Meeting people where they are.

Increasing access to medication for addiction treatment.

The challenge

In 2015, the San Francisco Department of Public Health declared public injection a public health priority.

As a result, San Francisco’s Low-Barrier Buprenorphine Program was born with the mandate to break down existing barriers to treatment and health care for public injectors. The result was an innovative street-based medicine approach, aligned with the Street Medicine Team’s mission of providing effective care for high risk, high vulnerability individuals experiencing homelessness, who were not getting what they needed elsewhere in the system.

Despite having programs that offer buprenorphine treatment within primary care and mental health centers in San Francisco, many individuals experiencing homelessness were not receiving treatment. Our needs assessment studies indicated that lack of treatment was due to barriers to access rather than lack of interest.

Barriers to Overcome

People experiencing homelessness with substance use disorders face multiple barriers accessing health care, including access to Medications for Addiction Treatment (MAT) to treat opiate dependence.  We are constantly working to understand and adjust our approach to improve access to effective treatment and health care.

Healthcare

Patients often distrust the health care system because of past negative or traumatic experiences particularly around substance use and the surrounding stigma.

Insurance Coverage

It’s common for people experiencing homelessness to lack insurance coverage.

Identification

Individuals may not have (and face barriers in obtaining) proper identification.

Appointments

Making and keeping appointments can be extremely difficult for people living with addiction and experiencing homelessness.

Priorities

Patients may prioritize basic needs or other goals that deviate from traditional primary care plans.

Care Coordination

Patients may have needs that require multiple disciplines within the health care system to address.

A different approach

Our program is for individuals experiencing homelessness. We operate at locations where our patients are already comfortable or residing and offer care regardless of insurance coverage on an open-access basis – with no appointments. We provide multidisciplinary care by professional and peer staff highly knowledgeable in harm reduction, low-barrier medication for addiction treatment (MAT) and working with the target population.

Dr. Barry Zevin discusses the effectiveness of a model that reduces the barriers people face, taking their most basic needs and daily experiences into account.

Common Misconceptions

“Homeless people and people who use drugs don’t prioritize their health.”

A pillar of harm reduction is believing that people will make positive health choices if those choices honor the reality and context of their lives. Our experience on the Street Medicine Team is that our patients, like most healthcare consumers, are concerned about their overall health, confused about their medical history, and want a trusted medical provider to believe and listen to their healthcare concerns.

“People will get sick if they use buprenorphine-naloxone and opiates together because of the naloxone.”

People do not get a medication-induced withdrawal from the naloxone preparation in buprenorphine-naloxone if they take the medication sublingually. Naloxone is not absorbed through the oral mucosa. People can experience a medication-induced withdrawal from the buprenorphine if taken too soon after using heroin or other opiates, including methadone. Carefully reviewing how to start buprenorphine to treat opiate use disorder should prevent medication-induced withdrawal. It is important to mention that some patients seem to have a sensitivity to the small amount of naloxone absorbed, and can experience side effects like nausea.

“The Street Medicine Team in San Francisco dispenses buprenorphine to people on the street.”

We do not directly dispense buprenorphine. We prescribe and facilitate access by working with San Francisco’s Community Behavioral Health Services Pharmacy or with a patient's preferred pharmacy. We help patients by accompanying them to the pharmacy if needed. We do not require patients to be in withdrawal before prescribing Buprenorphine. Our model is a non-facility based induction model. We educate patients on when it would be effective to start and allow them to start when they are ready.

“Patients using methadone or other long-acting opioids cannot transition onto buprenorphine.”

It is more challenging to start buprenorphine in the setting of long-acting opiates, particularly methadone. Patients who have been on high doses of methadone for long periods of time may require more support starting buprenorphine. Our approach on The Street Medicine Team is to assess the perceived barriers a patient is experiencing with whatever opiate they are using and work to address those barriers.

“It is not safe to prescribe buprenorphine if a person is using alcohol.”

Though alcohol is a sedative-hypnotic drug, there is no evidence to support that buprenorphine is absolutely contraindicated when people are using alcohol. Severe alcohol use disorder is a barrier to adherence. Our approach is to work with patients using alcohol to reduce their consumption, follow-up closely with frequent face-to-face visits, and partner with our pharmacists and other community allies to monitor for sedation and enhance adherence.

“Buprenorphine is a dangerous street drug adding to the national opioid crisis.”

Individuals experiencing homelessness are at high risk of lost and stolen medications due to the insecurity of their living situation. They are also known to have distinct patterns of sharing drugs and medications with partners and other opioid users. Our concerns are somewhat relieved by the unlikelihood that diverted buprenorphine in the community will cause serious harm. In the community in which we work and in which there is possible diversion there are no infants or young children and very few opioid-naïve individuals who could be harmed from an overdose of buprenorphine used alone. Buprenorphine is unlikely to cause an overdose even in an opioid-naïve adult and is less likely to cause an overdose if mixed with sedatives than commonly used street opioids combined with sedatives.

Measuring Outcomes

For our program, success is measured by retention in care. Additional measures are improvement in patients’ overall health and functioning, as well a progress towards goals that are mutually established by the patient and the care team. This is in contrast to conventional thinking about buprenorphine treatment, where success is measured by short term and long term abstinence.

0 %

of patients returned for a follow-up visit

0 %

of patients were retained in care at one month

0 %

of patients who followed-up after intake demonstrated a significant reduction to their opioid use with at least one urine drug test that was negative for all opioids

0 %

showed evidence of abstinence from opioids on all tests

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