes de salud, incluida la cadena de hospitales más grande del estado, (MGB), están recurriendo a la inteligencia artificial (IA) en busca de soluciones.

En septiembre, justo cuando MacDonald estaba por quedarse sin sus medicamentos para la presión arterial, MGB lanzó un nuevo programa respaldado por IA llamado . MacDonald había recibido una carta de MGB informándole que ningún proveedor de atención primaria en la red estaba aceptando nuevos pacientes para consultas en persona. Al final de la carta había un enlace a Care Connect.

MacDonald descargó la aplicación y pidió una cita de telemedicina con un médico. Luego pasó unos 10 minutos conversando con un agente de IA sobre los motivos por los que quería ver a un doctor. Después, la herramienta envió un resumen de la conversación a un médico de atención primaria que podía atender a MacDonald por videollamada.

“Creo que tuve la cita al día siguiente o dos días después”, señaló. “Fue una diferencia enorme comparada con que me dijeran que tenía que esperar dos años”.

Disponible las 24 horas

MGB explica que la herramienta de IA puede atender a pacientes que consultan por resfriados, náuseas, erupciones cutáneas, esguinces y otros problemas comunes de atención urgente, así como problemas de salud mental leves o moderados y cuestiones relacionadas con enfermedades crónicas. Después de que el paciente escribe una descripción de los síntomas o del problema, la herramienta de IA envía a un doctor una sugerencia de diagnóstico y un plan de tratamiento.

Care Connect cuenta con 12 médicos que trabajan con la IA. Se conectan de manera remota desde diferentes partes de Estados Unidos y los pacientes pueden recibir atención las 24 horas del día, los siete días de la semana.

Se trata de una de las muchas herramientas basadas en IA que hospitales, médicos y personal administrativo están probando para distintas tareas médicas de rutina, como tomar notas, revisar resultados de estudios, facturación y pedido de insumos.

Sus defensores aseguran que estos programas de IA pueden ayudar a reducir el agotamiento del personal y la escasez de trabajadores, al disminuir el tiempo que se dedica a registros médicos, derivaciones y otras tareas administrativas.

Pero no hay acuerdo respecto de y usar la IA para mejorar los diagnósticos.

Algunos críticos temen que los agentes de IA pasen por alto detalles importantes como por ejemplo la superposición de distintas condiciones médicas.

También señalan que las herramientas de IA no pueden evaluar si los pacientes pueden pagar la atención de seguimiento o si tienen cómo llegar a esa cita. Tampoco tienen en cuenta la dinámica familiar ni las necesidades de cuidado, aspectos que los médicos de atención primaria suelen conocer con el tiempo gracias a que establecen relaciones personales de largo plazo.

Desde su primera experiencia con la aplicación en septiembre, MacDonald ha usado Care Connect al menos tres veces más. En dos de esas veces terminó conversando con un doctor remoto, pero cuando necesitó pedir vacunas para un viaje, solo interactuó con el chatbot antes de ir a una clínica.

A MacDonald le gusta la comodidad del servicio.

“No tengo que salir del trabajo”, explicó. “Y me da tranquilidad saber que tengo una alternativa hasta que encuentre un médico que me atienda en persona”.

Así que mientras sigue buscando a ese nuevo doctor, MacDonald decidió continuar con Care Connect.

“Es una solución lógica a corto plazo”, opinó MacDonald. “A fin de cuentas, quien termina sintiendo las consecuencias de todo lo que pasa en el sistema de salud es el paciente”.

Escasez y agotamiento

Son muchos los factores que explican la falta de profesionales. Muchos médicos de atención primaria, como pediatras, internistas y médicos de familia, no están satisfechos con su salario. Ganan entre , en promedio, que especialistas como cirujanos, cardiólogos o anestesiólogos.

Al mismo tiempo, su carga laboral ha ido en aumento. Los médicos de atención primaria días cargados de consultas complejas, seguidos de noches dedicadas a actualizar las historias clínicas y responder mensajes de pacientes.

Cuando MacDonald se inscribió en Care Connect, era una de las 15.000 personas dentro del sistema Mass General Brigham que no tenían médico de atención primaria asignado. Ese número ha ido creciendo a medida que estos médicos fueron renunciando a MGB para unirse a redes hospitalarias competidoras.

, doctora de atención primaria en un centro de salud de MGB en Chelsea, Massachusetts, dijo que por ahora sigue trabajando en MGB, pero que se siente cada vez más frustrada con quienes dirigen el sistema.

“No hacen ningún esfuerzo para aliviar la escasez”, dijo Rao, quien también forma parte de un a los médicos de atención primaria de MGB. “Invierten el dinero en especialidades. La atención primaria se piensa como una parte periférica del sistema, cuando en realidad debería ser el centro”.

El año pasado, MGB se comprometió a gastar $400 millones en cinco años para mejorar los servicios de atención primaria, lo que incluye el contrato multianual con Care Connect.

“Care Connect es solo una de varias soluciones dentro de una estrategia más amplia para aliviar la crisis de capacidad en atención primaria”, dijo , director de operaciones de MGB, en un comunicado enviado por correo electrónico. “Nuestra inversión apunta tanto a retener a los médicos que ya tenemos como a atraer nuevos profesionales”.

Walls dijo que MGB ha aumentado el personal de apoyo para los médicos de atención primaria, implementado otras herramientas de IA y contratado a un nuevo ejecutivo para liderar los servicios de atención primaria. Algunas de esas medidas se basan en recomendaciones de los propios doctores de atención primaria.

Pero algunos de estos médicos dicen que se necesitan otros cambios, especialmente un aumento en los salarios.

Walls no reveló el monto exacto que MGB está destinando a Care Connect.

¿Puente hacia una mejor atención… o un parche?

MGB ha implementado otras herramientas de IA, incluida una que puede transcribir las conversaciones presenciales entre médicos y pacientes. Rao no está usando esa herramienta. Le preocupa que se filtre información de los pacientes y que se viole la privacidad médica, y no quiere que sus conversaciones se usen para desarrollar la próxima generación de programas médicos de IA.

“¿Y si están usando mis interacciones con los pacientes para entrenar su IA y después me reemplazan?”, se preguntó.

Ese no es el objetivo, aseguró , médica de atención primaria y responsable del programa en MGB. “Todas las decisiones sobre el cuidado de los pacientes siguen estando a cargo de médicos de carne y hueso”, aclaró.

“No estamos reemplazando la atención primaria presencial”, dijo. “Sigue siendo importante, y la mayoría de los pacientes aún reciben atención primaria en persona”.

Pero entre algunos médicos de atención primaria de MGB persiste el temor de que Care Connect termine, poco a poco, reduciendo el acceso a las consultas en persona. De los $400 millones que MGB prometió invertir en atención primaria, ellos quieren que se destine menos a la IA y más a contratar personal y aumentar salarios.

, internista en MGB y también parte del movimiento de sindicalización, dijo que el uso de Care Connect solo puede cubrir un bache. “Eso suena a un parche para un sistema roto”, dijo.

Expansión de la inteligencia artificial

A mediados de diciembre, los médicos de Care Connect atendían entre 40 y 50 pacientes por día. Este mes, MGB planea ofrecer Care Connect a todos los residentes de Massachusetts y New Hampshire que tengan seguro médico, y contratar más médicos para el programa a medida que sean necesarios.

Los pacientes pueden usar el programa como si fuera un servicio de atención urgente, explicó Ireland. También pueden decidir que uno de los médicos remotos se convierta en su doctor permanente de atención primaria.

“Algunos pacientes prefieren la atención presencial”, dijo Ireland. “Pero creo que hay un grupo de pacientes que valorarán el modelo de atención disponible las 24 horas los 7 días de la semana y decidirán formar parte de esto”.

Care Connect no está pensado para emergencias ni para exámenes físicos, aclaró. Y los pacientes que necesitan estudios o imágenes son derivados a clínicas o laboratorios de la red.

Pero los médicos remotos pueden manejar algunos de los temas de rutina que atienden los médicos de atención primaria, afirmó Ireland, como infecciones respiratorias moderadas, alergias y enfermedades crónicas como diabetes, colesterol alto y depresión.

opina que solo los problemas de salud inmediatos, no los crónicos, deberían estar en esa lista. Lin es jefe de atención primaria en la Escuela de Medicina de la Universidad de Stanford y fundador del equipo de investigación sobre IA aplicada en salud.

“En su estado actual, el uso más seguro de esta herramienta es para problemas más urgentes”, afirmó Lin. “Infecciones respiratorias altas, infecciones urinarias, lesiones musculoesqueléticas, sarpullidos”.

Para pacientes con múltiples enfermedades crónicas como hipertensión y diabetes —o con afecciones graves como enfermedades cardíacas o cáncer—, Lin afirmó que nada reemplaza a un profesional humano que te vea regularmente.

Aun así, Lin reconoce que el resumen generado por la IA después de la consulta puede ayudar a que el médico sea más eficiente. Y entiende por qué, para los pacientes, una opción virtual puede ser atractiva.

“Prefiero que estos pacientes reciban atención, si esa atención puede ser segura”, dijo, “a que no reciban atención en absoluto”.

La empresa que desarrolló la plataforma de IA para Care Connect, , asegura que el programa está ofreciendo atención segura y efectiva a personas con enfermedades crónicas y complejas, muchas de las cuales no tienen otra alternativa que ir a la sala de emergencias.

“Estados Unidos tiene un gran problema con la atención médica: temas de costo, calidad y acceso”, dijo , director ejecutivo de la empresa. “Para resolverlo, hay que empezar por la atención primaria, y para eso es necesario usar tecnología e inteligencia artificial”.

Además de Mass General Brigham, K Health colabora con otras cinco redes de salud, entre ellas y , con sede en Los Ángeles.

En un estudio , financiado por K Health, investigadores de Cedars-Sinai compararon cientos de recomendaciones de diagnóstico y tratamiento hechas por IA con las realizadas por médicos.

Los investigadores concluyeron que la IA fue ligeramente mejor al identificar “señales de alerta críticas” y al recomendar atención basada en guías clínicas, aunque los profesionales fueron mejores ajustando sus recomendaciones a medida que dialogaban  con el paciente.

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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.

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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.

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

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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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Después que lo pesaran, caminó hacia un consultorio decorado con calcomanías de planetas y personajes de dibujos animados. Una enfermera le tomó la presión arterial. Un pediatra le preguntó por sus estudios, su vida familiar y sus amigos.

Parecía un examen de rutina para adolescentes, de los miles que se hacen a diario en consultas pediátricas en el país. Hasta que el doctor le preguntó:

“¿Tienes deseos de consumir opioides?”. El paciente negó con la cabeza.

“¿Ninguno, en absoluto?”, volvió a preguntar Medina para confirmar.

“Ninguno”, respondió el adolescente, llamado Sam, con voz tranquila pero segura.

(En este artículo sólo se utiliza el nombre de pila de Sam porque, si se publicara su apellido, en el futuro podría ser discriminado en la búsqueda de vivienda y empleo por haber consumido drogas).

El doctor Medina está tratando a Sam por su adicción a estas drogas. Le receta un medicamento llamado buprenorfina, que reduce las ansias de consumir las píldoras de opioides más peligrosas y adictivas. Los análisis de orina de Sam no muestran signos de Oxycontin o Percocet, las pastillas que él compraba en Snapchat y que alimentaron su adicción.

“Lo que realmente me enorgullece de tí, Sam, es tu esfuerzo por estar mejor”, lo felicitó Medina, que trabaja en el

La Academia Americana de Pediatría recomienda . Sin embargo, , solo el 6% de los pediatras informa haberlo hecho alguna vez.

De hecho, al mismo tiempo que las recetas de buprenorfina para adolescentes , se las muertes por sobredosis en niños y adolescentes entre 10 y 19 años. Estas sobredosis, junto con los envenenamientos accidentales por opioides en niños pequeños, se han convertido en la en Estados Unidos.

“Estamos realmente lejos de donde deberíamos estar y nos encontramos bastante atrasados en varios aspectos”, comentó , jefe de Medicina para Adolescentes del Hospital General de Niños de Massachusetts y coautor de una encuesta entre pediatras sobre el tratamiento de adicciones.

Los resultados de las entrevistas mostraron que muchos pediatras no creen tener ni la formación adecuada ni el personal necesario para atender pacientes con adicciones, aunque Medina y otros médicos que sí lo hacen afirmaron que no han tenido que contratar más personal.

Algunos entrevistados explicaron que no atienden un número de pacientes que justifique formarse en esa especialización y otros piensan que la atención de adictos no es responsabilidad de la Pediatría.

“Gran parte de esas ideas son producto de la educación que reciben los médicos”, dijo , directora asociada al área pediátrica del Programa de Medicina de Adicciones de la Escuela de Medicina de Yale. “Como se considera algo muy especializado, no está incluido en la formación médica habitual”, explicó.

Camenga y Hadland mencionaron que las escuelas de Medicina y los programas de residencia pediátrica están trabajando para incorporar información sobre trastornos por consumo de sustancias a los planes de estudio. Esto incluye cómo abordar el consumo de drogas y alcohol con niños y adolescentes.

Sin embargo, los programas de estudio no cambian lo como para ayudar a la cantidad de jóvenes que luchan contra una adicción y mucho menos a los que mueren después de tomar .

Es una paradoja perversa y mortífera: mientras disminuye el consumo de drogas entre los adolescentes, las han aumentado.

La principal causa es la falsificación de pastillas de Xanax, Adderall o Percocet, adulteradas con fentanilo, un poderoso opioide. Casi el por sobredosis en jóvenes de 10 a 19 años se atribuyeron a estas pastillas.

“El fentanilo y las pastillas falsificadas realmente están complicando nuestros esfuerzos para frenar las sobredosis”, dijo , experto en Medicina de adicción y prevención de sobredosis en adolescentes de los Centros para el Control y Prevención de Enfermedades (CDC). “Muchas veces, estos jóvenes sufren una sobredosis sin siquiera darse cuenta de lo que están tomando.”

Terranella, que ejerce en Tucson, Arizona, opina que los pediatras pueden ayudar mucho si refuerzan la detección del consumo de drogas en sus pacientes y conversan con ellos sobre los riesgos.

También sugiere que receten más naloxona, el aerosol nasal que puede revertir una sobredosis. Está disponible sin receta, pero Terranella cree que una receta médica puede tener más relevancia para los pacientes.

De vuelta en el consultorio, Sam estaba a punto de recibir su primera inyección de Sublocade, una forma de buprenorfina que dura 30 días. Está cambiando a las inyecciones porque no le gusta el sabor de Suboxone, unas tiras orales de buprenorfina que debía disolver debajo de su lengua. Las escupía antes de recibir una dosis completa.

Muchos médicos prefieren recetar las inyecciones porque los pacientes no tienen que recordar tomarlas todos los días. Pero la inyección es dolorosa y Sam se sorprendió cuando le dijeron que se la aplicarían en el vientre durante 20-30 segundos.

“¿Ya casi terminamos?”, preguntó Sam, mientras una enfermera le pedía que respirara hondo. Cuando terminó, el personal bromeó en voz alta diciendo que incluso los adultos suelen decir palabrotas cuando les ponen esa inyección. Sam dijo que no sabía que eso estaba permitido. Lo que más lo preocupaba era si un dolor residual podría interferir con los planes que tenía esa noche.

“¿Cree que podré hacer snowboard esta noche?”, le preguntó al doctor.

“Estoy absolutamente seguro de que podrás hacer snowboard esta noche”, lo tranquilizó Medina.

Sam iba a ir con un nuevo amigo. Hacer nuevos amigos y cortar lazos con su antiguo círculo social de adolescentes que consumen drogas ha sido una de las cosas más difíciles, dijo Sam, desde que entró en rehabilitación hace 15 meses.

“Hay que concentrase en encontrar la gente adecuada”, dijo Sam. “Ese sería mi mayor consejo”.

Para Sam, encontrar un tratamiento contra la adicción en un consultorio repleto de rompecabezas, juguetes y libros ilustrados no ha sido tan extraño como imaginaba.

Su madre, Julie, lo había acompañado a la consulta. Dice que está agradecida de que la familia haya encontrado un médico que entiende a los adolescentes y a las adicciones.

Antes de empezar a ir el Centro de Salud Familiar Tri-River, Sam estuvo siete meses en tratamiento residencial y ambulatorio, sin que le ofrecieran buprenorfina para ayudarlo a controlar los impulsos de consumir y prevenir las recaídas. Sólo tratamientos residenciales para jóvenes la ofrece. Cuando Sam volvió a sentir fuertes deseos de consumir opioides, un consejero le sugirió a Julie que llamara a Medina.

“Dios mío, ojalá hubiera traído a Sam aquí hace dos o tres años”, dijo Julie. “¿Habría cambiado lo que sucedió? No lo sé, pero hubiera sido un nivel de atención más adecuado para él”.

A algunos padres y pediatras les preocupa administrar buprenorfina a un adolescente, ya que puede producir , incluida la dependencia a largo plazo. Los pediatras que la recetan evalúan el efecto de los posibles efectos secundarios en relación con la amenaza de una sobredosis de fentanilo.

“En esta época, en la que los jóvenes mueren a un ritmo realmente sin precedentes por sobredosis de opiáceos, es fundamental que salvemos vidas”, afirmó Hadland. “Y sabemos que la buprenorfina es un medicamento que salva vidas”, agregó.

El tratamiento de una adicción le puede insumir mucho tiempo a un pediatra. Sam y Medina se envían mensajes de texto varias veces a la semana y el pediatra recalca que no comparte ningún intercambio que Sam haya pedido que fuera confidencial.

Medina dice que tratar el trastorno por consumo de sustancias es una de las cosas más gratificantes que hace. “Si podemos solucionarlo”, dice, “habremos formado un adulto que ya no tendrá que preocuparse por estos problemas de por vida”.

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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 youth athletes 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,Ìý, 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 surve²âÌýshowed of people with opioid use disorder received medications such as buprenorphine ²¹²Ô»åÌý.

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. 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.”

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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.”

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