Paul LaKosky knows it’s hard to fight opioid addiction.
The Executive Director of Tacoma’s Dave Purchase Project, which runs the Tacoma Needle Exchange has seen time and time again the barriers his clients face to getting help.
“(We see) the hardest of the hard cases,” he said. “Many are homeless, with multiple conditions on top of opioid use. ... (It’s) difficult for a lot of people who want to get into treatment to navigate the bureaucracy.”
A new grant-funded program which started Thursday in Tacoma hopes to make it easier.
The “Meds First” initiative will park one of the Tacoma-Pierce County Health Department’s vans next to the Needle Exchange. Two people employed by the program, called “care navigators,” will stand next to the exchange. They’ll talk with clients who arrive, and ask if they would be interested in starting treatment.
If someone can and wants to start treatment, they’ll be taken to the van next door and started on prescription medication that day.
“The Needle Exchange is the obvious place to have a program like this,” LaKosky said. “We’ve built a long, established trust with the community we serve.”
What’s different about this approach?
It gives people “the right services, at the right time, in the right place,” said Alisa Solberg, the health department’s treatment services program manager.
The organizers hope to do this without charging the client.
“We really are trying to serve the people who are the most vulnerable, the people who need the service the most,” Solberg said.
‘Not easy to get into treatment’
Opioid addiction has been steadily increasing across Pierce County, health department statistics show.
The rate of opioid overdose deaths has more than doubled in the past two decades, according to the health department. In 2001, about five people died of opioid overdoses per 100,000 people in both Pierce County and across Washington state.
In 2017, nearly 12 people died per 100,000 people in Pierce County. This was higher than the state rate of 10 deaths per 100,000 people.
Pierce County also has a higher rate of hospitalizations due to opioid overdoses than the state average.
This rate has more than quadrupled in Pierce County since 2001. It increased from about five hospitalizations per 100,000 people to more than 20 hospitalizations per 100,000 people.
Yet the traditional places people seek help for addiction, such as rehabilitation centers, methadone clinics, or primary care offices, often have rules that exclude the majority of the people who need help.
“Only 10 to 15 percent of people can access care,” Dr. Caleb Banta-Green, an addiction research scientist at the University of Washington explained.
Banta-Green said that many of these places require people seeking treatment to stop using any other drugs. This can be challenging if a person with opioid addiction struggles with other simultaneous addictions.
These places can also be expensive, or require consistent attendance at appointments. This can make it difficult for those with unstable living situations to access care.
“People need to show up six days a week at 5 a.m. for methadone treatment,” LaKosky said. “(They have) not made it easy to get into treatment.”
‘On their terms’
This is where Meds First comes in.
It’s designed “to engage people where they are,” Banta-Green said. “We’re trying to do it on their terms.”
It allows those in the program to simultaneously take other drugs, and poses no restrictions on people if they miss appointments.
The program has hired the two “care navigators” based on proven experience working with people addicted to opioids. Solberg refers to one of the employed care navigators as a “peer.” This means the person is currently taking medication to recover from opioid addiction.
The care navigators need to be people who can gain the community’s trust.
“A lot of the people we are hoping to serve are people who are also experiencing homelessness, serious mental illness (or) very complex psycho-social circumstances,” Solberg said.
By situating the new program next to the Needle Exchange, Solberg hopes they’ll be able to meet people already looking for a change.
“Around 70 percent of the people who present at needle exchanges want help,” Solberg said. “They want to put their lives back together, and given the opportunity, they’re taking it.”
The program is based on research from a pilot program conducted in Seattle.
At a Seattle needle exchange, researchers offered clients free and low-cost medication in a similar setting. They prescribed the drug buprenorphine.
The Tacoma program plans to offer buprenorphine and other addiction treatment medications.
According to Banta-Green, these medications help reduce overdoses by about 40 to 60 percent in opioid users. Buprenorphine works by binding to opioid receptors, preventing the symptoms of withdrawal.
It prevents opioid users from getting high if they were to take an opioid drug, eliminates cravings, and helps a person feel “normal.” It’s also an incredibly safe medication; Banta-Green said it’s nearly impossible for adults to overdose on it.
Despite the benefits, Solberg said there’s no clear timeline as to when people who start taking such medication would be able to stop it.
“We want to begin treating Opioid Use Disorder in the same way we treat any chronic disease,” she said. “Some patients will need opioid treatment for the rest of their lives. Some may ... need treatment for 6 months or a year.”
Within the first five weeks, the Seattle pilot program filled all the available slots. After that, staff compiled an extensive waiting list.
Over the course of a year, 147 people participated in the program. Most returned for follow up visits after the first visit. The majority of those who returned continued to show up relatively regularly for appointments.
The main problem the pilot program encountered was that only 17 percent of participants transitioned out of the program and started receiving medication from a primary care doctor.
The program’s limited funds wouldn’t be able to support so many participants long term.
“We want to get them into primary care so they have a medical home,” Solberg said.
The organizers think the program is revolutionary because it’s helping people who wouldn’t be getting help in any other setting. Banta-Green painted a dire picture of what would happen to the participants if the program didn’t exist.
“People would continue using illicit opioids, and many of them would die,” he said.
‘A long time coming’
Tacoma and Seattle are two of four places in the state to get a Meds First program as part of a $7.8 million grant from the Paul G. Allen Family Foundation, Washington State Health Care Authority, Premera Blue Cross and The Ikigai Fund at Seattle Foundation.
The other Meds First programs are in Spokane and Walla Walla.
The grant will pay employees’ salaries, and for research costs associated with the program. Tacoma’s program will use a corner office in the health department and one of the health department’s vans.
Once the two-year grant runs out, the team hopes to find a more sustainable way to fund it. Solberg said they do not yet know where the money to continue it would come from.
“It’s going to take a collaborative and systemic response,” LaKosky said “... That means elected officials (will) need to advocate for this.”
Patients will use their insurance to pay for the medications, if they have it.
Solberg estimates that about 70 percent of those who enroll in the program will qualify for Medicaid.
Yet many people who frequent the Needle Exchange don’t have IDs, or don’t know that they could qualify for insurance, LaKosky said.
Until someone can enroll in insurance, Solberg said the grant would cover the cost of medications. She emphasized that the program wouldn’t have enough funds to pay for many people’s medication.
“We really are relying on the fact that the majority of patients do qualify,” she said. “... With the current grant coverage we’d be able to cover about 150 slots for people who were not able to pay.”
The program had a “soft opening” six weeks ago, and has since enrolled 41 people, almost quadruple the number they expected in that time.
Tacoma’s team of two care navigators, a nurse care manager, and a medication prescriber can handle about 100 patients at a time, Solberg said.
This means it’s likely the program will have more demand than it can fulfill. Solberg said the team doesn’t know how it will choose who will get care if the program reaches capacity.
“It’s a start, and we have to start somewhere,” LaKosky said. “Will we exceed capacity? Undoubtedly.”
The group stressed the importance of the program.
“I think it is a long time coming,” LaKosky said.