The Community of Grace: Addiction Support Services

Interview: Dr. Aislinn Bird, Alameda County Health Care for the Homeless

The subject of addiction was one that came up in the course of our reporting on the Community of Grace. We wanted to find out what support services are available in Oakland, especially to people who are unhoused. So producer Lucy Kang spoke with Dr. Aislinn Bird of Alameda County Healthcare for the Homeless about what it takes to get clean, why it’s so much harder when you don’t have housing, and what more is needed.

If you’re seeking addiction support services, you can call the Alameda County ACCESS Line at 1-800-491-9099.

Naloxone, or Narcan, is a medication that reverses opioid overdoses and can potentially save someone’s life. For more information on Narcan, check out the links here and here


Lucy Kang: The subject of addiction was one that came up in the course of my reporting on the Community of Grace. I was curious about what support services are available in Oakland, especially to people who are unhoused. So I asked Dr. Aislinn Bird of Alameda County Healthcare for the Homeless about what it takes to get clean, why it’s so much harder when you don’t have housing, and what more is needed.

Could you introduce yourself to start and tell me a little bit about what you do?

Dr. Aislinn Bird: Yes, my name is Doctor Aislinn Bird. I’m a psychiatrist with Alameda County Health Care for the Homeless. I am a staff psychiatrist with the Trust Clinic, which is a unique collaboration between LifeLong Medical and Alameda County Health Care for the Homeless. We provide integrated care to folks experiencing homelessness.

Kang: So it sounds like the bulk of your patients are folks who are currently unhoused, is that correct?

Dr. Bird: Yes.

Kang: And in a your experience working with your patients who are  unhoused, what types of substances do you see people struggling the most with?

Dr. Bird: So number one is alcohol, which we don’t talk about as much we are, there’s a big focus in the heroin epidemic, which is killing people. But alcohol is actually the number one killer in terms of substance use disorders. So a lot of alcohol. There’s a lot of methamphetamine use as well, which is very hard to treat. There’s actually no no good treatment for meth use disorder. And then a lot of heroin as well.

Kang: Take me through some of the stages of what a person would feel when they’re trying to stop using.

Dr. Bird: So with any substances, when you stop using it you have, tend to have the opposite effect of what that drug causes when you’re intoxicated.

Kang: I guess since you brought up alcohol addiction, talk me through what stopping alcohol looks like.

Dr. Bird: Stopping alcohol can is can be very difficult. It’s difficult to stop any substances. But alcohol in particular can be life-threatening when you stop using. If you are using a large amount and daily, withdrawal can be, you know, feeling shaky and nauseous, antsy, irritable, unable to sleep. But it can be life threatening to the point of having withdrawal seizures or delirium tremens, which is where you hallucinate and your body can get to the point of going into shock. And it can be deadly.

Kang: How long do those withdrawal symptoms last typically?

Dr. Bird: Anywhere from a couple of days to to a few weeks. So with methamphetamine, when you’re intoxicated on meth you feel really great. You have a lot of energy. You don’t need a sleep very much. And a lot of times people do start using meth to avoid sleeping because it does not feel safe to sleep on the street.

And also a lot of the people I work with have post-traumatic stress disorder. And one of those symptoms is nightmares. So I’ve worked with a lot of people who start using math to avoid sleeping and not experience those intolerable PTSD related nightmares. So when you stop using meth you can you have the the opposite effects of the intoxication. So you’re really tired, very irritable, can have body pain, sleep a lot.

So a lot of times we’ll say like, oh someone is crashing. Well, they will just sleep for days and then wake up and just fill not so great. It can bring up a lot of other symptoms, a lot of other psychiatric symptoms because meth and other substances tend to mask a lot of underlying conditions that people have.

Kang: So how long does it take before someone who’s stopped using meth feels back to, I don’t know, some state of normal?

Dr. Bird: It really depends on the amount that someone is using and how frequent. I have worked with patients who’ve experienced meth induced psychosis. So that is hearing things that other people wouldn’t hear, feeling really paranoid, sometimes seeing things that other people wouldn’t see. And those symptoms, if someone is using a large amount of meth everyday, those symptoms can last even a year after your last use. So really, it really depends, but usually people start to feel a little bit back to normal after a week or two.

Kang: And what about the process of stopping something like heroin?

Dr. Bird: Yeah, stopping heroin is very difficult. Again, the withdrawal symptoms are the opposite of the symptoms that you get from the heroin intoxication. So you can fill very antsy, restless, anxious. There’s a lot of GI symptoms, so nausea, vomiting, diarrhea. You can have bone pain. A lot of patients say that they their body hurts so much that they just want to die. Unable to sleep, shaking, goosebumps. You can be teary-eyed; your nose can run. It’s very very uncomfortable and very difficult to have such a severe GI symptoms when you’re living on the street.

Kang: Does that more or less overlap with what any type of opioid withdrawal would look like too?

Dr. Bird: Exactly, yeah, heroin and any opioid-related painkillers.

Kang: And how long do those withdrawal symptoms usually last again?

Dr. Bird: It really can depend on the amount and frequency that someone is using. At least a few days but up to a week.

Kang: How much more difficult is it for patients who are going through withdrawal while there are also unhoused?

Dr. Bird: It’s very difficult. I mean it’s hard for anyone of us to be sick or not feeling well when we’re in our own safe warm bed and have access to a bathroom. But having all of those symptoms when you are sleeping on the street or a tent and don’t have easy access to a restroom is incredibly difficult.

Luckily with both heroin and alcohol, we have good treatment to treat the substance use disorders and to help someone through the withdrawal process.

Kang: Can you tell me what those treatments look like?

Dr. Bird: Of course. So for alcohol, a lot of times we’ll give someone a benzodiazepine taper to slowly taper off the the effects of alcohol. And this prevents your body from going and having a seizure or going into that shock. And then we have a great medication called Naltrexone, which is a medication that you take daily that can it cuts down on cravings to drink alcohol. And then if you do drink alcohol, you don’t have the same euphoria and the same positive effects from from alcohol.  And that medication also comes in a one-month injection because it can be hard to remember to take medications every day.

There’s also other medications called antabuse, which if you take this medication and you drink alcohol you physically become sick. I personally rarely prescribe this medication because I don’t want to cause my patients harm. But some some patients do do prefer this medication.

And then for heroin, there’s two medications that really can help with opioid use disorder. One is suboxone, also called buprenorphine. And this is a again a great medication to help prevent you going into withdrawal and having cravings to use heroin.

The other medication is methadone, but with methadone, you need to go into a methadone clinic every day for an observed dosing. With suboxone, you can get a prescription from your doctor that has a special license. And so you only need to see your doctor once a week or every few days depending on the patient’s treatment plan.

Kang: Yeah, I guess I’m curious, do you have a sense of like how often relapse occurs?

Dr. Bird: Very frequently, you know. Substance use disorders are a medical condition and relapse is part of that process. So that’s where it’s not just medication but social support, attending groups and also having a sense of purpose. A lot of times people will use as something to do and also to mask underlining behavioral health conditions.

So substance use disorders are a medical condition just like diabetes. Unfortunately, there is a lot of stigma around substance use disorders. A lot of folks will say like, “Oh why can’t you just stop, you know. You know the alcohol is bad for you. You know that you’re going into the emergency room yet again for an abscess to to shooting up substances. Like, just stop.”

But it is not that easy, that there is an emotional and psychological component to substance use disorders. Physically, you have that the cravings, addictions. If you don’t use a substance, you can go into withdrawal. But then psychologically you’re used to using certain substances and a lot of times we use substances with our friends or our social group. So even people who smoke tobacco so I can be really hard to continue to socialize with friends who continue to smoke because that is one way that they relate with their friends and peers.

Kang: So since substance use disorders are so stigmatized, how does that impact people’s decision of whether or not to come seek treatment?

Dr. Bird: It greatly impacts someone’s ability and interest, even just talking about their substance use disorder. There’s a lot of shame. People can feel really embarrassed. You know addiction is, I think the word shame comes to mind because people feel so badly that they can’t just stop.

You know, there’s this dialogue that, oh if you’re strong enough and you have the the willpower that you can just stop on your own, which is just not true. 

Kang: Could you sketch out the landscape of what some support services are available to people who live in Oakland?

Dr. Bird: Yes, so a lot of times people start the recovery process by going to a sobering center. So in Alameda County our sobering station is called Cherry Hill. And anyone can go there. They’re open 24/7, but your length of stay there is for 23 hours. And this is a time just to have a safe place to go through the withdrawal process. They also have a detox center where people can stay three to five days.

And then while you’re at the Cherry Hill detox center, they can help refer you to a substance use treatment program, and anyone can refer themselves to a recovery program through the Alameda County Center Point. And this is a free 1-800 number that anyone can call when they’re ready for treatment. And they will refer you to one of the many recovery programs in Alameda County.

Kang: What’s the number that folks can call?

Dr. Bird: They can be reached at 1-800-491-9099.

Kang: Is there a cost associated with these services?

Dr. Bird: Usually I’m your health insurance will pay for it. It really depends on the program. But Cherry Hill is free.

Kang: Is Cherry Hill the only detox center in Alameda County?

Dr. Bird: Yes, it is. Yeah, and it’s we really need to have more of these resources, have a place that people can go have safe, have medical care. And a lot of times when people, when someone is ready to enter recovery, it’s so important to act right then and get them linked up to the services that they need right at that moment.

Kang: I mean is Cherry Hill able to accommodate the number of the numbers of people who are seeking its support?

Dr. Bird: Definitely not. Yeah, there’s a lot more resources are needed to care for our folks with substance use disorders.

Kang: But it sounds like there’s a little bit of a bottleneck just in the spaces that are available for people. Is that true?

Dr. Bird: Yes, definitely. The waitlist is easily one to two to three weeks, which is really hard if someone is ready right now and wants to start this process. There’s almost always a way to get into a program.

Kang: The waitlist you mentioned of one to three weeks, is that for these treatment centers or is it for Cherry Hill?

Dr. Bird: The wait is for a long-term treatment program. Cherry Hill usually have space in this sobering station.

Kang: Cause what you’ve described is that there’s sort of like a window of opportunity during which someone you know has the desire and motivation to get clean. Why is this window so important?

Dr. Bird: Well, you know, there’s so many factors and that keep someone in using substances. And we’ll have these moments of wait, I want to change. And that window of time when someone is ready and willing to make a change doesn’t always last for very long because there’s a lot of other pressures to continue to use, not only physically but also psychologically where you know, this is a habit, you’re used to feeling good. But also socially, you know, again a lot of times people do use with friends or peers.

It’s really important to capitalize on this window when someone is is feeling ready and that they know that the system is there for them and they will get the care and support that they need at that time. And all the different substance use treatment programs have different philosophies. Some work better than others depending on the patient and the fit with the program. But we definitely need more more resources and programs that are aligned with harm reduction principles.

Kang: Could you just briefly discuss what harm reduction is?

Dr. Bird: Yeah, harm reduction is a philosophy and practice that really meets patients where they’re at. And so it doesn’t say for you to be in treatment, you have to stop right away. It really meets the patient where they are at in terms of their use. So this can look like continuing to use heroin but in a safe way, so using clean needles and having a buddy system and having Narcan on hand.

It could also look like how can we cut down on your use in a way that is safe, that will eventually ideally get the person to stop using, but that’s the ultimate goal. The ultimate goal is that people use in a safe way and know that there is a path outside of substance use disorders.

Kang: I guess without support services, how much less likely are people who are trying to quit using able to succeed?

Dr. Bird: It’s very difficult. There are people who can do it on their own.  But I think the rates of relapse are probably higher for those folks and it really does take a whole team, you know, to have a doctor to prescribe medications if that’s available, a case manager to help navigate the system, ideally peers who are also in recovery can be very, very beneficial. And just it helps with the stigma and knowing that that we’re not alone.

Kang: So what are the what are the biggest challenges that you see to individuals who are unhoused and trying to, you know, manage addiction?

Dr. Bird: There’s a lot of stigma that comes up with being houseless. A lot of times people don’t feel comfortable going into a nice clinic or feel like they won’t be treated with the respect that they deserve or be judged for how they look. So that is just an added level of stigma and judgment that our patients have to face, not to mention was we were talking about just the stigma and shame that comes with having a substance use disorder.

Just accessing resources can be very difficult. It can be really hard to maintain the same phone number when you’re experiencing homelessness. And after you do the intake with Center Point they often have to call you back, let you know where you’ve been referred to, how long the wait list will be. And if you don’t have a reliable phone number, it’s hard to follow up with a patient. That is where having a good team and a case manager and someone who can be the point person for that patient is very important. And that’s why having our programs work closely together and working as a team with good communication is critical for providing this care.

Kang: And then what are the biggest challenges I guess on a citywide or countywide level towards addressing addiction issues in unhoused communities?

Dr. Bird: Well, I think just we need more money and resources all around. One way that Alameda County Health Care for the Homeless has addressed this is by starting the street psychiatry team.

So we actually go out into encampments every day and provide addiction medicine services to those folks living in encampments. So I work go out with a team one day a week and can do evaluations for substance use disorders and can prescribe medication right on the spot. So this is one small program that is really trying to break down the barriers that people experiencing homelessness have in accessing resources.

So we do go to the same encampments every week and stick to our schedule. And our the main goal for, our program is called Street Health, is to connect a patient or the person that we’re working with experiencing homelessness to a medical home. So if they want to come to Trust they have that continuity of seeing our team on the streets. And then we also work at the Trust Clinic. But a lot of the encampments are relatively stable so it is possible to continue to follow up with our patients if we only see them on the street.

Kang: Do you go throughout Alameda County?

Dr. Bird: Yeah, we’re making steps to cover all of Alameda County. But right now we’re just an Oakland, primarily in downtown Oakland and West Oakland.

Kang: Is the Street Health program fairly new?

Dr. Bird: It is brand-new. We’re about to celebrate our one-year anniversary.

Kang: And what’s the response been from folks that you’ve worked with?

Dr. Bird: It’s been wonderful. A lot of times people don’t believe that we actually are doctors and nurses and healthcare workers right coming up to their home doing home visits in these encampments. So it’s we’ve had a great response so far.

Kang: Is there anything that I’ve missed that you think is important to let people understand?

Dr. Bird: That substance use disorders affects all of us, not just people experiencing houselessness. With people who don’t have a house, their substance use is just more out in public display. But really across all walks of life, all social economic status, substance use disorders affects all of us. It’s just that added stigma with being houseless, having your basic rights met with having a safe home and access to a restroom makes fighting addiction that much harder.

But there are some really great programs and resources out there for people. And if anyone is interested, I really encourage them to to reach out, and there’s there’s good people and good teams ready and waiting to help anyone in need.

Kang: And the Trust Clinic is one place that they can go?

Dr. Bird: The Trust Clinic is definitely one place that they can go.

Kang: Do you want to share the address?

Dr. Bird: Yeah, the Trust Clinic is at 386 14th Street in Oakland.

Kang: What’s your takeaway? You know you’ve been working primarily with unhoused folks for a number of years now. And yeah, just curious what what you take from that experience.

Dr. Bird: Really that housing is healthcare, that to provide the best care to folks, they need to have a safe place to call their own. And we know that people experiencing houselessness die 15 to 20 years earlier than those who are housed. So housing is healthcare, and we need more housing

Kang: Great, thanks so much.

Dr. Bird: Thank you.

Kang: That was Dr. Aislinn Bird who works with Alameda County’s Healthcare for the Homeless as part of the Trust Clinic and the Street  Health program. If you’re seeking addiction support services, you can call the county ACCESS Line at 1-800-491-9099.

Dr. Bird also wanted me to mention that Naloxone, or Narcan, is a medication that reverses opioid overdoses and can potentially save someone’s life. For more information on Narcan, check out the links in our episode page.