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The
addiction treatment program at Highland Hospital’s emergency room is
only one way that cities and health care providers are connecting with
people in unusual settings.
Another
is in San Francisco, where city health workers are taking to the streets
to find homeless people with opioid use disorder and offering them
buprenorphine prescriptions on the spot.
The city is spending $6 million on the program in the next two years, partly in response to a striking increase in the number of people injecting drugs on sidewalks and in other public areas.
Most of the money will go toward hiring 10 new clinicians for the
city’s Street Medicine Team, which already provides medical care for the
homeless.
Members of the team will
travel around the city offering buprenorphine prescriptions to addicted
homeless people, which they can fill the same day at a city-run
pharmacy.
At
the end of a recent yearlong pilot, about 20 of the 95 participants
were still taking buprenorphine under the care of the street medicine
team.
Dr. Barry Zevin, the city’s
medical director for Street Medicine and Shelter Health, hopes to
provide buprenorphine to 250 more people through the program. That’s
only a tiny fraction of the estimated 22,500 people in San Francisco who actively inject drugs, he said, but it’s a start.
What
follows is a condensed, edited interview with Dr. Zevin, who has been
providing medical care to the homeless in San Francisco since 1991.
Why offer buprenorphine on the streets instead of in a medical clinic?
Most
health care for the homeless happens under the model of waiting for
people to come in to a health center. But a lot of people never come in.
There are a lot of mental health, substance abuse and cognitive
problems in this population, a lot of chronic illness. Appointments are
the enemy of homeless people. On the street there are no appointments,
and no penalties or judgments for missing appointments.
Are you finding a lot of enthusiasm for the buprenorphine program?
Virtually
all the people we interact with are interested. The people we approach
on the streets and in encampments tend to be the longer-term users. At
our needle exchange sites, it’s younger people who have maybe spent less
time using.
Do
you try to make sure that people are taking the buprenorphine you give
them, and not selling it to others who might abuse it? Do you check to
see whether participants are still using illicit drugs?
We’re
paying attention — we’re doing urine testing. But it’s not a barrier.
People can still be in the program. Our pharmacist today said it looked
like one patient was still using and hadn’t had a toxicology that showed
he had bupe in his system for a couple months. So we will give him a
three-day supply, then check him again. If he’s not taking the
buprenorphine, we will offer observed dosing daily for the next three
days.
I
do have to worry about diversion, but I want to individualize care for
each person and not say that that worry is more important than my
patient in front of me, whose life is at stake.
What happens if a patient in this program is using other drugs besides opioids — like methamphetamine or cocaine?
It’s
really, really hard to treat people with co-occurring meth and opioid
use disorder. Only a few places have such a strong trend of people using
both these drugs, and San Francisco is one of them. Easily 75 percent
of my patients use both every day.
But
at least we are reducing the risk of death, even if somebody’s only
taking their bupe some of the time. It’s especially important now
because of the poisoning of the heroin supply with fentanyl.
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