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San Francisco's Bold Plan to Treat Homeless Drug Addicts

San Francisco's mayor wants to create a special medical team -- the first of its kind in the nation -- to spread out onto the city's streets and give homeless people a drug that one expert calls "blindingly effective" at abruptly stopping heroin cravings.

By Kevin Fagan

San Francisco's mayor wants to create a special medical team -- the first of its kind in the nation -- to spread out onto the city's streets and give homeless people a drug that one expert calls "blindingly effective" at abruptly stopping heroin cravings.

Mayor Mark Farrell is set to announce Thursday that he is including $6 million in his current budget proposal to fund the 10-person team over the next two years, with the aim of prescribing the medication buprenorphine to at least 250 street addicts.

Buprenorphine, widely available only in recent years and commonly known by its main brand name Suboxone, works faster and causes fewer side effects than methadone. Given the heroin epidemic that is swelling the city's streets with dirty needles and addled users, it's being seen as a potential game-changer.

"The consequences of standing still on this issue are unacceptable," Farrell told The Chronicle. "Drug abuse is rampant on our streets, and the recipe of waiting for addicts to come into a clinic voluntarily is not working. Plain and simple. So we're going to take a different approach."

The Department of Public Health, which will run the team, began testing out the effectiveness of prescribing buprenorphine in tent camps in 2016 -- and since then, nearly 60 percent of the approximately 200 people who began taking the drug are still working on being clean, officials said. That is remarkable considering more than 80 percent of heroin users relapse into addiction after starting treatment; most then give treatment another try.

The department estimates there are 11,000 heroin addicts in San Francisco who use needles. There is no accurate count on how many of those are homeless, but it is believed to be in the thousands. The Public Works Department alone picks up more than 12,500 discarded needles every month at homeless hot spots and encampments.

"This is a great innovation because we are going out to people where they are, not waiting for them to come to us," said Director of Public Health Barbara Garcia. "We want to get people into treatment because of not just the heroin epidemic, but the danger of overdose. But we have this situation where people can be afraid to come in for care because of the stigma and maybe even a fear of being arrested even though we don't arrest people in our clinics.

"So we're making sure, with this approach, that we really reach people," she said. "This is what the rest of the country needs to think about. They need to follow our lead on this."

The money Farrell proposes to spend would come from the city's general fund, but about $900,000 would be reimbursed each year to the city by Medi-Cal.

Dr. Alex Stalcup, a national expert in addiction technique and head of a clinic in the East Bay, said he is excited at the prospect of San Francisco launching a buprenorphine team. He has been prescribing it on a limited basis at his clinic since 1990, when he first heard of "this amazing new drug" in Britain.

"From the very first patient, I was nearly on the edge of tears when I saw buprenorphine's effect," Stalcup said. "I saw people coming in throwing up, messing their pants, in terror from the junk (heroin), and 15 minutes later they were sitting up having a cup of tea. It is blindingly effective.

"It clearly saves lives. It ought to be part of the national program. And people who go into tents, like San Francisco has done to distribute Suboxone, they are my heroes."

Methadone is considered an effective treatment for heroin addiction. But the advantage of buprenorphine is that rather than gradually pulling an addict away from cravings as methadone does, it stops them almost immediately -- and, unlike methadone, it blocks opioid receptors in the body so effectively that it's virtually impossible to overdose, or even feel an effect, if a user relapses and shoots smack.

Like methadone, however, buprenorphine must then be taken regularly to keep the hunger for heroin suppressed. Most patients can taper off buprenorphine quicker than methadone to become medication-free, but for each some doctors recommend long-term usage. They also recommend a range of other treatments and therapies, in conjunction with medication, to help those with substance use disorder stay clean.

Perhaps most significantly, however, is the legal aspect that makes the proposed new team possible. Under federal law, methadone can be prescribed and disseminated only at a special methadone clinic. But buprenorphine can be prescribed by a doctor and handed out immediately at a pharmacy, and the drug can be given to an addict in a one-week pack of daily doses, which means he or she won't have to return for resupply right away.

In a pinch, the street team can go fetch the medication and give it to the addict on the spot -- an important capability, given the notorious inability of chronically homeless people to keep appointments. But driving a user quickly to a pharmacy has worked very well, said Dr. Barry Zevin, who led the buprenorphine test program, and as head of the public health Street Medicine division would oversee the new team.

"This treatment has been remarkably effective," Zevin said the other day as he saw patients at his downtown clinic. "In the short term and the long term, it takes away any craving for opioids, and that's quite an amazing effect.

"It also sits on the opioid receptors and won't let anything else in, which prevents overdoses and the feeling of being high. Almost everyone is initially skeptical about that, but it's true. And yes, it is amazing."

"Amazing" is also how 24-year-old Ronald Sellers describes what buprenorphine has done for him since Zevin helped get him on the medication eight months ago at his tent encampment in the Bayview neighborhood.

"I tried methadone, but I couldn't go in to the clinic every day while I was living in a tent," Sellers said when he dropped into Zevin's clinic for a checkup. "But Suboxone? It stopped my heroin craving, like, right then and there -- and I got to take home a week's supply. I was able to get straight for the first time in years."

After letting Zevin's team work on his other medical issues, including recurring sores, Sellers finally moved into a Navigation Center all-service shelter two weeks ago and is now on track to get permanent housing. Drawing people in for encompassing medical care is a prime secondary goal of the buprenorphine program, Zevin said, and Sellers chuckled when he mentioned that.

"Seriously, I never trusted doctors before, but this guy -- he actually talks to me, and not just to write some s---ass report," Sellers said. "If he hadn't talked to me about Suboxone I probably wouldn't get (help for) all the other stuff."

Zevin allowed himself a small smile. "See you next Monday?" he said.

"Yes sir," Sellers replied.

(c)2018 the San Francisco Chronicle

Caroline Cournoyer is GOVERNING's senior web editor.
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