Opioid Treatment Can Succeed in the Most Unexpected Places

The final plenary session at this week's Rx Drug Abuse & Heroin Summit in Atlanta focused on programs that have improved linkages to ongoing care for individuals with opioid use disorders. Leaders who have helped to create treatment opportunities at sites ranging from state prisons to syringe exchange programs urged attendees to think unconventionally about where people in need can be reached effectively.

“We hear, 'Meet them where they're at.' I say, 'Treat them where they're at,'” said Sharon Stancliff, MD, associate medical director for harm reduction in health care at the New York State Department of Health.

In the mid-2000s, the New York state health agency released funds allowing Stancliff to introduce buprenorphine treatment at syringe service programs, and the state saw encouraging engagement and retention rates as a result. There are now 12 “drug user health hubs” across the state where injection drug users can receive services beyond needle exchange at these syringe service sites.

“You can see needle exchange as a place you can refer to for a variety of services,” Stancliff said. She cited as an example in New York the Albany County Jail's practice of referring released inmates to Catholic Charities for continuation of the medication treatment they receive while jailed, at the syringe exchange site run by Catholic Charities.

Session presenter Josiah Rich, MD, an attending physician at Miriam Hospital in Rhode Island and director of the Center for Prisoner Health and Human Rights, has been an instrumental leader in his state in what has become the nation's most extensive example of integrating medication-assisted treatment (MAT) into corrections. Rich pointed out that politicians often talk about adding “beds” as if being in a treatment bed will magically release an individual from the grips of opioid addiction and withdrawal, when the scientific evidence actually demonstrates that the approved medications for opioid addiction are what can allow the other components of recovery to take hold.

“The medications are the treatment,“ Rich said. “None of it works as well as medications first.”

Also participating in the summit's Thursday plenary session was Edward Bernstein, MD, professor in the Department of Emergency Medicine at Boston University School of Medicine. Bernstein directs one of three regional opioid urgent care centers that speed the process of linking emergency medical patients to ongoing care. The program sites are a peer support clinic that operates daily and an MAT clinic that is open every day but Sunday. The vast majority of patients are homeless and Medicaid-eligible.

In the first quarter of this year, Bernstein reported, 148 urgent-care patients received initial doses of buprenorphine in the emergency setting, and 214 received methadone in the emergency department. “This is a big cultural shift,” Bernstein said, facilitated in Massachusetts in part by a state law requiring hospital emergency departments to have waivered physicians on staff.

Can this happen elsewhere?

During the plenary session's question-and-answer period, an audience member observed that the profiled programs are located in New York, Massachusetts and Rhode Island and asked how these kinds of efforts could be brought to states not seen as being as progressive on treatment. Stancliff advised, “Find some champions that can talk to their own peers.” She observed that much of the increasingly favorable attitude toward treatment in the law enforcement community is attributable to police leaders talking to their colleagues.

Rich also pointed out in his remarks that change does not come fast even in places seen as more amenable. When he first tried to apply the lessons that had been learned about HIV eradication in Rhode Island prisons to the subject of addiction, he ran into “brick walls,” he said.

“The brick walls were really about the stigma around this disease,” Rich said. The pervasiveness of the opioid crisis has certainly helped to bring those walls down, as it is now difficult to find a correctional officer whose own life hasn't been touched in some way by someone with an addiction, he said.

Choosing a medication option

Rich said he is often asked which of the three federally approved medications he would recommend for the criminal justice population with opioid use disorders. He replies that this should be an individualized decision. Where all of the options are available, systems may find that inmates not only want the treatment but know which one they want, based on their past experience. “They don't feel right on one medication or the other,” he said.

Stancliff, who works in the New York health department's AIDS Institute, said that around half of the clients inducted onto buprenorphine in the drug user health hubs are also receiving counseling, which is recommended in national guidelines but not required in the regulations governing buprenorphine treatment. She urged attendees not to let concerns about medication diversion risk become an insurmountable barrier to offering MAT.