San Francisco Has Doubled Participants of This Opioid Treatment. Here's Why

The first time Alyssa Ibarra tried to get suboxone, a medication proven to treat opioid use disorder, she bought it from someone off the street.

After an ankle injury in 2014, she started using Vicodin and Percocet recreationally and later developed an addiction to opioids after experiencing postpartum depression.

“When I tried to stop, I remember just feeling really hopeless,” Ibarra said. “I didn't even think, ‘I'm having withdrawals.’ I just thought it was the postpartum.”

Until recently, medications for opioid use disorder, like methadone, suboxone or buprenorphine, a generic form of suboxone, have been so tightly regulated that only about 27% of Americans with opioid use disorder have been able to access medication-assisted treatment, according to a 2022 study by doctors at Rutgers and Columbia universities.

At the same time, overdose deaths have increased locally (PDF) and across the U.S., killing nearly 107,000 people nationally in 2021, largely driven by synthetic opioids such as fentanyl, which is up to 100 times more powerful than morphine.

But local public health professionals and federal drug regulators are beginning to address the gap in access to medication-based treatment, so people like Ibarra can get the safe access they need faster.

“When someone needs it in the moment, they need it in that moment. They can't wait months for an appointment,” said Dr. Christine Soran, medical director for San Francisco’s public Outpatient Buprenorphine Induction Clinic. “The city is putting resources behind it, and almost every medical provider I talk to is on board with this kind of treatment.”

In San Francisco, the number of people who receive buprenorphine has doubled since 2013, according to data from the Department of Public Health, with a 53% increase in the past five years. Ibarra is part of that group.

The increase is largely driven by two changes: The federal government loosening its dispensing regulations, and San Francisco public health officials seizing the opportunity to expand medication-assisted treatment services.

In December 2022, President Biden signed the bipartisan Consolidated Appropriations Act of 2023, which removed a federal requirement known as the X-waiver, which blocked some medical professionals from prescribing buprenorphine for opioid use disorder.

As of 2020, only 5% of U.S. physicians had approval to prescribe buprenorphine or suboxone, according to a 2021 study conducted by emergency room physicians across the country and backed by the Foundation for Opioid Response Efforts, which funds research on solutions to the overdose crisis.

Under the X-waiver, the U.S. Drug Enforcement Agency required any clinician who wanted to prescribe buprenorphine to undergo certification training, unlike most non-addiction-related medication treatments where doctors can decide what works best for the patient.

Now, more doctors, pharmacists and even first responders are able to prescribe buprenorphine to people who can benefit from it.

During the pandemic, the San Francisco Department of Public Health started delivering medications to people living in permanent supportive housing buildings and single-room occupancy hotels, where a large portion of the city’s overdose deaths have occurred.

Now, every Wednesday and Thursday, Damian Peterson, a psychiatric clinical pharmacist at the Department of Public Health, fills his backpack with patients’ prescriptions, plus the overdose reversal medicine Narcan, and other supplies that patients may request to help cut down on drug-use harms.

Peterson said he regularly visits 19 buildings, mostly in the Tenderloin and SoMa neighborhoods, and reaches about 70 clients.

On a recent Thursday, he took off by foot around 1 p.m. to deliver buprenorphine to Bryon Killilea, who lives in the Dudley building on 6th Street. The two have been meeting there about once a week for the past five months.

“Around here, the pharmacies are ridiculous,” Killilea said. He used fentanyl on and off for about 15 years, he said, and said the delivery program for buprenorphine was much easier than his experience with retail pharmacies.

“They had a flyer out here and I came out and talked to them,” he said. “The hassles of going to places on BART, or needing to go every day, this sounded like a better option to have it delivered, and time-wise, it just worked out. And they were really nice.”

The time he’s gotten back has allowed him to spend more time with his 10-year-old son.

“I’m just feeling more normal, not as antsy,” Killilea said about how buprenorphine has helped him cut back on fentanyl. “I recommended it to a couple of my neighbors. I think this is a good thing.”

The U.S. is, in a way, now playing catchup with other countries that have made medication-assisted drug treatment widely accessible for decades.

In France, all registered doctors have had the ability to prescribe buprenorphine since 1995; the French government changed its dispensing policy after the heroin epidemic devastated the country in the '80s and '90s, and the policy change led to a 10-fold increase in patients being treated with buprenorphine, according to one 2004 study analyzing the policy shift.

Within four years of opening up access to buprenorphine, opioid overdose rates in France declined 79%, the study found.

San Francisco hopes to see similar success. But there are some major differences in the U.S. drug supply today from the time of the heroin epidemic here, in the 1980s and ’90s; the local illicit drug supply has become more dangerous with the introduction of fentanyl, which began ramping up in San Francisco around 2018.

Fentanyl is 50 times stronger than heroin and commonly used in medical settings for pain and after surgeries. Due to its unique chemical structure, it reaches opioid receptors in the brain faster than heroin or morphine. And its high potency makes it stick to fat molecules in the body longer than other opioids, which in turn can make it even more difficult to treat opioid withdrawal.

That means first responders and public health professionals will have to act more quickly when someone is ready for treatment.

Starting April 1, San Francisco Fire Department personnel began assessing people prior to taking them to the hospital, and administering buprenorphine after an overdose or if someone is experiencing withdrawal, and consents.

“Expanding access to life-saving medication is a critical part of our work to prevent overdoses,” Mayor London Breed said in a press release. “By giving our emergency responders the training and ability to deliver buprenorphine in the field, we can reach more people more quickly.”

While medication can address some of the physiological parts of opioid addiction, addressing other issues such as trauma, isolation and access to resources like food and housing are inextricably linked to recovery.

“Patients tend to be more successful if they feel like they have input on their recovery and what that looks like,” said Paulette Walton, a nurse practitioner at Outpatient Buprenorphine Induction Clinic (OBIC), shortly before meeting with a patient on a recent afternoon.

Ibarra started coming to OBIC in the summer of 2021 after experiencing an addiction to Percocet, and briefly using heroin. For the last two years, she has regularly visited the clinic for her medication and counseling.

Ibarra said the stabilization this has led to has changed her life. She returned to work as a hairstylist and was promoted to manager. She’s parenting her young daughter. She’s dating again.

“They think rock bottom is literally losing everything,” Ibarra said. “But for me, rock bottom was just that the first thing I think about waking up now, just opening my eyes, I was reaching to grab my pills. And that was scary by itself.”

Ibarra’s recovery is ongoing. Currently, she’s thinking about changing her daily suboxone pill to a monthly, long-acting injectable. And she will continue to see her doctor at the clinic, where she said she’s found a care team that works for her.

“They sit here and talk to me. They remember things about me,” Ibarra said. “They say, ‘I'm proud of you.’ It's the support that I get here that I don't get at home.”