As a medical student in the Bronx, Michael Fingerhood often witnessed patients who happened to be heroin users. “They’d be admitted for fevers or for local infections at their injection sites, and once that problem was solved, we’d discharge them and say, ‘See you later,’” he recalls. “We didn’t seem to address why they were injecting drugs. I thought: Why can’t we do something about this?” 

So he did. In 1993, just a few years out of residency (1986-89), Fingerhood persuaded trustees at Johns Hopkins Bayview Medical Center to invest in a small outpatient clinic dedicated to providing primary care to patients with addiction. In the years since then, he has built one of the country’s most respected chemical dependence clinics. One of the clinic’s central tools is buprenorphine, an under-the-tongue medication that blocks cravings for opioids. Buprenorphine was synthesized more than 40 years ago, but until recently, federal regulations made it difficult for outpatient practices to treat more than a handful of patients at a time. 

Now Fingerhood and his colleagues are demonstrating that it can be done at scale: As of October 2017, they have more than 600 patients being treated for opioid use disorder with buprenorphine. 

And their work goes beyond buprenorphine alone: They’ve redesigned opioid-related care delivery from top to bottom, tightening protocols to help keep patients from getting lost after they’re discharged from Johns Hopkins Bayview’s inpatient chemical dependence unit and deploying community health workers to stay in contact with patients in their homes. They’ve also developed interventions for those who were formerly opioid dependent who’ve just been released from jail—a point when the risk of overdose is high. Most ambitiously, they’ve built new systems for screening all patients in Johns Hopkins Bayview’s Emergency Department for opioid use disorders. 

“We put the new screening protocol into place at the end of June,” says Carol Sylvester, vice president for care management services at Johns Hopkins Bayview. “When patients are identified as opioid-dependent, they’re referred to Dr. Fingerhood’s clinic and
others in Baltimore City for follow-up. [Last] August, 43 percent of patients who received referrals for treatment showed up for the follow-up visit with treatment programs.” 

Fingerhood would like to train emergency department doctors not only to refer but to initiate treatment on the spot. “When you refer someone out, you’ve often lost them,” he says. “When you screen someone and find that they’re using opioids, there’s usually a lot of emotion in that conversation. You can tell someone, ‘I can help your tomorrow be better than today, if you’d like to try.’” Giving an initial dose of buprenorphine during that very first encounter, Fingerhood says, can be a powerful tool. When a patient experiences a day without cravings, the idea of recovery suddenly seems more tangible. 

The care delivery integration in Fingerhood’s clinic works in both directions. “The fact that we’re seeing our patients so frequently for their buprenorphine treatment means that we’re also keeping an eye on everything else,” he says. “If they have hypertension, we’re looking at that. If they have diabetes, I say, ‘Bring in your meter and we’ll look at your numbers.’ If they have HIV, we can check on their medication adherence.” 

Fingerhood would like to see primary care doctors across the country embrace the practice of prescribing buprenorphine for those with opioid addictions. Lack of time—to take on new patients and provide the necessary counseling during follow-up—is a key reason cited by doctors who decline to do it. 

While acknowledging that structural barriers are real, Fingerhood also believes some avoid prescribing buprenorphine because of ignorance and stigma. “Some doctors think, ‘I don’t want to have that kind of person in my waiting room,’” he says. “But those patients are already in your waiting room, and you’re not treating them.”