Creating Partnerships to Provide Mental Health and Substance Use Services in Vulnerable Communities
All BHLI projects are as multi-faceted as the problems they address. The unique BHLI approach is to combine research, community partnership, project design, implementation and evaluation with training, education and workforce development while creating innovative and comprehensive approaches. When working with highly vulnerable populations and creating solutions for complex problems, a holistic approach is required. The projects described below are examples of the BHLI approach.
BHLI Project Connections Buprenorphine Initiative: Provides buprenorphine induction and stabilization treatment for vulnerable populations unable to connect with traditional programs but desiring recovery. BHLI partners with grassroots recovery programs and community stakeholders to provide effective treatment
Background: Opioid dependence is a significant public health problem in the United States. "The Centers for Disease Control and Prevention calls the prescription opioid epidemic the worst of its kind in U.S. history." [Chirkis, Huffington Post, "Dying to be Free". "Between 2002 and 2012, the number of people who reported using heroin within the previous year increased by 265,000." [Chirkis] It is a disease of the brain and for the majority of those who are afflicted, the most effective treatment is medication. The two major medications are methadone and buprenorphine. Buprenorphine is extremely safe and very effective. It is nearly impossible to overdose on buprenorphine. Additionally, when combined with naloxone as in the drug Suboxone [bup/nx], the drug is formulated so that user will not be able to achieve a "high" even if more of the drug is taken. Studies evaluating the effectiveness of buprenorphine maintenance treatment programs in primary care settings have shown them to be cost-effective, to have relatively high retention rates, and to reduce opioid dependence. It would be safe to assume therefore that suboxone is widely distributed and that the public health authorities are actively promoting programs that increase the availability of the treatment. However, that assumption would be wrong.
There are many reasons for the current failure to effectively provide treatment. First, there is a shortage of doctors available who are willing and able to treat patients with substance use disorders and are not comfortable prescribing the medication. Second, the federal rules create serious barriers to treatment by limiting the number of patients each doctor can treat and by prohibiting the certification of nurse practitioners. Third, these barriers continue because of the tremendous ignorance and stigma that is rampant in the medical profession, in the general public and in the recovery communities themselves about medication assisted treatment for substance use disorders. BHLI wanted to create a program that will bring treatment to these individuals who are currently outside of the traditional system of care. Since recovery programs in the community provide a sanctuary for many of these individuals, BHLI developed a model for bringing the suboxone treatment program into the recovery center.
Model: The BHLI buprenorphine model is currently operating at four sites, two of which just opened in the Fall of 2017. At each site there is a clinical team consisting of a registered nurse, a physician, outreach workers and peer support recovery specialists at the site. A primary care physician who is also an addictions specialist sees the patients once a week in the community sites and writes the prescriptions. The nurse evaluates and screens the patient and confers with the doctor and site staff during the week. The patient calls in to the nurse daily for the first week and any other time that the team determines that additional support/oversight is need. The patient is expected to attend daily meetings at the site and to see the addictions counselor as well. No medication is kept at the sites due to safety concerns in the community. The team meets weekly for rounds and if a patient is struggling they are brought into the team meeting to discuss a plan for moving forward. BHLI staff, join the clinical team for every 6 weeks to discuss overall problems, successes and strategies. Over the past 7 years, over 600 individuals have been enrolled in the program and approximately 30-35 % have been successfully transitioned into ongoing primary care clinics. These numbers are significant not only because they mean that people are continuing treatment, but also because this population previously did not access primary care providers and frequently have serious medical problems that are untreated. Transitioning people to primary care provides for comprehensive medical treatment, including treatment for HIV/AIDS and Hepatitis C as well as continued drug treatment. The BHLI program is committed to integrating both suboxone treatment and the patients into the traditional medical system of care.