Doctors Should Be Handing Out Addiction Meds on Demand

Burlington, Vermont, police chief Brandon Del Pozo—a former deputy inspector and nearly 20-year veteran of the statistics-driven NYPD—has a new vision for policing during an opioid crisis. His primary metric for success is reducing overdose deaths—not increasing the amount of drugs seized or raising the volume of arrests. It’s a potentially transformative model that deserves to be replicated widely.

To put saving lives first, Del Pozo has begun an innovative program aimed at getting proven anti-addiction medication into the hands of those who need it—regardless of whether or not they want to quit illegal drugs entirely.

“The number-one job of a police department is to protect and rescue its community from harm,” Del Pozo tells me, “Right now, fatal opioid overdoses are the number-one harm to practically every community in America.”

Traditionally, police departments have measured their effectiveness by completely different markers, mainly tracking statistics like homicide, arrest, and prosecution rates. New York City’s much-debated “CompStat” program, which relentlessly focuses on addressing these numbers neighborhood by neighborhood, is often credited with helping reduce violent crime and is now used across the country and around the world.

But when the number of overdose deaths also becomes a key metric, a shift in priorities is necessary. That’s why Del Pozo and Chittenden County state’s attorney Sarah George recently announced that they will no longer arrest or prosecute people caught illegally possessing the anti-addiction medication buprenorphine in Burlington.

The new policy is part of a belated recognition across the US that drug-war policing can actually undermine public health. Buprenorphine, available in pill or sublingual film form, is one of two medications proven to cut the death rate from opioid overdose by 50 percent or more—but we make these drugs extremely hard to get. (The other is methadone, which is much more strictly regulated on the federal level, and so cannot immediately be made more accessible by cities or states).

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Only about a third of addiction programs offer these medications at all, even as yet another study out last week confirmed both their life-saving value and how underutilized they are. The study, published in the Annals of Internal Medicine, and including data on more than 17,000 people treated for overdose in Massachusetts, found that methadone cut death rates by 59 percent and buprenorphine by 38 percent. However, during the year following an overdose, only 30 percent of patients received any anti-addiction medication. (That figure included some who received a third drug, naltrexone, which wasn’t shown to reduce mortality, although since so few took it, the authors caution, any benefit might not have been measurable.)

Indeed, in most states, fear about diversion of buprenorphine to the black market dominates policy and has led to restrictions on prescribing and prosecution of patients who sell or give it away: Since buprenorphine is itself an opioid, it can cause a high if taken irregularly or by someone who is not already addicted to opioids. As I reported recently, even leading doctors who are clearly expert prescribers have been targeted by federal agencies concerned about diversion.

However—and especially in a street market where contamination of heroin with deadly fentanyl is ubiquitous—public health officials have long recognized that excess concern about diverted buprenorphine can itself be dangerous.

Research shows that requiring counseling or making people jump through other hoops in order to get buprenorphine isn’t necessary for it to be effective. The drug itself is protective against overdose and relapse, regardless. (This is why many addiction experts hate the term “medication-assisted treatment”—the medication is what is proven to cut mortality and relapse, so if anything is doing the “assistance,” it’s the other services.)

Studies also find that, overwhelmingly, people who buy street buprenorphine are doing so to stave off withdrawal—not to get high. For recreational use, heroin and opioids like oxycodone or hydrocodone are preferred. And illicit buprenorphine use by people who don’t already misuse other opioids is extremely rare.

Consequently, since buprenorphine is safer, any time an opioid user—even if not the intended patient—takes it instead of street-sourced opioids, the risk of death is reduced. As George put it bluntly in a recent interview with Vermont’s Seven Days, “I believe we need to be encouraging diversion.”

The idea is to make buprenorphine almost as easy to get as heroin so that even people who aren’t ready to quit entirely can reduce their risk of dying. Such “low-barrier” or “low-threshold” distribution programs have already been started in cities like San Francisco and Philadelphia.

In San Francisco, for example, a street medicine team from the Department of Health visits places like parks frequented by homeless people who use drugs and offers three-day prescriptions to those in need, which they can pick up for free at a nearby pharmacy. Such prescriptions are also being made available at needle exchanges.

“It’s not the lowest of low-barrier programs, but we’re trying,” says Jamie Carter, an addiction medicine fellow at the University of California, San Francisco, who has worked clinically with the team. “I think we should make it as easy as possible for people to have access to buprenorphine.” Ideally, physicians would be able to give out the drug itself on the spot.

In Philadelphia, the Prevention Point needle exchange can also start people on buprenorphine, but in order for them to stay on it and be covered by Medicaid, urine screening and attendance at some type of counseling is required. “I just don’t understand why this is harder than getting a prescription opioid [for pain],” says Silvana Mazzella, the associate executive director of Prevention Point.

Nonetheless, a study of the Philadelphia program published in February found that 56 percent of participants were still enrolled a year later, which is comparable to treatment initiated in more typical medical settings.

Many hospital emergency rooms—including some in Philadelphia, San Francisco, Boston, Denver, and New York—are also offering to start buprenorphine treatment immediately, typically for overdose victims. A few, however, also provide the drug to people who are in opioid withdrawal. And some ERs have very low barriers: The program at Bellevue Hospital in New York City, for instance, doesn't require counseling or drug-free urine, and the Bridge Clinic at Massachusetts General in Boston is similarly accessible.

Del Pozo wants to go even further. “If somebody’s simply in withdrawal or they want to see how buprenorphine would affect them… or they’re like, ‘I don’t want treatment but I do want buprenorphine…’ that’s great, they would get it at the syringe exchange,” he says. And, he also wants to help those who get buprenorphine outside of official channels by not arresting or prosecuting them.

Adding these policies to structures already in place could give Vermont the best opioid addiction treatment system in the US. For one, it’s already miles ahead of most states in terms of access to medication treatment. In 2012, the state opened a centralized “hub and spoke” system in which people who need more intensive treatment get care at specialized “hubs” and, once stabilized, are transferred to “spokes” for long-term management—or back to the hub if their problems worsen.

In most other communities, in contrast, there is little coordination or centralization, which means it’s hard for people to find out when and where open treatment spots exist or to get back into care rapidly after a relapse.

Vermont’s networked system has dramatically increased access to care while nearly eliminating waiting lists for those who seek help. Overdose survivors who are admitted to the emergency department in the state’s hospitals are also now being offered buprenorphine and instant entry into ongoing treatment when they leave.

And, if all goes as planned, those who just want to try buprenorphine or use it from time to time to improve their functioning and reduce their risk of dying will be able to get it for free or low cost later this summer at Burlington’s needle exchange, Safe Recovery.

To keep on top of the crisis and make sure everyone is working together, Del Pozo holds regular “CommunityStat” meetings with Burlington Mayor Miro Weinberger and representatives of health agencies, the needle exchange, law enforcement, and other relevant groups. As with CompStat in more traditional policing, the idea is to track exactly what’s going on locally, find out what roadblocks still exist, and figure out how to get around them.

At a meeting I attended last month (I was invited to give a talk on my book), a representative from the state medical board gave a presentation on how the board flags doctors who might be running “pill mills.” This is a concern for low-threshold buprenorphine prescribers because, if doctors give out the drug as harm reduction—that is, without requiring counseling or urine screening—they might look suspicious to regulators or law enforcement.

“What we’re going to try to do is make sure that the Vermont Medical Practice Board understands that the standard of care we’re proposing, low-barrier administration, is evidence-based: It has studies that show it unequivocally saves lives,” Del Pozo says.

And by shifting their attention away from street buprenorphine use, Del Pozo and local prosecutors also hope to make it more attractive to people who aren’t ready for any other kind of help. “A person who is seeking out black-market buprenorphine is in a much better and safer place than if she were seeking out heroin or fentanyl,” he says, “If you are serious about what it takes to reduce mortality in American communities, then you have to recognize that any sort of buprenorphine is better than not having it out there.”

He adds, “Every dose of buprenorphine consumed is at least a dose of heroin not getting consumed, if not several.” Moreover, every dollar spent on street buprenorphine is one not spent on heroin or fentanyl. The more treatment is able to compete with dealers, the smaller the illicit market will get.

Other countries like France that faced opioid overdose epidemics in the past have been able to cut deaths by 80 percent by providing widespread buprenorphine access. Vermont has advanced further than any other American state in terms of coming close to providing genuinely easy access and, as of 2017, it had the lowest overdose rate in hard-hit New England.

Now, Del Pozo is trying to make Vermont's approach even better and offer the system as a model for other states. Working with researchers at Johns Hopkins, the Police Executive Research Forum, and with former Obama drug czar Michael Botticelli, he just released a set of ten evidence-based strategies for police and communities to use to fight overdose. The most important concept is to put saving lives back at the top of the agenda.

Correction 6/27/18: This story has been updated to reflect that the Burlington Mayor's office is involved with CommunityStat meetings.

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