America’s opioid epidemic has had a huge impact on the well-being of individuals and communities across the country, and 20 years into the epidemic there is a growing need for services. From 1999-2018, there were almost 450,000 overdose deaths from prescription and illegal opioids.1 There were 70,980 drug overdose deaths in the United States in 2019, an increase of 4.6 % from the prior year. Opioids were involved in 50,042 of these deaths.2 Health centers in many communities have been on the front lines of dealing with this ongoing epidemic. The number of health centers that provided medication assisted treatment (MAT) services increased from 48% in 2018 to 64% in 2019,3 with 142,919 patients receiving these services in 2019.4 In 2019, HRSA awarded more than $200 million to 1,208 health centers across the nation to support programs and services focused on combating the opioid crisis.5
The COVID-19 pandemic has exacerbated an already tenuous situation for many people. As businesses closed and isolation became necessary, many individuals suffering from opioid use disorder (OUD) lost the services and connections that helped them maintain stability and sobriety. Reports from national, state, and local media all indicate that opioid and drug-related mortality have increased since the pandemic started.6 In the first three months of 2020, an estimated 19,416 people died from a drug overdose compared to 16,682 during the same three-month period in 2019.7 The CDC estimates that the U.S. might see more than 75,500 drug related deaths in 2020.8
We checked in with colleagues at Fenway Health and Central City Concern to learn about the programs and strategies they’ve developed to tackle the opioid crisis, and how they’ve addressed the unique challenges brought about by the COVID-19 pandemic.
Fenway Health, Boston, MA
Fenway Health in Boston, MA, was founded in 1971 and first opened as a one-day-a-week drop-in center staffed by volunteer medical students dedicated to serving the diverse Fenway neighborhood—a neighborhood that includes many seniors, LGBT people, low-income residents, and students. In 2018, there were a total of 1,991 overdose deaths in Boston, of which 88% involved an opioid of some type.9
I spoke with Jimmy Kamel, NP, the Clinical Coordinator of the Medication-Assisted Treatment (MAT) Program at Fenway Health. He explained that a core tenet of their program is that no one who needs help is turned away.
"No one who needs help is turned away" Fenway Health makes an active effort to incorporate medication assisted treatment into primary care and it is available at all three of their locations. Approximately 150 patients are actively enrolled in Fenway’s Substance Abuse Treatment Program, and an additional 50-100 patients have been engaged in care at some point within the past year. Fenway offers rapid enrollment, and most patients are able to receive an intake appointment to get care within 24 hours of their initial call. Thirty of the health center’s forty-five medical providers have received a Drug Addiction Treatment Act (DATA) waiver and can prescribe medication for the treatment of OUD, which helps ensure that the health center has the capacity to help people who want to pursue and engage in OUD treatment. There are two needle/syringe exchange service sites that are affiliated with Fenway via partnership with Access: Drug User Health Program/AIDS Action. Fenway's goal is to expand the scope of services that are available to their patients within the health center, Kamel explained, noting that “We find the more we can do under one roof, the more patients are likely to engage with those services.” While Fenway sometimes needs to refer patients out, they do so primarily for higher-level care such as intensive outpatient treatment.
Kamel attributes Fenway’s success to both the resilience of its patients and the ability of its medical providers and behavioral health specialists to approach treatment for OUD as they would for any other chronic illness. He reflected on the importance of treating all patients without judgement and with compassion and respect, explaining, “There is a power in language that is often underestimated. When a patient meets with someone in the health care system and that provider doesn’t refer to them as clean or dirty then there is the potential to build a therapeutic relationship that is beneficial and helps patients reach their goals.” Kamel noted that groups like AA are not always encouraging of medication for addiction treatment. Recognizing that this is a barrier to recovery for many people, Fenway decided to establish specific therapy for patients prescribed suboxone or any type of buprenorphine as part of their MAT regimen, and offers recovery groups for people getting MAT.
The COVID-19 pandemic has been a catalyst for extending medical access through telehealth and telephonic services. The temporary waiver of federal regulations allowed doctors to write prescriptions based on these virtual appointments. According to Kamel, this regulatory change has made it possible for Fenway to expand its reach: “[Telehealth] has minimized the obstacles that potentially come with having to come [to the health center] in person. I think it has allowed more patients to engage in care who otherwise maybe would have thought twice about making the trek out to Fenway.” Fenway has also made a concerted effort to connect patients with resources like phones so that they can engage in telehealth, including recovery group sessions. Outreach workers affiliated with the Access needle exchange programs are available to help patients pick up their medication from the pharmacy.
"I can't blame anyone who doesn't want to go back and engage with a system that made them feel anything less than human" Face-to-face interaction is often a key component of opioid use disorder treatment, and Kamel acknowledged that there were fewer people attending the group Zoom sessions than there were enrolled in the program. He emphasized, however, that in the early months of the pandemic, more patients sought treatment than had done so pre-pandemic; he was confident that Fenway’s system would continue to be effective, even with the changes brought about by COVID-19. Again emphasizing the need for respecting each patient, Kamel commented, “One of the things I am particularly proud of is that patients will feel human when they come and interact with our program and our healthcare system. I can’t blame anyone who doesn't want to go back and engage with a system that made them feel anything less than human.”
Fenway has not stopped offering in-person medical services. If a patient has been screened for COVID-19 symptoms, they can still come in for treatment. Going forward, Fenway would like to give patients more options for care that include telehealth to improve accessibility. Kamel also expressed appreciation for the SUSTAIN Communities grant sponsored by GE and the Mass League, the state’s primary care association, which awarded Fenway $150,000 for OUD services. In addition to the money, Kamel remarked that the availability of SUSTAIN program mentors from other organizations, including Boston Medical Center, has been invaluable. “We don’t need to recreate the wheel every time and this also gives us the opportunity to spread these programs to other health centers.”
Central City Concern, Portland, OR
Central City Concern was founded in the 1970s specifically to address the needs of people struggling with alcohol disorders and houselessness. Its programs and services today reflect this early focus. Then known as the Burnside Consortium, CCC initially offered recovery treatment and housing. Recognizing that health care services were essential, CCC took over the management of Portland’s Old Town Clinic, a health center that had been in operation since the late 1970s, and incorporated the health center into its services. In 2003, CCC was designated as a federally qualified health center.
While Oregon's drug overdose deaths have remained level since 2012, 339 deaths were reported in 2018. However, deaths involving synthetic opioids other than methadone have increased. The number of reported opioid-related deaths more than doubled from 43 deaths in 2016 to 97 in 2018.10
"We recognize that recovery is truly a continuum for each individual." Dr. Andy Mendenhall is the Chief Medical Officer at Central City Concern, and talked with me about their programs and services. CCC now provides health services to approximately 9,212 patients, many of whom are homeless and seriously and persistently mentally ill.11 In 2019, 2,182 (24%) of the patients CCC served had an alcohol-related disorder and 3,613 (39%) had other substance-related disorders (excluding tobacco). About 500 patients also receive care from CCC’s community partners in support of recovery from opioid use disorder. Over the last two years, CCC has focused on expanding the services it offers in-house, which today include outpatient treatment, residential withdrawal management, and some residential treatment for patients with substance use disorder. CCC also provides a variety of behavioral health services, including one-on-one drug and alcohol counseling services and recovery groups. “We recognize that recovery is truly a continuum for each individual and we want to empower each individual’s choice.” said Dr. Mendenhall. “We are fortunate that our internal continuum of care gives us the ability to take a patient-centered approach and match the services that a patient is open and willing to receive and able to engage with.”
"The pandemic itself has created challenges for our patient population in many ways and it has increased isolation and despair." Building on its early roots, CCC develops and operates a range of transitional, permanent and family supportive housing programs designed to support patients in recovery, and the need for such programs, with integrated health services, has become especially clear in recent months. Dr. Mendenhall remarked, “We know that the pandemic itself has created challenges for our patient population in many ways and it has increased isolation and despair. It has contributed to relapse and it has worsened the pressure on an already strained system so homeless folks are likely spending more time outside because transitional housing is slower.”
One of CCC’s housing services is the residential 29-bed women’s treatment program. Women are able to keep their young children with them at the program, and the average length of stay is six to seven months. Dr. Mendenhall noted that he is especially proud of the work they have done to help pregnant patients who need medical stabilization.
Essential to the recovery process is engaging deeply with patients, including those who are in the early stages of exploring or considering recovery, but may still be actively using. These individuals are also at risk of Hepatitis C and HIV. Dr Mendenhall explained that all people who seek opioid use disorder treatment are immediately screened and tested for Hepatitis C and HIV. They have the opportunity to receive treatment for HIV and Hep C regardless of whether they are engaged in substance use disorder services and even if they are still actively using. Mendenhall said, “This is a key evidence-based step to ensure that the folks who are still actively using substances have access to Hepatitis C and HIV treatment and it also reduces transmission in the community that can occur more broadly through sharing of needles.”
"The key to success for us is low-barrier access" Like Fenway Health, CCC has made an aggressive pivot to telehealth services that includes remote telephone and video, and two “tele-suites” located in one of its transitional housing buildings, where patients can have private video consults with their provider. Stressing the importance of continuing to make it easy for patients to get care, Mendenhall remarked, “The key to success for us is low-barrier access and low-barrier re-entry, so when folks are showing up and asking for care, we will provide it.”
Community health centers have been successful largely because they make it easier for underserved people to get healthcare, and respond to the specific needs of their local communities. The pandemic has highlighted cracks in the health care system and heightened both risks and challenges, but it has also allowed community health centers to innovate and adapt to ensure access to care. As the United States continues to grapple with the effects of COVID-19, aggressive steps must also be taken to help people suffering from opioid use disorder. Like Fenway and Central City Concern, the nation’s community health centers will continue to play an important role as they remain on the front lines, fighting both the continuing opioid epidemic and the COVID-19 pandemic.
Photo courtesy of Central City Concern
-Irene Bruce, December 2020