Can Vermont Fix Its "Dysfunctional" System of Treating Opiate Addicts? 

According to conventional wisdom, the hardest part of beating an addiction is admitting that you have a problem. But for hundreds, perhaps thousands, of Vermont addicts who are hooked on heroin or prescription painkillers, the hardest part is finding someone to treat their dependency.

Opiate abuse in the Green Mountain State has reached epidemic proportions in the last decade, as it has across the nation. But Vermont finds itself in a unique predicament: The state has more doctors per capita than any other who are authorized to prescribe buprenorphine, a prescription drug used to wean patients off opiates. Yet addicts and substance abuse experts say it can take months, sometimes years, to line up a physician willing to prescribe “bupe.”

Equally challenging is landing a slot in one of Vermont’s four methadone programs, which have long waiting lists and prioritize pregnant mothers and intravenous drug users.

The result, say substance abuse experts, is that a pregnant mom receiving methadone treatment may be sharing her home with a partner who’s still using because he can’t find anyone to treat his habit.

“It’s ludicrous,” says Bob Bick, director of mental health and substance abuse services at HowardCenter, which runs the state’s largest methadone clinic, the Chittenden Center in Burlington, as well as substance abuse treatment center Twin Oaks Counseling Services in South Burlington. Over the last five months, the two programs have had a combined waiting list of between 400 and 500 people seeking treatment, a situation Bick calls “unacceptable.”

“The reality with substance abuser treatment generally — and specifically opiate addiction — is that when the patient says, ‘I’m ready and amenable for treatment,’ we need to be able to provide that treatment on demand,” he adds. “The pull of the drug is so strong … motivation can change so quickly that in two days they’re back on the street using again.”

With so many Vermont physicians certified to prescribe buprenorphine — often referred to by the brand name Suboxone — why aren’t more doctors doing so?

Several years ago, Bick explains, Vermont acknowledged that its four methadone programs couldn’t handle the growing need for opiate treatment, driven largely by the rise in prescription pill abuse. (Those meds have now overtaken heroin as the most abused form of opiates.) In response, the state sought to get more doctors federally certified to prescribe buprenorphine. Unlike methadone, which is administered in a clinic, buprenorphine is a take-home medication.

But many doctors quickly realized they were “out of their realm,” Bick explains, when it came to addiction treatment. As word got out that these doctors were prescribing buprenorphine, their practices were “inundated” with patients — some seeking legitimate treatment, others looking to resell the drug on the street.

“In many ways, this is a difficult population to treat,” says Beth Tanzman, assistant director of the Blueprint for Health at the Department of Vermont Health Access. “Many of these prescribers are primary-care physicians, OB/GYNs or other physicians, for whom their practices are not set up to do the kind of monitoring or managing of these patients that’s required.”

Tanzman reports that there are 195 doctors eligible to prescribe buprenorphine in Vermont. But that number paints a distorted picture, she says, as many will only treat patients with whom they already have a relationship. Just 44 physicians see more than 30 bupe patients at a time, which requires additional training and certification under federal guidelines. The result: Many Vermont docs can prescribe the drug, but few are willing to take on new patients to do so.

And for those who do, it’s not as simple as writing a script and sending the patient home. Patients begin buprenorphine treatment through a process called “induction,” Tanzman explains. Essentially, it involves titrating, or gradually replacing their street opiates with the medication, over four to five days, so withdrawal symptoms don’t become unbearable.

Because induction is difficult for patients, Tanzman says, their odds of success are much better if they also have access to mental health experts, substance abuse counselors and other services, including social workers, to help manage the transition.

But as Bick points out, some doctors who got certified to prescribe bupe had no prior experience in addiction therapy. In some cases, they wrote prescriptions for larger quantities of Suboxone than was necessary, a portion of which ended up on the streets. Suboxone is now the most abused drug in Vermont’s prisons, and Bick says HowardCenter’s clinics see opiate-dependent patients who report that it was the first drug they ever abused.

Moreover, due to “very loose” federal guidelines, Bick adds, some physicians saw Suboxone as “an entrepreneurial opportunity” and opened large practices treating 200 or more patients at a time. These “pseudo-clinic operations,” he says, were accidents waiting to happen.

In April 2011, Synergy Consulting Group in South Burlington, a large, for-profit provider of buprenorphine, shut its doors with no warning, stranding about 175 patients without access to medication, counseling and drug-testing services. The state stepped in and asked HowardCenter to take over the practice, which it now operates as Twin Oaks.

“At that point, the state recognized that they had a really significant problem,” Bick adds, “because there were a number of these large practices carrying 100, 150, 200 or more patients and there was no state oversight at all.” Bick calls that system “pretty dysfunctional.”

The Vermont Department of Health has since adopted emergency rules to cover so-called “medication-assisted therapy” — i.e., buprenorphine and methadone — for opiate dependency.

The state is also working to create five statewide “integrated substance abuse centers,” says Tanzman. This “hub-and-spoke” model would create five regional methadone providers — the “hubs” — which would also offer specialized services such as mental health and addiction counseling. They’d also function as consultants for doctors who provide buprenorphine — the “spokes” — so they’re better equipped to manage these patients.

According to Tanzman, the estimated new cost for the project is $4 million for fiscal year 2013; that cost doubles in 2014. At that rate, Vermont could afford to treat about 5000 patients for opiate dependency by 2015. (Currently, the state is treating roughly 2800 with buprenorphine and another 600 with methadone.)

If $8 million sounds high, Tanzman points out that the state expects “significant savings” in other areas. Opiate abusers are already “high-system users,” she notes, costing millions not only to the health care system but also to law enforcement, the courts and corrections. If everything goes according to plan, Tanzman expects the feds will cover about 90 percent of the cost.

However, implementing the hub-and-spoke model will also require that family practitioners in the community rethink their attitudes about treating addicts, says St. Albans pediatrician Fred Holmes, who is currently treating about 60 patients with buprenorphine. The 67-year-old is planning to retire in July but has yet to find another physician to take his caseload.

Opiate addiction, “from my perspective, is no different than treating a youngster with cystic fibrosis or asthma or a seizure disorder of diabetes,” says Holmes, in that “the format is the same: [You need] an interdisciplinary team. It’s just the team looks different.”