SF's Mobile Clinics Made Opioid Treatment More Accessible During the Pandemic. But Will They Stay?

Things at the opiate treatment program at San Francisco General Hospital look a good deal different these days from before the pandemic hit.

For starters, there’s now an option to pick up methadone from a mobile clinic stationed in the hospital’s shaded parking lot, rather than in the traditional clinic inside Ward 93. More crucially, patients can now get the dosage level they need, when they need it, and are able to take their medications home with them — allowances that were previously restricted.

In the spring of 2020, as many medical facilities limited their indoor services, the mobile clinic’s two vans set up shop, enabling patients to continue receiving their addiction-related medications and other treatments without interruption.

Early indicators suggest the changes have helped more patients stick with their substance-use treatments at the hospital’s 50-year-old Opiate Treatment Outpatient Program (OTOP).

“More people are coming, and more people are staying” with their treatment plan, said Dr. Lisa Fortuna, chief of psychiatry at SF General.

But as local and federal pandemic emergency orders — and many of the programs that came with them — come to an end, the future of the mobile clinic is uncertain.

Tamra Lombardo, a former heroin user who has received treatment from OTOP for nearly 10 years, said the outdoor site is more discreet and much easier to access compared to the hospital ward, which she frequented before the pandemic.

“I haven’t missed no days here. It’s more convenient and a lot smoother. It’s way better, I think,” said Lombardo, 52, after picking up the cherry-flavored dose of methadone from one of the clinic's vans on a recent Friday, with her dog Eddy at her side. Finding a program that works, she added, has allowed her to focus on her work as a caregiver.

Lombardo is one of about 600 OTOP patients, roughly 75% of whom now use the program's mobile clinic, according to Hasija Sisic, a nurse manager. Participation in the program, which dropped considerably during the first year of the pandemic, has since rebounded and even exceeded pre-pandemic levels, according to data provided by the program.

That retention is sorely needed as cities throughout the region, and country, continue to grapple with an overdose epidemic driven by potent opioids like fentanyl. In San Francisco alone, nearly 2,000 people have died of drug overdoses since 2020, according to data from the Office of the Chief Medical Examiner.

Seven days a week, OTOP nurses work out of the clinic's large white vans in the hospital parking lot, near Potrero Boulevard. On Monday through Friday, one of the vans also parks in the Bayview neighborhood.

On a recent Friday afternoon, nurses outside the hospital dispensed methadone and buprenorphine — medications used to reduce withdrawal symptoms — while offering program patients snacks, water and canisters of naloxone, an overdose-reversal nasal spray.

After picking up their doses, patients talked with counselors in person or on iPads in heated booths inside the vans. At the start of the pandemic, the program gave out free mobile phones to almost all patients, many of whom lack reliable internet access, so they could be reached for daily check-ins.

Sisic said she hopes the mobile sites will continue to operate, even as emergency orders sunset.

“We are still talking to the state to at least consider that this might be a good option to keep, because there are a lot of regulations,” she said. “But it’s very needed and we do have the skills.”

Opioid withdrawal symptoms can be extremely painful and, in some cases, fatal. So when methadone was approved by the U.S. Food and Drug Administration in 1972, San Francisco became an early adopter in dispensing it. That effort was later incorporated into the city’s strategy to help combat HIV among injection drug users during the start of the AIDS epidemic in the early 1980s.

But many health experts now argue that standard treatment for substance-use disorders has failed to keep pace with the ever-expanding landscape of increasingly potent and dangerous street drugs.

Treating the withdrawal symptoms of fentanyl, for example, an opioid that’s 50 times more potent than heroin, requires a higher initial dose of methadone than what’s typically allowed by the Substance Abuse and Mental Health Services Administration, the federal agency that regulates how opioid-treatment drugs are administered.

Before the pandemic, federal health authorities strictly regulated many aspects of opiate treatment programs in an effort to stem overdoses of methadone, which is itself an opioid. Rules around treatment dictate everything from dosage levels to when and where patients consume their medications.

Some of those rules were temporarily relaxed at the start of the pandemic, as drug treatment centers scrambled to prevent overcrowding and continue programs.

Under the updated COVID-era federal regulations, health care providers can prescribe higher doses of methadone depending on a patient’s needs. Stabilized patients also have more access to take-home medications and can attend counseling by video or phone rather than in person.

Before the pandemic, “we couldn’t go up as quickly on dosage to get to the appropriate dosage that stops cravings of opioids,” said Dr. Andrew Tompkins, head of UCSF’s Division of Substance Abuse and Addiction Medicine. “And all counseling had to be face-to-face. We weren’t allowed to use telehealth or telephone.”

Now about 82% of patients in the program qualify for at least one take-home dose, up from the roughly 25% who qualified before the pandemic, Tompkins said.

And so far, concerns about take-home methadone doses leading to increased overdoses “have not borne out” (PDF), according to a recent UCSF report. In observing opiate treatment programs in five different states, the study's authors found no significant increase in methadone diversion or overdose after take-home regulations were relaxed in 2020, as compared to previous years.

The study goes on to suggest that expanding methadone and buprenorphine treatment options can begin to address some of that history of “medical racism and treatment segregation.”

A recently proposed federal rule change could make the loosened opiate treatment rules permanent. Specifically, it would allow providers to continue prescribing take-home doses of methadone and allow treatment programs to be initiated through telehealth consultations.

Being able to receive take-home medication has been a welcome change for patients like Debra Allen, a Tenderloin resident, who has attempted opioid treatment for years to combat her cocaine and heroin addiction.

The mobile clinic allows her to more easily hop on and off the bus to pick up her medication, and it’s a calmer environment than the buzzing methadone clinic inside the hospital, she said.

“This site is nice. I’ve been here a long time. Other ones are nasty and dirty. Here they keep the bathroom clean,” Allen said.

“You can be using so long you get immune and you have to go up [with your dosage],” she said, adding that this treatment approach “makes me not want heroin.”

Lombardo, one of the longtime patients, said she’ll keep returning for treatment as long as the vans are around.

“I don’t have to use the junk out there anymore. I’ve lost a lot of people I know to that,” she said. To other folks who might be considering treatment, she recommended the mobile clinics: “Take the time to try it. The more you put into it, the more you will get out of it.”