(112) Retrospective Analysis of Buprenorphine Initiation in an Urban Street Medicine Program

Background & Introduction: A record-high 653,104 people experienced homelessness on a single night in January 2023, representing a 12.1% increase over the previous year. People experiencing homelessness (PEH) are particularly susceptible to adverse health outcomes. Notably, this population remains at increased risk for addiction with substance use cited as both a cause and response to homelessness. Moreover, with escalating amounts of fentanyl on the street, PEH experience opioid overdoses at a disproportionately high rate. Street medicine (SM) programs, while providing general medical care, represent key avenues for the initiation of medication for opioid use disorder (MOUD) in an effort to reduce overdoses in this at-risk population. However, MOUD initiation in SM programs remains an understudied topic. As such, this analysis sought to describe the demographics, treatment outcomes, and health care utilization of patients initiated on Suboxone by an urban midwestern SM program.

Methods: We completed a retrospective review of all patients initiated on Suboxone from January 1, 2022, to December 31, 2023, in an urban midwestern SM program. After identifying patients that received an initial Suboxone prescription during the study period, the EMR was queried for demographics, ED visits, chief complaints, and Suboxone follow-up appointments. Outcome measures consisted of overdose-related, opioid use disorder-related, and total ED visits while hospital utilization was measured by number of Suboxone follow-up visits in the 12 months prior to and after Suboxone prescription with chi-square denoting statistical significance.

Results: Of 134 patients receiving a MOUD prescription by the SM program, 115 patients were initiated on Suboxone with the largest age group represented 36-45 year olds (n=45, 39.1%). In the 12 months prior to Suboxone initiation, this cohort accounted for 221 ED visits of which 79 pertained to OUD-related chief complaints. In the year following medication initiation, cumulative ED visits declined to 191 of which 44 related to OUD, representing a significant decrease in visits specifically surrounding opioid use (p < 0.05). Furthermore, a notable reduction in overdose ED visits was observed with 26 documented the year prior and 13 in the following year. In terms of health care utilization, 51 (44.3%) patients recorded a follow-up visit for Suboxone with 16 seeking continued care from the SM program and 35 establishing with another provider. Of the 64 patients that did not have a recorded follow-up on their Suboxone prescription, 6 patients were noted to engage in long-term treatment outside the 12-month period following Suboxone prescription. Furthermore, a subset of patients was later initiated on methadone and subsequently did not follow-up on their Suboxone prescription.

Conclusion & Discussion: The integration of Suboxone within the SM program was associated with a decline in total ED visits with significantly lower OUD-related encounters in the 12 months following initiation. Notably, ED overdose visits declined by 50% in the year following Suboxone prescription. Furthermore, 44.3% of patients sought continued care, indicating that accessible MOUD for patients is associated with positive outcomes directly related to OUD, ED utilization, and overall health care engagement. While this analysis is limited by setting and sample size, these conclusions provide strong evidence of the impact of Suboxone initiation in reducing opioid-related ED utilization while encouraging sustained engagement in care among a cohort of patients. Ultimately, SM programs represent promising avenues to initiate Suboxone and reduce overdoses in the unhoused population.

References: (1) U.S. Department of Housing and Urban Development. (2023). The 2023 Annual Homelessness Assessment Report (AHAR) to Congress. https://www.hud.gov/americangrants
(2) Stablein, G.W., Hill, B.S., Keshavarz, S., Llorente, M.D. (2021). Homelessness and Substance Use Disorders. In: Ritchie, E.C., Llorente, M.D. (eds) Clinical Management of the Homeless Patient. Springer, Cham. https://doi.org/10.1007/978-3-030-70135-2_12
(3) Han, B. H., Doran, K. M., & Krawczyk, N. (2022). National trends in substance use treatment admissions for opioid use disorder among adults experiencing homelessness. Journal of substance abuse treatment, 132, 108504. https://doi.org/10.1016/j.jsat.2021.108504
(4) Yamamoto, A., Needleman, J., Gelberg, L., Kominski, G., Shoptaw, S., & Tsugawa, Y. (2019). Association between homelessness and opioid overdose and opioid-related hospital admissions/emergency department visits. Social science & medicine (1982), 242, 112585. https://doi.org/10.1016/j.socscimed.2019.112585