Emily Katz, the supervisor of an opioid treatment program at DESC, remembers how clients commonly get Suboxone, a treatment for opioid use disorder.
A client would schedule more than five hours for the process. A nurse administers Suboxone — strips of medicine that dissolve under the tongue — and regularly take the patient’s vitals. When the time was up, they are sent off, even though the process wasn’t enough for a person to be inducted in the treatment.
“Hope you don’t use more tonight,” she remembered thinking as a patient would go back out into the world.
A newly expanded DESC program aims to get past that model and instead empower patients to administer medication-assisted treatment (MAT) options themselves with on-call support from a health care professional and delivery of medications wherever they may be — an apartment, a street corner or an encampment. They can also walk into the office, if they choose.
“Big picture: What we’re looking to do is make it easier to get suboxone than it is to get heroin,” said April Gerard, DESC’s Opioid Treatment Network nursing supervisor.
The program takes its lessons from longstanding research that suggests helping people when and where they need it is a critical first step to addressing addiction. This low-barrier model means that the carrot is not paired with a stick; clients are brought into the program and get Suboxone without requirements of sobriety.
“We’re not looking for ways to kick them off of the program,” Katz said.
The OTN team is stationed in a DESC satellite office at 216 James St. in Seattle, around the corner from their well-known homeless shelter on Third Avenue, and consists of two nurses, a care coordinator, a substance use disorder counselor, part-time advanced registered nurse practitioner (ARNP) and a data collection specialist, all funded through a two-year grant from the Substance Abuse and Mental Health Services Administration (SAMHSA), a U.S. federal agency.
The program was up and running in April 2019 and currently serves more than 100 clients. They probably have room for roughly 50 more, Gerard said.
Those patients may venture into the office, but they don’t have to. Even the initial intake, at which they are educated on how the medications work, can be conducted off-site. It’s rare for Pamelyn Saari, the program’s ARNP, to oversee a dose in the exam room down the hall from the offices where the rest of the team meets, although patients are free to come in and pick up their medications if they choose.
Instead, Saari drives her car out to meet the patient and deliver the supplies. If they have questions or need more support when she’s not physically present, patients can text her or other team members for guidance through the process.
This way, patients have the ability to take the medication when they need it to curb the cravings for heroin rather than hope a scheduled visit syncs up with their drug use.
Federal, state and local governments have been dealing with the onslaught of the opioid epidemic for years. Conventional wisdom is that the crisis stemmed from new theories of pain management pioneered in the 1990s, combined with unethical practices from opioid manufacturers who hid the drugs’ addictive nature from doctors and patients.
According to the Centers for Disease Control and Prevention (CDC), more than 70,000 people died from overdoses in 2017. Opiates accounted for nearly two-thirds of that total.
The rising death toll has medical practitioners working to break down barriers that stand between patients and treatment by changing the clinical setting to make opioid treatment more accessible.
Suboxone is a relatively easy way to make that happen.
The drug is a partial opioid agonist that prevents the body from going through the full “withdrawal cascade” without making the user high. At best, it numbs the patient a little bit, but it has a ceiling effect at roughly 32 milligrams, meaning there is no further therapeutic effect.
That, in part, is why medical professionals can prescribe the drug to patients and deliver enough. It isn’t a highly sought-after drug on the street, where heroin and fentanyl (a powerful synthetic opioid) are easy to get and provide the high that people with substance use disorders seek.
That doesn’t mean the treatment comes without stigma or reproach. As recently as last year, the law permitting the use of mat came with language declaring that the goal was complete abstinence from opioids.
That isn’t how Gerard sees her role.
“Our mission is harm reduction, overall,” Gerard said.
If harm reduction is the goal rather than full abstinence, it gives practitioners more options and patients more opportunities to stay engaged in the treatment process.
University of Washington and Seattle and King County Public Health (Public Health) researchers demonstrated the same principal with a different application: Connecting patients to opioid treatment through their needle exchange made it more likely for folks to continue to use treatment.
They also didn’t require patients to be sober to remain in treatment.
“If folks didn’t stop using, we weren’t going to stop giving them medicine,” said Brad Finegood of Public Health in September 2019. “It’s like cancer. If the cancer doesn’t go away, do we stop giving them chemotherapy? If their diabetes is uncontrolled, do we stop giving them insulin? Of course we don’t.”
But not everybody shares that philosophy.
For detractors who believe the process doesn’t have enough guardrails, Katz has a message.
“We are doing this safely. This is safer than our clients dying.”
Ashley Archibald is a Staff Reporter covering local government, policy and equity. Have a story idea? She can be can reached at ashleya (at) realchangenews (dot) org. Follow Ashley on Twitter @AshleyA_RC.
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