This is the third story in a three-part series examining the realities of methamphetamine use in Oakland and efforts to address this growing public health crisis. If you’re new to the story, start with our first piece to understand the basics of the crisis.
In 2017, Dr. Andrew Herring, an emergency medicine doctor and director of research at Oakland’s Highland Hospital, took on his biggest project yet: starting a patient-centered, open-access clinic for Oaklanders with substance use disorder looking for treatment.
The main idea behind the new clinic was to initiate medication-assisted substance use disorder treatment the same day patients arrived in the Emergency Department, instead of waiting until days after when a person might be hard to contact or not as open to treatment. This approach was inspired by a 2015 Yale School of Medicine study and kick-started with a California Health Care Foundation grant. Initially, Highland Bridge Clinic focused on providing the drug buprenorphine to treat patients suffering from opioid addiction. Soon, it expanded to treat patients with alcohol, methamphetamine, and other substance use disorders, as well.
But whereas patients with opioid or alcohol use disorders have medication-assisted treatment options, there are not yet any FDA-approved medications for people who suffer from meth and other stimulant use disorders. At Highland and elsewhere, the only real treatment option that has historically been available to patients addicted to meth has been psychotherapy—until now.
This year, new treatment options for people who have meth use disorder will be coming to Alameda County. The first, known as ‘contingency management’, is a highly-effective, evidence-based behavioral therapy for meth and stimulant use disorder. At least three East Bay providers will offer contingency management therapy. The second is a Highland Hospital-based clinical trial for medication-assisted meth use disorder treatment. Both treatments assume that many patients will relapse, which addiction professionals emphasize is a critical part of the healing process.
While Herring and his colleagues are excited about the opportunities for care that these new developments will offer, he acknowledges that getting reliable funding and approval for treating substance use disorder is a bumpy road, with obstacles that are often rooted in bias.
“It’s not some big shocker that the treatment of substance use disorder has suffered from stigma and underfunding,” he said.
Oakland’s methamphetamine crisis—Read parts I and II in this series
Health experts and social workers say meth use, and harms associated with it, are rising fast and treatment options are limited.
Health care and harm reduction workers say people of color and unhoused residents are disproportionately impacted by the drug’s rise in recent years.
For years, the scale of addiction to meth and other substances in Oakland has stretched resources. Not only are funds insufficient to create a robust addiction medicine infrastructure that could offer treatment and care to all Oaklanders with substance use disorder, but acquiring those limited funds is a big undertaking. Often, programs are forced to apply for sporadic, short-term grants, making their already challenging task gargantuan.
“It’s like a nation-building project,” Herring said, pointing to the many twelve- and eighteen-month grants that have driven much of his work. Because funding is so often offered on short-term bases, the progress Herring and his colleagues can make with a single grant stalls when the money runs out.
“Hospitals can’t hire people if they know that the funding is going to run out in a year,” he said.
As a result, the program options for people with substance use disorder in Alameda County are more limited than they could be. Whereas other counties in California offer residential medical detox programs, Alameda County lacks any such facility. That means that patients who might benefit from medical detox, as opposed to social detox, have to travel to access an in-patient program, which can be challenging if a patient lacks the financial resources to do so.
“These treatment systems are so inadequate for a lot of these populations,” said Dr. Erik Anderson, an emergency and addiction medicine specialist at Oakland’s Highland Hospital, and one of Herring’s colleagues.
Another important example of how Alameda County’s public health programs to address the addiction crisis are underfunded is the fact that the county lacks a machine that could test the chemical makeup of drugs. With the high rate of fentanyl contamination in Oakland’s meth, heroin, and cocaine supplies, such a machine would almost certainly prevent hundreds of potentially-deadly overdoses per year.
Anderson said that such a machine would be crucial for Oakland and the county. “San Francisco has one. But who’s going to pay for it? Who’s going to operate it here? It’s more complicated and frustrating,” he said.
Still, Highland doctors have productive relationships with the county’s public health system, which they say has noticed the hospital’s focus on providing equitable care.
“Alameda Health System…has invested significantly in our program at a faster pace than other places, because of the volume, for one thing, but also because we focus on things like equity,” said Anderson.
For instance, when Oakland doctors asked for money from AHS to support inpatient addiction counseling services, which they say has been shown to improve mortality, health disparities, and equity metrics, AHS provided the funding without hesitation.
To Anderson, that makes it clear that people are paying attention to the issue, and that progress is happening.
Highland’s “low-threshold” model offers addiction care on the spot
In Oakland and across the country, the start of the COVID-19 pandemic saw rates of overdose deaths increase. That rise has been attributed to a greater number of people developing substance use disorder as a result of challenging circumstances brought on by the pandemic, as well as a more potent drug supply involving substances that are often laced with deadly fentanyl.
During the same period, Highland Bridge Clinic has seen surging numbers of patients seeking addiction treatment, and the clinic’s patient volume has expanded by as much as ten times since the beginning of the pandemic. “The program’s grown dramatically,” said Anderson.
To the addiction professionals at Highland, that growth shows the extent to which Highland’s program fills a gap in the community and public health care in Oakland. It also speaks to the unmet need for substance use treatment in Alameda County, especially in safety-net settings which, like Highland, provide care to low-income people. Many of those patients are insured by Medi-Cal, California’s federally-funded public health insurance program, while some have no medical coverage at all.
At Highland, providers have figured out that the best way to get treatment to people with substance use disorder is to remove as many hurdles as possible. The Bridge clinic’s “low-threshold” model means that it is open access from Monday to Friday, and offers after-hours support via emergency departments throughout the county.
“Folks are able to walk in without an appointment,” said Dr. Monish Ullal of Highland Hospital. On a cold day in January, Ullal warmly greeted a patient who was seeking help for alcohol abuse. The patient was able to get started on a medicated treatment that was covered by insurance within an hour.
For Ullal, the Bridge Clinic’s open-access model differentiates it from other primary care facilities.
“If you and I want a primary care appointment, we have to book it months in advance. If we’re more than fifteen minutes late, we might be forced to reschedule. If insurance is inactive, we might have to sort that out before we can even talk to somebody,” he said. “None of those things are true here.”
If a patient is unable to travel to the hospital, the clinic makes it easy for that person to get treatment by offering prescriptions over the phone as well as providing text-message counseling services.
“People can call a phone number and get started on buprenorphine immediately,” said Anderson. “I think that’s been a really important model to have for folks.”
Patients can also be referred to the clinic from the emergency department. Often, this happens with the help of a patient care navigator, a community health worker who is trained in harm reduction and who connects the patient to the clinic. Some, like Adam, who has been in recovery from alcohol addiction for ten years, have histories of substance abuse themselves. Adam feels that his personal experiences help him meet patients where they are.
“I’m just able to have open, honest conversations at a pure level,” Adam said. “Being super active in recovery means that I know a lot of tools and techniques.”
New treatment options for meth use disorder are coming to Oakland
In the past, addiction was seen as a personal moral failing, causing the medical system to treat people in ways that were punitive, often shunting patients into the criminal legal system. Today, health care workers increasingly understand that addiction is a chronic disease that requires treatment.
“Now, we just have a completely different narrative,” Herring said.
For stimulant use disorder, one of the most effective treatments is contingency management, an evidence-based behavioral therapy that helps reduce methamphetamine use by providing patients with highly-regulated positive incentives, including gift certificates and cash, as goals are met. Doctors are encouraged by outcomes that clearly show contingency management helps people to use less frequently, reducing their risk of overdose, and improving their overall health and quality of life.
In the coming months, several clinics in Oakland will begin to pilot Medi-Cal covered contingency management treatment programs for patients with stimulant use disorder through a state-wide initiative to improve care for lower-income Californians.
Dr. Clyde Lewis, Director of Substance Use for Alameda County Behavioral Health, the agency that will be overseeing the program, said the state first approached him and behavioral health leaders in other counties just under a year ago, inviting them to operate pilot programs through existing clinics and providers. In Alameda County, this will include Horizon Services’ Project Eden, which is based in Hayward and provides outpatient substance use disorder treatment for youth and their families.
Through the 24-week program, beneficiaries, who must be eligible for Medi-Cal, will receive a $25 gift card weekly for successfully meeting their contingency management goals, for a total possible incentive of $600.
“I want to make it clear that we are not rewarding people for not doing drugs,” said Lewis, emphasizing the treatment’s scientific basis and proven efficacy. “That’s a narrative that needs to be quelled.”
According to the California Health Care Foundation, contingency management is proven to achieve desired health outcomes (in this case, reduced stimulant use), and has been used in the past to treat various substance use disorders, as well as to encourage the public to act in ways that benefit public health. In 2020, for instance, people were offered vouchers in exchange for receiving the COVID-19 vaccine.
Contingency management as a treatment for stimulant use disorder has a history going back decades. “It’s not a new therapy. It’s been around for a long time,” said Catherine Hayes, a nurse practitioner, and president and co-founder of Cardea Health, a local nonprofit that connects marginalized populations to health care and other services. According to Hayes, contingency management was initially developed for cocaine abuse in the 1980s and it has been used in the VA health system for some time.
Yet, due to historical biases against substance use disorder, and because contingency management is not a medication and may not look like other forms of behavioral therapy, health care systems as well as the general public have been slow to accept it as a treatment.
“Much of the substance use disorder treatment field…has been challenged by stigma and biases against people who use drugs,” said Catherine Teare, the associate director of people-centered care at the California Health Care Foundation.
For Dr. Aislinn Bird, a psychologist with Alameda County Health Care for the Homeless, past resistance to offering contingency management as a public health benefit has been more than frustrating–it has prevented lives from being saved.
“I mean, literally, people are dying, and we couldn’t implement [contingency management] because you couldn’t use federal funds for the incentives, which was just maddening,” she said. Until last spring, it was suggested that contingency management might violate federal anti-kickback laws.
At present, California is the first and only state in the country that allows state funds to be used for contingency management incentives, and Alameda County is one of just seventeen counties in the state rolling out such a program.
“My hope is that people will see the great work that we’re doing here, and then it will be implemented across the state and across the country,” said Bird.
“I’m really excited for people to have the ability to receive an evidence-based treatment for stimulant use disorder,” said Teare, who praised California’s move towards a comprehensive, “soup to nuts” approach to mental health and substance use disorder treatment, which she said represents a departure from the patchwork systems of the past.
Separate from the Alameda County Behavior Health pilot program, Bird and Hayes joined forces to launch a grant-funded program, which will include contingency management in its list of services offered at Oakland’s Henry Robinson Center, a long-standing shelter on E. 16th Street.
“We really wanted to focus on folks living in emergency shelters or transitional or interim housing who are struggling with substance use,” said Hayes. While substance use affects Oaklanders of all income brackets, people who have lower incomes or are unhoused face additional and compounding barriers to care and recovery.
Because contingency management is a relatively straightforward treatment, requiring neither medication nor fancy equipment, it can be offered to patients in their own spaces, including shelters and encampments.
“Contingency management can happen anywhere,” said Bird. “There are teams that are doing this on the street. It doesn’t have to be in a clinic or an office.”
Contingency management can also be paired with other behavioral and medication-assisted therapies, including buprenorphine, making it especially effective for people who are poly-substance users.
“One of the great things about contingency management is it also opens up the door to talk about other harm reduction practices,” said Bird, such as carrying Naloxone, an easy to administer medication that can reverse an overdose, using clean needles, and accessing other forms of care.
Bird and Hayes say they have received positive responses to the prospect of the program, which is set to commence in June, from residents of the Henry Robinson Center.
Contingency management isn’t the only new initiative on the horizon for treating meth use disorder. The Alameda Health System’s Highland Hospital has also been slated for a clinical trial funded by the National Institute of Health that will study medication-assisted treatment for stimulant addiction.
Called MURB for short, it is one of several trials through the NIH’s NIDA Clinical Trial Network studying stimulant use disorder. Oakland’s Highland Hospital is one of just five sites across the country at which the MURB trial will take place.
The methamphetamine treatment trial’s results are far from guaranteed. “It is a phase two trial, which is like a science experiment,” said Anderson. “We don’t know if this is going to work.”
During the trial, which doctors hope will begin this spring, one group of participants will receive a placebo, while a second group will get a month-long injection of buprenorphine, which is known to block opioid receptors, but has also shown some evidence of reducing stimulant cravings. All participants must suffer from moderate to severe meth use disorder and have had some exposure to opioids over the previous month. They will also take part in twice-weekly sessions of cognitive behavioral therapy.
“It’s highly controlled,” said Anderson.
Addiction professionals think that Oakland is the right place for this work to be done
While the folks at the Highland Bridge Clinic are thrilled by the prospect of the trial, they also say it’s important to understand that safety-net hospitals like Highland often get overlooked for these sorts of high-profile studies. That oversight is a problem that, like many elements of addiction medicine’s history, is rooted in stigma and bias.
“Traditionally, research has just not supported places like Highland to do this work, because our entire population is stigmatized,” said Herring, adding that “Highland is a real center for people suffering from substance use.”
That reality is connected to racial inequities in health care. After the latest wave of the opioid crisis, which is noted for having affected wealthier white communities, researchers and funding agencies are seeing addiction as a “universal humanitarian crisis,” said Herring. As a result, federal agencies with significant resources like the National Institutes of Health are looking to communities that have histories of addiction with renewed interest and respect.
“Now, people see Highland as a place to learn, from which they can apply findings to the rest of the state and country. With that realization, we’ve been able to develop successful proposals and make relationships with successful and interesting researchers,” said Herring.
Addiction professionals hope that making contingency management and other treatments accessible for Oaklanders with meth use disorder will open the door to reducing stigma and increasing the number of people who seek treatment.
“By creating this aura around the benefits of entering into recovery, it will have a resounding effect throughout the community and positively impact all the people that we support and hope to support,” said Alameda County Behavioral Health’s Lewis.
For Bird, piloting meth treatment programs in Oakland is a way to act on the local community’s commitment to racial equity. In Alameda County, more white people than Black people use meth, but people of color are more likely to die from overdoses.
“Implementing one of the only evidence-based treatments that we have for meth use disorder really shows that we are providing the best care and addressing the race equity challenges that are literally killing our patients,” said Bird.
Faced with the prospect of two important clinical trials taking place at Highland, Anderson reflected on the significance of the research that is about to be done in Oakland. “All this stuff happens in San Francisco and at UCLA,” he said. “I think that there is some recognition on the part of the [National Institutes of Health] that they need to recruit more diverse patient populations in different care settings.”
“It’s exciting to do this work in Oakland,” he said.
To Herring, the greater harm-reduction community in the East Bay means that Highland has the support it needs from the people working on the frontlines of addiction care. “We’re really lucky that the harm reduction community in the East Bay is one of the oldest, most effective, and well-established in the country,” he said. “They’re there for the long haul.”
As he looks back at how far the Highland Bridge Clinic—and addiction care in Oakland—has come over the past six years, Herring said it’s clear that the local community is what empowers its success.
“Highland’s got a lot of challenges,” he said. “But it’s a really incredible place that has a long informal and formal history of creating trust and partnerships with the people of Alameda County.”