Assignment D

AJPH PRACTICE

Shelter-Based Opioid Treatment: Increasing Access to Addiction Treatment in a Family Shelter

In 2015, the Family Team at the Boston Health Care for the Homeless Program developed shelter-based opioid treatment (SBOT) as an option to treat opioid use disorder on-site at a family motel–shelter. Our ob- jectives in the small retrospective study outlined here were to assess SBOT’s feasibility and to describe patient characteristics and early outcomes in an effort to promote dissemination.

PROGRAM AND STUDY DESCRIPTION

The Family Team has treated adult and pediatric patients in a variety of settings, including motel–shelters, since 1986. At a 120-room family motel–shelter in Massachusetts, our team of one physician, one nurse, two case managers, and one behavioral health clinician has established a twice-a-week outreach clinic where the team members regu- larly encounter patients experi- encing medical (e.g., skin and soft tissue infections, hepatitis C) and social (e.g., unemployment, loss of child custody) consequences of opioid use disorder.

We reviewed the charts of adult Family Team patients who received buprenorphine pre- scriptions for at least three months between August 2015 and August 2016. We chose

a three-month threshold because of the brief chart review period and because a 12-week endpoint has been used in previous studies of buprenorphine.1

Between June 2015 and June 2016, the team cared for 669 adults and 405 children. During this time, 55% of motel–shelter residents were White, 33% were African American, 3% were Native American, and 15% were Latino. The prevalence of opioid use disorder—diagnosed according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition2— among our adult Family Team patients was 6%.

The opioid epidemic is par- ticularly devastating among those experiencing homelessness, for whom overdose—most com- monlyfromopioids—istheleading cause of death.3 Office-based opi- oid treatment (OBOT)—which consists of coordinated outpatient services including an opioid agonist such as buprenorphine4—is as effective among adults experi- encing homelessness as it is among housed adults in promoting sobri- ety and preventing overdose.5

However, patient-level (e.g., stigma, competing priorities), provider-level (e.g., the small number of licensed buprenorphine prescribers), and system-level (e.g., restrictions on how many patients physicians can treat)6 barriers limit access.

Families experiencing home- lessness account for 36% of the homeless population,7 and they face barriers to health care dif- ferent from those experienced by homeless adults without de- pendents.8 Barriers to OBOT for these patients include the need for child care during visits, con- cerns about the safety of children in the household, and family shelters distant from OBOT sites. Furthermore, young women and their children—the major con- stituents of families experiencing homelessness9—face unique health consequences of opioid use; for instance, both neonatal abstinence syndrome and hepa- titis C among women of child- bearing age are on the rise.10,11

Although opioid treatment pro- grams tailored to this population might mitigate these unique harms, no literature describing such programs exists to our knowledge.

SBOT attempted to address the various barriers that patients face, with the physician, nurse, behavioral health providers, and case managers all responsible for different components of the program (Table 1). For example,

physicians prescribing bupre- norphine on-site alleviated transportation and child-care barriers, intensive case manage- ment helped families deal with competing priorities such as finding work, and therapy helped patients address comorbid mental health conditions without having to leave the shelter. Patients who the team believed needed resources beyond the scope of the outreach clinic (e.g., patients who had relapsed multiple times while on treatment) were referred to our main facility where they had access to the support of a traditional OBOTprogram.Onlyonepatient in our first year was screened for SBOT but referred instead to our OBOT program.

PROGRAM EVALUATION

We recorded data on de- mographic characteristics in- cluding age, race/ethnicity, and family size; clinical factors such as medical and psychiatric comor- bidities; and treatment outcomes such as length of time in the program, reason for leaving, and urine drug test (UDT) results in the first (to approximate pre- treatment substance use) and third (to approximate substance use while patients were stable on treatment) months of treatment. We used the c2 test to compare

ABOUT THE AUTHORS All of the authors are with the Boston Health Care for the Homeless Program, Boston, MA.

Correspondence should be sent to Avik Chatterjee, MD, MPH, Boston Health Care for the Homeless Program, 780 Albany St, Boston, MA 02118 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.

This article was accepted March 10, 2017. doi: 10.2105/AJPH.2017.303786

1092 Public Health Practice Chatterjee et al. AJPH July 2017, Vol 107, No. 7

UDT results in the first and third months.

During the chart review pe- riod, 10 patients received

buprenorphine prescriptions for at least three months. Six patients were White, one was African American, one reported more

than one race, and two did not report race. Patients’ mean age was 35 years (range = 32–40), their median number of children was two (range = one to five), and five had a partner in the shelter. The Massachusetts De- partment of Children and Fam- ilies was involved in the care of children in five families (Table 2).

All patients had a chronic pain diagnosis. Five tested positive for hepatitis C, and none tested positive for HIV. All patients had anxiety and seven had depression or bipolar disorder. During the chart review period, the mean treatment duration was 7.4 months (range = three to 12 months; Table 2). Four patients reported a history of overdose prior to SBOT, but no overdoses were documented during the study period. Initial UDTs showed that nine of the 10 pa- tients had used unprescribed controlled substances (mostly marijuana and benzodiazepines) and that two had used opioids; by the third month, one patient had an opioid-positive UDT. Unprescribed controlled sub- stances were detected in 77% of 44 tests in the first month and 51% of 34 tests in the third month (P < .01). In their final month of treatment, three patients were employed, as compared with one at treatment initiation (Table 3).

ADVERSE EFFECTS AND LIMITATIONS

Four patients continued SBOT in the shelter after the review period, of whom one pa- tient was threatening toward clinic staff and was asked to transfer to a different OBOT program, and two patients moved to a different shelter and started OBOT. Of the four patients who moved from the shelter system into the

community, all relapsed and lost custody of their children.

Transition into the commu- nity was a significant challenge for our patients. Access to OBOT in the community remains lim- ited6 and involves the patient-, provider-, and system-level barriers that SBOT allowed patients to overcome. Housing sometimes became available quickly, without sufficient notice to transition care. Although we provided patients with pre- scriptions until their new pro- viders could see them, therapy and intensive case management were less available outside SBOT. A team specifically designated to help patients transition into the community, perhaps with home visits, may help prevent relapse.

A major limitation of our chart review was the small number of patients. In addition, previous studies of OBOT have involved populations that are predomi- nantly male,5 but our population was predominantly female, which is appropriate given that most homeless families have fe- male heads of household.9 An- other limitation was the lack of a comparison group against which to assess treatment success. We were also unable to assess diversion (sale or distribution to a third party) of buprenorphine, which can be a concern for cli- nicians,12 although a recent lit- erature review suggests that it is uncommon.13

SUSTAINABILITY The SBOT program con-

tinues at the initial family shelter and has expanded to a second site in the Boston area. Several factors supported SBOT’s feasibility and sustainability. For example, our integrated, interprofessional, team-based approach is known to serve vulnerable patients well.14

TABLE 1—Features of the Boston Health Care for the Homeless Program’s Shelter-Based Opioid Treatment Program

Program Feature Responsible Team Members

Signed contract outlining expectations Physicians, nurses

On-site buprenorphine induction Physicians

Physician visits beginning weekly and then spaced

out as clinically appropriate

Physicians

Nurse visit before each physician visit for medication

counts, counseling, and urine drug testing

Nurses

Integrated group or individual therapy on a

weekly basis

Behavioral health providers

Required intranasal naloxone prescription and training Physicians, case managers

Required lockbox for medications Case managers

Employment, housing, transportation, budgeting,

food, and parenting support

Case managers

TABLE 2—Characteristics of 10 Adults Enrolled in the Boston Health Care for the Homeless Program’s Shelter-Based Opioid Treatment Program: Massachusetts, 2015–2016

Characteristic No. or Mean (Range)

Female 6

Race

White 6

African American 1

> 1 race reported 1 Race not reported 2

Age, y 35 (32–40)

Partner in shelter 5

No. of children 2 (1–5)

Family Department of Children and Families involvement 5

Opioid use history

Oral opioids only 3

Heroin only 2

Both 5

Chronic pain 10

Anxiety 10

Depression or bipolar disorder 7

Posttraumatic stress disorder 5

Hepatitis C 5

HIV 0

Months in treatment 7.4 (3–12)

Buprenorphine dose, mg 18 (16–20)

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The nurse met with patients weekly to provide counseling, count pills, and collect urine samples. Behavioral health pro- viders offered group and indi- vidual therapy. Case managers addressed social determinants including employment and food insecurity.

In addition, considering its status as an outreach site, our clinic was well resourced, with dedicated space and the ability to send samples for laboratory test- ing. Expansion of Medicaid in Massachusetts since 2006 has provided a supportive environ- ment for such a program treating substance use among those facing homelessness.5 Also, according to UDT results, only two patients were actively using opioids upon starting SBOT, possibly in- dicating a more stable group more amenable to treatment.

PUBLIC HEALTH SIGNIFICANCE

Although much remains to be learned about this approach, implementation of a team-based opioid treatment program in a family shelter was feasible, im- proving access to addiction treatment in a diverse group of vulnerable adults. Patients avoi- ded overdose, decreased illicit substance use, and were able to obtain employment. Given its

potential to treat opioid addiction in this very vulnerable group, we hope for this approach to be replicated widely.

Avik Chatterjee, MD, MPH Aura Obando, MD

Erica Strickland Ariana Nestler

Rachel Harrington-Levey, PhD, MPH

Toni Williams, RN Terri LaCoursiere-Zucchero, RN,

PhD, FNP-BC

CONTRIBUTORS A. Chatterjee, A. Obando, and T. LaCoursiere-Zucchero originated the study. Dr. Chatterjee completed data analysis with assistance from A. Obando. A. Chatterjee led the preparation of the article, with significant contributions from A. Nestler, R. Harrington-Levey, T. Williams, and T. LaCoursiere-Zucchero. E. Strickland completed the chart review.

ACKNNOWLEDGMENTS We acknowledge the Family Team at the Boston Health Care for the Homeless Program;JessieGaeta,CaseyLeón, and the Research Office at the Boston Health Care for the Homeless Program; Jeanette Tetrault for her support of this project; and our patients.

HUMAN PARTICIPANT PROTECTION This study was determined to meet ex- emptioncriteriabytheinstitutionalreview board of the Boston Medical Center, and informed consent was not required.

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2. Hasin DS, O’Brien CP, Auriacombe M, et al. DSM-5 criteria for substance use disorders: recommendations and ratio- nale. Am J Psychiatry. 2013;170(8): 834–851.

3. Baggett TP, Hwang SW, O’Connell JJ, et al. Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period. JAMA Intern Med. 2013; 173(3):189–195.

4. LaBelle CT, Han SC, Bergeron A, Samet JH. Office-based opioid treatment with buprenorphine (OBOT-B): state- wide implementation of the Massachusetts collaborative care model in community health centers. J Subst Abuse Treat. 2016; 60:6–13.

5. Alford DP, LaBelle CT, Richardson JM, et al. Treating homeless opioid de- pendent patients with buprenorphine in an office-based setting. J Gen Intern Med. 2007;22(2):171–176.

6. Walley AY, Alperen JK, Cheng DM, et al. Office-based management of opioid dependence with buprenorphine: clinical practices and barriers. J Gen Intern Med. 2008;23(9):1393–1398.

7. US Department of Housing and Urban Development. 2015 estimates of home- lessness in the United States. Available at: https://www.hudexchange.info/ resource/4832/2015-ahar-part-1-pit- estimates-of-homelessness/. Accessed April 8, 2017.

8. Wood D, Valdez RB. Barriers to medical care for homeless families com- pared with housed poor families. Am J Dis Child. 1991;145(10):1109–1115.

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10. Tolia VN, Patrick SW, Bennett MM, et al. Increasing incidence of the neonatal abstinence syndrome in US neonatal ICUs. N Engl J Med. 2015;372(22): 2118–2126.

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12. Ling W. Buprenorphine implant for opioid addiction. Pain Manag. 2012;2(4): 345–350.

13. Yokell MA, Zaller ND, Green TC, Rich JD. Buprenorphine and buprenorphine/naloxone diversion, mis- use, and illicit use: an international review. Curr Drug Abuse Rev. 2011;4(1):28–41.

14. Iddins BW, Frank JS, Kannar P, et al. Evaluation of team-based care in an urban free clinic setting. Nurs Adm Q. 2015; 39(3):254–262.

TABLE 3—Early Treatment Outcomes Among 10 Patients Enrolled in the Boston Health Care for the Homeless Program’s Shelter- Based Opioid Treatment Program: Massachusetts, 2015–2016

Outcome Before Treatment 3rd Month of Treatment

Opioid use according to UDT test, no. 2 1

Unexpected UDT results, % 77a 51

Employed, no. 1 3

Overdose, no. 4 0

Note. UDT = urine drug test. aAmong UDTs collected in the first month of treatment.

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