In downtown Seattle, a program to treat opioid use disorder that is co-located with needle exchange services is showing promise for reaching people experiencing homelessness.  The program is based on a public health model that provides immediate, client-centered care and access to buprenorphine.

Initial findings from two different sources of data shows that the innovative Buprenorphine Pathways (Bupe Pathways) program may reduce opioid use and improve the health and well-being of some of our most vulnerable community members. A recent article in the journal Substance Abuse found that Bupe Pathways was successful at retaining people who often face barriers to more traditional treatment settings and showed evidence of reduction in opioid use. A separate qualitative evaluation found the program improved patients’ general health, access to health care, relationships and housing.

At the core of the model is co-locating the clinic with the Public Health Needle Exchange and the Downtown Public Health Center. This allows patients to begin treatment with buprenorphine as close to the time as they are ready, as opposed to waiting for appointments or needing to travel to other sites. The clinic also connects people to social services.

What makes the model unique
Bupe Pathways is based on a set of practical strategies to reduce the negative consequences of substance use or injection drug use that can lead to overdose and other drug use-related harms without requiring total abstinence. Access to treatment is offered in a compassionate, evidence-based, and individualized way by building relationships with patients.

Program staff recognize that the realities of poverty, racism, social isolation, past trauma, sex-based discrimination and other social inequities affect people’s capacity for effectively dealing with drug-related harm and successfully engaging in needed treatment. The program is designed to meet the needs of some of our most vulnerable community members: 83% are experiencing homelessness and 10% are in public housing.

As Thea Oliphant-Wells, Clinic Supervisor for Bupe Pathways describes:

“Prior to Bupe Pathways, it was very difficult to find a provider that would prescribe buprenorphine to people living homeless or those with polysubstance use. Appointment wait times, strict attendance requirements, and low tolerance for ongoing drug use meant that many people were unable to stay connected to the care they needed.

Bupe Pathways offers walk-in or scheduled appointments and we do our best to work with people to identify the barriers to their recovery goals and support them on their journey to improved health. We never give up on our patients and we welcome them back any time. Recovery is not a straight line for most people. Bupe Pathways allows people to set their own goals and their own pace.“

Demand for buprenorphine among needle exchange clients was high when the clinic opened in 2017, and initially surpassed the program’s capacity. To meet the need for treatment, the program continues to expand, with support from King County Executive and County Council to ultimately triple the number of people served from about 140 to 500 patients.

Key findings from the evaluation
Two sources of data provide insights into the program’s impact:

• As highlighted in the published report, clinical data from 142 patients revealed trends in retention and toxicology test results following enrollment in Bupe Pathways.
• A subset of current and former patients completed a survey about Bupe Pathways’ influence on drug use and quality of life.
  
  Substance use reduced: As noted in the published report, researchers looked at urine toxicology test results of 146 patients and found that the percentage of tests that were positive for non-prescribed opioids significantly decreased from 90% at enrollment to 41% after stabilizing in the program. 
  
  As Dr. Julia Hood, Epidemiologist for Public Health – Seattle & King County explains:
  
  “Our data suggest that the program resulted in a reduction in non-prescribed opioid use.  For some patients, this may look like complete abstinence; for others, this may look like a reduction in how often or how much non-prescribed opioids are used.”
  
  Separate qualitative interviews found that 67% of patients said they decreased their use of non-prescribed opioids after enrolling in Bupe Pathways. Participants also noted reductions in stimulants (45%) and benzodiazepines (14%).
  
  Improvements in quality of life: Among surveyed patients in Bupe Pathways, over half noted improvements in their general health status. Thirty percent noted improvements in where they get medical care. Fifty-one percent noted improvements in their relationships. Some participants in the interviews also noted improvements in housing (20%) and employment status (10%).

Expanding access to treatment medications county-wide
From 2017 to 2018, the number of locations in King County that prescribed medication for opioid use disorder more than doubled from 45 to over 100.  From 2015—when the Heroin and Prescription Opiate Taskforce started to convene—until 2018, the number of Medicaid insured residents who were prescribed buprenorphine quadrupled from 1218 to 5048.

Across King County, partnerships between Public Health and healthcare providers have led to increased access to buprenorphine:

• in emergency rooms
• in the King County Jail
  – In June of 2018, Jail Health Services started offering continuation of buprenorphine in the King County jail for those entering with an existing prescription. By the end of 2019, the program plans to start patients in the jail on buprenorphine treatment.
• in shelters and encampments
  – A street medicine team will provide buprenorphine and other health and behavioral health services.

Public Health continues to support the on-going efforts to expand community-based treatment capacity for opioid use disorder so life-saving medication can be accessible to all those who need it.

For information on Public Health’s efforts to address opioid use disorder, visit www.kingcounty.gov/overdose

Originally posted 8/21/2019