By Morgan True
For Vermont Digger
In his 2014 State of the State address, Gov. Peter Shumlin pledged to get more opiate addicts into treatment, but as the state attempts to address the growing crisis, demand for services is still dramatically outpacing the capacity of local providers in Chittenden County.
There are nearly 300 people on the “active” waiting list for medication-assisted treatment at the Chittenden Clinic, despite a doubling of the number of patients the clinic serves, according to Bob Bick, Howard Center CEO. In 2014, the clinic treated 441 patients; today 894 patients receive treatment for opiate addiction at the clinic. More than half of the patients are injection heroin users.
“It’s not going away,” Bick said of the opiate crisis.
Vermont has seen a 250 percent increase in people receiving heroin treatment since 2000, with the greatest percentage increase, nearly 40 percent, in just the past year, according to state officials and treatment providers.
The Chittenden Clinic, which is run by the Howard Center, serves patients in Chittenden, Franklin and Addison counties. The Howard Center is one of 11 designated social service agencies in Vermont supported by state contracts.
People on the active list have been triaged based on need, have checked in with clinic staff in the last month and could start treatment tomorrow. The “inactive” waiting list numbers greater than 800, though some patients may have found help elsewhere, Bick said.
The Howard Center’s needle exchange still sees roughly 40 new people each month looking for clean needles to shoot heroin with, he said. Federal law requires that pregnant women and injection drug users be given priority for treatment slots, but some IV users are still waiting months for treatment.
For addicts using prescription opiates or just snorting dope, the wait can be “interminable,” Bick said.
While there are other options, medication assisted treatment is widely recognized as an effective way for people to combat addiction. Patients are randomly drug tested and 90 percent stay clean of other drugs while in treatment, Bick said.
Courts clog waitlist
Shumlin recently lauded reforms to the state’s criminal justice system at a campaign stop with Hillary Clinton. The governor told a crowd in Laconia, N.H. that Vermont gets addicts who have been arrested for nonviolent crimes into treatment.
“We brought in third-party assessors who got folks when they were busted, when they were down, when they were most likely to move into treatment,” he told the crowd.
That’s how the system is supposed to work, but that’s not the reality, according to substance abuse providers.
The criminal justice reforms Shumlin is talking about started largely in Chittenden County. Since 2003, Chittenden County has operated a Treatment Court that allows drug-addicted defendants to get help. Those who complete the program typically get their charges reduced or dismissed.
In 2010, Chittenden County began the Rapid Intervention Community Court for low-level offenders with addiction or mental health issues, which allows them to avoid charges altogether if they complete the program.
There are a “slew” of people from those diversionary court programs who can’t enter treatment at the Chittenden Clinic in a timely fashion because of the bottleneck for services, Bick said.
Many people released from prison should receive treatment at the clinic, but they land on the waiting list because the clinic is over capacity.
“It’s not just folks coming out of corrections, it’s people coming through the courts generally,” he said.
Not enough doctors
The Chittenden Clinic is a treatment “hub,” one of seven in the state and physician’s practices and health centers where doctors prescribe maintenance drugs are the “spokes” in the state’s opiate treatment model.
Spoke providers give addicts the opioid derivative buprenorphine, which delivers enough opioids to prevent someone from getting dope sick, but not enough to feel a high. Unlike methadone, doctors can prescribe buprenorphine from their offices and patients who are ready can take it without supervision.
It allows people to lead more normal lives, without the daily trips to the clinic for methadone, but heroin users taking relatively large doses need to step down with methadone first.
Both Subutex and Suboxone drugs contain the opioid buprenorphine, but Suboxone, unlike Subutex, contains naloxone, an opiate antagonist that further deadens any high addicts might experience. In another form, naloxone nasal injectors, commonly referred to by the brand name Narcan, are effective in reversing opiate overdoses.
Subutex, because it doesn’t contain the opiate antagonist, is sometimes diverted for use by addicts who are not receiving treatment. Though tamper resistant, providers say addicts are still able to shoot the drug, which sells on the street for $50 per 8 milligram pill.
According to Hal Cohen, the secretary of the Agency of Human Services, a shortage of spoke providers is contributing to the backlog. There are a “relatively low” number of buprenorphine prescribers in Chittenden County, Cohen said. As a result, they’ve hit a “saturation point” with the Chittenden Clinic’s ability to meet demand in the region, he said.
“We also need to improve our capacity to transition people who are stabilized out of treatment to appropriate aftercare,” Cohen said.
The clinic is only able to add 9 to 10 patients per month, Bick said. At the same time, there are 50 to 70 patients at the clinic who have progressed in recovery to where they could be treated with buprenorphine at a doctor’s office, he said.
In the month of August, Medicaid claims data shows 17 doctors in Chittenden County wrote at least one buprenorphine prescription for a total of 356 prescriptions, according to figures from the state.
The majority of Chittenden Clinic patients are on Medicaid, the low-income health coverage program, Bick said. In the past year, the number of uninsured patients at the clinic was cut in half, from 14 percent to 7 percent, largely due to Medicaid’s expanded eligibility under the Affordable Care Act.
Federal law sets an initial cap of 30 patients for doctors who complete a course to prescribe buprenorphine. After several months, that cap increases to 100.
Cohen said his agency is working with the University of Vermont Medical Center, the state’s largest hospital and community health providers to create additional capacity. UVM Medical Center currently has 14 doctors certified to prescribe buprenorphine, according to a spokesman.
Recently, Bick and other stakeholders, including the Chittenden County State’s Attorney’s Office and the UVM Medical Center sent a letter to Vermont’s congressional delegation encouraging them to support S.2645. The bill would increase the number of patients doctors could prescribe buprenorphine to and would also allow physicians assistants and some nurses to prescribe maintenance drugs as well, thereby increasing capacity.
Though diversion is a concern with some maintenance drugs, providers said addicts who currently buy it on the street would be less likely to do so if they had a doctor who could prescribe it to them.
Waiting lists eliminated elsewhere
Dr. Deb Richter, an addiction medicine doctor in central Vermont, works with a medication assisted treatment team coordinated by Vermont’s Blueprint for Health, a care management program designed to reduce costs and improve people’s health.
Case workers track down her patients’ urine tests and help make sure people get their daily meds. That frees Richter up to provide counseling and other support services to her patients and allows her to see more of them.
BAART Behavioral Health Services, which operates for-profit methadone clinics in Berlin, St. Johnsbury and Newport, has eliminated its patient waiting list by partnering with the Blueprint, Cohen said. “That’s a remarkable accomplishment and a good example of what can be done with a consolidation of resources,” Cohen added.
Richter said there are other innovative approaches the state could adopt, such as telemedicine — or treatment assisted by video conferencing. While she would prefer to meet with patients in person, she and other doctors prescribing buprenorphine could serve many more patients if counseling sessions could happen via video conference.
“Some of our patients have to travel as many as two or three hours every day to get their meds or meet with us and then we expect them to have jobs, too?” Richter said.
Recovery is tremendously difficult and often takes people multiple tries. Richter has patients in Chittenden County and it’s difficult to see patients drop out of treatment and then have to go back onto waiting lists, she said.
But as tough as the recovery process is, Richter said many of her patients give her great optimism. A man who was using and dealing heroin just a year ago is now clean and has a job. He recently bought a car and is making his child support payments, according to Richter.
If providers in the state are given the right capacity and tools, Richter said she believes waiting lists like the one at the Chittenden Clinic could be dramatically reduced in six months to a year.