SAN FRANCISCO — Shannon Ducharme was among her friend’s few lifelines: He was homeless and living in Golden Gate Park. Like many here, he was a drug user without access to basic health care services, a vulnerable young man in need but unlikely to seek out care miles away.
But when she ventured into the park to find him, Ducharme was surprised to find she’d been beaten to the punch.
A homeless outreach team here was not only checking in on her friend, but also scores of others among the city’s thousands-strong homeless population, many who had mental illnesses or who had exhibited risky drug use behavior.
“I was there to help my friend, and to take his dog to the vet,” Ducharme said. “And these people are here, doing what I’m doing, but with way more resources and getting paid for it.”
Ducharme went home and downloaded a job application. Three years later, she is an integral part of a team in San Francisco that bounces between rounds at a clinic in the Tenderloin neighborhood and on the streets. The goal: to present options for care to people who are unlikely to walk into the clinic on their own.
The San Francisco program, run by the city’s public health department, is one of a handful of novel programs around the country that are taking the unusual step of delivering comprehensive treatment to people with addiction — wherever they are.
These programs aim to help patients who can’t or won’t jump through the hoops of health care bureaucracy — appointments, referrals, paperwork, even obtaining a photo ID. It is one of the rare policy ideas that is giving health officials hope for reducing overdose deaths, even as Congress nibbles around the edges of the crisis and the Trump administration grows increasingly hostile to some harm-reduction initiatives.
“The outreach that we do, to say, ‘We saved your life last night,’ grabs people and gets people in treatment who would never get involved in outpatient treatment otherwise,” said Dr. James Langabeer, a professor of emergency medicine at UTHealth in Houston. “You don’t have to just wait and see who shows up at a psychiatrist’s office for care — we’re grabbing patients and getting them into treatment.”
On a recent Monday, the San Francisco public health department clinic where Ducharme works in the Tenderloin was buzzing with activity, as patients filtered through exam rooms.
San Francisco’s program, like others in Boston and across Texas, employs the unusual tactic of sending physicians and other health professionals who have waivers to prescribe buprenorphine to approach patients in vulnerable settings — in homeless shelters, at syringe exchange sites, at homeless encampments.
Mindful that many such individuals are fundamentally mistrustful of the health system and law enforcement, making initial approaches can be a delicate exercise. The program’s lead physician, Dr. Barry Zevin, prefers to travel without company when he makes his rounds on the city sidewalks.
But the strategy seem to be working. Half of the 300 patients initially prescribed the addiction treatment drug buprenorphine during a pilot phase are still in contact with the system, Zevin said.
A more limited sample at a separate program in Boston, according to Dr. Elsie Taveras, one of the program’s coordinators, has seen retention as high as 70 percent. Each performance so far exceeds typical success rates for addiction treatment, especially for such vulnerable populations.
In Boston, a pilot program uses a mobile van and near real-time data to engage populations viewed as at high risk for overdose. The van sets up shop at a time convenient to the community — typically mornings — and physicians who have waivers to prescribe buprenorphine see patients and, for those who’ve expressed interest, walk them through recovery options.
Those wishing to begin treatment often receive a prescription the same day. Health workers then walk or drive them to a nearby pharmacy, and the patients begin using the addiction medication under physician supervision.
Many of the programs also help distribute the overdose-reversal drug naloxone as part of their services. But each of the mobile programs — from Zevin’s walking patrols to mobile vans or even refurbished ambulances in Boston and Texas — has given health workers a chance to go a step further.
“We wanted to be very precise about what it was we’d do to add value in this space,” Taveras said. “We realized very quickly we needed staff who could prescribe addiction treatment outside brick-and-mortar facilities. We needed to be able to be a little more flexible in where our program was located.”
In several Texas counties, public health officials are leveraging built-in mobility they have realized was underused in addiction treatment. In some counties, the state health department has essentially deputized emergency medical technicians to assist in addiction care, using first responders who receive overdose-related 911 calls to record data and make initial inquiries about an individual’s interest in addiction treatment.
EMS personnel can drive them to a prescribing physician for a prescription, then to a medication-assisted treatment provider to begin treatment. As in San Francisco and Boston, individuals who’ve experienced a non-fatal overdose are often able to begin buprenorphine treatment within a day.
In Houston, where Langabeer helped initiate a program that sends paramedics to see overdose survivors the day after their hospital discharge, it’s too early for conclusive results. But early retention rates, Langabeer said, are far better than is typical.
And in Austin, overdose events trigger an alert to a team run by Mike Sasser, a community health paramedic whose unit is often able to meet patients as they recover in the hospital the same day, or at their home the morning after.
From there, Sasser is able to initiate a conversation about treatment options, and whether buprenorphine, a methadone clinic, or inpatient addiction facility might be best.
Since buprenorphine treatment must begin when a patient is experiencing some withdrawal symptoms, Sasser prides himself on offering patients rides when the morning comes.
“That’s the hardest part of the process — getting up while in withdrawal,” Sasser said. “So often I’m able to give a ride to a courtesy appointment where someone can be induced on buprenorphine.”
“That’s the hardest part of the process — getting up while in withdrawal. So often I’m able to give a ride to a courtesy appointment where someone can be induced on buprenorphine.”
Mike Sasser, a community health paramedic in Austin
Those programs, however, often only go halfway to achieving the outcomes city officials might envision if they were not encumbered by federal law.
Some advocates would like to see the mobile programs paired with supervised injection facilities, where drug users are encouraged to consume in an environment staffed by medical professionals.
Public health advocates say it’s safer than the alternative — drug use away from emergency response, or fentanyl testing, or access to clean needles that can prevent the transmission of infectious disease. And just as importantly, many stress, supervised use sites can provide a gateway to treatment that results in ending risky drug use altogether.
The federal government has long been hostile to such efforts; the Trump administration has reiterated that stance amid escalating overdose numbers and as more local health officials seek to lower death rates by any means necessary.
Rod Rosenstein, the deputy attorney general, referred to the sites as city-sponsored “centers where drug users can abuse dangerous illegal drugs with government help” in a recent op-ed. The Justice Department has also promised “swift and aggressive action” against local governments that open sites despite their prohibition.
Even in California, a bill passed by the legislature that would permit such facilities has sat unsigned on for two weeks on the desk of Gov. Jerry Brown (D), even while lawmakers and mayors who advocate better harm-reduction measures pressure him publicly to sign it.
Similarly, since buprenorphine is a controlled substance regulated by the Drug Enforcement Administration, some programs view the inability to provide the drug on the spot as inhibiting their efforts to provide on-demand addiction care.
Neither Boston’s van nor Zevin’s street patrols can give out the addiction medicine, due in part to concerns about the drugs being diverted for illicit use. But, Zevin and others have said, most buprenorphine diversion doesn’t take place among individuals seeking opioids for euphoric effects.
Numerous patients in the San Francisco clinic told similar stories of friends, mistrustful of the health care system, who nonetheless sought buprenorphine on the black market not for the euphoric effects associated with opioids but for the drug’s intended use: mitigating withdrawal symptoms.
With the federal government not yielding on supervised injection or how it regulates addiction drugs, health departments are left to operate within existing regulations.
And across the country, many say they are nonetheless seeing progress.
Before 9 on a recent morning in San Francisco, a man sitting steps from a crowded subway entrance made no effort to conceal that he was preparing to inject heroin. A block away, in Zevin’s examination room, patients old and new filtered in and out of the clinic near the Tenderloin.
Clinicians were proud to introduce Jon Debella, known as “Monkey,” who began treatment years ago at the San Francisco County Jail. An outreach worker asked then if he was interested in buprenorphine — he recalls responding “hell yeah” — and Debella has been seeing Zevin for over a year, often with his dog, Peaches, in tow.
The same afternoon, he was encouraging Zevin to write him a prescription for a two-week supply instead of one. Zevin wasn’t sold — but he allowed himself to smile at his patient’s reasoning.
“Then I don’t have to see you as much just to tell you the same shit,” Debella said. “I never run short. I’m always right on schedule.”