The van was coming for Richard Rivera, but it was taking a long time. He waited inside the entrance of Saint Anthony Hospital where he had spent the past three days getting off heroin. His next stop: a sober-living facility.
As his addiction counselor, DeValle Williams, kept a silent watch, the 49-year-old Rivera griped about the people who found him a bed 22 miles away, complete with meals, job training and gym access.
"They couldn't find me a place closer?" he grumbled.
Would Rivera get in the van, Williams wondered. Or would he walk away?
Long before President Donald Trump declared the opioid crisis a national emergency and pledged to "overcome addiction in America," Williams was fighting in the trenches, where it's tough to tell victory from defeat. More than 64,000 died of drug overdoses last year in the U.S., most from opioids.
At 41, he's been a counselor for two decades, the last few years helping people with drug addiction. Now he runs a new program that works to get hospital patients struggling with opioids directly into treatment.
Similar programs, called "warm handoffs," have been shown by early research to decrease the chance of relapse. Funding comes from last year's 21st Century Cures Act, which sets aside $1 billion to tackle the deadliest drug crisis in U.S. history. Illinois is spending $2.4 million of its Cures Act money for warm-handoff programs at Saint Anthony and eight other hospitals.
All states got a slice in April and expect to get more next year. They must spend 80 percent on opioid addiction treatment and many are teaming up with hospitals on new strategies, as opioid-related hospitalizations soar.
Williams and others on the front lines see the Cures money as a glint of hope, but they know addiction is a powerful adversary.
Those who seek help at Saint Anthony are hard cases. They come with arrest records, broken relationships and mental health problems. Open-air drug markets flourish mere blocks from the small Catholic hospital, a 119-year-old pillar of Chicago's working-class, gang-ravaged southwest side. As in other hospitals across the nation, doctors in the emergency room treat overdose after overdose — sometimes reviving drug users they've revived before.
Rivera arrived here on a Saturday sick from heroin withdrawal. He got hooked on heroin two years ago when a friend asked him to help sell it. "I started little by little," he recalled. "Three days later, I'm a junkie."
His public health insurance would cover three days in the hospital's new medical detox unit on the sixth floor. Rivera would receive methadone to ease his nausea, cramps and shaking legs. And he would meet with Williams.
"My job is to read people," Williams said.
Part of a three-person team, Williams sees any patient who will talk with him. He and his colleagues coach, listen and attempt to match people with addiction treatment in the community. They track patients after they leave the hospital, offering treatment to those who've said no in the past and following the progress of patients in recovery.
The work is challenging. Even as a team member found housing for Rivera, Williams studied bus routes and methadone centers so he could arrange care for another patient who asked for treatment near her home so she could keep babysitting her 11-month-old grandchild. And then he took a call from downstairs: A middle-aged woman, a former patient, was in the hospital's clinic, tearfully begging for another chance. Williams went down to speak with her.
Minutes later, he worked the phones between bites of pizza in the cafeteria. This was tricky. The woman had burned bridges by walking out of treatment. Williams pounded the table as he talked to a treatment center that didn't want to see her again. "This is me groveling," he said. "This is me begging. I need that bed ... What do I have to do?"
He left messages. Some lines rang and rang.
Although Williams is embedded at Saint Anthony, he and his team work for a large nonprofit treatment provider, Gateway Foundation, one of several groups helping Illinois on the hospital project. Similar hospital-based programs are springing up in Florida, Georgia, Wisconsin, Connecticut, Pennsylvania, Michigan and Vermont, also funded with the temporary Cures dollars.
"It's all about not giving up" on patients, Williams said. "Take all their excuses away."
The next day, in Room 636, Rivera put on jeans and a baseball jacket, getting ready to leave. First, he had to meet with Alexander Hannah, a case manager from an insurance company with a state contract to keep Medicaid costs down.
Rivera was just one of Hannah's caseload of 102 of the most expensive patients. He made calls to change Rivera's approved pharmacy to one within walking distance of the facility where he would be living. He gave Rivera the name of the closest hospital, and told him that he should be able to find work nearby.
Hannah and Rivera exchanged a fist bump. It was time to head downstairs. The van was coming.
"I'm not feeling good today," Rivera said in the lobby. "I'm getting chest pains."
Williams watched as Rivera walked into the hospital emergency room instead of through the front door. Then he watched him slip away. Rivera would be seen hours later jaywalking across a busy street and disappearing into an alley. In the days to come, his cellphone went unanswered.
Williams was undeterred. "It's just part of the job," Williams said in the elevator as he headed back to the sixth floor, where four other heroin users were trying to change their lives.
"I used to go home and cry," Williams said. "I've spent many days crying, cursing and yelling."
He learned, though, not to judge progress by a single day. People with cold feet, people who relapse, sometimes return to treatment. Like the woman who showed up pleading for another chance — she was now in treatment.
Nobody knows the best way to measure success in the fight against addiction. The things that are easiest to count — new doctors trained, new patients entering care — aren't particularly good predictors of long-term abstinence or lasting recovery. This particular week, eight opioid-addicted patients were admitted to Saint Anthony; the team helped half of them start treatment.
Progress — and failures — will be reported to the state of Illinois and the federal government. Ultimately, Congress will decide whether to give more money to this and other efforts.
Thursday morning. The van was coming, this time for 58-year-old Albert Nunley.
Two days earlier, he told a counselor he'd been using heroin for nearly 40 years. The fentanyl now lacing the heroin on the streets was scaring him. A friend recently died of an overdose. His doctor kept telling him to quit. Above all, Nunley felt guilty around his grandchildren.
"I don't want to die from drugs," he said.
Heroin for him wasn't about getting high, but about fending off withdrawal sickness. "You got to snort two dime bags in the morning, two in the afternoon and two at night. Just to make yourself feel right," Nunley said.
Now he was heading to his first appointment at a methadone clinic, treatment arranged by the warm hand-off team. He smoked a cigarette outside the hospital. He'd been dressed and ready since dawn.
"I'm going to walk that straight line," he declared as the van pulled up. He clutched a plastic bag containing an umbrella, pretzels and some paperwork as he got in.
"You got all your discharge paperwork?" Williams asked from the driver's seat.
"Yeah, I got all that."
Nunley had goals, small ones: "I done took my first step. Now I want to ... stay focused ... on doing the things I got to do. Going to AA meetings and things like that. "
The van arrived at the treatment center. Williams and Nunley shook hands, and Nunley walked through the door.
Follow AP Medical Writer Carla K. Johnson on Twitter: @CarlaKJohnsonCopyright 2018 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.