Vermont charges ahead on opioid addiction battle

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Vermont's health care system isn't waiting for the implementation of a new federal law intended to expand access to opioid treatment and has instead taken steps on its own to make treatment more available.

While doctors and state officials say those steps are beginning to bear fruit, they acknowledge that with several hundred people across Vermont still languishing on waiting lists, more needs to be done.

In July, President Barack Obama signed S.524, the Recovery Enhancement for Addiction Treatment Act, commonly known as the TREAT Act. Its aim is to expand access to treatment nationwide for addiction to drugs such as heroin and prescription painkillers.

Obama expressed frustration with congressional Republicans blocking close to $1 billion that would support the rollout of initiatives in the new law, noting that 78 people in the U.S. die every day from opioid overdose.

In Vermont, the situation is similarly stark with 76 people dying from opioid overdose in 2015, according to Health Department figures, making it the most deadly year for overdose in recent history.

Treatment providers in Vermont expressed optimism that provisions in the new law would expand access to treatment in the state.

Some of those provisions have already taken effect, while others are still in the federal rulemaking process, but with more than 300 people on waiting lists for treatment statewide — and many more having given up on finding a treatment slot — the state and its health care system are taking steps on their own to make sure more people are getting help.

Under the new law, physicians can now apply for a waiver to prescribe opioid treatment drugs to up to 275 patients, an increase from the previous limit of 100. Anthony Folland, clinical services manager at the Health Department, said only two doctors in the state have applied.

That's because there are few clinics with the infrastructure to support a doctor seeing that many patients. The two who have applied, Dr. John Brooklyn at the Chittenden Clinic in South Burlington and Dr. Nels Kloster at the Hawthorn Recovery Center in Bennington, are expected to hear back about their applications soon, Folland said. Brooklyn also sees patients at the Community Health Centers of Burlington.

Another provision of the TREAT Act that providers in Vermont say would have an even greater impact on reducing the number of people waiting for treatment is one allowing physician assistants and nurse practitioners to prescribe opioid treatment drugs.

Smaller clinics and doctors could then treat a far greater number of patients, they say. However, that provision is still mired in the federal rulemaking process. The law gives regulators 18 months from when the bill was signed in July to complete that work, according to Folland.

Vermont has a higher percentage of nurse practitioners in its health care system than the national average, making their participation as prescribers especially meaningful.

State and its largest hospital stepping up

After state and local elected officials applied behind-the-scenes pressure for much of last year, the University of Vermont Medical Center has greatly ramped up its treatment programs.

Day One is the hospital's outpatient addiction treatment clinic. It used to help patients with alcoholism, but over the last year Dr. Patricia Fisher has helped the clinic expand into opioid treatment.

Fisher said she was tapped for the task by the medical center, because "in a previous life," as she puts it, Fisher practiced addiction medicine as part of her work for the Community Health Centers of Burlington.

Over the last several years, Vermont's Health Department has worked to create a system of hub and spoke providers to treat opioid dependency. The hubs are large-scale clinics treating hundreds of patients who need a great deal of supervision and counseling to control their addiction, while the spokes are smaller physician practices serving patients who don't need the same level of support services.

Day One is serving as a bridge in Chittenden County between the regional hub, the Chittenden Clinic in South Burlington, and spoke providers in the area, Fisher said. Its team of doctors and counselors has helped 87 people transition from the Chittenden Clinic to doctors' offices since April, she said.

That's when primary care doctors working for the hospital began taking patients with opioid addiction, she said. Here again, the UVM Medical Center has stepped up to help.

There are now 46 doctors working for the hospital who are licensed to prescribe buprenorphine, which delivers enough of an opioid to prevent withdrawal symptoms, but not enough for people to experience a high. A year ago, fewer than five UVM Medical Center doctors were licensed, Fisher said.

The combination of counseling and buprenorphine is what's known as medication-assisted treatment, and it's widely recognized in the medical community as the most effective treatment for opioid addiction.

Initially, the hospital's doctors were reluctant to take on medication-assisted treatment, expressing concern that people struggling with addiction would be disruptive and difficult to manage, Fisher said.

Fisher said she told them: "'These patients are already in your waiting room. You're just treating them for all their health conditions except their addiction,' and once we got started, they said, 'Oh, yeah, I do know these patients, they're really not any more problematic than any other patients.'"

Still, doctors need help addressing problems that people recovering from addiction face outside the confines of the exam room. That's where the state has stepped up, implementing a program to offer that additional support.

Vermont will pay for doctors treating patients for opioid addiction to hire nurses and counselors based on the number of Medicaid patients seen by their practice. Medicaid is the low-income government health care program, or essentially a government-run insurance program for the poor.

"It's not just a prescription we're handing out," Fisher said, adding that every patient meets with a nurse practitioner or licensed alcohol and drug abuse counselor.

Those state-paid nurses and counselors, known as MAT teams, allow doctors to focus on patients' health status, while the team focuses on ancillary problems like helping patients find stable housing, look for jobs and manage the challenges of daily life while recovering from addiction. "MAT" is an acronym for "medication-assisted treatment," or the combination of prescribed treatment drugs and counseling.

Fisher said that because there are fewer privately insured patients seeking opioid addiction treatment, the nurses and counselors paid for by Medicaid are able to help all of the patients that come through a doctor's door.

"Our primary care docs are not as overwhelmed by this as they thought they were going to be when we started, and they're ready to do more, which is encouraging," Fisher said.

As of June, there were 2,621 Medicaid patients being treated in so-called spoke practices or doctors' offices around the state, according to Folland, the Health Department's clinical services manager. There are now 269 doctors licensed to provide medication-assisted treatment, he added.

The problem is that, despite the greatly increased number of spoke practices, each one is treating only a handful of patients for addiction. At the same time, people continue to take treatment drugs for years or even decades as they rebuild their lives.

With people who are deciding to seek help continually pouring into hubs, but many fewer leaving the spokes, a bottleneck has persisted, leaving many on waiting lists to start the process.

While it will make a major difference when nurse practitioners and physician assistants are able to step into the role of prescriber, as the TREAT Act will eventually allow, Fisher said a dearth of nurses and counselors to fill out the MAT teams is making it difficult to further scale up the spoke practices.

Both the hubs, like the Chittenden Clinic, and the spokes, like the primary care practices owned by the hospital, need more nurses and counselors.

The MAT teams may be able to lure more nurses and counselors away from Howard Center, which operates the Chittenden Clinic, with better pay. But Fisher said they need to be careful not to cannibalize another important part of the treatment system.


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