King of the Streets

When Adolphus Nickleberry woke up in the hospital, he had an IV in his arm and an intubation tube down his throat. He was restrained by his wrists to the bed. A doctor looked down at him. “Welcome back,” the doctor said. “Again.” 

It was the fifth time in November 2018 alone that Adolphus had visited the ER at University of Utah Hospital in Salt Lake City. Each time an ambulance had to be called because the 58-year-old had collapsed in respiratory failure after smoking crack cocaine, his emphysema-damaged lungs unable to get oxygen into his bloodstream with the addition of the toxic smoke.

“Man, what are you doing?” Nickleberry thought. “This life ain’t me. I want my own apartment, my own car. I want my family back in my life.”

Ryan Morgan, a licensed clinical social worker at University of Utah Health’s Intensive Outpatient Clinic (IOC), learned Adolphus was back in the ER the next day. The IOC provides long-term medical and mental-health care tailored to the individual needs of marginalized and impoverished patients who have lengthy, complex histories of addiction and trauma. Traditional clinics struggle to care for patients like Adolphus, so they end up repeatedly going to the ER or the hospital, placing a significant financial and medical drain on the health care system.  

Adolphus wanted to return to a treatment center where he’d done several stints at before. But when Morgan asked the center, they said their wait time was a year.

Morgan knew that Adolphus couldn’t wait that long. He called a director at the treatment center. “Adolphus is in the ED again,” Morgan said, a note of urgency in his voice. “We’re afraid he’s gonna die.” There was silence on the other end of the line. “Have him come here Saturday,” the director said.

Adolphus Nickleberry and the Intensive Outpatient Clinic have much in common. Both were driven by deeply personal goals. Peter Weir, MD, the IOC’s founder and executive medical director of population health at University of Utah Health, wanted to fundamentally change health care by addressing gaps in care. Adolphus wanted to become the caring parental figure his tragic childhood and addiction denied his children.

To reach those goals, both found themselves navigating sometimes surprising and certainly challenging byways of new worlds.

The IOC pursued controversial approaches: a harm-reduction model to addiction, which provides additional tools for providers working with patients unable or unwilling to stop substance use, along with an integral mental-health model where social worker and medical provider had equal voice and footing on the team.

Adolphus had to learn to step out of his street role as a hustler who trusted no one to open himself up to the point of vulnerability so his IOC team could help him. He also had to find it within himself not only to stick to his commitment to sobriety but to learn to listen to his own instincts when he knew what was best for his recovery—even if it flew in the face of what he was being told by a treatment center or the IOC.

Ultimately, their journeys were indelibly intertwined. Adolphus and the IOC both had to prove that they could live up to their own promises of profound change.

A quiet, polite man with a deeply rebellious, even subversive streak, Peter Weir invested everything in the IOC’s success. His passion lies in rethinking health care so it can be patient-focused, affordable, and accessible.

University of Utah Health Plans agreed to fund the clinic through its Healthy U Medicaid program in exchange for bringing down the costs of some 100 Salt Lake County residents who, as identified through claims data, were consuming significant health resources through repeated visits to the ER and subsequent hospitalization. When Weir told one doctor how the model worked, she laughed him out of her office.

The clinic opened in February 2017 in the basement of University Hospital, manned by a part-time medical provider, social worker, case manager, and assistant. Six months later, Weir knew he was onto something when the IOC’s first social worker told him something surprising: every IOC patient had a history of childhood trauma.

A second theme emerged to link the IOC’s patients together: staying with them long-term and never giving up on delivering individualized care and support. “Our clinic is designed in every way to earn and develop trust with our patients,” Weir said. What helps to build that trust is what mainstream medicine doesn’t offer: home visits and working with patients to address substance abuse rather than demanding sobriety.

“That’s our currency,” Weir said. “Trust is what gets the relationship going.” Childhood trauma was something that Adolphus knew intimately. Born in Salt Lake City, he grew up in the Rose Park neighborhood. Adolphus adored his mother, Jessie Lee, who had sickle cell anemia and stayed at home to care for her four children. His father, Adolphus Sr., struggled with asthma. He cleaned downtown offices at night, sometimes with his children helping by emptying wastepaper baskets while their father mopped and buffed floors.

As Jessie Lee got sicker, she couldn’t care for herself. One day, five-year-old Adolphus came home from school to find his 35-year-old mother’s bed empty. She had been taken to University Hospital. But he didn’t say goodbye. The next time he saw her, she was lying in a funeral casket, her face covered by a veil.

Three years later, tragedy struck again. One cold night in January 1969, when Adolphus was eight years old, his 53-year-old father came home from work, entering uncharacteristically by the front door. He had had a severe asthma attack. “Should we call Dr. Bailey?” his brother asked, but their father said no. Doctors were expensive. The next morning, their uncle went to check on his brother. “He’s passed away,” he said.

Without a male role model, Adolphus latched on to an older brother who used drugs, partied, and had gone to prison. At his nearly all-white junior high, Adolphus played basketball and ran track and field but found he fit in best with the students who skipped school and smoked weed. 

By the time Adolphus was 15, those students had gone from fighting white kids to Pacific Islander youth. One day, to impress his friends, Adolphus took his grandfather’s gun to school. He pulled it out when someone gambling with his friend refused to pay a debt. A school cop appeared and Adolphus took off running, only to be arrested shortly after. He was court-ordered to an adolescent treatment program, but as soon as he finished the program, he was using drugs again.

When he was 19, Adolphus started dating 17-year-old Audrey Drawn. She loved the color of his eyes and his smile. He was the best person you ever wanted to know, Audrey thought, who would give you anything and everything. But once he started drinking, he changed. If somebody talked to her, he clenched his fists; if somebody looked at her, he threw punches.

A few years later, Adolphus began using crack cocaine. He dealt drugs to finance his own habit and, in the process, became known on State Street, North Temple, and downtown for his drug contacts—an uncrowned king of the streets.

When Adolphus was arrested and jailed for drug-related offenses, Audrey went to see him. She was pregnant with their first child and wanted him to remember that his family was waiting for him on the outside. But rather than fight his charges, Adolphus took a plea deal. Audrey was left alone to support baby Candice, and, later, Aubrey, whom she had with another partner.

Adolphus got out of prison in 1987 and went to a halfway house, only to take off and start using again. He’d be gone for two or three days on a drug binge, then return home wanting only to sleep.

He dealt drugs to finance his own habit and, in the process, became known for his drug contacts—an uncrowned king of the streets.

As his daughter Candice and stepson Aubrey got older, Adolphus missed out on much of their lives. To Aubrey, it seemed like his stepdad was always in prison wearing his white inmate uniform or on the street chasing his next high. But despite the absences, Adolphus did the punishing and grounding, even from prison.

After another stint of using, Audrey and Candice cut ties. The one person Adolphus remained close to was Aubrey, who idolized him for his good looks, charismatic manner, and presence. But the anguish of Adolphus’s constant absence haunted him well into adulthood. He followed his stepfather’s path, using drugs and spending time in prison.

Yet where Aubrey’s journey differed from his stepfather’s is that Adolphus’s very absence and failure as a male role model drove Aubrey to finally quit using heroin so he could be there for his own children. One night in 2016, Aubrey chose his family over drugs—a decision Adolphus had yet to make.

Recovering from a stroke in 2014, 53-year-old Adolphus was diagnosed with COPD, diabetes, and high blood pressure. Three years later, the IOC discovered Adolphus among some of the top users of hospital and ER resources in claims data. His doctor at the time, Paige Patterson, MD, brought him to the IOC’s temporary location (it subsequently moved to West Valley to be more accessible to its patient community). When Adolphus went down to the University Hospital basement with her, he knew all too well what else was on that floor. “Damn,” he thought. “Is this part of the morgue?”

At first, he told IOC staff what he thought they wanted to hear. Morgan, the social worker, knew about addiction through his father’s struggles with alcoholism. He understood that addiction equaled isolation, and that often therapists and treatment providers find it hard to see the human beings behind their addiction.

The IOC helped Adolphus get a housing voucher, then an apartment in downtown Salt Lake City. In mid-2018, he told his team that he was done with his treatment and felt fine. But Kay McMahon, PA, a recently hired IOC medical provider, was far from convinced.

It had been 14 years since the former partners had seen each other, and as they sat around on the deck that evening, he told her he was starting over.

McMahon worked hard to overcome Adolphus’s initial mistrust. Because he was so sick with COPD and in the midst of substance-abuse recovery, McMahon was frightened for him.

Again, Adolphus fell off the IOC’s radar. They kept pushing and checking in on him, only to get radio silence. He spent his rent money on drugs, let people from the street shower and party at his apartment, and soon lost his housing voucher. He reached out to the IOC for help getting his apartment back, but Morgan wanted to have a wider conversation.

“I think we need to get you back into treatment,” Morgan said. “Let’s try to figure that out.” But Adolphus wasn’t listening. For a few months, he managed to keep a hotel room going. Adolphus continued showing up in the ER again and again with crack-triggered respiratory failure. Morgan told him repeatedly he needed treatment. After that fifth ER visit in November 2018, Adolphus agreed.

When he arrived at the door of the treatment center an employee said: “This is your third time. Please make it your last.”

Adolphus graduated from the treatment center to a clean and sober living facility in Sandy, but after a few months there, he felt it wasn’t working for him. Adolphus took public transportation from Sandy to downtown Salt Lake City every day to look for an apartment. A complex accepted his application for a sixth-floor one-bedroom apartment. That wasn’t his only success that summer. He also reconnected with his family.

He and his stepson Aubrey hung out together, finally bonded by family rather than addiction. Adolphus had also become closer to his daughter, Candice. Aubrey asked his mom if he could bring Adolphus to her 2019 Fourth of July barbecue at her Ogden home. She agreed.

It had been 14 years since the former partners had seen each other, and as they sat around on her deck into the evening, he told her he was starting over. “I’m clean. I don’t want to do this no more.”

At the same time, the IOC was improving their patients’ lives in addition to providing medical care. Because the clinic was in a stable place, Weir knew it would be good timing to bring on new leadership. He hired Stacey Bank, MD, a family medicine provider, to take over as medical director.

She quickly learned how forward-thinking the IOC was. At her old clinic, if a patient didn’t come to an appointment, it was difficult to make follow-up calls. But at the IOC, there was an expectation that follow-up calls to a struggling patient who had fallen off the radar were an essential part of the practice.

Six months after Bank joined, the COVID-19 pandemic began. For many patients, the clinic and its staff were their only point of contact. The clinic was like family, and they missed the structure of regular appointments within a defined physical space. Several patients decompensated behaviorally.

While some of Adolphus’s fellow IOC patients struggled with deteriorating mental health, Adolphus was unfazed. He continued his meetings online, exercised, watched The Young and the Restless—his favorite soap opera for 30 years—and, when he saw homeless men on the streets with no one to talk to, tried to offer them comfort.

He wanted to do more for the addicted, the homeless, and the formerly incarcerated, as well as teens drawn to the life that he had followed. But he feared he could never become a counselor with his lengthy criminal record.

He worked with Michelle Betts, his case manager at the time, to apply to the Board of Pardons for a pardon for his 27 convictions—seven of them felonies, the rest misdemeanors. He completed all the leg work, returning to prisons and jails to retrieve records, including discipline and other paperwork. Together, they turned in the 190-page application. 

Adolphus’s story was captured in a film for U of U Health. Meet Me Where I Am follows Adolphus through his journey at the IOC as he worked to rewrite his story with the help of compassionate providers. One Tuesday afternoon in May 2022, Adolphus waited nervously in the clinic’s reception area as officials from the Department of Corrections, Adult Probation, and Parole, Utah’s government planning and budget office, and U of U Health Plans arrived for a screening of the film and a discussion about the issues it raised. In total, close to 30 people filled the room. Adolphus couldn’t help but notice he was the only Black person in the room.

After the movie was shown to applause, Adolphus told the room that he had recently been certified as a peer support specialist. “I’m ready to help whoever needs it,” he said.

One official called what the film revealed “the holy grail,” taking a trauma-informed approach to care to “treat people like human beings.” Another added, “It’s just a seed planting at this point. But we have to figure out how to capitalize on this beautiful thing you’re doing.”

Some of the conversation focused on cost savings, a theme central to the success of the IOC model. Bank told the room the IOC was saving U of U Health Plans about $2 to $3 for every $1 they spent on the clinic. One official spoke up emotionally, drawing nods of recognition and approval from law enforcement and correction officers. “Instead of hurting people, we can be healing people,” she said.

A corrections employee argued that the prison needed to rethink re-entry specialists within a social work context. “This is the model here,” he said about the IOC’s work. “We can be part of that.” Adolphus summed up the meeting and its surprising nature—along with his recovery and return to family life—in awestruck tones. “I didn’t think I’d ever be in a room like this,” he said.