On the streets of Boston, the potholed path to treatment often starts with a sandwich. Egg salad is the favorite. Today it's ham. Phil Ribeiro tucks one into the bag of a man who is breathing, but either so sedated or deeply asleep that he's difficult to rouse.
"Hopefully he doesn't wake up next to a flock of Norway rats," says Ribeiro, a public health advocate with AHOPE, the needle exchange program run by the Boston Public Health Commission.
Ribeiro moves on, looking for more ways to spread "a little bit of love" among the dozen or so sleeping bags under a bridge within sight of Boston's TD Garden.
"Our whole focus is being a bridge to care, a bridge to addiction treatment," says AHOPE director Sarah Mackin.
That bridge includes a physician and an oversized white van that parks daily in one of four overdose hot spots around Boston.
The Care Zone van, funded by the Kraft Center for Community Health at Massachusetts General Hospital and the GE Foundation, is one of a half dozen or so projects across the country testing models for this theory: If the U.S. wants to end the opioid epidemic, it must make treatment as available as drugs.
Trust In Addiction Outreach
The Care Zone team pairs veteran outreach workers with a doctor and a case manager.
Ribeiro and Mackin, veteran street workers, typically make the first contact with an occupied sleeping bag. Dr. Jessie Gaeta, chief medical officer with the Boston Health Care for the Homeless Program, approaches once it’s clear that a new face won’t send the person back into hiding. She knows many of these prospective patients feel shunned by mainstream medicine.
"We’re trying to let people know we’re not there to arrest them. We’re not there to clean up their encampment and kick them out," Gaeta says. "All we want to know is, do we have something you need and want, and if we do, great, here it is. And so we gradually build a relationship that way."
Still, it may be weeks before small offerings — a sandwich, clean needles, some naloxone (brand name Narcan) — earn the Care Zone team the trust of chronic drug users. Once the relationship is established, Gaeta treats wounds around an injection site, checks for heart and lung infections, and vaccinates patients against hepatitis, measles and meningitis.
And right under a bridge, Gaeta can pull out her prescription pad and help a patient begin treatment for their opioid addiction.
She, Mackin or Ribeiro will walk the person from their concrete camp to a pharmacy for their first dose of buprenorphine, commonly called Suboxone. It's a less potent opioid that curbs cravings for stronger drugs.
Sometimes Gaeta asks patients to return to the van for a more thorough examination. Sometimes that's almost as difficult as earning their trust.
Gaeta recalls one patient in particular, a 33-year-old woman named Bri. (We're just using her first name because Bri is addicted to illegal drugs.) Gaeta says she met Bri in a downtown alley. The doctor detected heart trouble. Bri said she had survived several overdoses.
"She was interested in trying Suboxone," Gaeta says, "but she was very sick."
Gaeta says she decided to try to walk Bri a few blocks to the van. "And in that few blocks, I can’t tell you how many men propositioned her," Gaeta says. "I felt like I was competing with their time and literally, was like, 'Step aside, she is not going with you, she is coming with us.' "
Gaeta explains how she drove Bri to a detox program, where Bri would start taking Suboxone. Eventually, Bri relapses, and Gaeta says she lost track of her for several months. Then, earlier this month, Bri reappeared.
'I’m So Glad You’re Here'
On this day, Gaeta ushers Bri into the van’s mini-exam room where Bri tells the story of her latest overdose, on board a bus from Boston to New Hampshire.
"The bus driver, thank God, had Narcan," says Bri. "If the bus driver did not have Narcan, I don't think that I would be here."
Gaeta listens intently.
"I’m so glad you’re here," she tells Bri. "It sounds like last week was hell, what you went through."
Bri slides onto a shortened exam table while Gaeta checks her heart. Bri has had endocarditis, a heart valve infection that’s common among injection drug users. Gaeta tells Bri her swelling is done, but she wants Bri come back to the van on Monday for more blood work. This is on a Friday.
"Mostly, I want to make sure you make it through the weekend to see me on Monday," Gaeta says.
Gaeta wants Bri to start Suboxone again right away. But Bri wants to wait. She's homeless and doesn’t want to make the transition from fentanyl to Suboxone, a partial withdrawal that brings on a fever and nausea, while on a sidewalk or some park bench. Bri says she'll start on Sunday, when she can crash at a friend’s place.
"I can be there all day on Sunday, so when I’m not feeling well I could just stay in bed," Bri tells Gaeta. Gaeta is worried about this plan, but Bri won’t check into a residential program.
As they wrap up, Gaeta takes both Bri’s hands and looks her in the eye. "You’ve just had an overdose. We’ve done a lot of planning for the next 36 hours to make sure you’re not going to die even as you still inject today and tomorrow," Gaeta says, then pauses. "I’ll see you Monday."
Bri’s is one of 316 prescriptions for Suboxone given to patients via the Care Zone van since it launched 18 months ago. Gaeta says 90% of them are filled. Of those prescriptions, 78% are for refills.
Gaeta and other physicians based out of the Boston Health Care for the Homeless Program treat roughly half a dozen people a day in busy areas like downtown. Outreach workers log, on average, 21 daily street encounters — 5,315 in total, to date.
"We shouldn't have been surprised that if you bring a program on demand to the population that needs it most and make it easy for them to access care that it was going to be successful, said Kraft Center director, Dr. Elsie Taveras.
Taveras sends regular updates to her business, civic and law enforcement contacts in the neighborhoods that agreed to host the van. Downtown North Association director Jay Walsh says the results are tangible. Walsh looks across Causeway Street at the now empty front stoop of a convenience store.
"Before you’d have six or seven people under the influence of drugs, leaning up against the wall, blocking access to the store," Walsh says. He credits the Care Zone van. "They’re saving lives and giving people a chance to escape the world that they’re in," Walsh says.
Barriers To Treatment
Except that treatment alone may not provide an escape route.
A man named Cody started Suboxone more than a year ago via the van. Cody remembers an outreach worker kneeling down next to him as Cody leaned against a dumpster, a needle in one hand.
Cody says he's relapsed four or five times. It's tough to avoid drugs, says Cody, when people around him on the baseball field where he sleeps at night are using. But Cody says he wouldn't be trying Suboxone again, now, if it weren't for the van.
"They've reached that goal," says Cody, "the goal of making it as easy to get treatment as it is to get drugs."
The country is a long way from meeting that goal, says Dr. Andrew Kolodny, co-director of opioid policy research at Brandeis University. He says traveling vans and outreach workers are one solution in urban areas. The solution will be different in suburban and rural areas.
"Once [they're] in every county in the United States, there's a place somebody can go and get started on treatment for free, that same day," says Kolodny, "that's when we'll really start to see overdose deaths come down, significantly."
Dr. Barry Zevin, medical director of street medicine and shelter health at the San Francisco Department of Public Health, says there are still too many barriers to more accessible treatment. Some insurers don't fund street services. Few doctors and nurses are trained in both addiction medicine, and few have experience working on the streets. Too many addiction clinics require appointments. And, there's still too much shaming.
"There are people out there who need treatment and who are amenable to treatment, for whom the barriers to getting treatment are too daunting," says Zevin. "Go out, figure out the barriers and then one by one see how many you can remove."
Even with no or very low barriers, some patients struggle to begin or stay in treatment. Bri didn't show up for her Monday appointment, and Gaeta hasn't heard from her.
The Care Zone van costs $160,000 to outfit. It was donated by Ford Motors. The annual operating budget is approximately $200,000. The Massachusetts Department of Public Health supplies the naloxone distributed to patients.
Organizers hope to expand both the routes and the hours later this year.