Frequently Asked Questions

Approach

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

The program is built on the understanding that aspects of substance use and our society’s attitudes toward substance users can be destructive to an individual’s health, and broader social systems. This program focuses on reducing the most severe harms, including fatal overdose, infectious diseases, neglect of overall health, needle waste in the street, and violence and crime.

The target population for this program is high-risk / high-vulnerable people experiencing homelessness. We operate at locations where the target population is already comfortable or residing and offer care regardless of insurance coverage on an open-access basis—with no appointments. The program provides 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.

This program is for individuals experiencing homelessness. Due to poverty, related discrimination, disadvantage, and disability, and to the lack of affordable housing, many participants may remain homeless and continue to experience problems related to homelessness. Additionally, the current pattern of substance use in the target population is predominantly the use of opioids and methamphetamines together, which is a challenging addiction disorder to treat.

Among the participant population, there is a lack of trust in medical systems. Participants often don’t have identification, insurance coverage, and have difficulty keeping appointments. Additionally, different goals between participants and prescribers create a barrier for the participants to engage.

There is often a need for more intensive care than traditional clinics offer. Limited capacity to treat common co-occurring medical and psychiatric problems results in behavioral issues which can result in Restriction of Service for the client.

We educate and counsel participants, navigate them to an appropriate National Toxicology Program (NTP) based on their needs, and continue to offer them other healthcare services.

Program Participants

Our target population is people experiencing homelessness with moderate to severe opioid use disorder (OUD) and other substance use disorders (SUDs) who are not otherwise receiving adequate and effective treatment.

Street Medicine Health Workers and other community partners conduct outreach and engagement. Individuals in targeted areas and designated sites are informed about SFDPH efforts to reach and help active substance users who inject in public places. Our education and practical assistance focus on:

  • Referral to street medicine for assessment for low barrier buprenorphine start
  • Reducing syringe and needle waste left in public places
  • Facilitating access to treatment, including navigating to methadone treatment and residential or outpatient treatment programs for those who are appropriate and interested
  • Assistance to obtain Medi-Cal for those eligible

Street medicine nurse, NP pr MD conducts the initial assessments in the location most comfortable to the participant. The locations might include streets, parks, encampments, sobering centers, harm reduction centers, navigation centers, or in open-access clinic spaces.

Assessments include history (health history, substance use history, previous experience with MAT), a focused physical exam, and evaluation of possible barriers to care. Lab testing including urine toxicology is done when practical and is not creating a barrier to care. At times, we defer the test until it is clinically safe to do so.

In the initial weeks of treatment, participants are seen once or twice a week. Depending on the participants’ needs, these visits are with a combination of nurses, medical providers, and clinical pharmacists. Health workers and outreach may see participants even more frequently. Participants who stabilize are seen less often, usually monthly.

Participants fall in and out of treatment for a variety of reasons. We attempt to outreach participants and stay connected (jail visits, for example, if individuals are incarcerated.) If the participants return, they are welcomed back and assessed for how to improve their care and connection in the future. Participants who request re-prescription (re-engagement) after a period out of care, usually receive it.

Medication

Our team does not hand out buprenorphine and only prescribes buprenorphine.

We prescribe buprenorphine at the first visit if it’s beneficial to the participants’ care.

We work closely with Community Behavioral Health Services (CBHS) pharmacy, a program of the San Francisco Department of Public Health.

In the initial weeks of treatment, participants are seen once or twice a week. Depending on the participants’ needs, these visits are with a combination of nurses, medical providers, and clinical pharmacists. Health workers and outreach may see participants even more frequently. Participants who stabilize are seen less often, usually monthly.

CBHS has extensive experience in educating and counseling high-risk participants and working closely with community-based providers. They can offer up to five days a week dispensing or direct observed therapy. CBHS is co-located with a clinical program that can provide point-of-care urine drug screening and therapeutic monitoring for buprenorphine.

We work with participants to understand their needs and priorities. Due to limited hours of operation, location, past negative experiences, or rarely being restricted from service, some participants prefer or require other pharmacies.

The most typical expected duration of the initial prescription is 3-4 days.

Most participants receive one week of medication at a time.

In general, if a participant can safely manage one month of medication, they are ready to transition to a regular office-based opioid treatment program. Also, if a participant has a verified and realistic plan to leave San Francisco, we may give a 1-month supply to help assure they can connect to care at their destination.

We do not directly dispense buprenorphine. We prescribe and facilitate access by working with our SFDPH CBHS pharmacy or with a participant’s preferred pharmacy. We help participants by accompanying them to the pharmacy if needed and in rare instances, we may prescribe the medication and have a team member pick it up and deliver it to a participant.

Yes, we administer Naltrexone XR in our open access clinic and at other sites. We can dispense or order commonly needed medication including antibiotics and hypertension medication.

Our model is a non-facility based induction model. We educate participants on when it would be effective to start and allow them to start when they are ready.

The Street Medicine team physician or nurse practitioner with the Drug Addiction Treatment Act of 2000 (DATA 2000) waiver evaluate participants face-to-face. The following information is documented:

  • Diagnosis of moderate to severe opioid use disorder
  • Challenges to success of treatment including co-occurring disorders
  • Presence of absence of community support and stresses
  • Presence or absence of contraindications
  • Presence or absence of concerning activity on review of CURES (CA PDMP)
  • Consent to treatment
  • Participant goal and level of determination to engage in the program
  • Documentation in electronic health record (or paper format for later documentation in EHR)

 

 

We use a harm reduction approach. If treatment appears to be doing more harm than good we may change, intensify, or stop the current treatment model (including buprenorphine prescription) and offer an alternative approach. On rare occasions that participants need to change treatment due to safety concerns (for example violent or threatening behavior toward another participant or staff), we are usually able to manage this with our flexible locations and approach.

Ongoing Care

We monitor diversion among our participants and in the community. At present in our community Buprenorphine appears to be used almost exclusively by opioid users for avoiding withdrawal when they do not have access to other drugs, or cannot initiate abstinence attempts. We’ve found that Buprenorphine stays within the group that is our target population. 

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. 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.

We provide education and counseling to all participants. We assess counseling needs at every encounter and advise the type based on participant’s request, functioning, current substance use patterns, and participant’s progress toward goals for stability. Specialized counseling is available for participants who request or require counseling beyond the capacity of program health workers, nurses and medical providers.

All of our staff are trained to offer counseling and education on Medication-Assisted Treatment (MAT). We’ve partnered with the Center for Harm Reduction Therapy and provide harm reduction psychotherapy to participants on-site at several of our sites and in an innovative street counseling model. Additional counseling is available outside street medicine by referral to substance use disorder treatment programs on an as-needed basis.

Policy & Regulations

Opioid use disorder is the primary focus of our program. We address alcohol use disorders, and other substance use disorders while treatment for acute and chronic co-occurring medical and psychiatric conditions are also available. The most commonly prescribed medication is buprenorphine for OUD and Naltrexone XR and other medications are given when appropriate for OUD, AUD.

Success Factors

The primary measure is retention in care. Additional measures are improvement in participants’ overall health and functioning. For our program, success is measured in relation to goals that are mutually established by the participant and the care team as compared to standard buprenorphine treatment, where success is measured by short term and long term abstinence.

Staff & Resources

Staff includes health workers, doctors, nurse practitioners, registered nurses, harm reduction psychotherapists, psychiatrist, administrator (monitoring compliance, outcome measures, etc)

We offer a centrally located open access clinic, syringe access sites, navigation centers, encampment health fairs, and street outreach.