Chris Ruffino, 55, spent 27 years cycling in and out of jail and suffering from an untreated opioid use disorder. After a peer counselor from a street medicine program in San Francisco told him about treatment options, Ruffino headed to a clinic and met Barry Zevin, medical director of Street Medicine and Shelter Health. Zevin, sensing Ruffino’s anxiety, spoke with him outside, in the pouring rain, and started him on a course of Buprenorphine.
“I was ready, I had wanted to quit, and methadone didn’t work for me, but having the doctor literally meet me where I was made all the difference in my getting treatment,” said Ruffino, a father of “three great kids” who is off opioids and now works as a drug counselor.
San Francisco’s street medicine team brings doctors and other health professionals directly to people living on the streets to hear their stories and earn their trust. They provide as many services as the person will accept, from housing and food to medication and medical treatment, including addiction treatment.
Recently the city announced a $6 million investment to expand a yearlong pilot program that connected close to 100 people who are homeless and dealing with heroin and opioid addiction with ‘low barrier” access to buprenorphine, a drug that is often very effective as a treatment for opioid use disorder. Buprenorphine (brand names Subutex or Suboxone) is a daily pill, or strip that dissolves in the mouth, that reduces the cravings for opioids and the intense physical pain of withdrawal.
The primary goal of the pilot was to see if it could keep people who are homeless and struggling with opioid use disorder in treatment, said Rachael Kagan, a spokesperson for the San Francisco Department of Public Health. Additional goals, said Kagan, included improved health, reduction in heroin use and drug use abstinence.
About a quarter of the participants had previously started on buprenorphine but were not in treatment when the pilot started. In November, at the end of the yearlong pilot, 22 percent of participants were still under the care of the street medicine team and 22 percent were still taking buprenorphine after 12 months, an encouraging result that resulted in the pilot’s expansion, said Zevin, who headed the pilot and is directing the expanded initiative.
The key to the initiative, Zevin said, is recognizing that “These vulnerable and complex patients care about their health, but they have suffered from stigma that makes it difficult for them to access the health care system.”
Most treatment clinics work on an appointment system that assumes patients will show up on time. Keeping appointments is challenging for people living on the street, who often deal with mental illness, drug use, very little money and the memory of being treated with disrespect and disdain by health care providers.
Breaching these barriers is difficult, so patients in the pilot and in the expanded program can be evaluated in locations throughout the city. Sites include parks, encampment health fairs, the emergency room and inpatient facilities of Zuckerberg San Francisco General Hospital and needle exchange sites. Help is also available at clinics and health care navigation centers, with no appointments necessary. Buprenorphine is, however, dispensed only from a central pharmacy that contracts with the city.
“Homeless people who use drugs are especially vulnerable, and our system of care needs to adapt,” said Barbara Garcia, director of health at the San Francisco Department of Public Health. “By going directly to them with compassionate outreach and expertise, we are able to help a group that we were missing by relying on a more traditional structure of clinic visits that does not work for everyone.”
A key component of the program is to involve patients in their own care, Rachael Kagan said. Once a patient is assessed and chooses to begin treatment, the provider works with the patient to develop a care plan that considers the patient’s previous barriers to care and treatment. In addition to starting buprenorphine, treatment options may include transitioning to a methadone program if appropriate, entering residential treatment and addressing other health needs to help the patient stabilize and remain in care.
Attitudes matter too, said Diana Coffa, a staff member on the new initiative and the family and community residency director at San Francisco General Hospital and associate professor of family and community medicine at UC San Francisco. “Even if a patient presents to a treatment program requesting help, there is a prolonged intake with questions such as ‘how do you spend your money’ and then you are told to come back in a week, when you wanted to start treatment then and there.” Patients in those encounters have a sense of being toyed with, said Coffa and they have a week to lose their motivation. “But with the new program we can say to them, you want treatment, let’s do it today, let’s lower the barrier. Let’s only ask the questions that matter most.”
A dramatically new approach is key to the pilot’s success, Coffa said. “The norm in residential addiction treatment is that people have to prove they are motivated,” she said, “as opposed to the low-barrier concept.” Too many programs take a moralistic approach to addiction, blaming it on lack of will power or moral character instead of illness. “But in reality, if someone doesn’t take your help, you must not be offering the right help,” said Coffa.
Acknowledging the role that racism plays is crucial, Coffa said. “When addiction was primarily harming people of color, the reaction was very moralistic, but now that it is increasingly a white epidemic, we are starting to have more of a compassionate approach.” The change in attitude is appropriate, said Coffa, but she adds that “we must continue to be compassionate with the next drug crisis, which may not be only white.”
According to the California Department of Public Health, no other communities in the state have started identical programs but Barry Zevin said he fielded inquiries from across the state during a recent presentation at the annual meeting of the American Society of Addiction Medicine, which was held in San Diego. He’s been in touch with addiction specialists in several California cities who are interested in duplicating San Francisco’s program.
“San Francisco for many reasons is a good city to test this intervention, as it has a large homeless population and many addiction resources,” said Gail D’Onofrio, head of the emergency department at Yale New Haven Hospital.
D’Onofrio is the lead researcher on clinical trials in several cities that are examining the feasibility of starting treatment when people with substance use disorders come to the emergency room. She gives high marks to the San Francisco treatment program. “I think this is a very innovative idea,” she said. “If it proves to be an effective model, then other cities should test implementing the practice.”