I know that Dr. Hsu has a lot of great information to share, so we'll get going, but hello everyone and welcome. My name is Dr. Amy Yule. I am pleased that you're joining us today for the Opiate Response Network presentation addressing disparities in opiate use disorder treatment among people experiencing homelessness. Here is the funding and disclaimer statement for the talk. And then today's webinar has been designated as one AMA category one credit for physicians and credit for participating in today's webinar will be available for 60 days and you'll receive information after the presentation, I think at the end of the presentation on how to claim your seeming credit. Next slide. I also wanted to make you aware that the PDF of the slides will be available in the chat and so kind of look here to find the PDF and download that. And next slide. And then also wanted to note that captioning is available for today's presentation. To enable the captions, please click show captions at the bottom of the screen. Click on the arrow and select view full transcript to open the captions in a side window. Next slide. And then we're hopeful that you'll have questions and that we can have a bit of a discussion at the end of the talk. And so please put your questions though into the Q&A and again we'll have about 10 to 15 minutes at the end of the presentation to share questions and respond and have some discussion. Next slide. And so I'm pleased to welcome Dr. Michael Hsu. Dr. Hsu is a board certified psychiatrist and an incoming faculty at the Greater Los Angeles VA Medical Center and the UCLA David Geffen School of Medicine. He completed his medical degree at Hopkins, John Hopkins, his psychiatry residency in Boston at Brigham and Women's Hospital and Harvard Medical School where he was the chief president of outpatient psychiatry and then went on to complete an addiction psychiatry fellowship at Emory School of Medicine. He was awarded the APA F SAMHSA MFP fellowship grant from 2021 to 2023 to investigate access challenges to opioid use disorder treatment among individuals experiencing homelessness and other marginalized patients. His other research interests include cannabis and internet gaming disorder and outside of work, he enjoys playing tennis, traveling, and cooking. So thank you for joining us and I'll turn the talk over to you. Great. Thank you so much, Dr. Yu for that introduction. So one quick disclaimer, I am on a scientific advisory board for a nonprofit that helps address mental health and gaming, internet gaming challenges for young people, but otherwise don't have any other disclosures or funding related to this talk. In terms of the learning objectives, so one is to understand the disparities in opioid use disorder treatment access among people experiencing homelessness and other marginalized populations, to assess factors contributing to disparities in access to opioid use disorder treatment among marginalized populations, and to explore interventions to improve treatment access to medications for opioid use disorder. So first I'll be talking about the epidemiology of opioid use disorder and overdose deaths among people experiencing homelessness, and then I'll transition into access challenges to opioid use disorder treatment and with potential interventions. So overdose rates have risen over the last few years. I don't think this comes as much of a surprise to many of you all, but we have seen a rise leading up to and during the COVID-19 pandemic, and if you're looking at data specific to patients experiencing or people experiencing homelessness, for example in Los Angeles, we also see this steady rise as well of deaths overall across the board, but also in looking at what are causing these deaths among people experiencing homelessness, again this is data from L.A. County, we see that drug alcohol overdose surpassed coronary heart disease as the major contributor to mortality rates up until 2019, which is as much of the data as we have here. And in looking at what are some of the substances contributing to these overdose deaths, a majority in Los Angeles was actually found methamphetamine, followed by fentanyl, which as you can see there was a steady increase in that as well, and heroin, cocaine, as well as alcohol are also contributors. And here's a graph just showing sort of prevalence estimates of, again, what substances are contributing to overdose, but also the red line here, receiving medications for opioid use disorders. So there has been sort of a steady increase in adoption of medication for opioid use disorder among people experiencing homelessness, but we definitely want to see that improving beyond 25%. So I talked about data from L.A. County. There's also data out of Massachusetts published in 2022 based on this paper shown here where a drug overdose was also found to be the number one cause of death among people experiencing homelessness among the sampled population, and overdose mortality among people experiencing homelessness was 12 times higher than housed Massachusetts individuals. Another sort of harrowing aspect of this study was that 24% of their sample that they followed from 2003 to 2017 actually died by overdose by the end of the study. So that was definitely sort of just striking in terms of the morbidity and mortality of this. Opioids were involved in a vast majority of cases, although polysubstance use and synthetic opioid use really has increased over the last few years. Another interesting finding they had was that men were more likely to have alcohol plus opioid involvement versus women who were found to have benzodiazepine plus opioid involvement. So I talked about L.A. County, I talked about Massachusetts. New York also releases an annual report on deaths among people experiencing homelessness, and you can go ahead and read this if you like, but essentially overdose was again the number one cause of death in New York City among people experiencing homelessness in their most recent publication. So we talked about how overdose rates have really increased and has really taken over as the number one cause of death among people experiencing homelessness in major cities, but beyond overdose, opioid use disorder really confers many other social and psychomedical challenges for individuals, challenges such as chronic infections like HIV and HCV, unemployment, incarceration, mental health issues like depression, anxiety. And so these are sort of additional risks and morbidity that this patient population holds from this rise. So I just talked about some of the epidemiology of opioid use among people experiencing homelessness, and I'll be going into some access challenges to getting treatment. And I want to start off by first establishing that people experiencing homelessness do benefit from opioid use disorder treatment just as much as housed individuals. There's been several studies looking at both outpatient treatment as well as residential programs, and they do benefit. People experiencing homelessness though might have lower treatment retention and higher dropout rates than housed individuals, although this evidence is mixed, but this kind of just speaks to, and something that I'll be harping on later on in this talk as well, just the importance of thinking about how to engage and retain people experiencing homelessness in treatment, given the challenges that they have out on the streets in terms of being able to meet the needs of the clinic and treatment. Harm reduction may result in better outcomes than abstinence-based models in some cases, and again, I'll talk more about this as well. So medications for opioid use disorder, they're effective for people experiencing homelessness, but are they actually able to get on this? Do people take it as well? This data that we're looking at here and the studies that have been done show that people experiencing homelessness are significantly less likely to have ever received outpatient OUD treatment or medications for opioid use disorder compared to housed individuals, and that people experiencing homelessness also prefer residential programs and medically supervised withdrawal inpatient units as well. As you can imagine, there's a whole host of challenges trying to engage with recovery out on the streets when you have people all around you who might be sort of potential triggers or offering substances and things like that, and the many stressors of being on the streets. So that is sort of a preference that has been shown in studies. And interestingly, people experiencing homelessness may be more likely to initiate medications for opioid use disorder or alcohol use disorder on addiction consult services compared to housed patients. So thinking about hospital-based models of care and how to engage people experiencing homelessness through that as well. So population-based studies have also shown that there exists disparities among minoritized and marginalized populations when it comes to getting access to buprenorphine and other medications for opioid use disorder. So individuals who receive buprenorphine treatment are more likely to be white, educated, and employed as opposed to people of color or less educated or unemployed. Buprenorphine prescribing is more prevalent in higher-income areas and in zip codes with a higher percentage of white residents. This was a study done out of New York. And urban-rural disparities also exist with regards to accessing buprenorphine treatment. So then the question comes about what factors contribute to access disparities among people experiencing homelessness? And this is sort of a question that has been studied to some extent, but there's definitely room for understanding this question. As you can imagine, there are likely many systemic issues that contribute to this access disparity, which I'll be talking about. Some of these systemic issues might also trickle down to individual issues as well, building of distrust towards the system because of interactions that people have had with the system in the past or perceptions about the medication due to stigma or community or spiritual background. And, again, this is a question that me and my team felt like was understudied, and that's why we conducted a study out in Boston near MassCast, which is an area near Boston Medical Center, which is known to be an area of higher rates of opioid overdose, where there is a high density of emergency shelters and treatment centers as well. And our team went out on the streets to interview 28 participants, and I'm just going to show a little bit of our findings here in terms of trying to answer the question of, you know, what are some of these access challenges that people are having? So the inclusion criteria that our study had was age of 18 to 65, a diagnosis of opioid use disorder, and having experienced homelessness in the past year. And many of the participants that we interviewed were active or recent users of injectable opioids versus prescription. So the average age of the participants that we interviewed was 44, and the distribution was pretty even across black or African American, nonwhite, Hispanic, and white. And interestingly, or kind of based on the way that we target our sample, a majority of our patient population was not in active treatment using medications for opioid use disorder. And this is, again, to highlight some of the challenges that some of the studies in the past have done in trying to answer the question of access that have been done, for example, in clinical settings, where many of the patients who maybe aren't engaging in outpatient treatment or who are not able to gain access to that may be left out of that sample. So that was one of the reasons why we did employ sort of a targeted sampling on the street in order to hear from people who are not able to access treatment. So of those who were using medication for opioid use disorder, a majority of them were on methadone, with one patient on oral naltrexone, another patient on IM, and another on subcutaneous buprenorphine or sublocade. One thing that you might notice is missing from this whole pie chart is any form of oral or sublingual buprenorphine or suboxone, which many of us sort of outpatient substance use treatment providers might think as a first-line treatment. It was kind of shocking to see that none of these patients were on that, but I'll speak a little bit into that and some of the challenges that people spoke to. So we also took a look at race and how that could be impacting whether people had received a buprenorphine or suboxone in the past, given sort of the studies that have led up to this particular study on a population level and the disparities that were found there. So in looking at buprenorphine monoproduct, we compared differences between white and BIPOC patients and found that 60% of our patients who were white reported that they got buprenorphine monoproduct in the past, whereas only 10% of our BIPOC patients did. So our sample wasn't that large. It was 28. It wasn't meant to sort of drive statistical power, but this was statistically significant in our sample and was kind of striking to see this difference, even in sort of a socioeconomically homogenous population, that there still persists potentially some difference in terms of ethnic background and their receiving of buprenorphine treatment. In looking at combined product buprenorphine naloxone or suboxone, we still see a little bit of a difference. All of our white participants got suboxone in the past, but a little bit less than 80% of our BIPOC patients did. This was not statistically significant, but again, just kind of shows a directionality to this disparity here. So a majority of our data came out of the qualitative interviews that we had with people on the streets. And from that, we determined nine themes from this data that I'll kind of quickly go through while highlighting a few of them. So the first theme was reduced services due to the COVID-19 pandemic. So many people reported that there were just less beds available for inpatient managed withdrawal or residential programs. And as I mentioned before, people experiencing homelessness do prefer recovery and a place where they can be kind of safe and housed. And so this is definitely a barrier that came up during the pandemic. There was also an emphasis on fewer treatment beds for women in particular, which was something that we hadn't really seen much of in the literature or in studies in other cities. So it's unclear if this is a local issue or systemic, but there were definitely many who felt like that treatment beds for women were not as available as well. And this was exacerbated during the COVID-19 pandemic. And the third theme was transportation challenges, getting to the clinic. As you can imagine, this would be a challenge if you don't have a car or don't have access to bus passes and things like that. And many of the social services centers were also closed during the pandemic, which made things challenging. Cumbersome treatment schedule, the rigidity of engaging in methadone treatment and sort of the daily requirements initially from engaging in that treatment as well. This is not something that's necessarily specific to people experiencing homelessness, but that was something that was brought up. This is a number five, but a lost or stolen medications was a fifth theme. And essentially, this was kind of an interesting point that was brought up as well as you know many of us have probably had the experience of people coming into the emergency room or an outpatient clinic reporting that their medications were lost or stolen and it was just kind of striking to hear how much this had impacted people's treatment continuation how this much that's how this has impacted people's treatment in general and disrupted it and how clinics you know understandably so in some cases might might be might perceive this as sort of diversion or or even malingering in some cases and how because of that might be more cautious refilling medications or continuing treatment and sort of how difficult that was for people experiencing homelessness i and i wanted to just bring up a couple of quotes here uh one was um the emergency room the staff there treat you like an addict that stigma is definitely there i don't like it i think it is depressing it causes anxiety they make you feel like you're not worthy of being in emergency room they'll give you a suboxone but they don't say come back but they they say don't come back again tomorrow for it and it's like well someone stole my meds what am i supposed to do so again um sort of story of someone who lost their medication is trying to get back into treatment and um sort of how discouraged they felt uh trying to navigate that um another patient said well the messed up part is having to come in every day i tried to do take home methadone but the bottles got stolen from me when i tried to explain what happened to the clinic they didn't want to hear it so now i have to go in every day instead of twice a month that take home is incentive because you don't have to come in every day every day i get here before 11 and get out around one um and so yeah this is again another patient who um had lost her medications and many of the clinics we work at might have punitive policies or might even discontinue treatment you know at the face of a kind of potential diversion or anything like that um but again just showing how um how this can be disruptive for some people and really discouraging in terms of engaging in treatment um another theme was precipitated withdrawal um and how sometimes this can be traumatic especially uh knowing how it can be difficult navigating induction with some of our synthetic opioids like fentanyl as well and sort of the uh the degree of precipitate withdrawal and and it's not just the experience of it but also hearing from others on the street who had that experience as well could be a barrier perceptions that taking medications means replacing one addiction for another um some individuals reported that they felt like um they saw that suboxone or buprenorphine was being sold on the street alongside other uh full agonist um uh products like um heroin or or fentanyl and associated these treatments or associated these opioid products together and had a hard time seeing buprenorphine as a treatment and so sort of highlighting kind of the importance of discussing these differences with with patients and just making sure that um that can be teased out for them um community disapproval of MLUD um and stigma especially uh potentially in in families or religious groups and negative experiences at treatment clinics such as discrimination based on race gender or neglect was another theme so I'm hoping that one of the takeaways from this presentation is also that um you know this is really a multi-factorial challenge uh that on an individual and a systemic level in terms of what are people facing in trying to get access or in in engaging with treatment with medication for opioids disorder and I just wanted to highlight that with a couple of cases and their sort of individual story and what what's challenged them to um get into treatment or to engage with it um so the first case is a 28 year old cisgender latinx man with a history of bipolar disorder and schizophrenia this participant reported distrust towards drugs medical providers and the government strongly believed that he could overcome addiction on his own I really don't know what's in it but I guess you really don't know what's even in other drugs if you really think about it my biggest fear is them putting a chip in me and freaking controlling me he believed that medications like suboxone had bad side effects in terms of impacting his mental health and I recall that someone told him that someone had actually died by overdose on suboxone so he said there's more of my bipolar and stuff like that I don't know how I react to it I'm just worried about it he also strongly believed that taking suboxone was replacing one addiction for another and um but he interestingly strongly agreed to the question of having access to substance use treatment so this kind of just paints a picture of multiple factors that might be driving this individual's relationship with the system one being his psychotic illness another being potential bad experiences in the past or hearing from poor experiences about medications for opioid use disorder and some of the challenges that that he might have faced with that there's another participant who's a 55 year old african-american cisgender man who cited difficulties with transportation to substance use clinics said that he faced discrimination in terms of accessing resources for housing mental health care said they only worry about their kind caucasians I don't need no attention they didn't give me all the help that they should have given me with resources and other services if you're homeless he strongly believed that taking medications for opiate disorders also odds with his religious beliefs so he says I trust in God why would I want to use any other drugs if God could help me only God can help me and then I can help myself he also strongly believed that medications for opioid use disorder just replaces one addiction for another and say that he has never been given information about suboxone despite engaging with multiple settings for substance use treatment as well so this was kind of striking to hear that someone who has been in the system for so long hasn't been sort of introduced to a buprenorphine or suboxone or discussed about potential induction on this as well so thinking about physician bias thinking about some of the structural vulnerabilities as well in terms of being able to get access to resources that would help this person navigate the treatment paradigm as well as his spiritual beliefs as well so and transportation so again sort of this multifactorial challenge and so you know I mentioned physician bias and I just wanted to just kind of point that out as well as something that definitely does need to be addressed in terms of the stigma in our system and among providers as well so there's a study that that interviewed people who were addiction treatment program directors that served and show that people who served a higher proportion of those experiencing homelessness might have more negative attitudes around the use of buprenorphine and that another study showed that providers are hesitant to describe prescribe MOUD for individuals with co-occurring alcohol or benzodiazepine use as many of the people experiencing homelessness might have sort of a polypharmacy picture and they're also post-discharge recovery homes that refuse patients who are on medications for opioid disorder and you can imagine how that could be a treatment barrier some of the other barriers as well that I may or may not have mentioned include the stressors of housing instability and isolation getting access to broadband or smartphones or digital literacy which could impact people's engagement with virtual care this stigma of substance use and homelessness in the system again criminal justice involvement and general sort of distrust from experiences in the past or other contributors so I just talked about access challenges to abuse disorder treatment among people experiencing homelessness and I'll end with talking about some of the potential approaches or interventions and some of the more kind of innovative approaches that have come out over the last 5-10 years as well so I'm thinking about approaching and intervening for people experiencing homelessness I like the kind of full four-pronged approach that Dr. Jakubowski described in a paper in Journal of Addiction Medicine in 2020 and she and her colleagues talk about one same-day treatment so essentially discussing how there's really no evidence to delay treatment beyond sort of that first day despite concerns that people might not engage in treatment if it was provided on that first day or medications were provided there actually been studies that have shown that retention in treatment in same-day treatment actually is pretty high even after three days or a week and that there's no difference in terms of treatment retention whether or not they get it on the first day or later on so in thinking about same-day treatment you can also think about home inductions as well and again just sort of lowering that barrier of course there are challenges that come with this like cumbersome programmatic requirements in the system you work in or prior authorizations and waiting lists and all this can create delays in getting medications for opioid disorder or treatment and but something to think about and then harm reduction so thinking about models beyond sort of abstinence that can really help engage people in treatment and meet them wherever they're at and really the goal of harm reduction and substance use treatment in general part of it really should be improving quality of life and overdose but also reducing risks like HIV and hepatitis C transmission and things like that and harm reduction methods can help you meet people where they're at or while also sort of treating the whole person and really discouraging MLUD discontinuation as well which I'll talk about also the next slide and then next thirdly flexibility strict regulations around methadone maintenance or providing opioid use disorder treatment only if people fulfill certain kind of programmatic criteria or sort of rigid requirements like picking up medications daily at a certain time or mandatory intensive psychosocial counseling whereas this could work for some you know for others sort of having greater flexibility can be helpful as well and then being available in non-traditional settings like mobile treatment sites or emergency housing units and emergency rooms and and things like that or through needle exchange programs so again you know this approach isn't necessarily for everyone but in terms of thinking again about the challenge with working with people experiencing homelessness and trying to meet them where they're at engaging and retaining you know this is definitely an approach to keep in mind but again there might be some people who do need a higher level of care who do want to engage in a setting that that might be more suitable to them but yeah so other considerations include not withholding MLUD treatment or excluding patients unless medically necessary and you know there are definitely treatment practices that you know might deem people ineligible for buprenorphine treatment or might discontinue it because of potential concerns for diversion so really considering shortened prescription durations or requesting counts of remaining medication films instead of treatment discontermination for this patient population if possible you know again it's it's certainly a complex sort of weighing of the risks and benefits to as well but sort of as a general rule of thumb also thinking about not using strict urine toxicology screening requirements to start these medications and addressing diversion through consulting local PDMP services as well so for example not withholding treatment because patients are also drinking or on benzodiazepines you know sort of that was kind of an older recommendation to to withhold potentially but you know that that's currently not the sort of treatment approach that we recommend currently so I'm going to be talking also about some of the more recent interventions that have been employed and discussed one is mobile OUD treatment so in 2021 the DA really helped to open doors for opioid delivery through mobile units and and their policy making and as you can imagine mobile OUD treatment clinics may help improve engagement and care and address challenges pertaining to transportation and insurance although in some cases transportation can still be a challenge as patients have to have to get to the mobile care site but it definitely does help a lot especially in urban settings as well or in areas where there might be a higher density of people who need help but don't have a clinic site there and oftentimes these mobile clinics come with a collaborative team which may include primary care peer recovery coach a therapist and slash or a nurse who can help deliver extended release medications or fentanyl testers naloxone even prep and condoms as well as clean injection kits and if you're interested in learning more about mobile clinics or thinking about starting one in your own system you can kind of explore sort of various other ones that have been employed and that are actively being assessed including the project connections at re-entry or p care in baltimore road to care at umass memorial new jersey mobile medication units and the san francisco mobile van through opiate treatment outpatient program and this is by no means an exhaustive list this is sort of an intervention that's being employed in many different places but these are some of the studies that you can kind of explore if you're interested in learning more about that some of the challenges that people have faced with mobile treatment or might have with it i wanted to bring up as well so one of the challenges is potentially poor treatment retention at month one and 12 months out another challenge is longitudinal follow-up with primary care there was a paper out of health affairs of perspective done last year where where the authors felt like mobile clinics were not sort of getting people into longitudinal and primary care follow-up and that they're in a quote-unquote perpetual induction phase through that so again you know thinking about you know how do you incorporate sort of these addiction treatment programs with longitudinal treatment as well and yeah so i'll also bring up housing first as a model and this is a policy offering unconditional permanent housing as quickly as possible to people experiencing homelessness so essentially not requiring substance use treatment or not having sort of strict barriers to getting housing but thinking about housing as a way to address both their sort of whole person issues as well as some of the addiction issues that they're facing so this kind of terminology and program started in new york city in the early 1990s but has really spread out into various regions in the u.s including the west coast europe and around the world due to substantial evidence regarding improvement in certain outcomes although with that you know there's also been been sort of pushed back from the community to some extent like in the san diego union tribune there is a title of is the housing first model helping to end homelessness or does it enable drug users so let's take a look at some of the studies that have been done with housing first and to see you know you know how does that how can that come into the treatment paradigm for this patient population so first off i just want to mention that housing first model it seems to really help people retain treatment so there's a new york study where 51.6 percent of patients who are given housing first retain methadone treatment after three years versus 20 of those who are not in the program it can also help reduce health care utilization reducing ed visits hospitalizations and time spent hospitalized of course really helps people in terms of their housing instability and also may improve autonomy community functioning quality of life and life satisfaction so definitely a lot of sort of potential positives that come out of it what about housing first and the direct outcomes to substance use treatment so this is kind of something that's still being teased out and still sort of a challenge for housing first models and one of the systematic reviews and meta-analyses published in 2019 suggests that there's no clear change either way in substance use with housing first model okay there were some positive signals in non-randomized studies when looking at housing first versus treatment first but there were also some negative studies as well for example housing first model in paris with patients who had serious mental illness where alcohol consumption actually increased after four years of housing first model compared to treatment a traditional treatment and sort of a negative outcome also in a canada-based housing first model as well so there still needs to still work to be done in terms of how to engage patients in both helping with their necessary human need of housing, but also how do we incorporate substance use treatment in a way that doesn't raise barriers, but also meets people where they're at and is able to address those. And that again is part of the harm reduction approach, which has been shown in the housing first model to also lead to better outcomes with opioid and stimulant use compared to abstinent approaches. I thought this was a nice perspective piece by Dr. Kelly Duran last year talking about opioid overdose and homelessness. And I'll just read part of this excerpt here. So she says, or the authors say a common assumption is that there is a unidirectional causal pathway between drug use and homelessness, that as people become homeless because of their drug use, this misconception places the blame on the individuals and away from the root structural contributors to homelessness, as well as perpetuates stigma and points to the wrong solutions. In reality, the association between homelessness and drug use is bidirectional and homelessness itself plays a role in drug use and overdose risk. So again, just highlighting the stress and the multifactorial challenges that people face when they're not housed in stolen or lost medications, all these things can contribute to drug use or lack of engagement or difficulty engaging in treatment. So I'll leave this to you all if you guys wanted to read that further. Additionally, in terms of addressing some of the challenges, especially with our BIPOC patient population and potentially some of the spiritual and religious community backgrounds that might be sort of potentially stigmatizing towards treatment, there's been some great collaborations done with faith-based communities and academic or hospital-based care, as well as outpatient treatment. So one of these projects was the Imani Breakthrough Project led by faculty over at Yale University, where they partnered with seven or eight Black and Latino churches in the area and helped to essentially run groups and build relationships with people and meeting people where they're at in terms of their spiritual beliefs and their addiction treatment. And this is definitely sort of exciting in terms of helping engage people in treatment and lowering those stigmas and barriers. And there was another partnership that I was fortunate enough to be kind of part of, which was a partnership with various providers and lay volunteers and faith leaders in a partnership out near Mass Cast or near the Boston Medical Center called the Miracle Mile Ministries and Together Initiative and being able to again just build relationships with individuals who are experiencing homelessness and help them navigate sort of the existing resources and system in order to engage, improve treatment engagement, and address the stigma. So another potential intervention is shelter-based treatment programs. This is sort of self-explanatory, so I won't go too much into this, but you know, placing the treatment in emergency shelters can help address logistical barriers, comorbidities, imposing employment and housing needs, etc. And other interventions that I may or may not have mentioned that you can look into are supervised injection sites, naloxone distribution, fentanyl test strips, safer drug supply, enforcement of fair housing policies, and again the importance of addressing the housing challenge, aligning new housing funds such as Relief Economic Security Act and American Rescue Plan Act and coronavirus aid with harm reduction and redressing long-standing inequities in housing and health opportunities. So I also wanted to highlight that collaboration is key in this field as well. That's, for example, in one of the papers that was looking at a mobile health clinic in an area, you know, they talked about partnering with community pharmacies for buprenorphine stocking and getting identification agreements. Other studies partnered with city leaders and law enforcement and community advocacy groups, again just recognizing that there are many stakeholders to this system and it is a challenging sort of issue to address and does require collaboration with these different stakeholders. So you can look into those papers as well if you're interested. Some recent policy changes that have been navigating towards expanding access, including SAMHSA proposing updated criteria for take-home medications, lowering barriers for admission to OTPs, and broadening use of telehealth and harm reduction care models, and the waiver requirements for buprenorphine treatment were also removed in January 2023. So some of the next steps in policy, really improving pharmacy access to buprenorphine by addressing prioritization and payment challenges, safe means of storing MOUD, especially to address the loss of stolen medications and treatment discontinuation from that, remedying long-standing inequities in health and housing. We also need more robust and comparative effectiveness studies in our research to understand the effects of interventions on overdose rates and develop better understandings around the racial and ethnic disparities in OUD treatment access and how to address structural vulnerabilities There's this one paper, lowering the barriers to medication treatment for people with opioid disorder that I cited here. I definitely recommend giving that a read as well in terms of the policy and research approaches. So in conclusion, people experiencing homelessness respond well to MOUD and other forms of opioid use disorder treatment. Individual and systemic factors contribute to lack of access to opioid use disorder treatment among people experiencing homelessness and low threshold buprenorphine treatment, including harm reduction approaches are necessary to engage people experiencing homelessness in treatment. So I'll just leave you all with a couple of questions to ponder on in terms of your individual or system clinic that you work in and, you know, thinking about what challenges do people experiencing homelessness face accessing OUD treatment in your healthcare system and what interventions are needed to improve access to care? How can we advocate for this population based on what we've heard today? So that's all I have for you all. Here's a list of references. Yeah, thank you, Dr. Hsu. That was a really comprehensive and very well-organized talk and really appreciate you highlighting the challenges that people experiencing homelessness experience when trying to access treatment for opioid use disorders and then also interventions to address these type of challenges. So I have a lot of questions. There's also some questions in the chat. And so one of those was given the risk of theft on the streets, how successful do unhoused patients seem to be on sublingual buprenorphine? Sorry, what was that first part of the question was given the risk of theft on the streets? Oh, gotcha. Given the risk of theft. Yeah. So, so as I mentioned before, in one of the slides previous that, you know, outcome studies looking at buprenorphine and other outpatient treatment really are comparable to those of house individuals. So I'm thinking about people who are able to get onto buprenorphine. You know, they tend to do well in it, but, but some of the challenges, of course, is, you know, what about theft? And what about those lot? What about people who are losing medications? And that's, that's where currently, you know, our system is not really meeting a need for these patients in terms of having a safe storage for these medications. And, you know, some of the policies that I've heard being brought up that could be helpful to address this would be like lockers and in pharmacies or in treatment settings or things like that, where people can access these medications easier. But, you know, sometimes if people, you know, also subcutaneous buprenorphine could be something that people could engage with long-term that could reduce some of those necessary touch points with, with patients and address sort of the lost, a stolen kind of vulnerability that they have. But yeah, I hope I answered that question. It's a challenging one. There's no, there's no easy answer to it. But yeah, you know, when it came up in supervising a resident about someone experiencing homelessness on masks and casts yesterday in supervision, and I, I struggle with like how, if there are strategies to support patients to hold onto their medications and, and kind of be more successful in not losing them or misplacing them. You know, we do think a lot about diversion of stimulant medications or theft of stimulant medications among college students. And so I'm always having conversations with them about having like a kind of a lockbox or things like that, but those are heavy to carry around and not, not really practical. And so it's helpful to think about the lockers, but if anyone in the audience has any other ideas, I think it's a definitely a pressing issue for both for medication for substance use disorders, but also for the co-occurring psychiatric disorders. So, but in kind of along those lines, I think one barrier also to accessing medication is just the requirement often by pharmacies to have an ID and didn't know if you've seen other like, or creative ways that people have gotten around that requirement or, or kind of things that you've seen programs do to support patients with, with actually getting the medication from the pharmacy. Yeah, I did read one study where they were able to negotiate with pharmacies to help lower sort of that ID requirement at the first visit. And so I haven't seen that being practically used where I've practiced, but that's definitely yeah, that's definitely a huge challenge. And then of course trying to implement programs where we could quickly get individuals IDs as well. But of course that doesn't sort of address things in the shorter term, but yeah, I don't know if others have seen other approaches. I'd love to hear as well. Maybe some will come out, but I mean, I do think you raised an important point about like, is there some way that we can advocate with, with the RMV or these kinds of systems that issue IDs to have some sort of like fast track or streamlined way for people experiencing homelessness to get an ID to be able to access medication. I mean, particularly around all, because there's so many things that you need an ID for that just, it really creates a lot of barriers. So yeah, I think it's a really good point that you brought up that we can address. And then I was just wondering if kind of creative strategies to support communication with individuals experiencing homelessness with the pandemic in Boston, there kind of was funding and grant funding for a period of time during COVID to purchase phones for patients or kind of burner phones and kind of purchase minutes for the phones. But that does require a lot of grant funding and, and whatnot. And, and so I think it does help, but then the phones get lost as well. And so also don't know, wasn't sure if you've heard of or seen strategies to kind of support communication for people experiencing homelessness. Yeah, no, that's a really, that's a really good question. I think on the clinical side, it is really challenging and I've definitely, I've worked with some of those, I guess, foundations or advocacy groups to help provide phones for, for, for patients, but they do, they do lose them as well. The one thing that I think of are sort of the community or sort of the community partnerships and the, or premier groups that have, that have been able to engage with, with this population that are out there, like on, on a daily basis or Boston healthcare for the homeless program, which has staff out there on a daily basis. So just having if there's a way to partner with the people that are walking with individuals kind of closer than, than our sort of our weekly or monthly touch points in the clinic. I think that could be a potential Avenue. Again, this is something that's kind of still in the works or developing. I haven't seen it done all that well yet, but I have seen where, you know, some of these sort of partnerships or collaborations are able to, to have more touch points and then they are able to connect and provide information to some providers or get them into treatment when they need it. And sort of thinking about how do we build those out a little bit better. So that's, yeah, that's the only thing I can think of, but I mean, I think you also do raise an end point. Maybe that there's also a way that we could be coaching patients. Cause I don't know that I've ever coached them to ask like an outreach worker to borrow their phone or like, or if they could call together. And I mean, hopefully these outreach workers are amazing. And hopefully they're offering that option, but maybe that's also something we could coach patients to, to self-advocate for if they have lost their phone, if they could call together to help reconnect with the clinic or use the outreach worker to define the right phone number and some of those kinds of things. Yeah. Yeah, no, no, absolutely. And yeah, thinking about like another pro, I guess, in terms of the housing first model and having a landline access or other sort of challenges that could be addressed through that, you know, that would be, I'm sure like another helpful aspect. And along the lines of housing first, I have heard that challenges with overdose when people are kind of newly housed and kind of, and so don't know if you've seen creative ways to decrease overdose risk in, in kind of these housing first models or ways that they're addressing it. Yeah, no, that's definitely an important challenge, especially, yeah. And thinking about, yeah, just going from the streets where they might be using high potency products to maybe abstaining for a bit of time or being in the home and not, not having people around, you know, what, what happens in those settings. So the, I, I haven't seen sort of any specific interventions to help with that. And I caveat that with that. I haven't been able to be, I haven't sort of worked with the housing first model personally yet, but some of the things that, that I can think about are in terms of maybe engaging with community, even while they're still in a housing first model and, and helping to build a network in that area so that, that, that there are people around them who might be aware something happened and how do we help support that. Sort of a more left field intervention that is not a near future thing or, or practical thing even right now is there, I know that there are, there's a mobile app that's being developed that can detect overdose based on sort of a, I guess it's like a sensor that can detect your breathing rate as well, if you're within a few feet. So again, this requires many loops to be passed, the hoops to be passed through, especially for marginalized populations that even gain access to phones or, or apps or even studies like that. But you know, thinking about are there remote ways to detect overdose as well. And then yeah, fentanyl test strips, of course, and other, yeah, having Narcan kits ready and things like that. But yeah, I don't, I haven't seen anything else like that, but I'd love to hear more about that and learn more about that. Yeah. Yeah. Yeah. I haven't kind of, I think it's just, yeah, it's a challenge or that their own house is a place near Madison casket where they did have a housing first model and did struggle with, you know, kind of in this kind of place where people have individual rooms, like how often do we do kind of checks to see, you know, kind of to monitor for overdose and, but it's struggle. So, but really appreciate your advocacy and your work in this area and, and look forward to seeing more of your research in the future. So, and so with that, we just have a couple more minutes, if we could go through the next couple of slides. So I wanted to raise everyone's awareness. If you're interested in learning more about substance use disorders, there are three or four different virtual learning collaboratives that are starting, I think next week. And these are opportunities where you can learn asynchronously with a group and kind of learn together about different topics, including adolescent substance use, a lot about adolescents. So kind of a lot of opportunities to learn about treating adolescents with substance use disorders. Next slide. And I think that that's it. We really appreciate you all joining the webinar today. And this will be available if you want to watch it again in the future, and then the slides are available. So thank you so much, Dr. Hsu, for your time.

opiate use disorder treatment

homelessness

same-day treatment

harm reduction

flexibility in treatment options

transportation challenges

collaboration with community organizations

racial disparities

treatment access