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In the streets of Boston, the path to treatment often begins with a sandwich. Egg salad is the favorite. Today it is ham. Phil Ribeiro puts one in the bag of a man who breathes, but either soothed or deeply asleep, that it is difficult to wake up.
"I hope that he will not wake up next to a group of Norwegian rats," said Ribeiro, public health advocate at AHOPE, the needle exchange program run by the Boston Public Health Commission.
Ribeiro continues on his way, looking for more ways to spread "a little bit of love" among dozens of sleeping bags under a bridge at the sight of Boston's TD Garden.
"Our main goal is to be a bridge to care, a bridge to addiction treatment," said Sarah Mackin, director of AHOPE.
This bridge includes a doctor and an oversized white van that is parked daily in one of four overdose hotspots 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 about half a dozen projects developed in the country to test this theory. treatments as available as drugs.
Trust In Addiction Outreach
The Care Zone team associates experienced field staff with a physician and case manager. Ribeiro and Mackin, experienced street workers, usually make the first contact with a busy sleeping bag. Dr. Jessie Gaeta, Chief Medical Officer for Boston's Homeless Health Care Program, approaches as soon as it is clear that a new face will not send the person into hiding. She knows that many of these potential patients feel rejected by traditional medicine.
"We are trying to let people know that we are not there to stop them, we are not there to clean up their camp and evict them," says Gaeta. "All we want to know is if we have something you need and want, and if we do, it's fine, here it is, and we're building a relationship gradually." like this."
However, it may be that weeks go by before small offers – a sandwich, clean needles, naloxone (Narcan brand name) – earn the trust of users in the health care area.
Once the relationship is established, Gaeta treats wounds around the injection site, verifies heart and lung infections, and vaccinates patients against hepatitis, measles, and meningitis. And just under a bridge, Gaeta can take out her notebook and help a patient begin treatment for her opioid addiction.
She, Mackin or Ribeiro will accompany the person from her concrete camp to a pharmacy to receive her first dose of buprenorphine, usually called Suboxone. It is a less powerful opioid that limits the cravings for more potent medications.
Sometimes Gaeta asks patients to return to the van for further examination. Sometimes it's almost as difficult as winning their trust.
Gaeta remembers one particular patient, a 33-year-old woman named Bri. (We're just using her first name because Bri is an addict.) Gaeta says she's met Bri in a downtown alley. The doctor has detected heart problems. Bri said that she had survived several overdoses.
"She was interested in trying Suboxone," says Gaeta, "but she was very sick."
Gaeta says that she decided to try to take a few steps to Bri up to the pickup truck.
"And in those few blocks, I can not tell you how many men have proposed it," Gaeta says. "I felt like I was competing with their time and literally, it was like: 'Spread out, she's not leaving with you, she's coming with us.' "
Gaeta explains how she drove Bri to a detox program, where Bri would start taking Suboxone. Bri eventually relapsed and Gaeta said to have lost sight of her for several months. Then, earlier this month, Bri reappeared.
"I am so happy that you are here"
That day, Gaeta brings Bri into the van's mini-exam room, where she tells the story of her last overdose on a bus from Boston to New Hampshire.
"Thank God, the bus driver had Narcan," says Bri. "If the bus driver did not have Narcan, I do not think I would be here."
Gaeta listens attentively.
"I'm so happy you're here," she told Bri. "It looks like last week was hell, what you went through."
Bri slips on a shortened exam table while Gaeta examines her heart. Bri had endocarditis, a heart valve infection common among injecting drug users. Gaeta tells Bri that her swelling is over, but she wants Bri to come back to the van on Monday for more blood. It's a Friday.
"Mostly, I want to make sure you'll be here all weekend to see me on Monday," Gaeta said.
Gaeta wants Bri to restart Suboxone immediately. But Bri wants to wait. She is homeless and does not want to transition fentanyl to Suboxone, a partial withdrawal that causes fever and nausea on a sidewalk or park bench. Bri says she'll start Sunday, when she can crash into a friend's house.
"I can be there all day on Sunday, so when I'm not feeling well, I can stay in bed," Bri told Gaeta.
Gaeta worries about this plan, but Bri will not be part of a residential program. As they finish, Gaeta takes Bri's two hands and looks her in the eyes.
"You've just overdosed, we've done a lot of planning for the next 36 hours to make sure you will not die even if you inject yourself again today and tomorrow," says Gaeta, before pausing. . "I'll see you on Monday."
Bri's is one of 316 Suboxone prescriptions given to patients by the care zone van since its launch 18 months ago. Gaeta says that 90% of them are filled. 78% of these orders relate to renewals.
Gaeta and other Boston Homeless Healthcare physicians treat about half a dozen people a day in busy areas like the downtown core. Neighborhood agents record an average of 21 street meetings per day – a total of 5,315 to date.
"We should not have been surprised if you offered an on-demand program to the people who needed it the most and made it easier for them to access care," said Kraft Center Director Elsie Taveras. .
Taveras regularly sends updates to its commercial, civic, and law enforcement contacts in neighborhoods that have agreed to host the van. Downtown North Association director Jay Walsh said the results are tangible. Walsh looks at Causeway Street in the now empty front steps of a convenience store.
"Before, you would have six or seven people under the influence of drugs, pressed against the wall, blocking access to the store," says Walsh.
He attributes the van Care Zone.
"They save lives and give people a chance to escape the world they are in," said Walsh.
Barriers to treatment
Except that treatment alone can not be an escape route. A man named Cody started Suboxone more than a year ago via the van. Cody remembers a nearby officer kneeling beside him as he leaned against a dumpster, a needle in his hand.
Cody says that he has relapsed four or five times. It's hard to avoid drugs, says Cody, when people around him on the baseball field where he sleeps at night use. But Cody says he's not going to try Suboxone anymore, right now, without the pickup truck.
"They achieved that goal," says Cody, "making treatment as easy as drug treatment."
Dr. Andrew Kolodny, co-director of opioid policy research at Brandeis University, believes that the country is far from achieving this goal. He says that vans and outreach workers are a solution in urban areas. The solution will be different in suburban and rural areas.
"Once [they’re] In every county of the United States, there is a place where someone can go to start a treatment for free, the same day, "says Kolodny," it's at that time that we're really going to start to see a significant decrease in overdose deaths. "
Dr. Barry Zevin, medical director of street medicine and health shelters in the San Francisco Department of Public Health, said that there remained too many barriers to more accessible treatment. Some insurers do not fund street services. Few doctors and nurses are trained in both addiction and few of them have ever worked in the street. Too many addiction clinics require appointments. And, there is still too much shame.
"There are people who need treatment and who are ready to go for treatment, for whom the barriers to treatment are too huge," Zevin said. "Get out, find the barriers and then, one by one, see how much you can remove."
Even with little to no obstacles, some patients have trouble starting or staying in treatment. Bri did not show up for her Monday appointment and Gaeta did not hear from her.
The Care Zone van costs $ 160,000 in equipment. It was offered by Ford Motors. The annual operating budget is approximately $ 200,000. The Massachusetts Department of Public Health provides naloxone to patients. Organizers hope to develop itineraries and hours later this year.
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