Editor's note: This story was produced by The Granite State News Collaborative as part of its Granite Solutions reporting project.
Advocates Say Medication Assisted Treatment for Substance Abuse is Saving Lives
Those suffering from asthma, diabetes and heart disease can pick up medications to treat their chronic conditions at any number of pharmacies — without stigma. Yet, those with substance use disorder, another chronic condition, are treated differently even in accessing their medications.
“To have to go to an identified location every day to get medication for your chronic illness is just discriminatory on its face,” says Kevin Irwin, director of operations for the Seacoast-area Integrated Delivery Network, speaking specifically of methadone clinics that dispense a synthetic opioid as part of medication assisted treatment (MAT) for those addicted to opioids.
“Lots of people receive medications for chronic illnesses, whether it's for a month or it's for a lifetime or any time in between,” Irwin continues, “and we would never make people do that for their depression medication, for their diabetes medication, for their tobacco patch. Right? We would never make people do that.”
Irwin leads one of several regional networks, or IDNs, which aim to improve care transitions between providers, promote integrated physical and behavioral health as well as build mental health and substance use disorder treatment capacity. His work has led him to advocate for easier access to MAT services.
“It's fundamentally discriminatory and in as much as it is discriminatory, it has a lot of built-in limitations,” he says. “A lot of people can't, or don't want to, or aren't able to do that. Who the hell would want to?”
Methadone is not the only medication assisted treatment available in NH. In fact, methadone clinics are relatively rare in NH—there are only about a dozen throughout the state — because of the high regulatory hurdles that need to be cleared to start and maintain one.
Providers who have been authorized by the federal government, such as doctors, nurse practitioners and physician assistants, can also prescribe buprenorphine and naltrexone. The process for getting this medication requires weekly check-ins at first to refill the prescription. These visits are reduced as the patient stabilizes and ideally continues with treatment. But access to this therapy, and specifically to providers offering it, isn’t always easy to come by.
And access is critical to the $45 million hub and spoke opioid treatment model rolled out by the state earlier this year — the success of similar models historically relies heavily on MAT and easy access to it
Vermont’s Medication Assisted Treatment Model
The hub and spoke model originated in Vermont. One of the primary goals of the system was to improve access to MAT.
To do this, Vermont health officials immediately made a push to get as many doctors, nurse practitioners and physician assistants as possible trained and authorized to prescribe MAT.
Buprenorphine is an opioid, but it is also a partial opioid agonist, which means it can block so-called pure opioids, such as heroin, while mitigating withdrawal symptoms. Buprenorphine is often combined with naloxone (better recognized as the overdose drug Narcan) to create a product called Suboxone.
Under federal law, physicians need to complete an eight-hour training and nurse practitioners and physicians’ assistants a 24-hour training, to get a waiver that allows them to prescribe MAT medications.
Between 2012 and 2016, the number of waivered physicians in Vermont increased from 173 to 283, reflecting a 64 percent increase. Density of buprenorphine patients per provider also improved, with a 50 percent increase in those prescribing for more than 10 patients.
By September 2015, 23 percent of spoke providers had more than 30 patients and 10 percent had more than 50. From January 2014 to December 2015, 225 “stable” patients had transferred from hubs to spokes.
Additionally, the 2017 Vermont Blueprint annual report says that “60 new nurse practitioner and physician-assistant prescribers have obtained their waivers and are now prescribing medication for Vermonters with opioid-use disorder.”
According to a 2017 report published in the Journal of Addiction Medicine, Vermont at the time had 6,604 patients, out of the state’s total population of 625,000 who were receiving what’s called Opioid Agonist Treatment — treatment using either Methadone or Suboxone.
That represented 1.05 percent of all Vermonters or 10.56 people treated per 1,000 people. Five years earlier, only 3.76 people per 1,000 were getting this sort of treatment, according to the 2017 report.
Further, Vermont now has the highest capacity for treating opioid use disorder in the United States, with 13.8 patients potentially treated per 1,000 people.
According to the 2017 report, “If current physicians prescribed to the limit of their [medication assisted treatment] waivers, the state would have close to 150 [percent capacity in its spoke system.”
Medicated assisted treatment by the numbers
Providers and advocates say the evidence is clear that MAT gets more people into treatment, helps with treatment retention, saves money and, most importantly, saves lives.
“When we look at the overdose crisis — largely around fentanyl and other opioids —
the best tool we have right now is opioid agonist therapy, you know, buprenorphine and methadone” says Ryan Fowler, a recovery specialist at Granite Pathways in Manchester.
“When you look at communities who are hit with an overdose crisis and then you introduce low-barrier access to buprenorphine, you actually cut the overdose rate in half. And that's research domestically and internationally —you basically see this tool that when implemented in a low barrier model, you can cut overdoses in half.”
Two systematic reviews of MAT studies worldwide showed that MAT decreased overall opioid use, criminal activity and infectious disease transmission. It also reduced opioid-related deaths. A 2013 study published in the American Journal of Public Health found a 37 percent decrease in opioid-related deaths in Baltimore between 1995 and 2009 due to the introduction of low-barrier MAT.
The systematic studies also showed that MAT increases social functioning and retention in treatment, and that patients treated with medication were more likely to remain in therapy compared to patients receiving treatment that did not include medication.
Even though buprenorphine and methadone are opioids themselves, they have a beneficial chemical purpose in the user’s brain, according to the studies
“When someone is treated for an opioid addiction, the dosage of medication used does not get them high — it helps reduce opioid cravings and withdrawal,” according to the National Institute on Drug Abuse. “These medications restore balance to the brain circuits affected by addiction, allowing the patient’s brain to heal while working toward recovery.”
Studies conducted in Vermont in recent years showed similar results. For example, 100 patients were evaluated — 60 in hub-and-spoke MAT treatment and 20 not in treatment were evaluated for a 2016 study conducted by Richard Rawson, research professor with The Vermont Center on Behavior and Health at the University of Vermont.
Of those patients in treatment, there was a 96 percent drop in the number of days of opioid use after treatment. In other words, while patients used opioids for 85 of the 90 days leading up to treatment, they used opioids less than five days over a three-month treatment period with MAT.
This same study also showed an 89 percent drop in emergency room visits, a 90 percent drop in police stops and arrests, a 90 percent drop in illegal activity and a 100 percent drop in overdoses. While 25 percent of participants reported overdosing in the 90 days leading up to treatment, no participants overdosed in the 90 days after MAT treatment, according to Rawson’s report.
Finally, Rawson also found that there was a significant uptick in school and training attendance among the treated patients, although no significant change in the number of people going to work.
This study also showed that health care expenditures per capita were less for MAT-treated patients. In 2016, the average cost of health care treatment was $12,532 per capita. With MAT, it was $7,938 per capita.
Dr. John Brooklyn, credited with developing hub and spoke in Vermont, says their MAT system is now self-sustaining because of the way the state funded it initially. He explained that when Vermont health officials first rolled out the program, because the state had labeled opioid use disorder a chronic disease, officials were able to apply for an amendment to the ACA that allowed MAT and related services to be paid for with federal dollars over eight quarters.
After that period, health officials were able to show that offering these services actually ended up saving money overall. It saved so much money, that Vermont officials realized their health department could pay for these services themselves and built the cost into the budget.
Granite State News Collaborative reached out to DHHS spokesman Jake Leon and with Katja Fox, director of the DHHS Division for Behavioral Health, to ask whether NH officials were looking into funding MAT through the ACA. Neither responded.
When asked, Tom Sherman, D-Rye, who sits on the Senate Health and Human Services Committee, says he was unaware of this amendment in the ACA and would talk to both Vermont and NH health officials about it.
Sen. Cindy Rosenwald, D-Nashua, currently sponsoring a Medicaid reform bill at the state level, says she didn’t know much about that program, but that she was skeptical of a program that only offered funding for eight quarters and then went away.
It is also unclear at this point exactly what NH’s plan is when it comes to increasing the number of provider waivers and offering MAT.
Back in February, Fox says some grant money would go toward training providers in medication-assisted treatment and a tracking system to see how many of those providers are actually offering the treatment to patients. Neither she nor DHHS spokesmen Jake Leon had any further details. They also did not have the number of providers currently able to provide MAT in the state.
SAMHSA tracks the number of practitioners newly certified per year by state who are
eligible to provide buprenorphine treatment for opioid dependency. According to that database, the number of providers seeking a waiver to prescribe to 30 patients jumped from about a steady dozen or 14 per year in 2015 to 64 in 2016. Since then, an additional 345 providers have been certified to prescribe to a maximum of 30 patients and another 60 have been certified to provide buprenorphine to up to 100 patients.
But just because a provider has a waiver, doesn’t mean they are using it, confirms Shanna Large, Director of Substance Use Disorders at Riverbend Community Mental Health Centers – Choices program in Concord.
According to a SAMHSA provider locator database for NH, there are only 173 providers across the state that can prescribe to between 30 and 100 patients each. The bulk of those providers are concentrated in urban enclaves of Hillsborough, Rockingham and Merrimack counties. For example, Hillsborough County has 50 providers listed that can prescribe buprenorphine, while Coos County has four listed providers.
What’s the rub?
Large says some of the feedback from providers who get waivers is that they want to help but they still have reservations.
“They're scared of getting the patient stabilized and what that looks like,” she says I don't want to call a doctor scared — so, maybe they're unsure. Maybe that's a better word of the practice there.
“Addiction seems really scary to individuals.”
Sometimes, the aversion to getting or putting the waiver to use comes down to a negative view of people with substance abuse disorders and addiction, Large added.
“There is definite old-school thinking in the state and the nation, you know, it's not always seen as a disease,” she says. “They think it's a choice. … So, I feel like we're going through that trend of changing people's minds.”
Which is why Large, along with others in the treatment communities and members of the Integrated Delivery Networks, are doing what they can to offer support, clear up misinformation about MAT and addiction, and encourage providers to get their waivers and prescribe the medication to their patients.
“Our goal is really to get as many people as we can, as many [primary care physicians] as many [advanced practice nurse practitioners] that want to, to do this,” Large says. “Because what these PCPs don't realize is these people are already in their practices and it will help them make more educated decisions when prescribing.
“And we are here to help support you while they're learning as well. I mean, we have providers who offer mentoring and support.”
That creates a support network for physicians, Large says.
“So, if you have a hard case who's in your office and you have questions, you have someone to call—we're not asking you to do this by yourself. But the more people who know about the addiction that can treat the addiction, the more resources we have out in the community,” Large says.
That information is desperately needed, says Fowler, who points to a statistic that says 1 in 12 people in NH have a substance use disorder.
Additionally, offering MAT through a physician’s office could reduce the stigma to the treatment which ultimately removes one more barrier to recovery. It’s impossible to overestimate the detrimental effects that negative attitudes and prejudicial behavior have on treatment access and success, Irwin says.
Fowler agrees and wants to elevate MAT success stories.
“I would say the stories you hear are the negative ones are,” he says. “It's not gonna work for everybody.
“The stories you don't hear about are the guy who's managing your bank who's been on Methadone for 10 years or, you know, the guy who's working on your car and has been on Suboxone for five years. And that causes a lot of stigma, even within the recovery community.”
And, Fowler is one of those success stories. At the height of his active heroin addiction, a nurse practitioner suggested buprenorphine to him.
“It really did change my life dramatically,” he says. “I went from working 15 or 20 hours a week in a kitchen to working 40 hours a week and taking on more responsibility.
“My life really evolved in a short period of time. And I was able to grow as an individual.
Large says one of the best things about the new hub and spoke system in NH is that it has forced everyone — treatment providers and primary care doctors — to at least start talking to each other and working together on a regular basis.
She also says the inclusion of peer recovery specialists in emergency rooms and clinics around the state is helping to educate the medical community and the public about addiction and available treatment options.
Further, hospitals and associations are actively holding and advertising free waiver trainings, such as those offered the NH Medical Society, NH Bureau of Drug and Alcohol Services, and Anthem Blue Cross Blue Shield; Dartmouth-Hitchcock Medical Center; Catholic Medical Center; Frisbie Memorial; and online options through the American Society of Addiction Medicine, among others.
Large, who moved from Massachusetts to take the job at Riverbend, says she is optimistic about the overall trajectory of the medical and treatment communities on treatment for substance misuse disorder.
“I feel like I've really come to stay at the right time,” she says. “I always say I can either be depressed that I'm behind the eight ball and we’re like 40 years behind as a state, or I can be excited that we're on the cutting edge and we get to develop what's out there.
“And that's where I live—in that excitement on the cutting edge and being receptive to what else we can do to help this population that I'm so passionate about. You know, they are really, really great individuals.”
We want to hear your MAT success stories. Please share in the comments or contact us through www.collaborativenh.org.