Most primary care physicians don’t provide treatment for substance use disorder, but that is changing in Vermont
It was 2013, and a young man with opioid use disorder was invited to a meeting of senior leaders from the UVM Medical Center, government agencies and community organizations to share his story about the impact of a lack of treatment capacity in Chittenden County. He represented the hundreds of people on waiting lists at treatment centers as the opioid epidemic surged.
“I think that was the moment this institution pivoted and realized we had to do as much as possible to offer this care,” recalls Thomas Peterson, MD, chair of Family Medicine at the UVM Medical Center and Larner College of Medicine.
Peterson describes him as an engaging person who had been devastated by opioid use and was hoping, through treatment, to get his life together. “He wanted to be able to hold down a job, be a better father to his baby, and help his wife who was also addicted. In other words, he was trying to do the right thing, but we were not prepared to help him.”
At the time, the medical center’s primary care physicians were like their peers in the rest of the country: only a handful provided treatment for opioid use disorder (OUD). Now, nearly every family medicine physician at the medical center is doing so, and all family medicine residents receive training to provide it, but the national picture hasn’t changed.
80% Left Untreated
This helps explain why the National Academy of Sciences (NAS) was able to report in March that 80% of people who could benefit from treatment are not receiving it. Specifically the NAS, along with other prominent national organizations and government agencies, is urging expansion of Medication-Assisted Treatment (MAT), an approach that combines behavioral therapy with the use of prescription medications that have the ability to reduce the intense cravings that make opioid dependence so hard to overcome.
Experts have long lamented that the primary care workforce has stayed on the sidelines as the opioid crisis rages, but the NAS went much further, declaring it to be unethical for the medical community to fail to offer what has proven to be an effective, lifesaving treatment.
“Many physicians nationally are probably still in the same place where most of us in Vermont started six or seven years ago,” says Peterson. “We weren’t sure MAT was the right approach because it was not curative and came with frequent relapses, we didn’t have the expertise to provide it, and we had doubts our busy family practices could handle the extra effort it can take to manage these patients.”
Overcoming those concerns involved a willingness to learn from early adopters, a reconsideration of the disorder and those it afflicted, and some key support from the medical center and State of Vermont.
“Fortunately there were a few forward-thinking, motivated individuals in our community, such as Dr. John Brooklyn at the Community Health Centers of Burlington and Howard Center, who took this on without the kind of support we have now,” Peterson says. “I give them a lot of credit for showing the way and providing a great deal of education and at-elbow support as we moved toward embracing this therapy and these patients.”
Brooklyn, a clinical assistant professor of Family Medicine at UVM’s Larner College of Medicine, is credited with developing the “hub & spoke” system of care that has proven to be effective in reducing misuse of opioids and deaths from overdose. In this model the “hubs” – usually located at addiction treatment centers – are staffed by specialists who provide an intensive level of treatment and social services for patients who need that level of support. Spokes – most often a doctor’s office – offer less intensive, ongoing care. Brooklyn is now helping guide many localities and states throughout the country who are trying to replicate the approach.
Dr. Patti Fisher, who now serves as chief medical officer at UVM Health Network-Central Vermont Medical Center, was also a resource to her then-colleagues at the UVM Medical Center based on her years of experience providing MAT to patients at Community Health Centers of Burlington.
“My message was this care was not more risky or complicated than any other care I provided my patients. It was another tool in my toolbox to meet the whole needs of any individual patient walking into my office. And after all, it just doesn’t make sense to treat their heart problems or diabetes and then say sorry I can’t help you with your addiction.”
UVM Medical Center Interim President Stephen Leffler, MD, who has provided care in the hospital’s emergency room for nearly 30 years, believes new thinking about opioid use disorder and those it afflicts was another important factor in getting more providers on board.
“I think the medical community here in Vermont has evolved from seeing addiction as a moral failing to looking at it as a chronic condition just like high blood pressure,” he says. “We now believe these patients deserve to have their care normalized and de-stigmatized in a practice setting where all of their medical concerns can be addressed.”
The view of the treatment also had to change, according to Alicia Jacobs, MD, who treats patients at a practice in Colchester and is vice chair of Family Medicine.
“We all needed to accept that MAT is not going to eliminate relapses – they are part of the disease – and instead focus on this treatment’s tremendous value as a way to reduce the risk of harm, and even to save lives.”
Getting to Yes
As waiting lists for treatment grew, so did calls from policymakers and community providers for the UVM Medical Center, the state’s only academic medical center and largest provider of health care, to do more to help. It was clear the involvement of primary care physicians was the key to expanding treatment access, and work began to bring as many of them on board as possible. While that was underway, Dr. Robert Pierattini, the chair of Psychiatry, offered use of his office to a team of physicians, nurses and counselors for a weekly “pop-up” clinic to start reducing wait times for treatment until a fuller response could be put in place. The centerpiece of that response was launching the Addiction Treatment Program (ATP), a clinic staffed with addiction specialists which was designed to support primary care practices in treating individuals with various substance use disorders. Dr. Pierattini tapped psychiatrist, Dr. Sanchit Maruti, MD, to get it off the ground. “Our primary care physicians wanted to make sure the patients coming off the waiting lists were going to be medically stabilized and fully evaluated by addiction specialists like Sanchit before being sent to their practices, and I also think they needed reassurance that someone had their back in taking on this work,” says Pierattini.
Dr. Jacobs agrees. “Knowing Dr. Maruti and his team were on-call to provide guidance and any other support physicians needed, including assisting or assuming patient care during relapses or other complications, made a really big difference.”
“The ATP’s goal is to provide access to the highest quality care to patients and ongoing support for all UVM Medical Center and community providers who care for individuals with Opioid Use Disorder,” says Maruti. “With the support of the medical center’s leadership, we were able to recruit a multidisciplinary team of providers that could rapidly respond to this life-threatening condition.” This expert back-up is critically important due to the nature of the treatment and the disease. Starting MAT requires a medically supervised initiation process where close attention has to be paid to the medical history, the symptoms and other factors that can impact the FDA approved treatments, buprenorphine and methadone. Although those are opioids, when taken as directed they don’t produce the powerful euphoric effects that other opioids do when they are misused. The dosing and length of use are tailored to each patient. For some patients with OUD it can become a permanent part of their routine medical care, like taking medications for diabetes or high cholesterol.
The other key piece of support came from the State of Vermont which started funding mobile teams of MAT-trained nurses and Licensed Alcohol Drug Abuse Counselors who assist patients and primary practice staff in multiple facets of providing the treatment. These include providing clinical support in a compassionate and professional manner and resolving any logistical challenges that may arise.
“Once our practices knew they had the kind of support necessary to provide the best care, it eased concerns and our providers stepped up to help,” says Dr. Jacobs.
All of the providers involved also help patients address problems with housing and other issues that can make it more difficult for them to stay on track with both the medical and psychological components of treatment recommendations for their OUD.
A larger MAT workforce is one of the main reasons waiting lists were eliminated in Chittenden County over the next two years, and was a factor in a 50% reduction in deaths from opioid use in the county in 2018.
Making it Part of Their Job
Studies have established physicians typically receive very little training in addiction treatment in medical school or residency programs and view it as a job for licensed counselors and other specialists. The need to obtain a federal certification called an “x-waiver” to prescribe buprenorphine, the preferred choice of office-based providers, adds to the perception that addiction treatment is not their responsibility.
Peterson and Jacobs have created a new expectation by integrating x-waiver training into the Family Medicine Residency program, which is offered to Internal Medicine residents as well. They’ve also taken it a step further. “We won’t hire anyone who does not see this as part of their job,” Peterson says emphatically.
Primary care providers at the UVM Medical Center now consider treating opioid-dependent patients as a highlight of their work, and they’re asking for the opportunity to welcome more of them into their practices.
“We can see the positive difference this treatment makes in their lives, and we don’t often get to witness a profound change like that as a result of our efforts,” says Jacobs.
Being able to address all of their medical issues has also proven to be very valuable, even lifesaving. Jacobs recalls a MAT patient who was complaining of significant foot pain. Because he previously had no primary care provider and the problem wasn’t something to talk to his addiction treatment counselor about, it had gone untreated. Concerned the pain was being caused by poor blood flow, Jacobs sent him for testing and her diagnosis proved to be correct.
“This was a dangerous condition that could have led to loss of a limb or worse,” she says. “In fact, it opened the door to a new focus on his whole wellness and wellbeing.”
At a time when the federal government is calling for a 40% decrease in deaths from opioids in the next three years, Vermont’s model for engaging primary care providers in the battle against opioid use disorder could prove instructive to others confronting this challenge.
Education is key, says Peterson: “When our providers understood people are dying because of poor access to MAT, and that they are totally capable of providing it, they jumped in with both feet. I have to hope others will react the same way.”