The Boston Health Care for Homeless Program created an innovative program to prevent overdose deaths.
Like many communities, Boston has been hit hard by the nationwide opioid epidemic. An analysis of the causes of death among people experiencing homelessness in Boston reveals that drug overdoses are responsible for a third of deaths among adults under age 45 and that the increased number of overdose deaths has more than canceled out the decrease in HIV mortality over recent years.
The Boston Health Care for the Homeless Program (BHCHP) came up with an innovative solution for preventing overdose deaths and managing the increasing number of overdoses happening in and around the BHCHP facility. Using private and foundation funding, the agency opened Supportive Place for Observation and Treatment, SPOT. In a room that accommodates up to eight people, staff provide medical observation and, when necessary, preventive or emergency treatment for people who have already used drugs—most commonly a mix of several opiates, sedatives, and other substances.
Jessie Gaeta, M.D., the chief medical officer of the agency, and two of her colleagues wrote in "Health Affairs Blog" about the program’s first few months, which demonstrated promising results. The SAMHSA Homeless and Housing Resource Network caught up with Dr. Gaeta to see what had happened in the six months since the blog post.
How many people per month have been coming in to use the SPOT program?
We average about 300 uses per month by about 50 unique individuals.
What percentage of those go on to treatment or detox?
We only track the people who we take directly into treatment from SPOT, and that is about 10% of people. However, others go to treatment later, which is important because the people using SPOT have severe substance use disorders.
How frequently do staff have to reverse an overdose?
We have administered naloxone approximately 30 times. On the street or in people’s homes, naloxone is the only option for an apparent overdose. It is better to administer naloxone if there are any questions because the risks are minimal. In SPOT, because we are monitoring vital signs, administering IV fluids, and supplying oxygen to those with low oxygen levels, we need to use naloxone less frequently than we would outside of a medical setting. In fact, a lot of people using SPOT would be given naloxone if they were encountered on the streets in the same condition.
How widespread is opioid use among BHCHP clients?
We serve about 12,000 people per year, including families and children, and about 3,500 have a diagnosis of an opioid use disorder. To put this into perspective, about 2,500 are diagnosed with an alcohol use disorder. In the 15 years I have been here, these numbers have really changed—alcohol use disorder used to be the most common substance use disorder.
You mentioned that there was some initial resistance, even within your agency, to the idea of a safe space. Has that changed?
We made it clear from the beginning that this was not a supervised injection site, but people still worried that we were encouraging opioid use. SPOT has actually turned out to be a big relief for staff. We were discovering people overdosed in hallways and bathrooms, and staff would have to abandon helping others to respond. With SPOT, we’re preventing emergencies and allowing staff to do the important work they have to do throughout the building.
What staff resources are needed to start a program like SPOT?
We always have two staff in the room. One is an addictions nurse; the other is a non-clinical person who focuses on engagement. This person can be a peer who has been trained to provide supports. There seems to be growing interest in this type of program, and I hope that more people can get them going.
Alan Marzilli, Homeless and Housing Resource Network