In San Francisco, Opioid Addiction

in San Francisco, Opioid Addiction Treatment Offered on the Streets

The addiction treatment program at Highland Hospital’s ER is merely a method that cities and health care providers are connecting with people in unusual settings.

Another is in San Francisco, where city doctors are taking to the streets to seek out homeless people with opioid use disorder and offering them buprenorphine prescriptions on the spot.

The city is spending $6 million on the program within the next two years, partly in response to a striking increase within the number of individuals injecting drugs on sidewalks and in other public areas.

Most of the cash will go toward hiring 10 new clinicians for the city’s Street Medicine Team, which already provides medical aid for the homeless.

Members of the team will travel around the city offers buprenorphine prescriptions to addicted homeless people, which they will fill an equivalent day at a city-run pharmacy.

At the top of a recent yearlong pilot, about 20 of the 95 participants were still taking buprenorphine under the care of the road medicine team.

Dr. Barry Zevin, the city’s medical director for Street Medicine and Shelter Health hopes to supply buprenorphine to 250 more people through the program.

That’s only a small fraction of the estimated 22,500 people in San Francisco who actively inject drugs, he said, but it’s a start.

What follows may be a condensed, edited interview with Dr. Zevin, who has been providing medical aid to the homeless in San Francisco since 1991.

Why offer buprenorphine on the streets rather than during a medical clinic?

Most health looks after the homeless happen under the model of expecting people to return to a clinic. But tons of individuals never are available.

There are tons of psychological states, drug abuse, and cognitive problems during this population, tons of chronic illness.

Appointments are the enemy of homeless people. On the road, there are not any appointments and no penalties or judgments for missing appointments.

Are you finding tons of enthusiasm for the buprenorphine program?

Virtually all the people we interact with have an interest.

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 that have maybe spent less time using it.

Do you attempt to confirm that folks are taking the buprenorphine you give them, and not selling it to others who might abuse it? 

does one check to ascertain whether participants are still using illicit drugs?

We’re listening — we’re doing urine testing. But it’s not a barrier. People can still be within the program.

Our pharmacist today said it seemed like one patient was still using and hadn’t had a toxicology that showed he had been in his system for a few months.

So we'll give him a three-day supply, then check him again.

If he’s not taking the buprenorphine, we'll offer observed dosing daily for the subsequent three days.

I do need to worry about diversion, but I would like to individualize look after everyone and not say that that worry is more important then my patient ahead of me, whose life is at stake.

What happens if a patient during 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 couple of places have such a robust trend of individuals using both these drugs, and San Francisco is one among them.

Easily 75 percent of my patients use both a day.

But a minimum of we is reducing the danger of death, albeit somebody’s only taking their bupesome of the time.

It’s especially important now due to the poisoning of the heroin supply with fentanyl.