(110) Expanding Community-Led Partnerships: Residency Integration in a Harm Reduction Clinic

Background & Introduction: Harm reduction (HR) acknowledges autonomy of people who use drugs (PWUD), realigning clinical practice to respond to the spectrum of individuals’ goals.1 Using collaborative, non-stigmatizing approaches, HR engages patients who otherwise may be excluded from traditional healthcare settings. With origins in community mutual aid and advocacy, HR philosophies present an alternative approach to care from medical models of disease and treatment.2

Community-academic partnerships with HR approaches present a unique care model for PWUD and others to access healthcare in more accessible and “low-threshold” settings.2,3 One such partnership, between a community-based HR agency and academic medical center, has led to a novel care model for treatment of opioid use disorder by providing available, flexible, and co-located medical services within the community-based agency in a diverse urban setting with one of the region’s highest rates of opioid overdose and death.4 The site also provides risk reduction, including syringe exchange and an overdose prevention center (OPC) where people can consume drugs in a supervised setting, and health and supportive services including case management.

We describe the expansion of the community-academic partnership to trainees, increasing provider coverage at the drop-in medical clinic while providing residents hands-on addiction medicine training in a HR care model.

Methods: Agency clinic staff, academic addiction medicine physicians, and the chief resident of a primary care internal medicine training program designed a clinical rotation for residents to develop and apply skills in HR and addiction medicine while providing supervised patient care at the drop-in clinic. The chief resident, with full clinical privileges at the medical center, was allocated time to serve as preceptor, providing a no-cost physician to staff the clinic once per week. The chief resident had experience in addiction medicine in primary care settings and had access to addiction medicine faculty for support.

To create learning objectives, we solicited input from participants at the agency, including patients at the drop-in clinic; clinical and non-clinical HR agency staff; and medical center trainees and faculty. All residents first engaged in a half-day orientation at the HR agency, created and run by HR staff, and an existing 4-week addiction medicine ambulatory curriculum including didactics on HR, substance use disorders, and drug policy.

Residents received pre-reading on the HR agency and HR approaches. We actively solicited and incorporated feedback from patients, staff, and trainees in real-time. We solicited resident reflections 6-12 months after seeing patients in the clinic.

Results: Collaboratively created learning objectives included providing holistic, low-threshold, strengths-based, patient-centered clinical care in a community setting; applying an understanding of the lived experiences, psychosocial environments, systems of support, and health needs for PWUD and are unhoused to the practice of medicine; constructing clinically appropriate plans that acknowledge patient strengths, needs, and preferences; prescribing medication for opioid use disorder (mOUD); and recognizing and treating xylazine-associated skin and soft tissue infections (SSTI).

Six PGY-2 and six PGY-3 residents saw an average of 5.8 patients per day. Cases involved evaluation and management of opioid, alcohol, tobacco, and stimulant use disorders, including mOUD initiation and maintenance; evaluation and treatment of xylazine-associated SSTI; sexual health, including initiation of PrEP and DoxyPEP, and screening and treatment of sexually transmitted infections; routine primary care and chronic disease management, including care of people living with HIV; and urgent evaluation of acute medical needs across the HR agency, with patient-centered plans for referral for hospital care or close follow-up.

Real-time feedback led to additional pre-reading resources on low-dose and high-dose buprenorphine initiation, development of agency protocols for specific medical emergencies, and the creation of a 10-minute “chalk talk” on a low-threshold and patient-centered approach to the management of SSTI among PWUD and experience unstable housing.

Resident reflections noted the impact of a HR approach on patient care:

“You get to take care of [patients] in a more community setting and really get to meet them where they are” (R1)

“One patient with complex medical concerns… said she would never have felt comfortable walking into a traditional clinic to receive care but trusted the staff” (R2)

“Individuals have the ability to see a provider more on their terms - when they decide they want care, at a time of day that works with them, and for specific concerns that they establish as important on that visit. It is redistributing power and autonomy back to the patient” (R3)

Residents also highlighted unique aspects of having the drop-in clinic co-located with other services in the HR agency:

“Having the clinic and the safe injection site – as well as the many other resources available at the facility – together at one place is really helpful when trying to keep people engaged in care” (R1)

“Visiting the OPC and caring for patients [in the drop-in clinic] helped illuminate the barriers in accessing basic services, i.e. warm shelter and medical care” (R4)

Conclusion & Discussion: This is among the first community-academic partnerships to develop an integrated residency clinical experience within a community-based HR agency. Key to its success was an existing community-academic partnership, prioritizing and addressing community partner needs by leveraging no-cost chief resident time, input from relevant stakeholders on educational objectives, and real-time adaptations to feedback. Co-location of an OPC is an additionally unique practice setting. Residents applied HR principles and gained valuable insight from working with a community partner in a community space.

One resident, now in infectious disease, remarked how they have applied their experience to current training and practice:

“We had a session earlier in the year where we were given a bag of equipment found in a drug supply kit and asked to identify it – no one else in my group could but I was able to due to the session we had at [the HR agency] where we went through each item and its intended use. For someone working in infectious disease, this is incredibly important to understand. I've used this knowledge since to counsel patients on harm reduction methods when using” (R4)

Future work will continue to assess impact among residents and HR agency staff and patients.

References: 1. Hawk, M., Coulter, R. W., Egan, J. E., Fisk, S., Reuel Friedman, M., Tula, M., & Kinsky, S. (2017). Harm reduction principles for healthcare settings. Harm reduction journal, 14, 1-9.
2. Heller, D., McCoy, K., & Cunningham, C. (2004). An invisible barrier to integrating HIV primary care with harm reduction services: philosophical clashes between the harm reduction and medical models. Public Health Reports, 119(1), 32-39.
3. Jakubowski, A., & Fox, A. (2020). Defining low-threshold buprenorphine treatment. Journal of addiction medicine, 14(2), 95-98.
4. Jakubowski, A., Norton, B. L., Hayes, B. T., Gibson, B. E., Fitzsimmons, C., Stern, L. S., Ramirez, F., Guzman, M., Spratt, S., Marcus, P., & Fox, A. D. (2022). Low-threshold Buprenorphine Treatment in a Syringe Services Program: Program Description and Outcomes. Journal of addiction medicine, 16(4), 447–453.
5. Farhang, L., & Morales, X. (2022). Building Community Power to Achieve Health and Racial Equity: Principles to Guide Transformative Partnerships with Local Communities. NAM perspectives, 2022