Q&A: Physicians improve buprenorphine access for the homeless amid COVID-19

In the early days of the COVID-19 pandemic, the Drug Enforcement Administration announced it would temporarily ease restrictions on access to buprenorphine for opioid use disorder.

The relaxed rules allow physicians to prescribe medications through telehealth without first conducting an examination in person, according to researchers. They used this opportunity to create an intervention that could improve access to buprenorphine for the homeless population in Chicago.

“Our hope is to use this odd moment in history to better inform how we can best care for our most vulnerable patients in the future,” Leo Paul, MD, a family medicine resident at the University of Chicago, and colleagues wrote in Annals of Family Medicine.

In an interview with Healio Primary Care, Paul discussed how the intervention was created, barriers to implementation, and more.

Q: Walk us through how you developed this intervention.

A: In March of 2020, the DEA announced temporarily relaxed restrictions on the prescription of buprenorphine, allowing it to be prescribed via telehealth rather than necessitating an in‐person appointment.

Upon hearing this news, a member of a social services agency in Chicago with a mobile health van known as The Night Ministry contacted a buprenorphine-waivered family physician at Mile Square Health Center, understanding that the clinic had recently built a telehealth program in response to the coronavirus pandemic. Recognizing the increased need for medications to treat opioid use disorder during the pandemic due to the limited availability of illicit opioids during the lockdown, members of these two organizations partnered to create a protocol that adapted the telemedicine program to include van‐based buprenorphine inductions.

Q: What equipment, staff and financial support was needed to bring the intervention to fruition?

Rather than “reinvent the wheel,” we used many preexisting structures to implement this intervention.

On a basic level, this intervention requires an appropriately staffed mobile health van, as well as a team of buprenorphine‐waivered providers who are available to be on call for buprenorphine inductions.

As noted in the Annals of Family Medicine article, The Night Ministry already had a well‐established mobile health van, and Mile Square Health Center already had a number of

buprenorphine‐waivered providers, as well as a telehealth infrastructure that was developed during the initial weeks of the pandemic. Our intervention simply brought together these two pre‐existing services to address a critical need within the community.

Q: What barriers did you encounter when first implementing the intervention? How can these barriers be overcome?

A: We encountered a number of barriers in the first few months of our partnership, some of which were more navigable than others. For patients who were uninsured, we were able to offer the prescription benefits of a federally qualified health center with subsequent medication delivery by the mobile health van, resulting in access to buprenorphine with little to no cost. To ensure that members of our transient patient population were not lost to follow‐up, we held a weekly multidisciplinary meeting to review each patient case.

Q: How did you get patients to accept and take part in the intervention?

A: We ensured that the most forward‐facing members of our team were those who had developed longitudinally therapeutic relationships with our patients through The Night Ministry's mobile health van. Therefore, we recommend that buprenorphine‐prescribing clinicians seek out and partner with community agencies that are already working the front lines of street homelessness if this intervention is to be replicated in other communities.

Q: What is your take-home message for physicians?

A: While as family physicians we have the privilege to care for all patients who walk through our clinic doors, there are countless patients who do not actively seek care or do not have an established relationship with a clinic who still have critical medical needs. The opioid epidemic, even through the coronavirus pandemic, remains one of the most urgent issues in our society. This intervention seeks to identify the individuals who exist “outside” our medical system and provide them with much‐needed medical interventions. Therefore, this intervention is a call for physicians to look outside of their clinic walls and to assess and address the needs of more marginalized community members.

References:

DEA. DEA’s response to COVID-19. https://www.dea.gov/press-releases/2020/03/20/deas-response-covid-19. Accessed January 26, 2021.

Leo P, et al. Ann Family Med. 2021;doi:10.1370/afm.2636.