Originally published in Synapse on October 14, 1993.
Greg Hayner, PharmD (UCSF class of ‘77), has been working at the Haight-Ashbury Free Medical Clinic Detox Center for 14 years — 10 as chief pharmacist.
Synapse: What’s happening on the street and how have things changed over the years that you’ve been here?
Greg Hayner: Currently on the street we’re seeing a lot more heroin than we have for a while. There’s still plenty of crack. And then, apart from what we’re seeing come into the clinic, there’s a lot more LSD out there, a lot more people using things like MDMA (methylenedioxy-methamphetamine, also known as “ecstasy”), which weren’t even around when I started here. There are a lot of people going back to inhalants. We’ve still got cocaine [and] amphetamine available out there. I guess the biggest change that’s happened since I started was that at [that] time the clinic was mainly seeing heroin, a little bit of speed, not that much cocaine. We’d get some, but not anything like what it’s been since crack hit. And there were a lot more sedatives back then, too Quaaludes were still available. Also, some of the barbiturates like Seconal and Nembutal were not schedule II at the time, so we had a few people who were addicted to those. We virtually never see those anymore. There was a lot more prescription amphetamine abuse going on. Now, we’re mainly seeing street amphetamine.
Synapse: Have you seen changes in the method of ingestion? Are people still using needles a lot with heroin?
GH: People continue to use needles with heroin out here, although I understand in New York it’s somewhat different There’s a lot more people smoking it. And that’s partly because of the AIDS scare, but it also is partly due to the availability of very good quality Southeast Asian heroin, which we don’t really have much around here. Maybe AIDS will impact it enough, but economically, the pressure is for people to inject it.
Synapse: Would you say that the clientele that you see here are not necessarily all from this area, this neighborhood?
GH: No, they’re not all from this neighborhood. We do see a lot of people from the neighborhood. They’re primarily heroin people. But we draw from the whole city, and really from the whole Bay Area. We have never really specialized in [one] particular drug. Most of the other places around are methadone clinics and the only thing they really were set up to deal with was heroin. This clinic is about the only resource that people have for [problems stemming from]. We’ve had people come from as far south as Gilroy, Santa Cruz. We’ve had people come down from Yreka. We’ve drawn people from Reno... San Francisco County would prefer that we don’t see people from all these outlying counties, but there’s no other place for them to go. some other drugs. We’ve had people come from as far south as Gilroy, Santa Cruz. We’ve had people come down from Yreka. We’ve drawn people from Reno... San Francisco County would prefer that we don’t see people from all these outlying counties, but there’s no other place for them to go.
Synapse: Can you talk a little bit about the kind of treatment that is done here?
GH: We’re taking a symptomatic approach to drug withdrawal and trying to address, lately, drug cravings for stimulants. But with heroin detox, we’re treating it just the way you would flu. Your eyes are watery, your nose runs, you may have some nausea, vomiting and diarrhea, and your muscles ache.
Synapse: Sounds like the flu.
GH: Right, except for the fact that people are also jittery and can’t sleep. It pretty much runs a course of about a week. So we’ve broken those symptoms down into sets of things: we’re beating insomnia as a symptom, we’re treating anxiety as a symptom, we’re treating gastrointestinal problems as a symptom, and pain. And until very recently, most everybody was getting something for each one of those things. More recently, we’ve been using Clonidine, the Catapres patches. That actually works quite well for the anxiety. For a lot of people, it pretty much takes care of the gastrointestinal distress. It doesn’t treat pain, and it doesn’t really put you to sleep. We give them sleepers: Trazodone primarily, an antidepressant, so that we’re not giving them another addictive drug to go to sleep. And we’re relying primarily on anti-inflammatory drugs for the pain symptoms.
Synapse: Can you describe a typical week for you, what type of work you do?
GH: Well, we’re doing admissions usually Monday through Thursday...
At this point, as if on cue, Carl stumbled in because he had lost his inhaler, needed a new one and the free clinic across the street had kicked him out because he was drunk. Hayner spent about 15 minutes offering Carl options: “Try coming down and going back across the street;” “Maybe you could see our doc here;” “You could go down to St. Mary’s where they’ll take your Medi-Cal; they already know you down there, Carl.” Carl had reasons why none of Hayner’s suggestions would work. Mostly, he seemed just to want someone to listen to him for a while. Hayner obliged, though eventually Carl was sent out because he was being disruptive.
GH: OK... well, we have some of that going on. Most of our patients come here with other stuff besides primary alcohol problems. We’re helping doing the preliminary assessments up here.
Synapse: Here in the pharmacy?
GH: Yes, they fill out a questionnaire that asks what kinds of drugs they’ve been using; whether they have psychiatric history — either diagnosed, or we also ask them if they’re hearing voices, feeling suicidal, that kind of thing. So we’re helping determine if they’re going to be appropriate for admission. When they’re finally taken in, let’s see, we’re doing medical histories up here, we’re doing TB testing. Right now, we’re giving flu shots, tetanus shots if they’re willing. They see the doctor, get a physical, there are medications ordered for the detox, we’re getting labs on most of the people. Then as they come back, we’re seeing them in the pharmacy every day.
Synapse: So you dispense the daily medications?
GH: Just daily medications, at least for the active detox. We’re checking in with them on how bad their symptoms are, if they’ve got symptoms that aren’t being covered, making adjustments. We’re set up on medication protocols. Within the confines of those protocols, we’re able to change things and then get die doctors to countersign for us later. We’re doing sort of crisis counseling work. I’m ordering medications, medical supplies. We are also one of the few places anymore that will do drug information calls for the general public. Poison Control has restricted what they will take from people because, I guess, they’ve had to cut back on staff, probably because of their funding, and they don’t have time to take a lot of the questions that come up. We get questions from people going through detox on their own. We’re getting calls from physicians on how to detox people. We get calls from Poison Center [and] we get calls from Drug Information [Analysis Service] at UC. So we’re kind of a local resource. That takes up a lot of the day.
Synapse: You graduated from UC. How have you found that your education helped you in this field and where was it lacking? What have you had to do beyond that?
GH: Well, actually, it was really good in terms of the amount of medicine in the department of pharmacy curriculum. The clinical pharmacy program was really critical because we really do operate on a team approach here. We are fairly often conferencing on patients, and virtually everybody who has any involvement with a particular patient is involved: counselor, pharmacy staff, physicians. It’s really a relaxed type of atmosphere. I mean, we’re all on a first name basis with our patients, but also each other. It’s not doctor so-and-so. It’s really kind of a cooperative effort, which really wouldn’t be possible, I don’t think, without that kind of background. As far as, this field in particular, there really wasn’t much training at UC. There was some, certainly, that had to do with substance abuse, but it was meager. I think we had on the order of one or two lectures on drugs of abuse. My bias is that that’s not enough, no matter whether anybody goes into substance abuse work or not. I think it is a good area for pharmacists because we are taught a lot more about pharmacology than anybody else in the medical field. We know a lot more pharmacologically than most of the doctors, certainly more than most of the psychiatrists that are out there running these programs. I can’t think of any practice area that people would be in where they’re not going to run into somebody with a substance-abuse problem. A lot of times what happens is, as a result, those problems get ignored because if I think it’s part of being realistic that you recognize the fact that not everything these medications do is good. That’s what I think should be part of the education for all healthcare providers. you acknowledge that there’s a problem, then you’re kind of obligated to do something about it. And if you don’t know what to do about it, I’d say you’d tend to ignore it. I think it’s part of being realistic that you recognize the fact that not everything these medications do is good. That’s what I think should be part of the education for all healthcare providers.
Synapse: Have you seen problems with people who have gotten clean and later developed chronic pain for which they are prescribed drugs, and then they end up going back to their drugs of choice? What, if anything, do you think could be done about that?
GH: What really needs to be done there is that physicians need to be trained in what’s being called “recovery-sensitive” medicine. To realize that some medications, even though they’re not narcotic medications, can be problematic to a person who’s in drug recovery. People who are trying to stay off drugs do, of course, have medical problems come up, just like anybody else. And a lot of them have problems finding dentists and physicians who are going to really acknowledge the fact that they have a drug history and the need to be cognizant of that [in] prescribing. I think it’s just an education problem.
Synapse: In terms of administration, you don’t have to worry about payment forms, third party payers, Medi-Cal? Do you look for payment here?
GH: We do collect Medi-Cal. We don’t deal with third-party payers, mostly because the few times that we’ve tried to do that people lost their insurance. The company would pay our bill, but men they’d turn around and say to the person, “Well, now that we know you’re an addict, we’re canceling your insurance.” So we don’t do that one. We take what money city and county gives us, and we ask people to donate, but that’s it. Some of the other drug clinics in town, if you don’t pay them, you get shown the door. And most of the time, when people get to the point where they’re ready to get into treatment they don’t have any money. If they had any money, they would spend it on more drugs. They wouldn’t come to your door until they ran out of the money. That’s certainly one of the more attractive things about [our] set up. And I really hope this new Clinton health plan pans out. Hopefully, people will be able to get substance abuse treatment but they’ll also be able to get treatment for whatever is going on, at least on a basic level, no matter what their financial resources arc.
Synapse: Any other last comments for UCSF students?
GH: It’s fun. Come on down. We do encourage pharmacy students to think about coming through here. We have been able to take some medical students and psychiatry residents. I guess it’s been mostly on special arrangements. The majority of our medical staff are UC graduates. Most of us are at least adjunct faculty up there, so those kind of things arc arrangeable. I really encourage people to come. Even if it’s not something that they’d be interested in doing long-term, I think it’s good exposure for people.
