When physicians and staff at the South End’s Boston Healthcare for the Homeless (BHCH) established the SPOT observation area to help alleviate the opiate overdose epidemic right outside its Albany Street door, they didn’t know what to expect.
In two years, though, two things have become apparent.
One is that SPOT works.
But the second thing is that, sadly, they don’t believe it is enough.
Dr. Gabriel Wishik spoke with the Sun this week about the “lessons learned” from two years of operating the SPOT on the first floor of BHCH. He said they have found it to be very effective in engaging with and monitoring those who feel like they are in trouble after ingesting opiates, but it is the folks in that situation that don’t make it to SPOT that he worries most about.
“We didn’t know what to expect at first,” he said. “We felt like we saw a need. We opened up and we were full every day. I think we discovered there is a need definitely for this type of service…As an engagement center, it is extremely effective and we’re pretty happy about that.”
The Supportive Place for Observation and Treatment (SPOT) came to the community two years ago this April, asking the South End community for its blessing to operate a space where those in the midst of overdose could go to be observed. The operation is nothing more than six or seven recliners in what used to be the main conference room on the ground floor of the facility. Inside, two nurses and a harm reduction specialist monitor those who come in and feel like they are overdosing, or in some cases are brought in by friends or outreach workers. A physician such as Wishik oversees the operation from within the building.
Much of the clientele has grown accustomed to the space, and many return multiple times. A good deal of them, Wishik said, are people from the immediate area that they did not engage with previously – a very high risk population.
“There are a lot of good lessons learned,” he said. “Nobody is coming from very far away. It serves this block.”
But at the same time that he deemed it a success, he said it also showed how necessary he believes it is to take the matter one step further – and that step would be the controversial idea of Safe Injection Facilities (SIFs) so that they could be present when users are injecting. With the advent of Fentanyl being the primary street opiate, the onset of an overdose or death has become magnified, he said. It is difficult, if not impossible, to be able to navigate to the SPOT in such a time of crisis.
“People become unresponsive in seconds and at risk of dying within minutes (with Fentanyl),” he said. “They don’t have time to inject and then get to SPOT…So SPOT isn’t exactly reaching the highest risk. It’s really sobering to see how routinely this is occurring for people…The SPOT is useful, but it’s not everything. It has a limitation and can’t be utilized at the time of injection and that’s the hole some people are falling through and dying…It’s something we can’t do and I wish we could. People are dying left and right.”
Part of the success of SPOT is the fact that it’s so heavily used.
Over the past two years, 817 people have made 7,139 visits, and staff are able to use interventions that are less shocking to the system than a Narcan blast in an ambulance or on the floor of a Dunkin’ Donuts bathroom.
Most of the time, staff simply observes those at SPOT taking their vital signs. If they are distressed, they commonly use oxygen. They don’t often move to Narcan to reverse and overdose, but if they do, he said, they introduce it in small amounts.
That is so when the patient revives, they aren’t in the throes of withdrawal. A little known fact is that Narcan immediately induces withdrawal symptoms, which Wishik described as “torture.” Many times, because of that, a patient isn’t very reflective or open to talking about treatment. Their only inclination is to go out and use as quickly as possible again to get rid of the withdrawal symptoms.
With the SPOT treatment, he said, many patients are able to have that conversation about seeking treatment, understanding that they almost died and are at risk of actually dying.
“Some 24 percent eventually move on to treatment after referrals,” he said. “That is huge. That is not the main goal of SPOT, but the reality is this high-risk population will come to us when they are ready for that kind of treatment…We don’t require people to be in a state of sobriety. We are engaging people who are under the influence. People do come back and there is a rapport. It is seen as a safe space…We have that at SPOT. That moment of reflection does pay off…Because we are able to engage people in a safe place, they will confide in us.”
He also said they believe that it has saved the public health system a good deal of money from EMS calls and Emergency Room visits that were avoided.
“Our inclination is this is extremely cost effective,” he said. “We can’t prove that yet, but that’s our inclination.”
In summary, Wishik said SPOT is a success in its first two years of being piloted in the South End, and he invited others to begin using the model as well.
“A lesson we take is the SPOT is an intervention that applies when there is a lot of public intoxication,” he said. “This could be anywhere. It could be a pod in an emergency room. It could be anywhere where there is a lot of public use. We are hoping more people will take this and run with it.”