California testing Vermont’s model to fight addiction

The time for handwringing was over.

Vermont Gov. Peter Shumlin took the podium in 2014 and delivered a state-of-the-state speech devoid of the usual trappings.

“During the tenure of every governor there are numerous crises,” he said. “The crisis I am talking about is the rising tide of drug addiction and drugrelated crime. In every corner of our state, heroin and opiate drug addiction threatens us.”

He rattled off statistics: Vermont clocked a nearly nine-fold increase in people seeking treatment for opioid addiction. Deaths from heroin overdoses had almost doubled over the previous year. Nearly 80 percent of the state's prison population was addicted or incarcerated because of addiction.

“The time has come for us to stop quietly averting our eyes from the growing heroin addiction in our front yards while we fear and fight treatment facilities in our backyards,” he said.

Shumlin proposed a multi-pronged attack for his state. But what caught California's eye, and the attention of many other states, was its “hub-and-spoke” idea. Rather than simply expanding traditional treatment programs that depend primarily on abstinence, social support and the 12 steps of Alcoholics Anonymous, the governor pushed to fight addiction with medication-assisted treatment; to use drugs to fight drug addiction.

Regional medical addiction centers — the hubs — would provide expertise. Primary care doctors all over the state — the spokes — would learn how to use buprenorphine medication to treat addicted patients in their everyday practices. Counselors, nurses and other health professionals would support the work.

“Now, if you talk to the average person on the street in Vermont about opioid addiction treatment, to them it's medicine,” said Richard Rawson, a Vermont native and retired co-director of UCLA'S Integrated Substance Abuse Programs, who is studying the Vermont program's effectiveness.

“They get it. It's very much like being in Europe or Canada or Australia, where opioid use is viewed as a medical problem.”

California is spending $90 million to adapt this hub-and-spoke system for the state's tribal communities and other parts of the state where opioid addiction is most common. But in California, which is known nationally for relying on the “social model” of drug treatment — based primarily on 12-step style recovery — pushing medication-assisted treatment will be trickier, Rawson said.

“In Vermont, there was political will,” Rawson said. “They've made outpatient, medicationassisted treatment the standard of care, and pretty much avoided the huge rehab industry.”

Early results appear encouraging: This year, the number of overdose deaths in Vermont could fall by about 20 percent from 2016, when a staterecord 148 people died of opioid abuse. Vermont also now has the highest capacity in the nation to treat opioid addiction with medication, according to the Pew Charitable Trusts.

California ranked 29th, just ahead of Mississippi and just behind Tennessee. RELUCTANCE Fewer than 5 percent of licensed physicians in the United States have the federally-required waiver that allows them to prescribe the opioidblocker buprenorphine, according to data from the U.S. Substance Abuse and Mental Health Services Administration. That's just 45,000 out of nearly one million practicing doctors.

California falls far below the national average. Just 1 percent of doctors in the state – 1,063 of about 106,000 – can prescribe buprenorphine.

Vermont went from having just 10 buprenorphine providers in 2012 to having 85 this year, or about 4 percent of its practicing physicians, according to state and federal data.

Doctors aren't rushing to enlist in the battle against addiction because addicts have terrible reputations as patients, said many in the field. Addicts are often seen as difficult, manipulative and unable — or unwilling — to follow medical directions.

A study published in July by the Behavioral Pharmacology Research Unit at the Johns Hopkins University School of Medicine titled “Why aren't physicians prescribing more buprenorphine? ” found that more than half of doctors allowed to prescribe the medication weren't working with as many patients as they could. It also found that more than one in three doctors who hadn't sought permission to prescribe buprenorphine were unwilling to do so.

That's because the doctors didn't believe in the treatment; lacked the time to devote to additional patients; and believed reimbursement rates were too low, Johns Hopkins found.

With the governor's passionate push and an emphasis on education, Vermont managed to overcome those concerns.