There's a small line forming outside a plain white box truck in Seattle's Belltown neighborhood. A half-dozen folks are waiting on a gusty October morning for their turn to go inside and receive red liquid in a cup, medication that will help them get through the next 24 hours without opioids.

Or if they do use, to keep them alive.

It's life-changing for some, this treatment program on wheels, and it has faced obstacles in the past, but fentanyl's grip on Washington has given methadone distribution more urgency.

Taking the drug regularly is one of the most effective ways to satisfy someone's craving for opioids without the high, and it has decades of research to show it can help people stay alive and clean. But federal regulations have largely required someone to travel to a building every day — an obstacle for people without access to reliable transportation or who struggle to stay organized.

This truck in Belltown reaches that population — mostly people who are homeless or low-income. They are also some of the most disproportionately affected by fentanyl — people experiencing homelessness made up more than 23% of King County's total fatal overdoses last year despite making up less than 1% of the total population, according to this year's Point-In-Time Count. The vast majority of those were related to fentanyl, according to King County Medical Examiner data.

To bring methadone to this population, the federal government needed to lower barriers for treatment providers, and local investments helped put more trucks on the street. Washington now has 11 units that are either deployed or in the process of being certified.

They are in demand. The Belltown truck, one of three operated by Evergreen Treatment Services, serves 172 patients and, since August, has served 48 patients in Pioneer Square. Evergreen is currently working to launch a fourth.

"We're trying to be equivalent to a neighborhood pharmacy," said Sean Soth, director of health integration and innovation for Evergreen.

We Care Daily Clinics' three mobile units have seen similar, fast growth.

Dr. Tom Hutch, medical director of We Care Daily, said the majority of its mobile unit patients, who are primarily using methadone, come to them after other opioid treatment drugs didn't work for them.

"A lot of the patients that we're seeing have the most severe" opioid use disorder, Hutch said.

For Christina Bynum, 54, the Belltown mobile clinic is the difference between getting out of her apartment in the morning or letting her depression win.

After receiving her dose Monday morning, she was headed to a doctor's appointment, something she would have never kept in the past, she said.

"It gets me out of my house to be here," she said. "And it keeps me off of drugs."

A strict past

Methadone has been around for more than 50 years, and federal research shows it reduces fatal overdoses by up to 60%, as well as reducing use of illegal opioids and positively affecting crime stats.

Methadone is a full opioid, which means it will satisfy someone's craving, but if administered at too high a dose, it could make some feel euphoric or cause someone to overdose, explained Dr. David Sapienza, who oversees Public Health — Seattle & King County's low-barrier buprenorphine clinic.

The possible dangers combined with "war on drugs"-era views on substance use disorder led to strict controls. So people had to report to brick-and-mortar locations every day to take their doses. Getting medication to take home was arduous.

When buprenorphine, which King County's mobile clinics also provide, came along, it became popular because a patient could take it at home.

A negative stigma formed around methadone. Even locally, when Erin Goodman started working at the Sodo Business Improvement Area 10 years ago, many people blamed neighborhood issues on Evergreen's methadone treatment facility there, she said.

"We worked really hard on education on what they do there and how it works," Goodman said. "They really work hard to be a positive member of the Sodo community."

But fentanyl has refocused attention on methadone. To get off the drug, buprenorphine can cause severe withdrawal symptoms before the person taking it feels OK again. For homeless people, those withdrawal symptoms — including severe nausea and diarrhea — are made even harder without a home or access to a restroom.

One of the problems with methadone is that daily trip to the clinic.

In 1999, Evergreen got its first mobile clinic approved — the first of its kind for the state of Washington and one of the first in the nation.

But that allowance didn't last. The U.S. Drug Enforcement Administration stopped approving mobile medication units in 2007 and didn't reauthorize the work until 2021.

"The pandemic forced the hand of a lot of regulators to understand that we had to do things different," said Soth at Evergreen.

At the beginning of the pandemic, Evergreen worried about patients getting infected with the coronavirus when they came to the indoor Sodo center for daily methadone doses. They operate one of the largest brick-and-mortar opioid treatment programs in King County and were serving about 1,200 there.

So they started sending patients home with more take-home doses, Soth said, after much negotiation with federal agencies.

Now, many of Evergreen's patients who visit its mobile unit — open six days a week — are being sent home with at least one take-home dose, allowing them to alternate visits every other day.

Kevin Kiso, 58, gets a take-home dose from the Belltown site on Mondays, one on Wednesdays and two on Fridays to get him through the weekend.

He has started and stopped methadone throughout his yearslong recovery journey, he said. He recently moved into permanent housing on Capitol Hill after living in the Salvation Army's large shelter in Sodo for two years.

The new model has given him so much of his time back, he said. He enjoys spending his days in one of Seattle's public libraries or watching documentaries.

"I write a lot at home. It's great," Kiso said. "Life's good now."

The need to grow

It took Evergreen more than a year to get its first unit redeployed to Belltown once federal regulations eased. But now it has momentum.

Evergreen launched a second unit from its clinic in Olympia at the end of 2023. It drives to Shelton, Mason County, every day to offer treatment services in a more rural location; such locations have historically lacked access to medication-assisted treatment and have high rates of overdose. After about a year in operation, it's nearing capacity, serving about 130 people there, according to Soth.

"It's proving to be very, very needed and very utilized," Evergreen CEO Steve Woolworth said.

The city of Seattle gave Evergreen $1 million in 2023 to help it buy two new units. One is operating outside Evergreen's Sodo building after it sustained water damage earlier this year. A fourth unit is being certified.

We Care Daily, based in Auburn, launched one unit in Seattle and one in Tacoma in 2022.

It recently added a third this summer in North Seattle along Aurora Avenue and 137th Street. The mobile clinic is a seven-minute drive from the closest opioid-treatment facility, medical director Hutch said, and still its patient count has grown to about 80 patients in a matter of months. This signals to him that some people might be more willing to engage in mobile care than a traditional setting.

"Lower-barrier care does not always mean just an additional geographical location to provide that care in. It's sometimes: How does the staff look when you approach them?" Hutch said.

Sam McGrath, a team lead on Evergreen's downtown mobile unit, stood outside the truck in October, greeting new arrivals. He isn't wearing a lab coat and doesn't look like security. He said he's hopeful that if people feel known, if they feel seen, they'll keep coming back.

Then he recognized a man walking up in a green coat, carrying a blue Walmart bag and walked over to meet him.

"Hey, man," McGrath said. "Tell me your patient number."

"It's good to see you again."

Still, only about 1 in 5 people with opioid-use disorder access medication treatment, according to Hutch.

And access is just the beginning of a path to recovery.

Evergreen has seen an increase in people using fentanyl who start treatment only to stop shortly after, Soth said.

Fentanyl is so potent — about 50 times more powerful than heroin — that it takes a while to bump patients up to an appropriate treatment dose. They struggle to resist using during that lag time.

Matt, 33, who asked to not use his name for fear of finding future work, said he has tried methadone treatment in the past but given up when he didn't feel like his dosage was high enough.

Now, he's slowly climbing again after recently moving off the streets and into housing after more than 13 years, and he's hopeful that Evergreen's unit in Belltown will get him to where he needs to be to start a new chapter.

"Your cravings to use and all that will go away, and that's when you know your dose is at the right level," he said.

For some of the patients lined up outside Evergreen's truck, starting on methadone helped them get enough order in their life to finally follow up with a case worker.

Bynum said it helped her have the discipline to move off the streets after nearly a decade.

"Treatment doesn't always mean that once you're done with treatment your basic needs are met," said Sapienza at Public Health. Out of Sapienza's 480 patients this year, 83% are considered homeless. "It's not that everyone goes into treatment and then comes out with housing."

But for some like Bynum, it might be the push they need to put one foot in front of the other and start their day.

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