Opioids, part two
By Vanessa della Bitta — Treatment is expensive, as Skye Tikkanen pointed out last month in Part One of PD’s discussion of the opioid crisis. Tikkanen is a seasoned substance use and mental health therapist at Connections Counseling in Madison, as well as an active treatment advocate. She is also in long-term recovery, and she is far from alone in the tireless grind of trying to make recovery available to anyone who wants it.
According to a 2013 survey by Substance Abuse and Mental Health Services Administration (SAMHSA), 4.1 million people age 12 or older received treatment that year for a problem related to substance use, which only accounts for 18% of those who actually needed treatment. While those who may benefit from help and those who are willing to accept help do not overlap completely, the insufficiency of provided treatment is pronounced for other complex and systemic reasons.
Caroline Miller, Outreach Specialist with the University of Wisconsin-Madison and Consultant for Wisconsin Voices for Recovery, says, “I think at the top of the list as far as barriers [to treatment] is stigma, and the lack of knowledge around the science of addiction and recovery, and not seeing addiction for what it is as a medical condition, just like any other medical condition, like diabetes or heart disease or cancer.”
In addition to the pervasive cultural misunderstandings of this disorder and its treatment, our country’s inability to afford people widespread care it is a product of inadequate funding and healthcare coverage. In recent legislation we have seen an emphasis on harm-reduction and prevention approaches to opioid-related fatality and dependency, like increasing access to the overdose-reversal drug naloxone, and tightening prescription drug monitoring laws. While these kinds of measures are relatively low budget, Tikkanen says that providing suitable treatment services for individuals who are in need is high-cost.
The kind of treatment Tikkanen is referring to are things like detoxification services, inpatient and outpatient programs for substance use and co-occurring disorders, as well as medication-assisted treatment (MAT). MAT is a course of care that is being increasingly emphasized in policy, media, and the treatment field as a research-backed, standard practice. It involves prescribing a medication like methadone, buprenorphine (the primary ingredient in Suboxone or Subutex) or Vivitrol to a person on an ongoing basis in conjunction with counseling and other support strategies (like 12 step programs and participation in recovery communities).
The objective of MAT is to help stabilize the individual by curbing cravings and/or blocking the capacity to get high so that that person has the opportunity to focus on healing and rebuilding their life without those distractions. “We know that addiction is a brain disease,” says Tikkanen. “[The person’s] brain is telling them that they need that substance in order to survive.” Satisfying that perceived need for an opiate in a consistent, monitored manner can relieve the person from the intrusive obsession to use and the dangerous behaviors that often come along with it.
Methadone, buprenorphine and Vivitrol all act on the brain’s opioid receptors, but they each do so a different way, allowing them to function as distinct tools. Given their unique profiles, one may be more appropriate for some, while another one works better for others (think: different methods of birth control, or the range of medications for depression).
There are many schools of thought on best practices for using MAT and, while there is research substantiating its success rates, it is not without tension in the treatment world. Among providers and professionals, diverging opinions arise around questions of which medications are most successful, how “success” should be defined, the appropriate length of treatment, dosage, overall treatment goals, and how much to prioritize other treatment strategies and recovery supports. A person seeking treatment may have a very different experience with one doctor’s approach versus another.
BUPRENORPHINE ACCESS and CARE QUALITY
While methadone had been the mainstay in opioid dependence MAT for decades prior to the approval of buprenorphine by the Food and Drug Administration (FDA) in 2002, buprenorphine (also recognized as Suboxone or Subutex) has become perhaps equally popular over the last 15 years. To prescribe buprenorphine, doctors must first take an eight-hour training course created primarily by Reckitt-Benckiser, the original manufacturers of Suboxone and Subutex.
“In order to prescribe Suboxone,” says Tikkanen, “you’ve never needed a background in addiction. You can be an eye doctor, a foot doctor, or whatever you want to be as long as you have the credentials to prescribe, you can take the course.” While the certification-training requirement designates special attention to the characteristics of this drug and its treatment protocol, a lack of professional knowledge and experience with substance use disorder can have hazardous implications for a very vulnerable population.
When buprenorphine first came on the treatment scene in the United States, prescribers had a patient cap of 30, which meant they could only treat that many patients with the medication at a time. Soon, providers could apply to treat up to 100 patients after their first year following the training. This summer, the patient cap was federally raised to 275, and providers with credentialing in addiction medicine or addiction psychiatry may have the opportunity to apply to treat even more. Along with this, HHS is advocating for more buprenorphine prescriber training availability.
Considering the public health mentality of recent policy responses to the opioid crisis, expanding access to MAT by increasing the volume of patients a physician can see seems positive.
“The [patient] caps are a barrier,” says Tikkanen. “Docs fill up and then there’s nowhere to get medication-assisted treatment.” However, while increasing access is hugely important, this strategy runs the risk of compromising quality of care.
“Can a doc really pay attention to 200 people on their caseload?” she asks, conversely. “That’s a really challenging conundrum. What I’m hoping will happen is that prescribers will use support staff in order to effectively manage their caseloads so that they can provide the quality of care needed, but I don’t know that that’s going to happen. There’s no mandate for that to happen. I think that’s the best-case scenario… it’s that public health versus personal health issue that we’re bumping up against.”
There is significant range in how much a buprenorphine provider requires of the patient in terms of participation in the non-medication side of treatment while they are on the medication. Some may hold a person accountable to attending regular therapy or weekly groups, to having treatment goals or participating in a recovery community. Some providers do the minimum legal requirement of merely making sure that a person has access to substance use disorder therapy if they want it.
Tikkanen points out, “It’s called ‘medication-assisted treatment’ for a reason, because the medication is assisting the treatment. It’s not ‘treatment-assisted medication.’ It’s not, you know, just ‘medication.’ It’s ‘medication-assisted treatment,’ and actually getting treatment for the disease of addiction is so vitally important to having a full recovery.”
The new additions to MAT options—buprenorphine and Vivitrol—have changed the landscape of treatment in many ways. There are more people seeking treatment now than were a decade or two ago. Tikkanen says that research shows that there are more people getting and staying sober because of it. Still, MAT has been a polarizing topic among recovery communities, such as those formed around 12 step programs.
While programs like Alcoholics Anonymous and Narcotics Anonymous themselves remain neutral on the issue, in accordance with their governing traditions, many people on MAT feel stigmatized by opinions that circulate the groups surrounding them. From some, they hear the message that MAT is a crutch rather than a tool. Sadly, this kind of message can alienate people who are in need of the support that these universally free and accessible recovery communities are known for, challenging the hope of recovery.
One end of the spectrum views MAT as a magic bullet, and promotes as many people as possible taking advantage of it and staying on it indefinitely; at the other end, there is a perception that MAT can actually hinder recovery by perpetuating a cycle of opiate dependency and thwarting thorough transformation. Luckily, there is a lot of middle ground in between, allowing each individual to find out what makes sense for them. If they have the option, that is….
With respect to financial access, Vivitrol can cost $1,000 - $2,000 per month. Buprenorphine can cost more than $1/milligram, which racks up, if you are taking 8 milligrams per day and do not have insurance. Some doctors prescribing buprenorphine in private practice do not bill any insurance companies. Other doctors and clinics do take insurance, but some won’t take insurances like Wisconsin’s Badgercare, because it is cumbersome and not financially viable for them, in effect excluding a chunk of people in search of treatment.
HUB and SPOKE
Another challenge of getting people the help they need is the lack of an overarching treatment service structure that can align with the brief window of a person’s willingness to stop using. Often, when a person reaches out for help, their desperation and ability to surrender to that help can vanish in a matter of hours or minutes.
It is not uncommon for a person, in the most vulnerable of states, to call local Suboxone doctors to find that the ones they can afford are full or can’t see them for a few weeks—or, perhaps they call their insurance company to find that the inpatient treatment centers that fall within their network have no open beds. By the time a bed opens up next week, they’ve long since been using with no desire to stop, and loved ones lose another scrap of hope.
“Access to treatment in a timely manner really matters,” says Tikkanen. “Access to medication-assisted treatment when that’s what the individual wants really matters. Not having to jump through hoops in order to get into the treatment program you want. Once you have an established a relationship with a treatment provider that you like, being able to stay with that person really matters.”
In 2013, Vermont launched a statewide “hub and spoke” model of opioid use disorder treatment, which acts as an integrated system combining different services, in the order they are needed. According to the Vermont Agency of Human Services, a “hub” is a specialty treatment center that provides initial care, like MAT, comprehensive assessments, and consultations that result in appropriate referrals to different “spokes.”
Each “spoke” represents an ongoing piece of the care puzzle, like primary care providers, maintenance MAT providers, outpatient or inpatient services, pain management, family services, and other recovery support interventions. This kind of model makes use of services that are already operating within a community, but orchestrates them in a way that is intuitive and conducive to the rhythm of addiction’s symptoms. Tikkanen is advocating for Madison to go a step further and create a crisis center for families or individuals that is able to respond promptly and productively.
RECOVERY REQUIRES ONGOING SUPPORT
While it is imperative to be equipped to respond to the acute consequences of addiction—providing help fast, having Narcan available to treat overdoses, etc.—we also need to pay attention to the long-term realities for people living in recovery. For those who have substance use disorder, separating from their use cycle and physical dependency is only one aspect of the journey.
Tikkanen says, “People in recovery are wonderful people and can function as incredible parts of society … and they need support. If we want people to maintain their long-term sobriety, if we want them to be productive members of society, we have to help them do the rest of it too.”
Caroline Miller is an advocate for shifting the focus of our discussion of the opioid crisis onto long-term recovery support. According to Miller, the largest portion of the Wisconsin Department of Human Services block grant for mental health and substance use (about $26 million per year) goes to prevention measures. While these investments are key, Miller says we need to focus not just on “how we can prevent overdose deaths but how can we help someone sustain recovery once they leave treatment.” Both are about saving lives.
While “treatment” most often refers to services provided by professionals, “recovery” connotes a process that extends beyond that and touches all aspects of a person’s experience. Truly defining the term “recovery” is, in many ways, a solo venture, but it is usually considered a path of transformation—of reconnecting with one’s life and restoring a sense of purpose and wellbeing.
Both Tikkanen and Miller agree that one of the chief ingredients of a stable recovery is a solid support network—this may include friends, fellows in recovery, mentors, treatment providers, a 12-step sponsor, or family.
“Social support is huge in people finding recovery, staying in recovery, and maintaining recovery, and we don’t emphasize it enough when we talk about treatment and when we talk about recovery support services. I think we need to prioritize supporting recovery, and that means supporting MAT and access to naloxone/Narcan, but it also means at the same time supporting recovery community organizations and social support interventions and the ‘other side’ of prevention.”
In terms of specific systems of recovery supports and how to invest in them, Miller suggests that this is an area that needs more research, financial backing and organizing. She believes we need to think outside the box in terms of developing new interventions: “Social support strengthens the individual to be able to maintain recovery, and research shows that, but unfortunately there aren’t a lot of interventions that address that specifically.” A lot of the focus is on clinical and medical-based interventions, when there is a lot to be said for the strength of community-based support.
The passé expectation that a 28–day stint in rehab ought to keep a person clean for once and for all is gradually being displaced by a design of care that recognizes the chronic nature of substance use disorder. If the condition is ongoing and progressive, treatment must be a mirror. Miller advises that we continue to celebrate the new wave of positive, peer-influence approaches to recovery support, like the recovery high schools and collegiate recovery programs that are sprouting up across the nation.
ONGOING SUPPORT IN MADISON — JOINING TOGETHER
Madison’s recovery high school, Horizon, was founded in 2005, backed by a $10,000 private donation and six founding members, including Shelly Dutch, Director and Founder of Connections Counseling.
Efforts at the University of Wisconsin–Madison are a result of action by dedicated community members like Caroline Miller, and are now spearheaded by a student organization called Live Free–Student Wellness and Recovery. Live Free was awarded a grant for roughly $45,000 for this academic year, which will be used to organize support and an active social network for UW students in or seeking recovery, as well educate the campus community on addiction and recovery.
Connections Counseling—an outstanding outpatient program where Tikkanen has been a therapist for 12 years—is an ever-evolving powerhouse on the local treatment scene that nurtures community-based recovery through their mentorship program and routine sober activities that all are welcome to join. Safe Communities’ Parent Addiction Network is a fabulous resource for families and loved ones of folks with substance use disorder that provides information, suggestions, support, and organizes naloxone trainings for the community.
The slew of grassroots recovery organizations and networks doing their part in Dane County and across the country are a vital chunk of our solution. The more that people in recovery and their allies are willing to share their own experiences or exercise their voices, the more our collective strength can fight stigma and buffer us all against the fierceness of addiction.
“There is so much shame still around this disease,” says Tikkanen. “You know, I am a proud person in recovery and I’ll shout it from the rooftops because I think that it’s really important for people to know that this was the hardest thing I ever did in my life and I am so proud of my recovery and the person that I’ve become through it.
“Taking away that shame means that more people are going to make their way to treatment, that they’re going to feel capable of being in recovery, and that if they have a relapse they’ll stay connected to their supports and to their treatment providers in order to be able to keep working at it.”
We’ll follow up in December about law enforcement’s role in this epidemic, and the legal consequences of having substance use disorder.