By Lenny Bernstein
San Francisco will begin supplying anti-addiction medication to long-term drug users and homeless people on city streets, an attempt to overcome a formidable obstacle to treatment that has complicated efforts to address the opioid crisis.
The city announced Thursday that its medical providers will offer buprenorphine and naltrexone prescriptions at needle exchanges, in parks and in other places where people with opioid disorders congregate. Users will be able to pick up the medications, which block the craving for opioids and the painful symptoms of withdrawal, at a centrally located city-run pharmacy.
The city is billing the plan as the first of its kind in the United States, though a few other communities have tried similar programs over the years.
“If we’re going to save people’s lives, we can’t wait for addicts to come to us. We have to go to them and engage. And offer. And give support,” said Barbara Garcia, director of health for the city and county of San Francisco.
The United States faces a shortage of drug treatment options of all kinds. Medication-assisted treatment with buprenorphine, methadone and naltrexone is widely considered the most effective way to wean users off opioids, but it is still in short supply and relapses are common, especially among people with the most severe form of opioid use disorder.
Buprenorphine, taken as a film placed on the tongue or in pill form, is generally dispensed by doctors or other providers who must receive eight hours of special training. Typically they give it to users daily or supply them with a few doses at a time. Naltrexone is offered as an injection that lasts a month, but users must be clean for seven to 10 days before it can be administered, which makes it difficult to use on the street.
Buprenorphine also is sold illegally on the street by users seeking to stave off withdrawal symptoms or wean themselves from heroin. Several experts said even intermittent, self-administered use is preferable to the risk of heroin laced with powerful fentanyl that many users now encounter.
Users who live on the street, many of whom also have mental illness, often cannot keep scheduled medical appointments or lack the means to get to them. Others feel reluctant to use the formal medical system. So some cities bring medical and other services to them on the street.
“I think it’s a great idea,” Joshua Sharfstein, a professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health, said of San Francisco’s drug treatment plan. Bringing users into treatment depends on being in the right spot at the right time, when someone feels ready to try, said Sharfstein, an expert in medication-assisted treatment.
Heroin users “will go into withdrawal every eight to 12 hours, so when they’re ready for buprenorphine, you should give it to them right then and there,” said Sharfstein, who is not involved with the San Francisco effort.
The San Francisco program is expensive and labor-intensive. In a year-long pilot program, the city treated 95 people, 22 percent of whom stayed with the program. Twenty-two percent also were still taking buprenorphine at the end of 12 months. More than half the people had chronic medical conditions, two-thirds had psychiatric conditions and 61 percent used methamphetamine as well as heroin, according to the city. There are 7,000 homeless people in the city.
The new program is slated to start in the fall. By next spring, the city hopes to have 250 more people in treatment at an overall cost of $3 million annually.
In Contra Costa County, east of San Francisco, the government runs a less formal attempt to reach hardcore users on the street. There, street medicine teams hand out prescriptions twice a week that users can fill at any local pharmacy. Because some people may not be able to walk to a drugstore, outreach workers sometimes bring buprenorphine to users on the street, said Joe Mega, medical director of the county’s health care for the homeless program.
Mega said he has issued 21 prescriptions and that 11 recipients were continuing to receive buprenorphine after six months.
San Francisco is among a handful of U.S. cities making plans to open supervised drug consumption sites, where users are watched while they smoke or inject drugs by monitors who are ready to administer the overdose antidote naloxone. Such programs are widespread in Canada but against federal law in the United States.