Low-threshold extended-release naltrexone for high utilizers of public services with severe alcohol use disorder: A pilot study.

Extended-release naltrexone (XRNTX) is an effective treatment for alcohol use disorder (AUD). We sought to evaluate the feasibility, acceptability, and preliminary effectiveness and cost-effectiveness of XRNTX delivered as a stand-alone service to persons with severe AUD who are high utilizers of multiple urgent and emergency medical services (HUMS). Of 15 HUMS persons with severe AUD selected based on chart review, 11 agreed to participate. Participants received a mean of 4.5 injections (range 2-7). Modest benefits from XRNTX were observed in terms of patients' Urge-to-Drink Score and the costs of emergency medical services utilized. Though limited by a small sample size, costs including client utilization and study related expenses during the post-enrollment period were less than client utilization costs in the pre-enrollment period. We also observed non-significant improvements in the number of drinking days, but no change in quality of life as measured by the EQ-5D. Eighty-eight percent of participants perceived XRNTX as helping with their drinking. Findings need to be replicated in a larger study, however if replicated, the cost savings could be substantial.

Integrating buprenorphine treatment into a public healthcare system: the San Francisco Department of Public Health's office-based Buprenorphine Pilot Program.

Despite well-documented efficacy, US physicians have been relatively slow to embrace the use of buprenorphine for the treatment of opioid dependence. In order to introduce and support the use of buprenorphine across the San Francisco Department of Public Health system of care, the Buprenorphine Pilot Program was initiated in 2003. Program treatment sites included a centralized buprenorphine induction clinic and program pharmacy, and three community-based treatment sites; two primary care clinics and a private dual diagnosis group practice. The target patient population consisted of opioid-dependent patients typically seen in an urban, public health setting, including individuals experiencing extreme poverty, homelessness/unstable housing, unemployment, polysubstance abuse/dependence, coexisting mental health disorders, and/or little psychosocial support. This program evaluation reviews patient characteristics, treatment retention, substance use over time, patient impressions, and provider practices for the 57 patients admitted between 9/1/03 and 8/31/05. At baseline, over 80% of patients were injecting heroin, over 40% were homeless, and over one-third were using cocaine. Outcomes included an overall one-year retention rate of 61%, a rapid and dramatic decline in opioid use, very positive patient impressions of the program and of buprenorphine, and significant shifts in provider practices over time.

Investigating the effects of San Francisco's Treatment on Demand Initiative on a publicly-funded substance abuse treatment system: a time series analysis.

This study investigated effects of San Francisco's Treatment on Demand Initiative, which was designed to increase substance abuse treatment capacity, on the host treatment system. Secondary data on substance abuse treatment admissions, from 1995 through 2000, were obtained from the Department of Public Health, Community Substance Abuse Services, San Francisco, California. Data on 73,988 admissions were retained and grouped by week of admission. Time series analysis was used to assess the effects of time and treatment on demand (independent variables) on weekly number of admissions, sociodemographic characteristics and types of treatment received (dependent variables). As a function of treatment on demand, the number of weekly new admissions significantly increased. Standard outpatient treatment and comprehensive care admissions constituted greater proportions of admissions after treatment on demand. Persons with a primary heroin, cocaine or alcohol problem constituted greater proportions of admissions, and first-time treatment clients constituted a smaller proportion of admissions. Findings suggest that a capacity expansion initiative can increase system wide admissions and redistribute admissions among modalities towards more comprehensive care treatments.

Drug treatment outcomes for persons on waiting lists.

This study examined treatment access and outcomes for persons placed on drug abuse treatment waiting lists. Participants (n = 170) were recruited when they entered either a methadone detoxification program or a day treatment program, and were waiting for methadone maintenance or residential treatment, respectively. Participants were interviewed at baseline and 2-months follow-up. Excluding the index treatment episode, 73% received some treatment during the follow-up period. Mixed effects regression was used to compare short-term outcomes for clients who did and did not enter treatment following the index episode. We found increased drug problems, over time, for all participants. Those enrolled in treatment at follow-up reported higher employment problems (collapsed across time) compared with those not in treatment. Last, participants enrolled in any subsequent treatment showed a decrease in psychiatric problems over time, while those not enrolled in subsequent treatment showed an increase in psychiatric problems. Participants who entered treatment within 60 days after being placed on a waiting list showed improvement on psychiatric measures but not on substance abuse measures.

Access to drug abuse treatment under Treatment on Demand policy in San Francisco.

OBJECTIVES: We evaluated whether implementation of Treatment on Demand (TOD) policy in San Francisco was associated with improved access to drug abuse treatment. METHODS: Data came from San Francisco's treatment program waiting list over 4 years spanning the implementation of TOD policy. Access measures were monthly applicants waiting and days waited by treatment admissions. Quantitative analyses with 69 treatment facilities contrasted those receiving vs. not receiving TOD funds. Qualitative data came from interviews with facility administrators. RESULTS: There was a small statistically significant decline in monthly waiting lists in the number of people waiting for treatment during the study period. The days waited by those admitted to treatment, however, significantly increased in TOD-funded facilities. Facilities used varied criteria for completing the access measures, which limit the utility of the measures. CONCLUSIONS: Access to treatment improved slightly with implementation of TOD policy.

Drug treatment utilization before, during and after pregnancy.

This study retrospectively explored drug treatment utilization before, during and after pregnancy for all identified substance-using women delivering at a county hospital over a 4-year period (n=431). Drug treatment data were linked to hospital data to analyse treatment utilization. Fifty-three per cent received treatment the year before, during, or within the year after delivery, with a significantly higher proportion receiving treatment during and after pregnancy. There were significant increases in methadone and residential treatment services during pregnancy. Women spent significantly more time in treatment after delivery compared with before or during pregnancy. However, 47% of these women did not receive drug treatment. These findings support current literature suggesting that pregnancy presents an opportunity to engage women in treatment. However, there is a need to decrease the institutional, legal, and funding barriers that exist between health care and drug treatment providers. Utilizing available data to track perinatal substance use and treatment utilization are important to plan for adequate availability of treatment services for this population.

Fatal heroin-related overdose in San Francisco, 1997-2000: a case for targeted intervention.

Heroin-related overdose is the single largest cause of accidental death in San Francisco. We examined demographic, location, nontoxicological, and toxicological characteristics of opiate overdose deaths in San Francisco, California. Medical examiner's case files for every opioid-positive death from July 1, 1997, to June 30, 2000, were reviewed and classified as overdose deaths or other. Demographic variables were compared to two street-based studies of heroin users and to census data. From 1997 to 2000, of all heroin-related overdoses in San Francisco, 47% occurred in low-income residential hotels; 36% occurred in one small central area of the city. In 68% of deaths, the victim was reportedly alone. When others were present between last ingestion of heroin and death, appropriate responses were rare. In three cases, police arrested the person who called emergency services or others present on the scene. We recommend the development of overdose response training targeted at heroin users and those close to them, including the staff of residential hotels.