Integrating Buprenorphine Treatment into a Public Healthcare System: The San Francisco Department of Public Health's Office-Based Buprenorphine Pilot Program

Abstract

Despite well-documented efficacy, US physicians have been relatively slow to embrace the use of buprenorphine for the treatment of opioid dependence. In order to introduce and support the use of buprenorphine across the San Francisco Department of Public Health system of care, the Buprenorphine Pilot Program was initiated in 2003. Program treatment sites included a centralized buprenorphine induction clinic and program pharmacy, and three community-based treatment sites; two primary care clinics and a private dual diagnosis group practice. The target patient population consisted of opioid-dependent patients typically seen in an urban, public health setting, including individuals experiencing extreme poverty, homelessness/unstable housing, unemployment, polysubstance abuse/dependence, coexisting mental health disorders, and/or little psychosocial support. This program evaluation reviews patient characteristics, treatment retention, substance use over time, patient impressions, and provider practices for the 57 patients admitted between 9/1/03 and 8/31/05. At baseline, over 80% of patients were injecting heroin, over 40% were homeless, and over one-third were using cocaine. Outcomes included an overall one-year retention rate of 61%, a rapid and dramatic decline in opioid use, very positive patient impressions of the program and of buprenorphine, and significant shifts in provider practices over time.

Opioid Maintenance Treatment as a Harm Reduction Tool for Opioid-Dependent Individuals in New York City: The Need to Expand Access to Buprenorphine/Naloxone in Marginalized Populations

“…Interestingly, for patients who started buprenorphine maintenance, the retention rate corroborates those found in previous studies of agonist maintenance therapy. 8, 18 In our sample, 63% of the patients were still in the program after 6 months and 31% were continuously maintained on buprenorphine during the first 6-month period of treatment. After 12 months, 42% were still in the program.…”

“…18 In addition, a study from the Buprenorphine Pilot Program initiated in 2003 in San Francisco, aiming at supporting the use of buprenorphine across the San Francisco Department of Public Health system of care, showed a one-year retention rate of 61%. 8 This higher retention rate may be explained by a more stable and less marginalized population.…”

“…8, 9 The office-based prescribing of buprenorphine in various medical venues gives opioid users the opportunity to be treated in relatively regulation-free environments without confinement to residential facilities or having to attend regulated clinics daily. Since untreated addiction contributes to the spread of infectious disease and crime, it is important to have as many options as possible for treatment.…”

Buprenorphine and methadone treatment for opioid dependence by income, ethnicity and race of neighborhoods in New York City

“…Buprenorphine has been shown to improve treatment retention and health outcomes among low-income, socially marginalized populations (Hersh et al, 2011; Stancliff et al, 2012) including formerly incarcerated patients (Lee et al, 2012; Magura et al, 2009) who often express a preference for buprenorphine over methadone (Mitchell et al, 2012). Disparities in access to buprenorphine represent a missed opportunity to protect the health of these populations.…”

“…To address the uneven distribution of buprenorphine, all states now include some form of Medicaid coverage for buprenorphine (Rinaldo and Rinaldo, 2013), and certain major cities, including Baltimore and Boston, actively promote buprenorphine treatment in public clinics (Schwartz et al, 2013; Hersh et al, 2011). Beginning in 2005, New York City’s public hospitals publicized buprenorphine among patients, encouraged physicians to become certified, and offered buprenorphine in outpatient and inpatient settings (personal communication with Peter Coleman, M.D., June 24, 2013).…”