A Life Rebuilt

Posted by Danny Bonvissuto on Tuesday, July 18, 2023 in Features, Homepage Highlights, Summer 2023 .

On Nov. 19, 2020, Sabrina Johanson checked herself out of Vanderbilt University Hospital (VUH), went downtown to meet the father of her two children, and injected heroin and meth for the last time.

As an inpatient she had been receiving IV antibiotics for endocarditis, a heart infection from drug use that required six weeks of treatment ahead of a tricuspid valve replacement. She knew she needed to stay and continue treatment, but old habits die hard.

“He had drugs, I got high, and he left me on the riverfront,” Johanson said. “I was freezing cold and couldn’t walk. I had to crawl up these steps just to get to somebody, and said, ‘I’m sick. I just left the hospital, but I feel like I’m going to die, and I need to go back.’”

Within a few hours, Johanson was back at VUH, ending a chapter of life that began when her father died of an overdose in the family’s backyard. Johanson, who was 15 at the time, did drugs for the next 10 years and was homeless for the last six, living in and out of hotels and panhandling to support her habit.

“I’d wake up, do a shot of drugs and think, ‘What are we going to do?’” said Johanson, who grew up in the Antioch and Hermitage areas outside of Nashville. “I’d go outside of the hotel, walk up to people and ask them for money. A lot of people helped me, even though they shouldn’t have.”

Johanson’s children, now 11 and 8, lived with various family members when she was homeless and were placed in foster care when their uncle lost custody of them due to addiction.

When she was diagnosed with endocarditis, Johanson would direct her own discharge once she started feeling better, usually a few weeks into the process. This happened four times at Vanderbilt and another local hospital, but it wouldn’t happen again.

“I was like, I’m done fighting; I’m done trying to get high. I surrender. I give it to God,” she said. “I’ll never forget feeling like that. It was terrible. I said, ‘I’m going to stay in the hospital where I need to be. I’m going to let them help me get clean. I know God is going to help me through this. I give up on doing drugs. It’s too hard to do drugs. It’s too hard.’”

‘One-Stop Shop’

True to her word, Johanson stayed at VUH, completed the full IV antibiotic course and asked questions about addiction recovery. Had she come through VUH a few years earlier, she likely would have been handed a slip of paper with the names and numbers of treatment programs and had to manage that process on her own while learning how to rebuild her life as she prepared for and recovered from heart valve replacement surgery.

Now, VUH opens doors to recovery, and Johanson was set up for success when she was discharged on Dec. 31, 2020. She transitioned directly to Oxford House, a sober living home in Madison, Tennessee, and, after her heart valve replacement in early January, she started weekly appointments at the Vanderbilt Bridge Clinic, a short-term “one-stop shop” where she found support for her physical and mental health.

“Confronting an addiction is one of the most courageous things anyone can do,” said Shon Dwyer, MBA, RN, former president of VUH. “The Bridge Clinic fills an otherwise gaping hole in the continuum of care and provides the wraparound support that patients need. I commend Sabrina on her determination and thank the Bridge Clinic team for all the people they help on the road to recovery.”

A collaboration between multiple departments, the Bridge Clinic is run by the Vanderbilt University Medical Center ambulatory clinic enterprise and funded primarily by VUH, with supplemental support from the Tennessee Department of Mental Health and Substance Abuse Services (TDMHSAS). Its co-directors are David Marcovitz, MD, associate professor of Psychiatry and Behavioral Sciences, and Katie White, MD, PhD, assistant professor of Medicine in the Division of Infectious Diseases.

“If you look at the Venn diagram of infectious diseases and addiction, there is a significant amount of overlap,” said White. “Bridge Clinic is a place for patients who come to Vanderbilt through the emergency department or hospital to continue intensive treatment for their addiction plus have rapid access to wraparound services such as treatment for infection and pain. We structured the clinic around the thought that there are co-occurring disorders that come with a substance use disorder.”

White never intended to integrate her infectious disease practice with substance use disorders, but in recent years — in line with the national opioid crisis — she began to see more and more young, otherwise healthy patients with devastating, life-altering bacterial and fungal infections due to injection drug use.

“It was frustrating to treat a patient’s infection but not have the resources to address the risk factors that caused the infection in the first place,” said White, who joined the Bridge Clinic prior to its launch in 2019.

The Bridge Clinic is fully staffed with a team of psychiatrists, social workers and recovery coaches for the mental illness piece; primary care physicians for general medical needs; infectious disease specialists, including White; and pain management services for acute and chronic pain.

“Pain management is often unavailable to patients without insurance and certainly poses a risk factor for relapse if it’s not well managed,” White said. “This particular spot where we’ve positioned ourselves on the patient’s journey, and the way we’ve worked to minimize their challenges, is just magical to be honest. It lowers the barriers of waitlists, funding complications and having to report all over the place to get complicated problems taken care of.”

The Gift of Time

Before her surgical stitches healed completely, Johanson got a cashier job at a Speedway gas station but didn’t have insurance. Through the Bridge Clinic, she was enrolled in the State Opioid Response (SOR) Hub grant so she could have access to medication for her opioid use disorder and other co-occurring issues.

“We use the Bridge Clinic as a safe holding environment for care while enrolling patients in the SOR Hub grant from TDMHSAS once it is clear they intend to remain at VUMC for their longitudinal care,” says Marcovitz, who also serves as principal investigator on this roughly $2 million annual grant that designates VUMC as the Hub for Opioid Use Disorder Treatment for Middle Tennessee. “In the interim period, we do rely on some charity care — such as the Medication Assistance Program — from VUMC during this transitional phase.”

In March 2021, Johanson became a shift leader at Walgreens — her first job with benefits.

“When she got insurance at her job, we were able to transfer her off the grant without an interruption in care,” said B. Michelle Black, LCSW, a social worker who sees Johanson at the Vanderbilt Recovery Clinic, a long-term clinic where Bridge Clinic patients transition after they’re medically stable. “That’s the great thing about the grant — it gives patients access to consistent, long-term, evidence-based, quality services. It takes time. It’s much longer than a 28-day process when someone is attempting to stabilize emotionally, physically and environmentally, often from years of active addiction.”

Trust the Process

The Bridge Clinic offers patient-centered care that’s defined by each patient’s specific needs — every patient may not use every available resource, but it’s there if they need it.

One of a handful of transitional clinics in the United States with a low threshold to entry and harm-reduction bent, the Vanderbilt Bridge Clinic opened in the Village at Vanderbilt in May 2019 and moved to a permanent space on Belcourt Avenue in August 2021.

Open all day Friday, the current space was specially designed with multispecialty collaboration in mind: It has traditional psychiatry consult rooms and clinical exams rooms, a large and small group room and a setup for streamlined, point-of-care urine toxicology.

According to Marcovitz, when new patients arrive, they receive an orientation by a recovery coach, sign a treatment agreement and are assessed by providers across multiple disciplines. In return visits, patients are paired with different medical specialists (e.g., pain medicine or psychiatry) and other clinicians depending on their individual needs. Starting this academic year, the clinic added a grant-funded pain psychology intern to the robust interdisciplinary team.

Most patients have weekly appointments for the first eight weeks, then spread out to twice a month. Though the average length of stay is 90 days, some patients move through the Bridge Clinic quicker and others who need more support have stayed on the books for as long as a year.

“We retain roughly half of patients at three months,” Marcovitz said. “Typically, we engage them over the first month, then in month two or three we enroll them in our grant and transition them to our long-term clinic Vanderbilt Recovery Clinic where there is a greater depth of routine group psychotherapy.”

The no-show rate for new patients at the Bridge Clinic ranges from one-third to one-half, depending on the month; the Bridge Clinic offers special groups to keep patients in care and on medication when they miss individual visits.

In 2021, Marcovitz, White and their colleagues published a manuscript in the journal Trials discussing the inner workings of the Bridge Clinic and describing a randomized controlled trial looking at its impact on a host of important outcomes. The trial is being supported by the VUMC Learning Health System, and the authors hope to publish the final results later this year.

Rebuilding a Life

When Johanson came to the Bridge Clinic, her main focus was getting her children back, even as she juggled recovery, living in sober housing, getting a job, and a recent split with her children’s father, who is still in active addiction and is homeless.

“Many people come to us without housing or resources. We help them navigate rebuilding their lives. It’s a lot,” Black said. “I’m in recovery myself, and early on, life can feel very overwhelming. I supported Sabrina with problem-solving and early recovery guidance to help her reach her goals of staying sober and regaining custody of her children. Having support that’s consistent and ongoing and a team that believes in building an authentic relationship with the patient is essential.”

Unlike other treatment programs in Tennessee that often dismiss patients who return to use, the Bridge and Vanderbilt Recovery Clinic understands that recovery isn’t linear.

“Changing our behavior is gradual and returning to use is quite normal. If that happens, we continue to collaborate with patients to support their ongoing process of change,” Black said. “That’s a huge piece of what’s helped us create trusting relationships and keep people engaged in care.”

Within those relationships, Johanson flourished. During her year and a half at Oxford House, she collaborated with her children’s foster care mother on overnight, then weekend visits, until she earned back full custody.

“They moved in with me at Oxford House,” Johanson said. “From there, they went to school, and I went to work, and we figured it out.”

Today Johanson and her children share an apartment with her mother.

“My mom is mentally ill and has been disabled my entire life. We work as a team; she helps me out so much,” she said. “I have rent and a phone bill and so many other bills to pay; there’s no way I could do it by myself.”

Money is a motivating factor, but Johanson, now 28, is proud of her personal progress. She was quickly promoted to a supervisor role at Walgreens and is now an inventory specialist responsible for the entire store, including the pharmacy.

“I used to trade and misuse drugs, and now I have a pharmacy tech license and am legally counting medication,” she said. “It’s crazy how much my life has changed.”

Now that she’s responsible for her own health care, Johanson has an even greater appreciation for the full-service nature of the Bridge Clinic’s services.

“They helped me with my heart medicine and my recovery medicine. Now when I get sick, I have to figure it out myself,” she said. “I wish I could go back because they took care of me so well.”

Black says Johanson’s success is a testament to the Bridge and Vanderbilt Recovery Clinic model.

“She’s reached her goal of regaining custody, is living independently with her children and has created a safe and stable home for her family. That’s very empowering,” Black said. “A while back, Sabrina showed me one of her posts on Facebook: a picture during active use beside a picture of her in recovery. It’s quite powerful to see people struggling with just surviving day to day, then watch them thrive, smile, get cute nails and makeup, joke, and be who they really are. It’s cool to see them evolve into their sober selves.”

As for the many patients who are still struggling, especially those presenting to emergency rooms around Nashville with complex infections or following overdoses, Marcovitz hopes that policymakers and advocates will take notice of the lessons learned in the Vanderbilt Bridge Clinic.

“These services are insurance blind at VUMC but not free of cost,” he said. “It’s hard to show the return on investment in an environment where many benefits accrue not just to VUMC but to the state and region as a whole. Sometimes I think people need to just learn about how it helped one person.”