Expanding Buprenorphine Starts for People Experiencing Homelessness during COVID

Introduction: Opioid related mortality is highly prevalent in San Francisco. Since March 2020 COVID-related shelter-in-place (SIP) restrictions, there have been 252 deaths among people experiencing homelessness (PEH); most related to fentanyl overdose. Buprenorphine is an effective medication to treat opioid use disorder (OUD) and reduce opioid-related mortality. Since 2016, the San Francisco Department of Public Health (SFDPH) has reduced barriers to starting buprenorphine for PEH. To meet COVID social distancing requirements, the SFDPH helped temporarily house over 2000 PEH in tourist hotels since April 2020; providing housing stability and increased access to healthcare providers. To date, 38 PEH have died in SIP hotels—likely due to socially isolated use of opioids. In this study, we sought to evaluate low-barrier buprenorphine starts among PEH in San Francisco with focus on those affected by COVID-related SIP restrictions.

Methods: We conducted a quantitative analysis with retrospective chart review of all SFDPH patients who received a prescription for opioid-based therapy during the start of SIP (03/16/2020—06/15/2020). We excluded patients receiving Methadone Assisted Therapy, buprenorphine prescriptions for pain, and those started on medications for OUD during an inpatient admission. Our cohort of 279 patients included new buprenorphine starts, either via in-person or telephone encounters, further classifying them as “traditional” starts or “micro-dose” starts. We determined demographic, medical, substance use history, and healthcare utilization from medical records and SIP hotel intake forms. Our primary outcomes were number of total buprenorphine prescriptions, number of prescriptions filled, and number of individuals retained in care. We utilized California’s Controlled substance Utilization Review and Evaluation Systems (CURES) to measure number of filled prescriptions. Retention in care was defined as maintaining an active buprenorphine script within a two-week time period at 1, 3, 6, and 12-month follow-up since initial medication start.

Results: Since the beginning of SIP, 170 PEH were prescribed buprenorphine with 122 (71.8%) patients receiving at least 1 refill. Many of the buprenorphine starts (86) have taken place in San Francisco’s street medicine open-access clinic with 42(48.8%) of patients returning for a subsequent prescription. Fifty-seven patients started buprenorphine from outreach to their SIP hotel sites with 20 (35.1%) requesting subsequent prescription. The descriptive demographics of this population, healthcare utilization patterns, mortality and retention at 6 and 12 months among PEH are still under evaluation.

Conclusions: Buprenorphine is a safe medication to prescribe for OUD and can help reduce mortality in people who use fentanyl. Many PEH in San Francisco were started on buprenorphine since March 2020 despite COVID-related SIP restrictions. Retention in treatment was higher among those who accessed care at primary care sites including street-medicine open-access clinics. Three month retention in treatment was lower in SIP hotel sites, which may relate to varied demographics and reduced readiness for treatment. Lowering the barrier to access buprenorphine paves an opportunity to save the lives of people who use opioids, particularly in newly sheltered individuals who use fentanyl.

References: (1) Carter, J., Zevin, B., & Lum, P. J. (2019). Low barrier buprenorphine treatment for persons experiencing homelessness and injecting heroin in San Francisco. Addiction science & clinical practice, 14(1), 20.

(2) Lin, L. A., Fernandez, A. C., Bonar, E. E. (2020). Telehealth for Substance-Using Populations in the Age of the Coronavirus Disease 2019 Recommendations to Enhance Adoption. JAMA Psychiatry.

(3) Kourounis, G., Richards, B.D.W., Kyprianou, E., Symeonidou, E., Malliori, M.M. and Samartzis, L., 2016.Opioid substitution therapy: lowering the treatment thresholds. Drug and alcohol dependence, 161, pp.1-8.

Learning Objective: Participants in this poster session will be able to list three innovative ways to lower barriers to providing buprenorphine to vulnerable populations, such as people experiencing homelessness with ability to translate these lessons to local and state policies to reduce fentanyl-related overdoses.