Rapid initiation of buprenorphine/naloxone to optimize MAT utilization in Philadelphia

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With nearly 10% of the City’s population estimated to have an opioid use disorder and over 1200 overdose deaths recorded in 2017, Philadelphia is an urban epicenter of the opioid epidemic in the United States. The City has the highest rate of opioid overdose deaths of any of the largest cities in the country and there were more than 15,000 overdose responses made by the emergency medical services in 2017. Despite the prevalence of opioid use disorder and broad based support for treatment expansion, approximately 20% of the City’s medication assisted treatment capacity goes unused each year. While this treatment gap is multiply determined, the delays embedded in the typical screening and enrollment process, distance to treatment facilities, and the inherent ambivalence to initiate treatment among opioid dependent individuals, combine to serve as a significant barrier to treatment engagement. The proposed 3-year effort will evaluate a new, mobile strategy for rapid initiation of buprenorphine/naloxone, counseling, peer support and case management as a method for linkage to long term, evidence based medication assisted treatment. Inductions will be initiated in the individual’s home community, either on our mobile medical facility or via home visits. The mobile team will be led by a nurse practitioner (able to prescribe buprenorphine/naloxone in PA) and include a peer recovery specialist, and a case manager. The team will rapidly confirm opioid use disorder, complete informed consent, and begin induction procedures for a “transitional” (one month) course of treatment with buprenorphine/naloxone. During this time, the team will work with the participant to become engaged in existing medication assisted treatment programs. The type of ongoing treatment will be determined on an individual basis and will include options of methadone maintenance, buprenorphine/naloxone treatment, or extended release naltrexone (XR-NTX). Rates of treatment engagement and overdoses at six months will be compared to those participants recruited from the City’s existing assessment and linkage centers. A detailed cost analyses will be conducted to inform future use of this model should it produce positive results. Implementation partners will be Prevention Point Philadelphia and the Public Health Management Corporation. Scientific support will be provided by the University of Pennsylvania Injury Science Center, the Center for Health Economics of Treatment Interventions for Substance Use Disorders, HIV, and HCV and the Center for Studies of Addiction. A Community Advisory Board comprised of consumers, providers and advocates for the health of people with opioid use disorder will help to guide the implementation of the project.