NEW ORLEANS \u2014 Elyse Stevens had a reputation for taking on complex medical cases. People who\u2019d been battling addiction for decades. Chronic-pain patients on high doses of opioids. Sex workers and people living on the street.<\/p>\n
\u201cMany of my patients are messy, the ones that don\u2019t know if they want to stop using drugs or not,\u201d said Stevens, a primary care and addiction medicine doctor.<\/p>\n
While other doctors avoided these patients, Stevens \u2014 who was familiar with the city from her time in medical school at Tulane University \u2014 sought them out. She regularly attended 6 a.m. breakfasts for homeless people, volunteered at a homeless shelter clinic on Saturdays, and, on Monday evenings, visited an abandoned Family Dollar store where advocates distributed supplies to people who use drugs.<\/p>\n
One such evening about four years ago, Charmyra Harrell arrived there limping, her right leg swollen and covered in sores. Emergency room doctors had repeatedly dismissed her, so she eased the pain with street drugs, Harrell said.<\/p>\n
Stevens cleaned her sores on Mondays for months until finally persuading Harrell to visit the clinic at University Medical Center New Orleans. There, Stevens discovered Harrell had diabetes and cancer.<\/p>\n
She agreed to prescribe Harrell pain medication \u2014 an option many doctors would automatically dismiss for fear that a patient with a history of addiction would misuse it.<\/p>\n
But Stevens was confident Harrell could hold up her end of the deal.<\/p>\n
\u201cShe told me, \u2018You cannot do drugs and do your pain meds,\u2019\u201d Harrell recounted on a Monday evening in October. So, \u201cI\u2019m no longer on cocaine.\u201d<\/p>\n
\t\t\t\t\t<\/p>\n
\t\t\t\t\t<\/p>\n
Stevens\u2019 approach to patient care has won her awards and nominations in medicine<\/a>, community service<\/a>, and humanism<\/a>. Instead of seeing patients in binaries \u2014 addicted or sober, with a positive or negative drug test \u2014 she measures progress on a spectrum. Are they showering daily, cooking with their families, using less fentanyl than the day before?<\/p>\n But not everyone agrees with this flexible approach that prioritizes working with patients on their goals, even if abstinence isn\u2019t one of them. And it came to a head in the summer of 2024.<\/p>\n \u201cThe same things I was high-fived for thousands of times \u2014 suddenly that was bad,\u201d Stevens said.<\/p>\n Flexible Care or Slippery Slope?<\/strong><\/p>\n More than 80% of Americans<\/a> who need substance use treatment don\u2019t receive it, national data shows. Barriers abound: high costs, lack of transportation, clinic hours that are incompatible with jobs, fear of being mistreated.<\/p>\n Some doctors had been trying to ease the process for years. Covid-19 accelerated that trend. Telehealth appointments, fewer urine drug tests, and medication refills that last longer became the norm.<\/p>\n The result?<\/p>\n \u201cPatients did OK and we actually reached more people,\u201d said Brian Hurley<\/a>, immediate past president of the American Society of Addiction Medicine. The organization supports continuing flexible practices, such as helping patients avoid withdrawal symptoms by prescribing higher-than-traditional doses<\/a> of addiction medication and focusing on recovery goals other than abstinence<\/a>.<\/p>\n \t\t\t\t\t<\/p>\n \t\t\t\t\t<\/p>\n But some doctors prefer traditional approaches that range from zero tolerance for patients using illegal drugs to setting stiff consequences for those who don\u2019t meet their doctors\u2019 expectations. For example, a patient who tests positive for street drugs while getting outpatient care would be discharged and told to go to residential rehab. Proponents of this method fear loosening restrictions could be a slippery slope that ultimately harms patients. They say continuing to prescribe painkillers, for example, to people using illicit substances long-term could normalize drug use and hamper the goal of getting people off illegal drugs.<\/p>\n Progress should be more than keeping patients in care, said Keith Humphreys<\/a>, a Stanford psychologist, who has treated and researched addiction for decades and supports involuntary treatment<\/a>.<\/p>\n \u201cIf you give addicted people lots of drugs, they like it, and they may come back,\u201d he said. \u201cBut that doesn\u2019t mean that that is promoting their health over time.\u201d<\/p>\n Flexible practices also tend to align with harm reduction, a divisive approach that proponents say keeps people who use drugs safe and that critics \u2014 including the Trump administration<\/a> \u2014 say enables illegal drug use.<\/p>\n The debate is not just philosophical. For Stevens and her patients, it came to bear on the streets of New Orleans.<\/p>\n \u2018Unconventional\u2019 Prescribing<\/strong><\/p>\n In the summer of 2024, supervisors started questioning Stevens\u2019 approach.<\/p>\n In emails reviewed by KFF Health News, they expressed concerns about her prescribing too many pain pills, a mix of opioids and other controlled substances to the same patients, and high doses of buprenorphine, a medication considered the gold standard<\/a> to treat opioid addiction.<\/p>\n Supervisors worried Stevens wasn\u2019t doing enough urine drug tests and kept treating patients who used illicit drugs instead of referring them to higher levels of care.<\/p>\n \u201cHer prescribing pattern appears unconventional compared to the local standard of care,\u201d the hospital\u2019s chief medical officer at the time wrote to Stevens\u2019 supervisor, Benjamin Springgate<\/a>. \u201cNote that this is the only standard of care which would likely be considered should a legal concern arise.\u201d<\/p>\n Springgate forwarded that email to Stevens and encouraged her to refer more patients to methadone clinics, intensive outpatient care, and inpatient rehab.<\/p>\n Stevens understood the general practice but couldn\u2019t reconcile it with the reality her patients faced. How would someone living in a tent, fearful of losing their possessions, trek to a methadone clinic daily?<\/p>\n Stevens sent her supervisors dozens<\/a> of research<\/a> studies<\/a> and national<\/a> treatment<\/a> guidelines<\/a> backing her flexible approach. She explained that if she stopped prescribing the medications of concern, patients might leave the health system, but they wouldn\u2019t disappear.<\/p>\n \u201cThey just wouldn\u2019t be getting care and perhaps they\u2019d be dead,\u201d she said in an interview with KFF Health News.<\/p>\n Both University Medical Center and LSU Health New Orleans, which employs physicians at the hospital, declined repeated requests for interviews. They did not respond to detailed questions about addiction treatment or Stevens\u2019 practices.<\/p>\n Instead, they provided a joint statement from Richard DiCarlo, dean of the LSU Health New Orleans School of Medicine, and Jeffrey Elder, chief medical officer of University Medical Center New Orleans.<\/p>\n \u201cWe are not at liberty to comment publicly on internal personnel issues,\u201d they wrote.<\/p>\n \u201cWe recognize that addiction is a serious public health problem, and that addiction treatment is a challenge for the healthcare industry,\u201d they said. \u201cWe remain dedicated to expanding access to treatment, while upholding the highest standard of care and safety for all patients.\u201d<\/p>\n Not Black-and-White<\/strong><\/p>\n KFF Health News shared the complaints against Stevens and the responses she\u2019d written for supervisors with two addiction medicine doctors outside of Louisiana, who had no affiliation with Stevens. Both found her practices to be within the bounds of normal addiction care, especially for complex patients.<\/p>\n Stephen Loyd<\/a>, an addiction medicine doctor and the president of Tennessee\u2019s medical licensing board<\/a>, said doctors running pill mills typically have sparse patient notes that list a chief complaint of pain. But Stevens\u2019 notes detailed patients\u2019 life circumstances and the intricate decisions she was making with them.<\/p>\n \u201cTo me, that\u2019s the big difference,\u201d Loyd said.<\/p>\n Some people think the \u201conly good answer is no opioids,\u201d such as oxycodone or hydrocodone, for any patients, said Cara Poland<\/a>, an addiction medicine doctor and associate professor at Michigan State University. But patients may need them \u2014 sometimes for things like cancer pain \u2014 or require months to lower their doses safely, she said. \u201cIt\u2019s not as black-and-white as people outside our field want it to be.\u201d<\/p>\n Humphreys, the Stanford psychologist, had a different take. He did not review Stevens\u2019 case but said, as a general practice, there are risks to prescribing painkillers long-term, especially for patients using today\u2019s lethal street drugs too.<\/p>\n Overprescribing fueled the opioid crisis, he said. \u201cIt\u2019s not going to go away if we do that again.\u201d<\/p>\n \u2018The Thing That Kills People\u2019<\/strong><\/p>\n After months of tension, Stevens\u2019 supervisors told her on March 10 to stop coming to work. The hospital was conducting a review of her practices, they said in an email viewed by KFF Health News.<\/p>\n Overnight, hundreds of her patients were moved to other providers.<\/p>\n Luka Bair had been seeing Stevens for three years and was stable on daily buprenorphine.<\/p>\n After Stevens\u2019 departure, Bair was left without medication for three days. The withdrawal symptoms were severe \u2014 headache, nausea, muscle cramps.<\/p>\n \u201cI was just in physical hell,\u201d said Bair, who works for the National Harm Reduction Coalition and uses they\/them pronouns.<\/p>\n \t\t\t\t\t<\/p>\n \t\t\t\t\t<\/p>\n Although Bair eventually got a refill, Springgate, Stevens\u2019 supervisor, didn\u2019t want to continue the regimen long-term. Instead, Springgate referred Bair to more intensive and residential programs, citing Bair\u2019s intermittent use of other drugs, including benzodiazepines and cocaine, as markers of high risk. Bair \u201crequires a higher level of care than our clinic reasonably can offer,\u201d Springgate wrote in patient portal notes reviewed by KFF Health News.<\/p>\n But Bair said daily attendance at those programs was incompatible with their full-time job. They left the clinic, with 30 days to find a new doctor or run out of medication again.<\/p>\n \u201cThis is the thing that kills people,\u201d said Bair, who eventually found another doctor willing to prescribe.<\/p>\n Springgate did not respond to repeated calls and emails requesting comment.<\/p>\n University Medical Center and LSU Health New Orleans did not answer questions about discharging Stevens\u2019 patients.<\/p>\n \u2018Reckless Behavior\u2019<\/strong><\/p>\n About a month after Stevens was told to stay home, Haley Beavers Khoury, a medical student who worked with her, had collected nearly 100 letters from other students, doctors, patients, and homelessness service providers calling for Stevens\u2019 return.<\/p>\n One student wrote, \u201cMake no mistake \u2014 some of her patients will die without her.\u201d A nun from the Daughters of Charity, which ran the hospital\u2019s previous incarnation<\/a>, called Stevens a \u201clifeline\u201d for vulnerable patients.<\/p>\n Beavers Khoury said she sent the letters to about 10 people in hospital and medical school leadership. Most did not respond.<\/p>\n In May, the hospital\u2019s review committee determined Stevens\u2019 practices fell \u201coutside of the acceptable community standards\u201d and constituted \u201creckless behavior,\u201d according to a letter sent to Stevens.<\/p>\n The hospital did not answer KFF Health News\u2019 questions about how it reached this conclusion or if it identified any patient harm.<\/p>\n Meanwhile, Stevens had secured a job at another New Orleans hospital. But because her resignation came amid the ongoing investigation, University Medical Center said it was required to inform the state\u2019s medical licensing board.<\/p>\n The medical board began its own investigation \u2014 a development that eventually cost Stevens the other job offer.<\/p>\n In presenting her side to the medical board, Stevens repeated many arguments she\u2019d made before. Yes, she was prescribing powerful medications. No, she wasn\u2019t making clinical decisions based on urine drug tests. But national addiction organizations supported such practices and promoted tailoring care to patients\u2019 circumstances, she said. Her response included a 10-page bibliography with 98 citations.<\/p>\n Liability<\/strong><\/p>\n The board\u2019s investigation into Stevens is ongoing. Its website<\/a> shows no action taken against her license as of late December.<\/p>\n The board declined to comment on both Stevens\u2019 case and its definition of appropriate addiction treatment.<\/p>\n In October, Stevens moved to the Virgin Islands to work in internal medicine at a local hospital. She said she\u2019s grateful for the welcoming locals and the financial stability to support herself and her parents.<\/p>\n But it hurts to think of her former patients in New Orleans.<\/p>\n Before leaving, Stevens packed away handwritten letters from several of them \u2014 one was 15 pages long, written in alternating green and purple marker \u2014 in which they shared childhood traumas and small successes they had while in treatment with her.<\/p>\n Stevens doesn\u2019t know what happened to those patients after she left.<\/p>\n She believes the scrutiny of her practices centers on liability more than patient safety.<\/p>\n But, she said, \u201cliability is in abandoning people too.\u201d<\/p>\n \t\t\t\t\t<\/p>\n \t\t\t\t\t<\/p>\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/p>\nUSE OUR CONTENT<\/h3>\n