Low barrier buprenorphine treatment for persons experiencing homelessness and injecting heroin

There was a lot of enthusiasm about this study on twitter recently.

It appears to be based on this program highlighted in the NY Times last year.

. . . 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.

We’ve reviewed the evidence-base for buprenorphine in previous posts. (And, that the outcomes were not what most people imagine when they hear that it’s the most effective treatment or the gold standard for care.)

A frequent criticism of research is that it doesn’t reflect real world conditions.

Well, this study that actually used real-world, high complexity subjects, and examines an intervention getting a lot of recent attention—low barrier buprenorphine prescribing. The reported the following conclusion:

In conclusion, this study found that a low barrier buprenorphine pilot program successfully engaged and retained a subset of marginalized persons experiencing homelessness in care and in continued treatment with buprenorphine.

What was the intervention being studied?

The researchers studied a low-threshold, same day buprenorphine program co-located with medical outreach and harm reduction services, which they described as follows:

Patients are engaged by peer outreach workers or self-present on a drop-in basis to either a small open-access medical clinic or a nearby syringe access program, where a clinician provides comprehensive substance use assessment and education and calls in a same-day prescription for buprenorphine/naloxone to be filled at a community pharmacy that dispenses the medication free to patients who are uninsured or have Medicaid.

This is especially relevant because of growing calls for this type of low-threshold opioid agonist program.

Who was being studied?

The subjects received a buprenorphine prescription from the street medicine program and were complex cases.

The researchers did a retrospective chart review of 95 patients:

  • 100% used heroin and engaged in injection drug use
    • 61% used methamphetamines
    • 26% used cocaine
    • 8% used benzodiazepines
    • 12% met criteria for unhealthy alcohol use
  • 100% were homeless
  • 58% had a chronic medical condition, such as hypertension or hepatitis C
  • 66% had a psychiatric condition
    • 26% with bipolar disorder or a psychotic disorder.
  • 24% previously sought treatment at this program

How long was the study?

The study was 12 months. (That’s very good. This is considerably longer than most studies. The ideal duration would be 5 years, but studies of that duration are extremely rare.)

What outcomes did the study measure?

This study looked at 4 outcomes over 12 month:

  1. Retention in the program’s medical and harm reduction services
  2. Retention on buprenorphine
  3. Urine drug screen results
  4. Overdoses

Retention in care

Retention in the street medicine program, defined as a visit 1 week prior to or any time after each time point:

  • 74% returned for follow-up after the initial visit at least once during the 12 months of evaluation.
  • 63% at 1 month
  • 53% at 3 months
  • 44% at 6 months
  • 38% at 9 months
  • 26% at 12 months

Retention on buprenorphine

Retention on buprenorphine, defined as having active buprenorphine prescriptions for more than 2 weeks of the month:

  • 55% at 1 month
  • 41% at 3 months
  • 38% at 6 months
  • 34% at 9 months
  • 26% at 12 months
  • 46% had a treatment interruption of 1 month or longer with subsequent return to care

Those percentages seem to be reporting on the % at that particular check-in time, not continuous up to that point.

  • Twenty-nine patients (30%) were retained on buprenorphine for at least two of the evaluation time points (months 1, 3, 6, 9, or 12).
  • Of that 30%:
    • 14 (48%) had continuous active prescriptions for buprenorphine during the time they were treated.
    • 5 (17%) of these patients had an interruption in their buprenorphine prescription of 2–3 weeks,
    • 8 (28%) had an interruption of 4–6 weeks, and
    • 5 (17%) had an interruption of greater than 6 weeks. Seven patients (24%) had multiple interruptions.

Urine drug screens

Two hundred and six urine toxicology tests were completed by the cohort, and 71% of patients who followed up after intake had a toxicology test, with a mean of 2.7 tests and a median of one test per follow-up patient (range 0–25).

If 74% of the 95 followed up after intake, that’s 70 patients. If 71% of them had at least one drug screen, that’s about 50 patients.

The median of one test per follow-up patient would indicate that at least half had only 1 drug screen.

Of the 206 drug screens completed:

  • 63% were positive for opioids
  • 73% were positive for methamphetamines
  • 25% were positive for cocaine
  • 10% were positive for benzodiazepines
  • 81% were positive for buprenorphine
  • 23% of patients had at least one opioid-negative, buprenorphine-positive toxicology test.

Overdoses

Emergency department and hospital records were reviewed for adverse events, including deaths and nonfatal opioid overdoses.

  • 1 patient died from fentanyl and methamphetamine overdose
  • 4 patients received emergency or inpatient medical treatment for an opioid overdose requiring naloxone,
    • 1 of these patients had three overdoses that required naloxone,
  • 5 patients were treated for possible opioid overdose events not requiring naloxone

What we don’t know

There are a few questions the study didn’t answer that could have been answered with the data and outcome measures used:

  • How many subjects were continuously on buprenorphine?
  • Were there any subjects were negative for opioids and other drugs at all points (or most points)?

Other unknowns:

  • The article says that patients were offered referrals to methadone and residential treatment. How many accept those referrals and, if successful referral rates are low, why?
  • Were there any quality of life benefits for the patients?

Wrapping up

The study had some interesting thoughts on drug testing and outcomes:

Our urine toxicology results reflect adherence to buprenorphine concurrent with ongoing use of heroin and methamphetamines in a majority of the cohort. We found some evidence of periods of opioid abstinence, with 23% of patients having at least one opioid-negative, buprenorphine-positive test. In our clinical experience, many patients report taking buprenorphine regularly and using substantially less heroin, while still using heroin occasionally. We are exploring this phenomenon further through qualitative research and in-depth interviews with participants, as it is difficult to measure a decrease in amount of heroin use with the binary tool of a urine toxicology test.

And, under limitations:

Frequency of urine toxicology testing varied among participants, so results could be skewed by participants who had more tests and may not be an accurate reflection of the cohort’s substance use. We are not able to report or compare toxicology test results among individual participants at specific time-points because of the variability in testing practices.

Treatment as harm reduction or recovery facilitation?

This discussion of outcomes highlights the tension between treatment as harm reduction and treatment as recovery facilitation.

A recent opinion piece in Emergency Medicine News brings this tension into focus:

Despite press coverage to the contrary, this study [work done by the group led by Gail D’Onofrio, MD, at Yale on ED-initiated buprenorphine/naloxone for opioid use disorder] never demonstrated any impact of ED-initiated buprenorphine on the only objective measure used to assess sobriety, the urine drug screen, nor were any other outcome differences sustained at six months. (JAMA 2015;313[16]:1636; http://bit.ly/2PBwYWdJ Gen Intern Med 2017;32[6]:660; http://bit.ly/2Cj0lbY.)

Despite this, I’m convinced that within the next five years buprenorphine will be routinely administered in EDs for opioid use disorder.

I imagine that most people who are enthusiastic about these projects would respond that they are not looking for “sobriety.”

This is where clarity about goals for an intervention becomes especially important. If we can agree that addiction is a treatable chronic illness, it seems important to more clearly categorize interventions as treatments for the illness of addiction or as palliative care.

If we sell an intervention as treatment at the public level but treat it as palliative care at the academic level, the public, people with addiction, and people who care about them are likely to feel deceived. It also has the effect of eliding difficult conversations about resource allocation and capacity development. For example, is this $6,000,000 allocated to palliative care or addiction treatment? Because it’s not both.

UPDATE: Follow-up post here.

4 thoughts on “Low barrier buprenorphine treatment for persons experiencing homelessness and injecting heroin

  1. Hey Jason,

    Thanks for writing this. I really appreciate your perspective.

    I’m a bit confused about this “it can’t be addiction treatment and palliative care”. Here is a definition of palliative care I found:

    “Palliative care is specialized medical care for people living with a serious illness. This type of care is focused on relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family.

    Palliative care is provided by a specially-trained team of doctors, nurses and other specialists who work together with a patient’s other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness, and it can be provided along with curative treatment.”

    If addiction is a chronic and serious illness, palliative care is a very appropriate part of treatment, and could potentially be the only part depending on a patient’s choice. Perhaps it would be more accurate to say that buprenorphine is not by itself a curative treatment. Though in many ways the extension of life impacts of the drug probably go beyond what people might expect from palliative care.

    1. Thanks for the comment! Good to hear from you!

      I regretted framing it in a binary way pretty quickly but failed to add an update. I think I’ll do another post to address that.

      You’re right that there’s nothing wrong with palliative care. And, where buprenorphine is used in a manner that seeks to put addiction in remission, I’d call it treatment rather than palliative.

      My point wasn’t to criticize palliative care or medication.

      To me, this seems to be a case where the social marketing frames it as addiction treatment, but the academic evaluation of its effectiveness seems to approach it as palliative care, hence “If we sell an intervention as treatment at the public level but treat it as palliative care at the academic level, the public, people with addiction, and people who care about them are likely to feel deceived.”

      I see that as a serious problem that isn’t confined to this particular intervention or study.

      While I regret framing it as binary, I stand by this, “This is where clarity about goals for an intervention becomes especially important.”

      There’s a long history of moving the goalposts, lowering the bar, and assuming people with addiction don’t want or are incapable of recovery. Lack of clarity/transparency about goals and definitions leaves a lot opportunity for confusion and neglect.

      Hope you’re well. Thanks for reading!

    2. Hello Thomas – the whole concept of palliative care within the framework of SUD care makes me really really uncomfortable, even as I acknowledge that this is what is happening in some areas of our care system. Unlike cancer, the majority of people do not get care, and the care that is provided is low intensity / short duration – not the kind of care that has been found to be most effective, particularly for persons who have severe forms of it (unlike cancer). And having a few decades in the care arena has shown me that also unlike cancer, mid to end stage addiction is not something that has much quality in it, for the person the family of the person or the community, it is corrosive across society.

      No doubt that there there are clinicians out there a whole lot better than me, but I would have a rough time determining when we move from active treatment (throwing everything we have at it, which is how we treat cancer and have rarely treated addiction) and move to a palliative care model. It raises a myriad of ethical concerns for me and I wonder aloud here who are we really making comfortable, the person or a society who seems to want to do as little as possible for the one in four families experiencing an SUD – and I am grateful that no one had such low expectations for me when I sought help, because it may well have been the end of me.

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