Heidi Waite, 37, is a patient of Greater Portland Health who is going through the medication-assisted treatment program for her opioid use disorder. Derek Davis/Staff Photographer
Heidi Waite shuffles slowly through the halls of the clinic attached to Portland’s homeless shelter. The walls are sparsely decorated, save for a few bright abstract paintings on canvas.
“I don’t really do art,” she says. “But I love watching people do it. It’s amazing.”
Waite, 37, knows these halls well. She’s been coming to this clinic run by Greater Portland Health for a monthly shot of Sublocade, a drug used to treat addiction, since she moved into the city shelter in January.
The shot helps reduce her cravings for opioids and lowers her risk for overdose if she does relapse. She is one of about 20 people staying at the shelter who receive medication-assisted treatment for opioid use disorder – a disease that plagues many homeless people. The program, run by Greater Portland Health, operates on federal funds.
Greater Portland Health and city leaders say having this treatment available inside the shelter since it opened last March has saved lives, as has a recent increase in the use of naloxone, the drug that reverses an opioid overdose.
Naloxone has been administered more than 100 times at the shelter so far this year, according to the city, up from 30 times in all of 2023. Citywide, there have been just three overdose deaths this year and in January, Portland recorded its first month with no overdose deaths in over two years.
Shaza Stevenson, the city’s interim director of health and human services, says that’s because more people have moved out of homeless encampments and into the shelter.
“This shows that having everyone in one place made it possible for us to help,” Stevenson said. “Because if you’re out in the encampments, nobody sees these overdoses happening.”
Dr. Kevin Sullivan, the medical director of Greater Portland Health’s health care for the homeless program, said that one of the most challenging things about opioid use disorder is the near-constant need to use because the effects of street drugs last for such a short time. Most people with opioid use disorder will feel sick every few hours, he said.
“It makes it hard for some people to stay in the shelter, because even if you use right before you come in, you’re feeling terrible a few hours into the night, and you have no way to not feel terrible,” Sullivan said. “It’s impossible to get your life back on track if you’re just trying to find drugs all day so you don’t feel sick.”
Dr. Kevin Sullivan, a medical director for Greater Portland Health’s homeless health care program, at the organization’s clinic inside the city’s homeless shelter. Sullivan said having medication-assisted treatment available on-site helps keep people at the shelter. Derek Davis/Staff Photographer
‘I FEEL NORMAL’
Waite has struggled with addiction for most of her adult life. In her early 20s, a doctor prescribed her pain medications, and she got hooked.
She started using heroin and, later, stimulants like methamphetamines. She said she was first introduced to Suboxone after buying it on the street. She tried methadone to treat her addiction, too, but said it felt too similar to being high.
Waite lost her home in 2020 when her fiancé died. In the intervening years, she relapsed a few times, but she’s stayed on Suboxone through the ups and downs.
“I relapsed right after my mom died last year after I promised her I wouldn’t use anymore. I showed up here a mess after getting high. They were doing everything they could to help calm me down,” Waite said.
She said the Suboxone has made it easier for her to bounce back after relapses and get clean again. Her only complaint is the taste: “like a big dark orange in your mouth,” she said.
Waite says she likes being sober, and it’s allowed her to rekindle relationships with her family. Being in the shelter is hard, though, and spending time around people who still use makes her want to use more. But she said the proximity of the clinic makes her addiction feel more manageable.
“On heroin, all you do is sleep and make funny noises and do the dope dance.” She stands up to demonstrate, flapping her hands around her face, hitting her cheeks. She says she doesn’t want to feel that way again.
“I just feel normal now,” Waite said. “And I actually like it better that the clinic is here, that way I don’t have to go all the way to town to feel this way.”
INVALUABLE ACCESS
Courtney Sage, who manages the substance use disorder program at the clinic, said having close access to patients by being at the shelter has been invaluable.
“A lot of times, if we’re concerned about somebody, I can walk out into the shelter and find them. It helps us locate and check on our patients more regularly,” Sage said.
Courtney Sage, a substance use disorder program manager, talks about the medication-assisted treatment program at Portland’s Homeless Services Center. Derek Davis/Staff Photographer
That’s more difficult to do at their Bayside clinic, where the patients often live outdoors or are jumping around between temporary housing, she said.
Sage says the No. 1 indicator of success for medication-assisted treatment is clients returning again and again because it often means they are not using drugs. Or if they are, it will be easier for them to return to sobriety and avoid overdoses.
Currently, there are 20 people from the shelter enrolled in the program, and the clinic averages about one or two new clients a month. She said she has lost touch with only one.
“That’s incredible and very unusual,” Sage said.
“People who have never made it into our other clinics have made it in here,” said Sullivan, the medical director.
He said the goal of the program differs depending on the patient. Some people come in and are just looking for a way out of the constant loop of drug use: getting high, the drugs wearing off, the search for more drugs.
Even a temporary respite can allow patients to address other health issues, search for housing or begin to repair relationships. Other patients go into the program knowing they may be on Suboxone for years. Sullivan said some people stay on the drug for life.
“There are some patients we can slowly wean off, but others will always have that craving for opioids,” he said.
To be eligible for treatment, patients must be diagnosed with substance use disorder, a service they can receive at the shelter’s clinic. Patients receiving this kind of treatment have more success if they regularly come in for their medication, but even if someone relapses or uses drugs alongside their Suboxone, they are still allowed to continue with treatment.
“Even if someone is using and taking Suboxone, it’s safer than using without the Suboxone,” said Sullivan, because the drug decreases the chance of overdose.
The clinic keeps a few walk-in slots open a day, so if a shelter guest is interested in the program, they can usually be diagnosed and receive prescription that same day.
“Knowing that window of opportunity can be so small, if somebody is ready, we want to be able to make that happen right away,” Sullivan said.
HOW IT WORKS
Sullivan and Sage say medication-assisted treatment can save lives, but there is sometimes a public perception that using drugs like Suboxone means someone isn’t truly sober.
The drug stimulates dopamine receptors in a similar way that opioids do, so if someone who had never used opioids were to take Suboxone, they would feel high. But for opioid users whose brains can no longer adequately stimulate their dopamine receptors on their own, Suboxone simply allows them to feel functional.
“It’s like you’re driving your car and your foot’s to the metal and you’re going 100 miles an hour, those receptors are going off,” said Sullivan about opioid use. “What Suboxone does is make it impossible for the car to go above 50. It attaches really tightly to opioid receptors, so you’re still feeling relief, but it doesn’t turn them on all the way.”
“People who have been using for a while aren’t using to get high, they’re just using not to feel sick,” he said.
But even when patients do try Suboxone, challenges remain.
Sullivan had patients just a few years ago who weren’t considered sober by their bosses or probation officers. Things have changed since then, and law enforcement has caught up, he says. But the attitude remains.
“One of the big problems is the stigma. For years, a lot of recovery efforts didn’t accept MAT as sobriety and that scared a lot of people off. But with fentanyl on the scene it’s really a necessity,” Sage said.
Fentanyl is a highly potent synthetic opioid that is often mixed with drugs like heroin and cocaine. Experts say it has led to a spike in overdoses because drug users don’t always know what they’re taking.
Overdoses used to be more predictable, Sullivan said. A drug user would fall deeper into their disease, using more frequently in higher doses until they overdosed from taking an exceptionally large dose of drugs.
Now, he said the people most at risk for overdose – or “poisoning,” as he refers to it – are actually intermittent users. That’s because they haven’t built up the same immunity to opioids, so if they do encounter fentanyl, they have little defense.
“I say a poisoning because it really is unintentional – people do not know what’s in the drugs they’re taking,” he said.
Because of the unpredictability of the drug supply, Sullivan says every time someone uses drugs on the street they’re at risk for overdose.
“And that’s where MAT is crucial,” he said.
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