The San Francisco Department of Public Health (SFDPH) serves the people of the City & County of San Francisco. The 2018 population is 885,000, which represents residential population, and does not fully encompass San Francisco's daytime community. Emergency planning is based upon a figure closer to a population of 1.2 million, accounting for those commuting in as well as daily tourists.
Located in the Northern California, the City & County of San Francisco is approximately 47 square miles, representing a dense, highly-populated area.
The San Francisco Health Network is housed under SFDPH, representing the network of clinical services available to the community. This includes two hospitals, behavioral health, a system of primary care clinics, many of which provide care to underserved members of the community, such as low-income and homeless individuals. A critical population considered in emergency planning, the number of homeless individuals in San Francisco totals 7,499 (January 2017).
San Francisco previously had no plan in place to manage the needs of those requiring methadone in an emergency. The provision of methadone has been deemed an essential service that must continue in the face of disaster. Because of its addictive nature, methadone dosing and distribution is highly regulated. This presents a challenge, particularly to patients who dose on-site daily, if their clinic becomes non-operational following a disaster. The public health issue: how can this essential service be maintained? How can plans be centered upon a resource so highly regulated and secure?
Persons on a steady dose of methadone may be able to manage 1-2 days of no dosing without experiencing intense withdrawal. Severe and relentless, withdrawal symptoms include diarrhea and stomach cramps, nausea and vomiting, muscle and joint achiness. In addition to the discomfort and pain one experiences, a lapse in methadone dosing can increase the likelihood that a patient will seek illicit drugs. This in turn, increases the risk of overdose due to reintroduction of the illicit drug, paralleled with an increased risk of disease transmission. Missed doses of methadone for 3 days or more may result in reduced opioid tolerance. Consequently, this may increase a patient's risk of overdose once methadone is reintroduced into their system.
In 2017, the Methadone Emergency Preparedness Workgroup” was established to initiate planning efforts focused on a population that has previously been largely overlooked in emergency planning. The overarching goal: outline strategies to continue methadone dispensing operations during an emergency. The intended outcome is twofold: provide continuity of care resulting in improved patient outcomes, as well as reduction of unnecessary emergency room hospital surge. If patients know where to go to receive treatment, this may preclude them from presenting to (an already overwhelmed) hospital during a disaster.
The core workgroup represents opioid treatment providers, however additional partners play crucial roles, including Substance Abuse Services, SFDPH Pharmacy, EMS, Human Services Agency. Partners that are consulted with include: DEA, Methasoft, CA Department of Healthcare Services. Activities are implemented through monthly meetings to facilitate decision-making and to seek solutions.
Intended outcomes to support disaster planning/response for patients on opioid treatment:
- SFDPH Methadone Planning Operational Guide
- Clinic Emergency Response & COOP Plans
- Memorandum of Agreement, to include process standardization grid
- Emergency Communications Spreadsheet
- Patient Disaster Preparedness Brochure
- San Francisco Map of Methadone Clinics
- Reference documents incorporating this into SFDPH's Emergency Operations Plan
The objectives are in progress, with pivotal decision points and useful lessons learned already. Preliminary activities are taking place to ensure the successful development of these tools.
Targeted outreach has contributed to an engaged and active workgroup. When participation was low, direct phone calls were made to clinics, conveying an important message, demonstrating that their expertise is not only valued, but crucial to the success of the workgroup. As key stakeholders, they understand that their concerns are listened to, their voices heard.
The public health impact focuses on building a culture of preparedness. Process steps, identified barriers, and draft tools may be utilized and adopted by other jurisdictions. Opioid treatment patients will receive educational brochures outlining personal preparedness and recommended actions following a disaster. Counselors will initiate discussions with patients, providing education and triggering conversation previously not included during counseling sessions. The intent: pre-disaster awareness will reduce patient anxiety surrounding uncertainty of obtaining one's next methadone dose. This is coupled with the goal of prevention of patient suffering due to lapse in treatment.
SFDPH also aims to build a culture of preparedness among clinic staff, as demonstrated by the provision of COOP training, encouragement of staff call-down drills and recommendations to update plans.