According to the Centers for Disease Control and Prevention (CDC), more people died from drug overdoses in 2014 than in any year on record. Most of these deaths—78 every day—involved an opioid. Closer to home in Boston, deaths from opioid overdoses increased by 50 percent from 2014 to 2015 (Note 1). In our practice, Boston Health Care for the Homeless Program (BHCHP), based on the corner of Massachusetts Avenue and Albany Street (the epicenter of Boston’s drug activity), opioid overdoses have become the leading cause of death among our patients.
Overdoses were happening multiple times each week in our lobby, clinic bathrooms, and on the sidewalks and alleys adjacent to our building. Despite significant existing services aimed at the prevention and treatment of substance use disorders (SUD), we were not effectively engaging some of the highest-risk people with SUD. There was recognition among our staff, board of directors, and patients that in addition to improving screening for SUD, expanding access to opioid agonist therapy, broadly distributing naloxone (the rescue drug to reverse opioid overdoses), improving opioid prescribing practices, and expanding housing opportunities, we also needed to reduce the harms associated with ongoing drug use and provide a safe alternative to the street for people who are over sedated. Our goals are to respond with a new service that:
- Prevents fatal overdose;
- More effectively connects highest-risk individuals with addiction treatment; and,
- Addresses the impact of SUD on our patients, our organization, and our neighborhood.
An Observation and Treatment Facility is Not a Supervised Injection Facility
In April 2016, after extensively engaging public officials, consumers, and community groups, surveying consumers who self-identified as injection drug users, and securing $150,000 in grant funding from foundations and private sources, we opened our doors to Supportive Place for Observation and Treatment (SPOT).
- A drop-in facility with eight reclining chairs for people who are intoxicated from the use of sedating drugs including heroin, as an alternative to the busy street corner or alley. People walk in, and are sometimes assisted by friends or outreach workers. Some are carried or brought in by wheelchair. It is presently open Monday-Friday, from 8:30 a.m.-5 p.m.
- Medical care if overdose occurs. A registered nurse (RN) specializing in addiction performs continuous monitoring of vital signs, including pulse oximetry, and assessment of level of sedation. In consultation with a ‘rapid response clinician’ (physician, nurse practitioner, or physician assistant), supplemental oxygen, intravenous fluids, and naloxone are administered as needed.
- A gateway to treatment and other services. Participants are offered connection to any type of addiction treatment desired, as well as case management by a harm reduction specialist who focuses on low-threshold engagement and community-based addiction services. Peers who are in recovery themselves also provide non-judgmental relationship-building and support.
SPOT is not:
- A supervised injection facility. People are not allowed to inject substances inside the building.
- A needle exchange program. Needle exchange is available next door at the Boston Public Health Commission and our programs collaborate closely.
In the first 15 weeks of opening, we had 983 encounters with 218 unique individuals. The people using the program are extremely vulnerable and complex; most have mental illness and severe substance use disorder, and homelessness is ubiquitous. Most are using a “cocktail” of substances that include opioids (most often injected heroin or Fentanyl, a synthetic opioid that is highly potent and lethal), benzodiazepines (anti-anxiety medications, typically clonazepam), clonidine (anti-hypertensive medication), gabapentin (anti-convulsant medication), and promethazine (anti-nausea medication).
Typically with an opioid overdose we see significant respiratory depression, but this cocktail of substances results in what we describe as ‘overdose syndrome’ that is complex and different from pure opioid overdose, often resulting in bradycardia (slow heart rate) and hypotension (low blood pressure), out of proportion to the degree of respiratory depression expected with pure opioid overdose. This polysubstance overdose syndrome is prolonged, does not necessarily respond to naloxone, and sometimes requires supplemental oxygenation, intravenous fluids, and three to four hours of close monitoring before the patient’s deep sedation and vital sign abnormalities stabilize.
Without monitoring, people in this state who are otherwise on the street may experience respiratory or cardiac arrest out of reach of medical personnel, or be transported to an emergency department if found by bystanders. Other harms potentially avoided by providing a safe space for people who are sedated include violence — physical and sexual, theft, and exposure to extreme weather conditions.
Since opening, we have needed to transfer patients to the emergency department less than 15 times, mostly due to our limited hours of operation and the need to transfer care. Overall we have diverted emergency department use for about a third of our encounters. Our referral rates to addiction services are complicated to track, and we estimate that less than 10 percent have been linked to opioid agonist therapy or detoxification. As we build stronger relationships with patients that are repeat users of SPOT, we are hopeful that the uptake in treatment will improve.
The relationship we have with participants in SPOT is different than the relationship forged in other, more typical health care settings. We worked hard to gain trust and credibility and the conversation shifted away from participants feeling they needed to hide their ongoing drug use, and instead many participants began openly explaining the details of exactly what drugs they used and when, followed by, “I’m worried about what is going to happen. Do you mind if I stay here a while?”
Policy Lessons Learned So Far
Consumer Outreach And Ongoing Input Is Needed
Prior to the opening of SPOT, our strategy included engaging three main groups:
- Injection drug users: we fielded a survey of 237 people who self-identified as injection drug users to ascertain community need, factors associated with willingness to use SPOT; and perspectives on the design of SPOT.
- Our community-based board of directors, especially our consumer advisory board: We had extensive discussions regarding harm reduction to gain buy-in on the concept of SPOT. We engaged our consumer board members in weekly planning meetings, the hiring of staff, and as volunteer peer supports in SPOT.
- Community and neighborhood organizations: we passed out written materials and participated in numerous community meetings to address concerns about what neighbors have observed in their community and how SPOT might impact the community.
Engage Policy Officials As Early As Possible
Meet with city and state officials during the early planning stages to educate them on the issues and address concerns. Harm reduction strategies can be provocative and tricky for elected officials to embrace, but in Massachusetts, as in so many other states, we are confronted by a profound loss of lives due to this public health crisis and there is an urgent need for multi-prong approaches. We also needed regulatory support to license SPOT. Because we are licensed as an outpatient medical clinic by the Massachusetts Department of Public Health, licensure of SPOT was seen as an extension of our license and was a smooth process.
Leverage Partnerships With Harm Reduction Programs
We are fortunate to be located next to the Access Harm Reduction Overdose Prevention and Education (AHOPE) program, which provides needle exchange among other services on behalf of the Boston Public Health Commission. AHOPE was instrumental in our efforts to survey people at the local needle exchange, and the program has contributed immensely in the design of our community health center’s first explicit harm reduction program. Needle exchange programs, unambiguously anchored in a framework of harm reduction, are key partners for health care providers in addressing addiction and bending the overdose curve.
Secure Third Party Reimbursement
Grant funding from Blue Cross Blue Shield of Massachusetts Foundation and other private sources enabled our start up, and we are now in the process of readying to bill Medicaid fee-for-service for medically necessary encounters. We are collecting data on cost savings through emergency department diversions to make the case for managed care plans and accountable care organization reimbursement.
Manage The Media Message
The media has taken an interest in SPOT and can be an important partner in explaining to a larger community of stakeholders the need for new programs, but some stories in the media can be more stigmatizing and provocative. We have worked to carefully craft our message to promote an accurate portrayal of the program and the people it serves. Stories still often contain language about addiction that is stigmatizing.
Strategies to reduce overdose deaths require many different approaches. Efforts to decrease stigma, prevent SUD, increase access to evidence-based treatments, and support people in recovery are critical, but they will not be enough. We must also take steps to meet people with SUD along the way, even when they are not able or willing to access treatment. We must work to decrease the harms associated with ongoing opioid use, even when abstinence is not possible.
A current patient in recovery and member of BHCHP’s Board of Directors, says this more succinctly: “You can’t put dead people in detox.” SPOT provides accessible, non-judgmental, medically supervised care for highly vulnerable people with SUD who are intoxicated, increasing their chance of making it through the day, and sometimes even taking a step toward recovery. Moving forward, communities most impacted by overdose deaths should consider additional harm reduction interventions beyond naloxone distribution and needle exchange programs, including drop-in programs equipped to monitor intoxicated individuals like SPOT, and ultimately, even supervised injection facilities like found in other countries.
Boston Public Health Commission 2016