Q&A with Rebecca Trotzky-Sirr, M.D.

You are the jail health service director for Los Angeles County + University of Southern California Medical Center, which has one of the busiest emergency departments in the nation. What are the challenges of serving individuals involved in the justice system, especially those with mental and substance use disorders, in a busy emergency department?

As a community, we have the opportunity to treat patients with substance use disorders—in particular, opioid use disorder—as patients first. So, as healthcare team members, we can provide effective delivery of effective medications to treat opioid use disorder. But when we as a society choose to turn away from effective and science-based treatments, we tend toward criminalizing substance use disorders. In my job, I see the full spectrum of amazing outcomes when we deliver effective treatments to our patients, versus less amazing outcomes when we criminalize, arrest, and put in custody people with the same opioid use disorders.

One of the blessings I say we have as healthcare providers is that we get to do the right thing by the patient for their health no matter what. And that’s true whether they’re in custody or not. So, some of the moral quagmires and ethical dilemmas that sometimes get close to our legal system really become clarified in our healthcare system. In Los Angeles County, we get a lot of patients who are being released from state prisons, as well as patients who are in the county jail system. We treat them by delivering the right medication at the right time.

You serve as regional director of the California Bridge Program, which is designed to increase access to substance use disorder treatment in emergency departments and hospitals. Can you explain the pillars of the California Bridge Model and what you hope the program will achieve with this structure?

California Bridge believes in providing safe and effective treatments for people who use opioids with “no wrong door” access. So, at any point in our healthcare system—whether you’re touching us as a primary care patient, in urgent care, in the ER, or as a jail health patient—if you have talked to somebody on our team, you can start treatment for opioid use disorder right that moment without shame, bias, or stigma and in a supportive context. Human connections that build trust are critical to this treatment, which also means hospital culture must be welcoming and not stigmatize substance use. Then we bridge that care into the community to ensure that there is active support and follow-up for patients, as well as outreach to people who use drugs to increase access to care, equity, and harm reduction.

We started as a ragtag group of clinicians who were looking at the evidence and providing treatment to our patients with opioid use disorders just like we would for any other health condition, like diabetes and hypertension. With California Bridge, we’ve expanded to define this as the normal cultural value in the state of California, across 52 ERs and hospitals, in a variety of geographies across the state. I’m in busy downtown LA, but we’re also in rural communities, and we’re still able to deliver the same high-quality services.

Recently, we’ve expanded our efforts with money from the Substance Abuse and Mental Health Services Administration. It’s been a blessing to have the ability to increase our capacity and do this in a consistent manner. And expanding the work has allowed us to realize all the commonalities that we have, whether you’re an obstetric provider, a psychiatrist, a family medicine doctor, or an ER doctor. I think it has really unified our healthcare teams to be able to work together, and that’s been critical in allowing us to do this good work to increase access to evidence-based treatment across the state.

Based on what you have experienced in your work, what piece of advice can you give in helping the medical system and criminal justice system better work together to serve the needs of their clients?

There are a lot of opportunities to base our decision making in science rather than in antiquated myths that we have about drug use. Buprenorphine treatment is such an effective treatment for opioid use disorder, and it really changes the game for both the healthcare system and the criminal justice system. And when everybody gets on the same page, it is a beautiful thing to see. There are many opportunities for improving our communication across the team because we have such different anchoring experiences, whether you’re a sheriff or a physician.

We still are learning a lot in Los Angeles County about how to overcome bias and stigma in our jail health systems. It can be all too easy to get sidetracked by the myths about treatment for opioid use disorder. I hear these myths over and over, and I’m hesitant to repeat them because buprenorphine is so safe and so effective, and people are not getting high off of it. They come to me and tell me how clear-minded they feel, how grounded they feel, and that they are able to take responsibility for their actions. And that is just what I want my patients to be able to do.

It’s critical whenever my clinicians see a patient to make sure that they’re starting treatment, knowing that maybe down the road that patient might encounter a different healthcare team member, a different context, or a different environment where that treatment might not be supported. As long as we do the right thing every single time, it builds that culture of transformation where that patient can receive care regardless of where they are in the criminal justice system.

You have been a longtime activist for social justice causes. What led you to work with disadvantaged groups, including people with mental and substance use disorders, and people in jails and prisons?

I dropped out of high school, and I had my child fairly young, so I went to college as a single mom. But I grew up in the Midwest in a family and a community that valued building community. I knew I wanted to go into health care, but I didn’t think I could be a doctor. My social worker told me that I should drop out of college, and I should go learn how to do hair and makeup because that was going to be an effective way to build my life. That really ingrained in me the power of long-term change based on individual decisions and family decisions that are supported by building community.

I have extended family members with addiction and in the criminal justice system. And I think that’s a very common experience for everyone because they’re very common things. One of the transformations that I think will happen in the next generation is that more and more of us will come from diverse backgrounds that bring that empathy, and awareness, and perspective to our clinical encounters. As physician leaders, we’re told to leave our own experiences at home. But I’ve learned that when I’m able to share the vulnerabilities that I have and the issues that I have overcome, it creates a more honest conversation with my community. Do we want to invest in building people up, or do we want to invest in punishment that doesn’t actually generate effective positive outcomes for people? I think we have a responsibility to choose as a society how we want to transform lives.

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Criminal justice, GAINS, Jails & Prisons