As a Catholic Jesuit institution, if we can’t wade into these murky waters, who can?Fred Rottnek, M.D.
When you meet Fred Rottnek, M.D., MAHCM, it’s hard to know where to look first. His thick salt-and-pepper braid down his back. His office—liberally decorated with Hello Kitty memorabilia, in honor of his former cat, Baby Dirty Girl Brenda.
But it’s Dr. Rottnek’s tattoos that stand out the most, and help tell his story best. On his left forearm, in thick black typeface, reads a quote from the 8th Amendment, “Excessive bail shall not be required, nor excessive fines imposed, nor cruel and unusual punishments inflicted.” In 1976, the U.S. Supreme Court ruled that this amendment mandates anyone who is incarcerated has a constitutional right to healthcare. On his right arm, is an apocryphal, though popular, quote, “The hottest places in hell are reserved for those, who in time of great moral crisis, maintain their neutrality.” It’s what he calls his “tattoo of solace.”
The Long Path
A graduate of Furman College, Dr. Rottnek was the first in his family to go to college, and was then offered a full ride to Harvard to study bioorganic chemistry. Struggling with depression, he left Harvard and would later earn a theology degree in healthcare mission from Aquinas Institute of Theology.
Dr. Rottnek enrolled in the Saint Louis University School of Medicine in 1991, and as first-year student gravitated toward a mini-elective on homeless healthcare which allowed him to participate in homeless care at different shelters. He had considered going into psychiatry because of his own history, as well as a family history of depression and alcoholism. But he had a love for family medicine because it provided more tools which allowed him to work with patients.
At Home, Behind Bars
After training at Deaconess and UNC Chapel Hill, his practice was approached by the St. Louis County Department of Public Health to staff correctional healthcare at the Buzz Westfall Justice Center and St. Louis County Family Courts. “I had been doing homeless work for long enough that I figured jail was going to be homeless work, but with more resources. So I ended up transitioning into becoming the medical director,” said Dr. Rottnek.
“For over 15 years, that was my clinical work. I loved working with the patient population because the vast majority of people who are in jail are there because they don’t have resources—most have mental health issues, substance abuse issues or both.”
Dr. Rottnek was a tireless advocate for medical services for inmates. He was also passionate about opportunities for students. “I always had students and residents with me. We created an interprofessional practice. We had 11 different professions at the time I left, so we were able to do integrated care at that facility.”
2016 was a pivotal year in Dr. Rottnek’s life. At the same time St. Louis County considered privatizing health services at the jail, addiction medicine was recognized as its own specialty by the American Board of Medical Specialties. This provided an opportunity for Dr. Rottnek to become board certified in addiction medicine.
A Perfect Storm
The landscape of how addiction is impacting society has dramatically changed. A number of factors are colliding in a way that generates significantly more attention to the problem. In past epidemics, in which racial minorities were impacted disproportionately, access to treatment was not available.
A generation of young black men with addiction to crack and methamphetamine were incarcerated, ignored or allowed to die. The opioid epidemic has impacted well-resourced white people—and society is responding differently.
According to Dr. Rottnek, in 2017, at least 72,000 people died from drug overdoses in the U.S., the majority of which were caused by synthetic opioids. In the same year, 90,000 people died from alcohol-related use, and over 400,000 people died from tobacco-related use. However, many experts believe these numbers don’t tell the true story behind addiction-related deaths—opioid deaths alone are likely closer to 150,000.
Dr. Rottnek spends much of his time personifying each story within the aggregate numbers of patient populations and asking the deeper questions. “Why are people looking at addictive substances now as a good choice? That’s the issue that we really need to get to—why are we seeing these addiction rates climbing in general? Where is this hopelessness coming from? Why is this turn to chemicals making life more manageable? Why is it becoming a more prevalent occurrence? In the past, we used to moralize addiction; we referred to people with addictions as weak, or flawed, or lazy. Today we have the science that tells us that addiction works like many other chronic diseases,” said Dr. Rottnek.
“Because we have this perfect storm right now. We have the availability of drugs, the unpredictable potency and purity of it. Then we have a generation coming up that’s less resilient, more anxiety prone and put all that together and that’s kind of what’s been driving a lot of the epidemic.”
The way society as a whole is thinking about addiction is changing the way physicians are able to practice. Stigmas are eroding, families and communities are more willing to talk about addiction and support loved ones who are facing addiction, and physicians have more tools to help patients. The timing was right for Dr. Rottnek and his fellow SLU Addiction Medicine colleagues to create the Center for Substance Use Disorders and Pain Management.
SLU is a perfect setup for addiction medicine because we have people working in each of these areas that we can say, ‘Okay, how do we keep building this to find out how to help people thrive? How do we help people flourish? How can we offer the tools that people need to manage their wellness and to move forward?Fred Rottnek, M.D.
Changing the Face of Training: A Three-Pronged Model
As one key facet of the Center for Substance Use Disorders and Pain Management, Dr. Rottnek is leading the effort to create an Addiction Medicine Fellowship at SLU, with an anticipated launch date of July 2019. As a new certification, for the first five years it’s officially a specialty—if a physician can show that she has had significant experience working with addiction—she can sit for boards. After the first five years physicians will have to complete a one-year fellowship in Addiction Medicine. The Addiction Medicine Fellowship is appropriate for any board-eligible or board-certified physician. The “all-in” nature is the key to what makes the Addiction Medicine Fellowship a new model. It’s available and appropriate for any physician to build on a primary specialty. Addiction touches all lives, so the new Addiction Medicine Fellowship is for everyone—family medicine, ER, OB-GYN, pediatrics, psychiatry, surgical subspecialties—and others.
The Addiction Medicine Fellowship is led by Dr. Rottnek, Jaye Shyken, M.D., Jacqueline Landess, M.D., J.D., and Mirela D. Marcu, M.D. Drs. Landess and Marcu are both on the SLU Psychiatry Faculty. Dr. Landess was the psychiatrist at the St. Louis County Jail, and Dr. Marcu specializes in community-based psychiatry.
The need for addiction fellows is growing, and is touching every demographic. That growing need dictates additional training resources, and Dr. Rottnek has plans to address the fellowship demands. “Eventually, I’d love to see three fellows every year. One could be a fellow with a focus on the urban underserved core, because that’s where our residency program is, with the federally-qualified, student-run health center. A second track would be for someone interested in maternal-fetal medicine—working with Dr. Shyken. And a third track—with the VA. We have the opportunity to care for folks who served in the armed services or who have traumatic brain injuries and/or correctional healthcare,” said Dr. Rottnek. He is also exploring a fourth track in Emergency Medicine with SLU’s Division of Emergency Medicine.
Unlike other Addiction Medicine Fellowship programs in the U.S., the SLU program will train fellows in family medicine, maternal-fetal medicine and psychiatry services—providing a competitive advantage for the school. “All the fellows will have some training in each of those areas. With their elective choices, they’ll be able to tailor the year based on their interest and background,” explained Dr. Rottnek.
Creation of the new fellowship is just one aspect of Dr. Rottnek’s work. Because addiction medicine has the opportunity to create transformative change, it’s being addressed through an interprofessional, multidisciplinary collaborative approach. SLU has the medical staff, therapy staff and spiritual components to help people find meaning and value. SLU’s creating collaborations to help ensure patients have not only medical needs met but is connecting the dots of social determinants—including housing, education and jobs.
“SLU is a perfect setup for addiction medicine because we have people working in each of these areas that we can say, ‘Okay, how do we keep building this to find out how to help people thrive? How do we help people flourish? How can we offer the tools that people need to manage their wellness and to move forward?’” said Dr. Rottnek.
Hope on the Horizon
Traditional 12-step therapy models for people to come together for mutual support can be helpful for some, and medication models can provide concrete tools and medical management for patients. The number of options for patients seeking recovery have dramatically increased.
“Most students weren’t taught in medical school about how methadone, Suboxone and other medications work. They help regulate neurotransmitters so that cravings are under control. They give your brain time to heal. Then you can better engage in the therapy to build the type of life you want and deserve,” said Dr. Rottnek.
As these doors are opening, both within society and the medical field, Dr. Rottnek finds there are an increasing number of tools available to treat patients.
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