Ottawa Inner City Health’s Managed Opioid Program (MOP) combined injectable opioid agonist treatment with supportive housing for people with severe opioid use disorder and experiencing homelessness. An assessment of the program’s first year, published recently in the International Journal of Drug Policy, showed high retention rates and notable improvements in several measures of patient health and social wellbeing. At one year, retention was 77%, 45% stopped non-prescribed opioid use, 96% connected to behavioral health services, 42% reconnected with estranged families, and 31% started work or vocational programs.
HealthCity spoke with lead author Miriam Harris, MD, MSc, an addiction expert at Boston Medical Center and assistant professor at Boston University School of Medicine, about the program and how the MOP model might inform addiction treatment in the U.S.
HealthCity: Can you describe the managed opioid program study and its purpose?
Miriam Harris, MD, MSc: This program paired injectable opioid agonist therapy in the form of injectable hydromorphone, with assisted low-barrier housing. Our study retrospectively described the first cohort of 26 participants experiences with treatment and their treatment outcomes. We undertook this study because we think the Ottawa program was innovative and beneficial and merits a discussion with a broader addiction audience.
HC: How does injectable opioid agonist treatment differ from what people get at methadone clinics or at the safe injection sites that operate in some other countries and have been proposed in Massachusetts?
MH: First, injectable opioid agonist therapy is not available in the United States at this time, so this is very different from that perspective. In Canada, it is a treatment for people with severe opioid use disorder who have already tried first-line treatments like methadone, and despite trying these first-line, lower-risk treatments, remain severely addicted to opioids and are still injecting drugs. It’s very structured treatment and requires a lot of engagement.
"This Ottawa program took a group of folks with the highest risk and the most severe disease and, despite that, found better retention outcomes than with methadone or buprenorphine or with housing alone." Click To Tweet
Methadone vs. injectable treatment also differ in that one is oral, taken by mouth, and the other one is prescribed injectable treatment—injecting heroin or, in this case, hydromorphone.
Safe injection sites or safe consumption sites are quite different. They are a harm-reduction interventions for people with varying types of substance use and varying degrees of severity of their addiction. People may choose to use drugs at these sites without actually having an addiction. What safe consumptions sites do is provide a legal, safe, hygienic, warm, and welcoming space for people who use drugs to use without being persecuted and where they can access the materials they need to safely use drugs. They are observed after using their drug to make sure they don't have an overdose event.
HC: A key piece of this program was providing housing along with treatment. What type of supports linked with the housing are needed for success?
MH: One major support is expansive addiction treatment. Also, a recognition that people are not going to stop using the second they are housed—and having services that can flex to that. In this case, there was a safe and monitored injection space where people used their prescribed treatment. The supports also created an environment where participants felt safe disclosing their substance use. Almost 100% of program participants were still actively using stimulants, but they were not kicked out of the program. That is appropriate, and we should learn from that experience.
Other important services address other health and wellbeing metrics. There were cooking classes, for example, and group therapy sessions focused on re-engaging with friends and family and vocational programming. I think those are really important to the people getting the treatment—equally as important as the outcomes we talk about as public health or addiction providers, such as overdose rate and non-prescribed use.
Embedding mental health services, including psychiatric and pharmacotherapy and counseling, was really important. The vast majority of people in this program had severe mental health needs. Only about 50% were having those needs addressed in some form at the beginning of the program. By the end, almost all of them were.
HC: What do you see as the most promising outcomes in the Ottawa pilot?
MH: I think the retention outcome—77%—is incredibly compelling. This is a group of folks who were not retained on the other best treatments that we have, methadone and buprenorphine. So they've already demonstrated that that doesn't work for them, which reflects a very high degree of severity of addiction. They also were all experiencing homelessness, which we know has detrimental effects for one's ability to stay engaged in treatment.
So,this Ottawa program took a group of folks with the highest risk and the most severe disease, and despite that,found better retention outcomes than with methadone or buprenorphine or with housing alone—which are the interventions mainly implemented here in the U.S.
The big takeaway for me is that this study builds on many others that show injectable opioid agonist therapy is safe and effective. What this study adds is this innovation of combining low-barrier housing with harm reduction and addiction treatment and the value of that. Low-barrier housing with embedded innovative addiction treatment was effective and we should be thinking about how we could scale this and implement this in other settings.
HC: Were any outcomes of the managed opioid program surprising?
MH: One surprise was that the folks who stayed in the program had more than a 50% reduction in nonfatal overdose events, and no one died. These were people who had multiple overdoses before this program and were at imminent risk of death. So that's really remarkable. There were two deaths related to overdose among those who disengaged with the program, which I think speaks to how incredibly vulnerable to overdose this population was.
HC: Where does this method of pairing opioid treatment with housing stand right now in the U.S.?
MH: Here in the U.S., many of our housing programs do not tolerate substance use. So what are folks supposed to do who are actively experiencing addiction that's worsened by experiencing homelessness? Getting housing isn't going to magically resolve the substance use, yet that's the expectation that we have. That can be seriously problematic and dangerous, which is why a huge proportion of our overdoses in Massachusetts are among people who are housed, not only those who are unhoused.
I hope the low-barrier housing piece of this model isn't lost in the anxiety or excitement around the injectable opioid agonist treatment component. The treatment is interesting and important, but so is the housing. Housing alone is not enough, and treatment alone is not enough.
HC: Are you hopeful about the U.S. taking steps in this direction?
MH: There is action in terms of moving legislation forward for states to pilot safe consumption spaces. That's important, because looking at innovative housing models that include things like safe consumption spaces is an important policy direction the U.S. should be considering. I'm optimistic we'll have the tools to think about it soon. For example, Rhode Island recently passed legislation allowing for a pilot safe consumption space. That's a big deal for the U.S.
We have tools available now that we could embed within low-barrier housing to serve people with severe addiction who are experiencing homelessness. For instance, housing that includes wraparound services to prevent overdose; harm reduction staff who do outreach to folks in the housing; low-barrier addiction treatment, like starting buprenorphine or having methadone clinics connected to housing; and not making housing contingent on abstinence. We could be doing those things right now, and we don't have them, not even in Massachusetts.
HC: Now that we have this encouraging data for this relatively small sample, what types of further studies or pilots would you like to see?
MH: I'd love to see studies about safe consumption spaces and housing. I would love to see some interest from the National Institute on Drug Abuse (NIDA) in injectable opioid agonist treatment here in the U.S. as a third-line option for people who have not had success on methadone or buprenorphine—starting some clinical trials for that. And finally, I would love for us to more actively work with people who use drugs in the development of housing and addiction treatment—asking people who use drugs what they need, implementing that, and then seeing what happens compared to when you don't. That is really exciting, and we should be doing more of it. I think we would arrive at more effective and innovative housing and addiction treatment models much more quickly if this was the approach we universally took.