Harm Reduction in Detroit with Shaina Shetty, MD

[MUSIC] You're listening to Streetside. The Street Medicine Institute Student Coalition podcast. >> Hello and welcome to Streetside. This is the regular podcast of the Street Medicine Institute Student Coalition. I'm your co-host Michael Brennan and it is with great joy that I have Dr. Shayna Shetty today with me and would like to ask her to introduce herself. >> Yeah, my name is Shayna Shetty. I'm a family physician and a street medicine physician based here in Detroit, Michigan. >> Thank you, Shayna. We're so glad you're here and I'm going to ask you to expound on that a little bit. Tell us if your journey number one into medicine, number two into street medicine, number three into addiction medicine. Can you take us on your journey? >> Absolutely. So I grew up here in Michigan actually during the recession, right? At the time in Michigan, it was clear on the Detroit area, it was pretty clear to me that we have a very broken safety net system, right? It was obvious as a child. So I ended up going to college and I think I debated between social work and public health and maybe medicine. And I remember sitting in these classes, we learned about that river analogy, right? Where there's upstream effects and downstream effects, right? And you're finding folks at the bottom of the server stream and you're trying to figure out what's leading in there and you're trying to figure out how to address those things. And I remember I'd sit there in these classes, Michael and I would just be like, who's taking care of the folks at the base of the river, who's there for them? Because those were right people, that's where I wanted to be. And so I decided to go to medical school, mostly to try and address that need to take care of the folks at the bottom of the falls. And went to medical school and then ended up in residency in family medicine. I knew I wanted to work at a CUPC's, I knew I wanted to do broad spectrum, primary care, whatever that looked like. And so I trained in family medicine over at UIC in Chicago. And honestly, I fell into street medicine. There was a patient, I loved dearly, who had benzoye's disorder, opioid use disorder, was rough sleeping throughout parts of Chicago. And I was seeing him just about weekly, because we were doing a benzoye for him. And then he introduced me to world of primary action, he introduced me to the world of street medicine, he introduced me to an org that was supporting him. He took me there and I met the folks there and I joined them as a volunteer physician. And I felt like doing that work, that's where I met my people. Those are the people who were down at the bottom of the falls with me, right? And they were deeply invested in that. So yeah, I finished up my training. I was a volunteer physician kind of throughout residency. And then this job came up into trade that is based at an FQHC, but it's an FQHC, my site is in connection with the housing nonprofit. So I get to do a lot of street medicine work as a part of my day-to-day job. I get to do like a low barrier primary care, certain environment that is safe and feels good for folks navigating drug use and housing instability. And yeah, it's a dream job. It's hard for sure at times, but it is a dream job. And I've been here a couple of years now. Oh, that's fantastic. Let me let me clarify for our audience that FQHC federally qualified community health centers. And just we throw that lingo around, but some people might not know it. I'm curious in your current employment, are you on the street or in a clinic more? I do both. So I'm on the street, usually a day or two a week. And then I'm in clinic the other three days a week. So a little bit of both, yep. And when you go on the street, do you go to the same areas or are you? Yeah, generally. So we have like a street medicine team that's based out of our clinic. And in the city of Detroit, I think about it almost like as a miscalation team, there's a lot of other student-read street medicine teams and volunteer-led street medicine teams. And when they identify someone who requires sort of like consistent care, higher levels of care, substance use disorder, interest in starting medications, pregnancy, wound care, have CHIP, things like that, they'll refer them to our team. And then our team becomes kind of the continuity street medicine provider. So generally my area is on the east side of the city, just because we the city is so large, we can talk about that later, but I largely focus on the east side. And we've got a team that does west side and the woodward corridor as well. And how big are those teams and what are the composition? So it is me and then we've got a housing navigator slash peer and then we've got a community help worker. And then on a different day, we've got a different position and then we've got a nurse practitioner on that third day. So it's a tight knit team and I think that's kind of the way I like it in some ways. I think it we build really strong relationships just that way. My peer and my community help worker know the ground really well and know the people really well. So yeah. Oh fantastic. Tell us about your journey into the addiction medicine substance use disorder treatment. Yeah. Again, I sort of fell into it. I think it was a residency. I was fortunate to train in a place that gave me really fantastic training in this. We were also a federal health well federally coffee at health center, but also had a method of clinic based inside of it. So I got to do a mix of methadone and and deep and orr fiend. And I just loved it. I think so much of it, especially from a harm reduction standpoint, like it's pretty deeply intertwined with street medicine, right? It's it's truly centered on meeting the patient where they're at, addressing their needs as they see it. And so it felt like it just went hand in hand. And when you think about the, you know, the cold morbidity is obviously there's so much data around this. But more than that, I think it really just felt like the clinical practice and the way of being a doctor and being a provider, just just felt like intuitive, right? It feels like they they exist together. And so it just became a natural part of my practice, honestly. Yeah, it's it's to provide comprehensive holistic care means doing doing this piece of it. Tell us about Detroit. What what what does the point in point in time count look like for numbers of homeless? And then I'm also curious about the prevalent drugs. Yeah. So Detroit is really unique, right? It was a city that historically has been built for two million people and now has about 600,000 people currently living there. So by land, it is it is really really quite large. You know, compared to other cities, we don't have encampments in the same way. There are a fair amount of abandoned buildings or older structures where our folks actually reside in those buildings. And so our pit count, I think, is consistently not catching all of our folks. The pit every year shows about 1,500, I think 1,400 if I'm getting it exactly correct. I think on the ground, we know that that number is higher because you're not capturing folks who are living in these abandoned buildings. I think that the the need is quite high in Detroit. I think that is a history of this investment and structural racism and redlining and white flight and all the things that hit a lot of other post-industrial cities, but at a much harder level here in the city to Detroit. So I think if you include folks who are couch surfing and you know, all the things that come with with a lack of generational wealth, right? Those numbers are likely much, much higher. In terms of substance use here, I feel like it reflects a lot of the other Midwest cities. We see a lot of opioid use disorder, a lot of cocaine use disorder, a little bit of methamphetamine use disorder largely coming from the West side of the state, but that's new. I think I've got a couple of cases that not more than that. And yeah, that's mostly about it. Are you seeing the Zyla Zine wounds? We are, yes. Yeah, we're seeing Zyla Zine and then Meditomadine has been the newest Contaminant Nurt drug supply here. So yes, we're definitely seeing a fair amount of Zyla Zine wounds. Tell us more about that. Tell us more about the new contaminant. Yeah, Meditomadine. Yeah. Yes, so Meditomadine is also a veterinary tranquilizer. It's considered to be stronger than Zyla Zine in some way and it's tranquilizing effects, but the reported effects of it are about the same folks feel it as sort of that sedation that comes with taking a tranquilizer. The thought right now from what I'm saying from early data is it doesn't seem to cause the same wounds. Those wounds are really attributed to Zyla Zine, but I think the fear is just the shifting drug supply rate and the increase of overdose related to that. We're also seeing some car fentanyl in the city of Detroit. We've had a couple of deaths coming from Wayne County with car fentanyl and that is a version of fentanyl that is about a thousand times stronger. So it is much more intense and I've been doing a lot of talking to patients about that. Tell me, I don't know about this car fentanyl. Car fentanyl, yep. And it's a concentrated form of fentanyl. Exactly. Exactly. Exactly. Okay, with a much higher overdose. Exactly. Okay, tell us about your efforts in addressing the opioid use disorder in your patients. What are you doing for harm reduction? Yeah, so what's kind of nice is we're both a street medicine team and a certified harm reduction team, which means I carry all the supplies for use on our vehicle. So everything from straight pipes to bubble pipes to hammer pipes for folks who are smoking, different syringes, based on how a person or what size a person would require. We've got testing strips. I try to keep up to date with whatever we're seeing in the drug supply. So fentanyl, zylesine, metatoma, dine, sharks, containers, narcan, all of that. And I think that that's been really incredible because I think offering those harm reduction supplies along with our team really just helps us build a strong relationship, right? And so really being able to offer that as see people weekly, generally, especially with these wounds, right, continuing to offer them safer supplies, building relationships, building a sense of what's important to this person. And then eventually if they're ready and when they're ready, also knowing that I can connect them to treatment on our vehicle. For a lot of my folks on the street, the goal is not necessarily cessation of drug use, right? And it's really, really hard when you're up sleeping. But I do think there's really it's important for using people nor fiend as a harm reduction tool really to move towards more control use to move towards overdose prevention. And that is often what my folks will name as their goal. What do you what do you say is the pathway into a illicit use disorder? What do you what's the what's the pathophysial the pathogenesis of that? Yeah, it's a good question. And I I think it's different for every other for every person, right? I will often ask my patients like what their story is right where to start what's your history. And I hear all sorts of different things right? I hear folks who, whose parents may have used when they were kids, and that was how they were introduced, right? So maybe some genetic component. I hear folks who got in a really terrible car accident and as a result of medical trauma and difficult things there were started on pain medications and then escalated. And then so many of the people I see Michael are just folks who have suffered, right? Who have been dealt with a really, really hard set of cards. And use becomes a way of managing anxiety, depression, bipolar trauma, PTSD. It helps folks feel normal in some way or feel like they're able to deal with the day to day. And so it's different. But I think, you know, often use, I think, it's so interesting, 'cause there have been so many studies I think to really like try and qualify, like how does addiction happen, right? And I think a lot of families ask this question, a lot of my patients ask this question. And I don't think there is a clear answer. And I think that that's part of what I love so much about it is you have to sit with a person, right? And really understand them and really understand their history, their story and what they want. That's the only way to deal with it. So, yeah. - When it comes to patients self-medicating their depression anxiety trauma with illicit drugs, when do you do to get at the root of those problems? - So much of it is just conversation, I think, in relationship building. I think for many of the folks I meet on this street who are at the place where they're rough sleeping, possibly secondary, their substance use. At that point, there's not too many family connections, right? And so I think building relationships and helping people understand what they may be napping and helping them realize that they're maybe pathways to feel more therapeutic relationships is tremendously helpful. I also, I think that there's been a lot of mixed data about this coming up from the psychiatry folks, but I actually feel very strongly about treating undervalent mental illness. So go ahead and start that SSRI. Start the second gen psychotic start, whatever we need to start to help manage those symptoms and help this become easier to navigate. So I'll go ahead and do that as well. - I'm curious. Are you using long acting injectables on the street? - Yes, yes, yes, yes. - Tell us about that. - Yeah, it was a, I think I was really quite nervous about it as I got started, 'cause I'm, you know, a family medicine, but it is so challenging to navigate psychiatric care. And my first patient was someone who had at this point, you know, because of his disorganized behavior, been kicked out from a lot of the homeless service provider. So was not able to access the soup kitchens, was not able to access the shelters secondary to these outbursts. And we also could not figure out a way in the complicated system of community mental health to get them into an appropriate psychiatric provider. And so it became sort of like a risk benefit, you know, a thought process, right? At this point, this person, it's cold and Michigan, it's cold in the winter time. We need to do something. And so I consulted with a psychiatry colleague who guided me on dosing, guided me on his last admission at her hospital. And we started doing the injections and it was transformative, like his ability to engage now with street outreach providers, with housing navigation, it's everything. So it's definitely an area, I think I need to explain first. So I may practice a little bit more, to feel more confident, but I'm so grateful for psychiatry providers who understand that, you know, primary care and psychiatry can collaborate to really meet those needs. - How about psychotherapy? Does that happen on the streets? - I think, so I unfortunately my team does not have someone who is, you know, certified as a psychotherapist with any social work degree, anything like that. I think intuitively, I think it happens all the time through the relationships we build. So 100%, I think it's there. - Yeah, someone didn't form old, but-- - 100%-- - Yeah. - It's happening, building, building rapport. I, we had Liz Fry on this podcast recently. And she said something I thought was very striking that for trauma, for chronic PTSD, the thing people need, the antidote for that, is to build trusting relationships. And I see that as one of the prime movers in street medicine, is just to build social rapport with patients to build trusting relationships. And with the social relational poverty, being one of the drivers of homelessness, it seems like where we can really make a difference. Would you agree with that? - 100%, yeah. - Yeah. - Okay, so you've got your patients that are using illicit substances, let's just say fentanyl, okay, I'd use disorder. What therapies can you offer them? And what is your program look like for medication-assisted therapies? - Yeah, so there are the three major FDA-proof medications for opioid use disorder, got methadone, we've got meltroxone, we've got deep norphine. Methadone is challenging to navigate, right? Optumocarya is daily dosing. And in the city of Detroit actually requires, actually Wayne County requires a separate intake process through the community center, behavioral health center. So it's a multi-step process that is challenging for a lot of our folks that are us sleeping. Now, trekson is an opioid antagonist. We certainly can use it. I don't use it often on the street, honestly, because there's not good data around overdose reduction. And for me, on the street, and I think generally is the doctor, like my number one goal is overdose reduction. But someone feels strongly about it, certainly it is an option. Deeper norphine is largely my go-to. There are a couple different formulations of deeper norphine. There is just deeper norphine motto product, which is known as subutex. There is deeper norphine meloxone, which is known as meloxone. And then there is long acting deeper norphine. And that comes in two forms, for exodium sublucade. I largely on the street do usually the suboxone film because they're easy to control and easy to cut. And I find that most of my folks here really like to do what we call microdosing or low-dose initiation. I think this is largely a regional practice, because I know when I train in Chicago, folks there really prefer macrodosing. And so I think it depends on who you're working with. And I also like a fair amount of this is community buy-in and what folks are on them are doing, right? So in my practice, I usually counsel folks to take one of those eight milligram strips, cut it up into eight pieces. When you start to feel early withdrawal, take a tiny piece, another hour, take another tiny piece, build it up in your system slowly. The goal for the first week is just to get suboxone in your deep renorphine in your system, right? That is the number one goal. And I'll tell them that that's sort of the approach. If they do feel worsening withdrawal symptoms, really the way through is just more deep renorphine, so loading it up. I've been trying to do more long acting injectable deep renorphine on the street. I think I've got some community buy-in and one of the parts of the city, but it is a hard sell, I think. Getting a monthly injection when folks are still pre-contemplative about their goals, it's a hard thing. But I do think there's a lot of utility for it, especially when folks feel very strongly about, you know, maintaining reduction in use and feel comfortable moving forward. I usually will use either sublocate or brixatti. What's kind of nice is brixatti is a newer long acting injectable that comes in a couple of different formulations. So you've got a weekly injection, you've got a monthly injection. And there's newer data, I think coming out of the folks in New York and on point, where they're actually really using brixatti as a way of replicating that micro-induction that I do through the films. So I'm excited to see if anyone is willing to give that a shot here. I haven't gotten a new one, taking me a fun, but it's an exciting option. And then sublocate is that monthly injection that I'll largely find folks on the street too and do. Yeah, we've had trouble getting buy-in on the sublocate. Yeah. We make it available and we say, once a month, shot and people shake their heads and say, give me the films. Yeah. Is that your experience? 100% yeah. And I think some of it too is among my folks. Where someone was telling me they were part of an early study for the injection. And so I think that that left some bruising and scarring that they were hesitant about. And there's a lot of rumors around that. A fair amount of folks, they take care of are also sex workers. And it does leave that nodule under the skin. That folks feel like it's a sign. So-- How about diversion? Do you worry about it? Or do you take a fully harm reduction approach? I largely don't worry about it. I think I give folks the tools and they are welcome to use it in the way that they would like to use it. And I think that as long as I can document and tell for some of this is what I would recommend, after that, I've done my part. And I think everyone deserves a shot, right, no matter what. And if they can verbalize a plan for continuing the medication, that is enough for me. And our overdose rates here in the city, honestly, are still quite high. But throughout Michigan, they've decreased. But here in Detroit, they're actually still increasing. And so at the end of the day, if it doesn't go on the patient, I'm prescribing it to you. Maybe it goes to someone else. And I do see a fair amount of folks who picked up some and then give me a call. And I was like, you know, it's gotten kind of extensive to keep buying this. Like, I'd like to get it prescribed. And I'm like, wonderful. Let's do it. That sounds great. So no. What's the going rate on the streets right now? Seven hours for eight milligrams. About the same in Rochester, five to 10. It varies. Yeah. So we tried to flood the market with Bupernarfen. Exactly. Helper gets in the room in people's hands. Tell me about the support you offer patients that are trying to get offentional. I mean, obviously the medication is a big piece of that. But what other support do you offer? Yeah. I mean, comfort medications are always an option, right? So to really help with the symptoms part of things, we'll do so frame, we'll do a modium. With the Zalazing withdrawal and metatomidine withdrawal, I've really liked using low-fixidine, which is now covered by Michigan Medicaid. And then clonidine would be the other alternative that's often covered in other states. They both act on the alpha-alphyrscepter. So tends to be helped with that anxiety, agitation, things like that. And then so much of it, I think, is like the pre-contemplation, right? So we'll often give the script. And then I'll come back the next week. And I'll be like, how'd it go? and feel free to go. just haven't started it yet, right? And I think so much of that is I think just understanding what the barriers are, right? What's going on? Is it fear of precipitate withdrawal? Is it that we're not ready to make this change yet? Is it that, you know, we feel like we need additional support? I think that that is really just like continued engagement and that I had one person who took about three months, he held the script, he didn't, he didn't felt he held it, but just took three months at like weekly check-ins to sort of be like, "are you ready? Are you ready?" Then three months in he, he didn't, he's now consistently on it, right? But I think that's the beauty of it is you're there to support until someone is ready to start. Yeah. I would like to think that we are all addicted to something. I don't know. I believe that. And then we all can understand ambivalence. Any of us that have tried to give up, give up one of our little addictions, we, you know, we get ambivalent about it. So I think it's only reasonable that our patients would be the same. Tell me, tell me about crack cocaine use in Detroit. Is that prevalent and do you prescribe for it? It absolutely is. I see a fair amount of it. I do prescribe for it. I mean off label I'll use well butrinets usually may go to as long as there's not a cold-caring seizure disorder. That's usually what I'll start with. And on the table just kind of go from there. Larger I'll tackle the most my folks have cold-caring, hope it is just or in cocaine-user disorder. I usually don't see just single cocaine use disorder. There's a few folks I see in that category. But I'll usually categorize, I'll tackle the opioid use disorder first just because the risk of overdose is higher. And then I'll go to cocaine use disorder next. Is to pyramid anything you use? I have a reading of data on it. I would like to use it. I've not used it yet. So I think it's compelling data. Or just not there. Yeah. Yeah. Okay. And you get secondary benefit with the with the bupropium. Exactly. Well, be a trend, right? Exactly. For most of other problems. Exactly. Yeah. Well, this has been great and you've answered a lot of my questions already. But what do you find most challenging in this work? Oh, I mean, I think it's just witnessing the brutality of it all, I think. I think we're often caring for folks who slip through so many systems. And seeing that day to day can just be really, really challenging. And I think often feeling like, you know, you're sitting with this person through some of the hardest moments and bearing witness to that is a really, really hard thing. So yeah, I think that that's been the hardest part of all of this. I think the joy of it too, though, is that I have never felt alone in doing this work. And I think that's the beauty of it, especially here in Detroit, where so many of our folks are, you know, hidden in different abandoned buildings and harder to find. So much of what I do is based in connection and in working with our collaborators and then finding folks together and seeing them together. And so I think that's the beauty is I've never questioned like my meaning or my purpose in this. And I always have people termite me of it, you know, yeah. - Shoulder, shouldering each other up. - Exactly. - And Vicki Reynolds would tell us. - Exactly. - Do you want to tell us a story? Patient that you're really, I don't know, proud of or that that went really well and you felt really useful. - Yeah. I had a patient actually last year who was pregnant with twins. They were fetal growth, they had fetal growth restriction. And she, I met her as she was discharged from the hospital. She actually ended up leaving AMA with OPD's disorder, this new newly defined pregnancy. And so they destroyed her in the street. We went to her in campment and it was actually a friend of hers that I'd already known who showed me where she was sleeping. And so I met her there and we did most of her pregnancy care in the street. She was pre-contemplative about her goals around use, but was really thinking she wanted to parent and was also roughly thinking throughout this time with twins, which was a really, really difficult thing. And we, I think identified her when she was around 20 weeks because of the high-risk pregnancy, I would see her just about every week. I would drive her to her ultrasound and then get her to the places we needed to go. And about early in her third trimester, she decided, you know, like I want to give Bipronorphina shot, I really do. So we ended up getting her a drafted Mission to the hospital because when you're pregnant, you can do that. And got her started on Bipronorphine and she did really well on it. Fortunately, her housing lined up so she was discharged from there. She ended up in her housing placement, which was awesome. And she delivered the twins. And what's beautiful about it is she is, you know, she, I think in the hospital had been thinking about what her goals were, you know, whether she was in a place where she was ready to parent. And I think identified that she was not there yet, but she could find a family member who was able to take this twins in. And that's exactly what she did. And I now know her. She's about year later now and she's currently about to navigate to getting like custody of her kids and, you know, reparenting, which is beautiful. And I am just so proud of her for really thinking about what she needed in the moment, what she was ready for, giving herself time and grace to make herself ready to parent. Her self ready to parent. She now has a job. She's working and getting her degree and is about to be the parent to two beautiful, beautiful twins. And it's just, it's an amazing thing to watch and bear with a stick that, you know, she told me she was hoping for. Really keeps us going, doesn't it? Yes, it does. You know, like, you just need a few of those every, every month. Yeah. That's when everything. I've really been enjoying our conversation. We're coming, coming down near the end. Is there a question I haven't asked that you would like to answer? No, I think you asked all the questions. Have we covered it? Yes. Okay, because we ask all our guests to answer the question. If you could do one thing to make the world a better place, what would it be? I think it's to keep holding space for hope because I think hope is what makes this last one. Hope, hope, hope, hope. Thank you. Thank you. And then I want to ask as well, you, you, you, you obviously have done a lot of study and and self, self study on addiction medicine. What are the resources out there you would recommend for? Yes. So there's a fantastic book actually about just like the history of addiction by Carl Eric Fisher called the urge that I think is really, really excellent as just a concise history as to how do we get here from a policy standpoint and from just a research standpoint. He's a psychiatrist who also navigated alcohol use disorder and so it really reflects on it from a personal space. Outside of that, I think the curbside addiction podcast has been really, really excellent. They do really good, relatable, small pieces of episodes that I'll take as I drive. And then the SAMHSA guidelines are the PCSS. So, physician, critical support service, I think is what it stands for, but feel free to correct me if I'm wrong. They have a great series on alcohol use disorder that's really, really helpful. Oh, that's great. That's great. Thank you for that. And if our listeners wanted to connect with you, what would, how would they do that? Yes. I don't have a website or social media, but my email address is probably the best option. And so it's SSHETTY at CHAS Center. So it's CHAS Center. Thank you. That's SSHETTY at CHAS Center.org. You got it. CHAS Center. Yep. CHAS Center. Great. It's been a delight to have you on our podcast. I would like to come visit you and Detroit and accompany you on rounds and see the great work that you're doing. And you're always welcome to Rochester. Those of us, those of us up here on the, on Eastern Standard Time, and this will be published on Spotify and Apple soon. So we look forward to seeing you at the next symposium for the Street Medicine Institute. Absolutely. Thank you, Dr. Shae. The opinions expressed in this podcast were those of the individuals included and are not represented by the opinions of the Street Medicine Institute or the Street Medicine Institute student coalition. Do not use this podcast to medical advice and instead see your own provider for medical care.