(9) AnyTime, AnyWhere: Examining Low-Barrier Buprenorphine for Post Incarcerated Individuals

Background & Introduction: Among 2.5 million people in the U.S. with a diagnosis of Opioid Use Disorder (OUD), only 22.1% received Medications for OUD (MOUD)1. This treatment gap highlights the need for interventions that address barriers to care and facilitate use of MOUD. In particular, the time following incarceration represents a period of increased morbidity and mortality, especially for individuals who use substances. Most notably, there is a 12-fold increase in all-cause mortality and a greater than 100-fold increase of overdose in the first two weeks after release2. Reducing barriers to MOUD continuation or initiation immediately following release from incarceration represents a large gap in care provision.

In 2021, the Allegheny Health Network Center for Inclusion Health created a post-incarceration clinic called RIvER (Rethinking Incarceration and Empowering Recovery) clinic which provides low-barrier MOUD bridge prescriptions via telemedicine for individuals with OUD immediately upon release from jail, regardless of insurance status. This rapid initiation of MOUD before being seen in the clinic provides stabilization during high-risk transitions with the hopes of reducing detrimental outcomes in the immediate post-incarceration period. Our study aims to demonstrate that low-barrier buprenorphine offered on-demand via telemedicine can reduce overdoses and increase engagement in care.

Methods: We conducted a retrospective chart review of patients with OUD who were provided with a buprenorphine prescription telephonically (aka bridge appointment) immediately after release from incarceration from September 2021 to April 2023. Patients were engaged by an outreach-based team composed of community health workers, social workers, and a nurse navigator after being released from jail. Those interested in MOUD were provided with an immediate telemedicine appointment with a clinician and an initial prescription of MOUD as appropriate. An in-person follow-up appointment was subsequently scheduled. We abstracted patient demographics, housing status, ongoing substance use, date of first bridge prescription, and other health care needs from medical records3. We assessed engagement in clinic after an initial bridge prescription, patients with multiple bridge prescriptions, and total outpatient appointments. We reviewed emergency department (ED) and hospital records for opioid overdoses and ED visits for OUD-related issues. The study goals are to compare ED utilization and overdose rates between bridge patients who did vs did follow-up in clinic.

Results: Fifty patients with OUD (n=50) were provided with a bridge prescription via telemedicine immediately after release from incarceration, prior to an in-person visit with the RIvER clinic. Among the 50 persons eligible for analysis, mean age was 39, and 84% (42/50) of these patients returned for follow up in clinic after an initial bridge prescription. Of those, 58% (29/50) had 5 or more appointments in clinic, while 14% (7/50) had a single follow up. The average retention rate in MOUD clinics is low, with 30% to 50% reported in most settings4. In comparison to our study, the average amount of appointments in clinic was 9. 22 patients had multiple bridge prescriptions. 64% of patients had other health care needs, of which medical and psychiatric comorbidities and co-occurring substance use were common. Five (10%) of these patients visited the emergency department after engaging with RIvER clinic. Of the patients who eventually became established with the RIvER clinic and received a bridge script, 45 patients visited the ED in 2019. In 2021 after RIvER clinic was developed, of those same patients who became RIvER patients via a telemedicine bridge script, 19 visited the ED.

In this study, a large proportion of patients demonstrated sustained retention and reductions in opioid use. Out of the total patients who we gave a bridge script to, who did not end up coming in for an in-person appointment, two experienced an overdose and one patient had two overdoses (38%). Out of the total patients who did come in for an in-person appointment after their bridge script, three experienced an overdose (7%).

Case Description: The CIH RIvER Clinic is a post-incarceration clinic model that focuses on the delivery of low barrier buprenorphine utilizing the provision of telehealth. From September 2021 to March 2023, 50 unique patients were provided new start telehealth prescription for MOUD and 84% of these patients followed up in a traditional clinic setting. This quality improvement project underlines the necessity of creating alternate and low barrier ways of providing MOUD in high-risk populations.

Conclusion & Discussion: MOUD treatment for opioid use disorder is safe and effective, but is underutilized, in part due to barriers in treatment delivery. Providing low-barrier MOUD access in vulnerable settings that are accessible to patients improves patient initiation and retention on MOUD. Low-barrier prescribing expands access to MOUD with support for patients who have ongoing substance use. In the post-incarceration population, we show that the model increases medication access, engagement, and treatment retention, as well as a reduction in ED utilization and overdoses. In this retrospective descriptive chart review study, we found that low-barrier buprenorphine for persons with OUD was successful in reducing overdoses and engaging patients in clinical care.

References: 1. Results from the 2021 National Survey on Drug Use and Health: Summary of National Findings. Substance Abuse and Mental Health Services Administration. 2022. https://www.samhsa.gov/data/sites/default/files/reports/rpt39443/2021NSDUHFFRRev010323.pdf. Accessed

2. Binswanger IA, Stern MF, Deyo RA, et al. Release from prison—a high risk of death for former inmates. N Engl J Med. 2007;356:157–165.

3. Carter J, Zevin B, Lum PJ. Low barrier buprenorphine treatment for persons experiencing homelessness and injecting heroin in San Francisco. Addict Sci Clin Pract. 2019 May 6;14(1):20. doi: 10.1186/s13722-019-0149-1. PMID: 31060600; PMCID: PMC6501460.

4. Chan, Brian MD, MPH; Gean, Emily PhD; Arkhipova-Jenkins, Irina MD, MBA; Gilbert, Jennifer MD, MPH; Hilgart, Jennifer MSc; Fiordalisi, Celia MS; Hubbard, Kimberly BA; Brandt, Irene MA; Stoeger, Elizabeth BS; Paynter, Robin MLIS; Korthuis, Philip Todd MD, MPH; Guise, Jeanne-Marie MD, MPH. Retention Strategies for Medications for Opioid Use Disorder in Adults: A Rapid Evidence Review. Journal of Addiction Medicine 15(1):p 74-84, January/February 2021. | DOI: 10.1097/ADM.0000000000000739

5. Jakubowski A, Fox A. Defining Low-threshold Buprenorphine Treatment. J Addict Med. 2020 Mar/Apr;14(2):95-98. doi: 10.1097/ADM.0000000000000555. PMID: 31567596; PMCID: PMC7075734.