Treating Homeless Opioid Dependent Patients with Buprenorphine
in an Office-Based Setting
Daniel P. Alford, MD, MPH
, Colleen T. LaBelle
, Jessica M. Richardson
James J. O’Connell, MD
, Carole A. Hohl, MHS
, Debbie M. Cheng, ScD
and Jeffrey H. Samet, MD, MA, MPH
Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical
Center, Boston, MA, USA;
Boston University School of Medicine, Boston, MA, USA;
Boston Public Health Commission, Boston, MA, USA;
Health Care for the Homeless Program, Boston, MA, USA;
Department of Biostatistics, Boston University School of Public Health, Boston, MA,
Department of Social and Behavioral Sciences, Boston University School of Public Health, Boston, MA, USA.
CONTEXT: Although office-based opioid treatment with
buprenorphine (OBOT-B) has been successfully imple-
mented in primary care settings in the US, its use has
not been reported in homeless patients.
OBJECTIVE: To characterize the feasibility of OBOT-B
in homeless relative to housed patients.
DESIGN: A retrospective record review examining treat-
ment failure, drug use, utilization of substance abuse
treatment services, and intensity of clinical support by
a nurse care manager (NCM) among homeless and
housed patients in an OBOT-B program between Au-
gust 2003 and October 2004. Treatment failure was
defined as elopement before completing medication
induction, discharge after medication induction due to
ongoing drug use with concurrent nonadherence with
intensified treatment, or discharge due to disruptive
RESULTS: Of 44 homeless and 41 housed patients
enrolled over 12 months, homeless patients were more
likely to be older, nonwhite, unemployed, infected with
HIV and hepatitis C, and report a psychiatric illness.
Homeless patients had fewer social supports and more
chronic substance abuse histories with a 3- to 6-fold
greater number of years of drug use, number of
detoxification attempts and percentage with a history
of methadone maintenance treatment. The proportion
of subjects with treatment failure for the homeless
(21%) and housed (22%) did not differ (P=.94). At
12 months, both groups had similar proportions with
illicit opioid use [Odds ratio (OR), 0.9 (95% CI, 0.5–1.7)
P=.8], utilization of counseling (homeless, 46%; housed,
49%; P=.95), and participation in mutual-help groups
(homeless, 25%; housed, 29%; P=.96). At 12 months,
36% of the homeless group was no longer homeless.
During the first month of treatment, homeless patients
required more clinical support from the NCM than
CONCLUSIONS: Despite homeless opioid dependent
patients’ social instability, greater comorbidities, and
more chronic drug use, office-based opioid treatment
with buprenorphine was effectively implemented in this
population comparable to outcomes in housed patients
with respect to treatment failure, illicit opioid use, and
utilization of substance abuse treatment.
KEY WORDS: buprenorphine; drug dependence; primary care;
© 2007 Society of General Internal Medicine 2007;22:171–176
Opioid abuse persists as a pervasive public health problem in
the United States, both heroin
and prescription opioid
Opioid agonist treatment with methadone or
buprenorphine is effective for treating opioid dependence.
With the advent of sublingual buprenorphine for the treatment
of opioid dependence, primary care physicians in the United
States gained the opportunity to effectively treat opioid-
dependent patients in primary medical care settings, common-
ly referred to as office-based opioid treatment (OBOT).
In 2003, the primary care clinic at Boston Medical Center
(BMC) implemented an OBOT with buprenorphine (OBOT-B)
program employing collaborative care between physicians and
a nurse care manager (NCM).
All patients in the BMC pri-
mary care clinic OBOT-B program were required to have stable
housing, as clinical guidelines recommend a stable social
environment as an entry criterion for OBOT-B.
stability as a criterion for OBOT-B precludes homeless persons,
a population with a high prevalence of addiction,
a high risk of illness and death.
Unique challenges confront homeless individuals engaging
in substance abuse treatment,
which likely contribute to
their high rates of treatment failure.
homeless persons are correlated with relapse: lack of social
support; unstable living environment; and longer duration of
However, research has shown that
homeless persons’ success in substance abuse treatment can
increase under supportive circumstances.
despite limited literature on methadone treatment in homeless
populations, published data suggest greater success with
Received January 24, 2006
Revised July 17, 2006
Accepted September 27, 2006
Published online January 17, 2007