Expanding low-threshold buprenorphine to justice-involved individuals through mobile treatment: Addressing a critical care gap

Abstract

Background: Opioid use disorder (OUD) is highly prevalent among justice-involved individuals. While risk for overdose and other adverse consequences of opioid use are heightened among this population, most justice-involved individuals and other high-risk groups experience multiple barriers to engagement in opioid agonist treatment. Methods: This paper describes the development of Project Connections at Re-Entry (PCARE), a low-threshold buprenorphine treatment program that engages vulnerable patients in care through a mobile van parked directly outside the Baltimore City Jail. Patients are referred by jail staff or can walk in from the street. The clinical team includes an experienced primary care physician who prescribes buprenorphine, a nurse, and a peer recovery coach. The team initiates treatment for those with OUD and refers those with other needs to appropriate providers. Once stabilized, patients are transitioned to longer-term treatment programs or primary care for buprenorphine maintenance. This paper describes the process of developing this program, patient characteristics and initial outcomes for the first year of the program, and implications for public health practice. Results: From November 15, 2017 through November 30, 2018, 220 people inquired about treatment services and completed an intake interview, and 190 began treatment with a buprenorphine/naloxone prescription. Those who initiated buprenorphine were primarily male (80.1%), African American (85.1%), had a mean age of 44.1 (SD = 12.2), and a mean of 24.0 (SD = 13.6) years of opioid use. The majority of patients (94.4%) had previous criminal justice involvement, were unemployed (72.9%) and were unstably housed (70.8%). Over a third (32.1%) of patients had previously overdosed. Of those who began treatment, 67.9% returned for a second visit or more, and 31.6% percent were still involved in treatment after 30 days. Of those who initiated care, 20.5% have been transferred to continue buprenorphine treatment at a partnering site. Conclusions: The PCARE program illustrates the potential for low-threshold buprenorphine treatment to engage populations who are justice-involved and largely disconnected from care. While more work is needed to improve treatment retention among vulnerable patients and engaging persons in care directly after release from detention, offering on-demand, flexible and de-stigmatizing treatment may serve as a first point to connect high-risk populations with the healthcare system and interventions that reduce risk for overdose and related harms.

Opioid agonist treatment is highly protective against overdose death among a U.S. statewide population of justice-involved adults

“…We found that 100 individuals who had not been in treatment still died of an opioid overdose, revealing additional barriers among justice-involved individuals who may need treatment but do not access it, as has been reported in prior studies (24,25). These results highlight the need to design policies and programs that build multiple entry paths into treatment and additional supportive services such as low-threshold treatment options and care navigation that may help improve treatment engagement and outcomes (25,26). Among this cohort of justice-involved adults, Black individuals had lower odds of experiencing an overdose death than White individuals, which has been reported in other justice-involved populations (27).…”

“…This highlights the many challenges faced by this population that make treatment engagement and outcomes particularly complex. We found that 100 individuals who had not been in treatment still died of an opioid overdose, revealing additional barriers among justice-involved individuals who may need treatment but do not access it, as has been reported in prior studies (24,25). These results highlight the need to design policies and programs that build multiple entry paths into treatment and additional supportive services such as low-threshold treatment options and care navigation that may help improve treatment engagement and outcomes (25,26).…”

Opioid agonist treatment and fatal overdose risk in a state‐wide US population receiving opioid use disorder services

“…While treatment discontinuation is partly driven by the relapsing nature of OUD , retention could be improved through stronger promotion of long‐term maintenance as the standard of care and by eliminating programmatic, logistical and financial barriers. For example, addressing medication stigma and removing burdensome treatment requirements, such as daily attendance or zero tolerance , may encourage better and longer engagement . The risk that may be incurred immediately after treatment discontinuation also highlights the critical need to couple care with overdose education and harm‐reduction modalities, such as naloxone training and distribution .…”

Lessons from COVID 19: Are we finally ready to make opioid treatment accessible?

“…The truth, however, is that these requirements were never realistic or sustainable. Years of research have shown that requiring frequent visits, heavy monitoring, and mandatory participation in adjunct services to be eligible for life-saving medications created unnecessary barriers to accessing care (Krawczyk et al, 2019). Obstacles, such as long transportation times, difficulty managing appointments around work and childcare responsibilities, and the stigma associated with waiting in long lines to access treatment or provide urine drug tests under supervision, impede initiation and retention in treatment (Reisinger et al, 2009).…”

“…The current morass and devastation of COVID-19, therefore, offers an opportunity to adopt a much-needed revision to the status-quo and create a more sustainable, equitable, and harm reduction-oriented system. Existing models for services both in the U.S. and other countries exemplify the potential for offering opioid treatment through more accessible mechanisms (Calcaterra et al, 2019;Krawczyk et al, 2019), and simultaneously reducing both the over-regulation of scheduled agonist medications and the criminalization of drug use (Quintas & Arana, 2017). In addition, new protocols developed in response to COVID-19 will provide a natural experiment for clinicians, researchers, and advocates to study the impact of lower threshold treatment on patient health and overdose risk.…”