The Bend Bulletin, Oct. 20, 2016
The abuse of prescription pain killers and illegal drugs has tripled the rate of opiate overdoses in the U.S. since 2000.
Every day, 78 people die of heroin or prescription opiate overdose, a rate of about one person every 20 minutes.
Yet, the nation’s capacity to treat opioid addiction has not kept pace. A report issued last week by the Democratic staff of the Senate Committee on Finance highlights a treatment gap of more than one million Americans addicted to opiate drugs but not receiving the treatment they need.
“This is not spin. Those are hard numbers that indicate that the overwhelming majority of people are waiting in line for treatment and can’t get it,” Sen. Ron Wyden said. “This is really urgent, and we need to push back every which way.”
Treatment for opioid addiction can include individual or group therapy, outpatient or residential treatment or inpatient hospitalization. But there is strong evidence that medication assisted treatment, which uses prescription drugs to impact the opiate receptors in the brain to minimize the euphoric effects of drug use and ease withdrawal symptoms, might be the most effective approach.
The Food and Drug Administration has approved three medications — methadone, buprenorphine and naltrexone — to treat opiate addiction, but significant barriers exist preventing patients from accessing any of the three. Patients can get methadone or buprenorphine through opiate treatment programs, commonly referred to as methadone clinics.
But the number of treatment programs haven’t kept up with demand. In 2000, Congress passed the Drug Addiction and Treatment Act, which allowed physicians to apply for waivers to prescribe buprenorphine in office settings, but the number of doctors taking that step has been underwhelming.
Naltrexone has fewer regulatory restrictions, but is expensive and many health plans won’t cover it.
“Far more patients are in need of treatment than can currently access it,” researchers led by Christopher Jones with the FDA’s Office of Public Health and Analysis wrote in the American Journal of Public Health last year.
According to the most recent National Survey on Drug Use and Health, the rate of past year opioid abuse increased from 634 per 100,000 individuals 12 and older in 2003, to 892 per 100,000 in 2012, with 2.3 million people addicted in 2012.
But Jones and his colleagues found that in 2012, the maximum number of patients that could be seen by doctors with waivers was about 1.09 million. Another 311,000 patients were seen in methadone clinics. That represented a best-case scenario that still left some 914,000 individuals in the treatment gap.
It’s likely the shortfall is even greater. Physicians with waivers can treat up to 30 patients with buprenorphine in their first year, and then can apply for a waiver to increase that total. Congress increased that limit from 100 to 275 in 2016.
Surveys show, however, that prior to the expansion, physicians with waivers treated 57 percent of their maximum case load, and one in four physicians with a waiver saw no patients at all. About 55 percent of doctors with waivers agree to be listed on a federal treatment locater that links patients with services in their area. That increases the potential treatment gap by another half million patients, to as many 1.4 million people.
In Oregon, 13 out of every 1,000 individuals were addicted to opiates in 2012, second only to West Virginia, but the capacity for buprenorphine treatment though waivered physicians could treat fewer than four of those 13. While Oregon has 15 methadone clinics, most are operating at 80 percent capacity or higher. In 2013, 85 percent of the state’s residential beds and 75 percent of hospital inpatient treatment beds were full, leaving little room for additional growth.
Oregon has the highest nonmedical use of prescription painkillers of any state, but only one in 10 individuals with opiate addictions receive treatment. Oregon ranked 49th in the percentage of patients who needed care that received it, in the latest national drug use survey. As as result, opioid-related deaths continue to climb, reaching 522 in 2014, up 13 percent from the previous year.
Rural concerns
The problem is compounded in rural areas of the country. A 2015 study from the Rural Health Research Center at the University of Washington, found that fewer than half (46.6 percent) of U.S. counties had at least one physician with a waiver. Thirty million people, just under 10 percent of the population, resided in counties with no waivered physicians, and 82 percent of those counties were rural. Moreover, the majority of rural counties also lack mental and behavioral health professionals, leaving few options for treatment.
Nationwide, 2.2 percent of physicians had obtained waivers, concentrated mainly along the the coasts, with large swaths through the middle of the country with almost no waivered physicians. Ten Oregon counties, mainly in the eastern part of the state, had none.
Holly Andrilla, a biostatistician who worked on the analysis, said about a third of all waivered physicians are the only ones with waivers in their county.
“They don’t have any backup,” she said. “That’s really problematic, if they go on vacation, or if they retire or they move.”
Andrilla and her team recently surveyed rural physicians to find out why more aren’t signing up for waivers. She said most doctors were concerned about the risk of diversion. Buprenorphine, commonly known by the brand name Suboxone, has a street value because it can help addicts with withdrawal symptoms in between heroin use.
Physicians also cited the lack of other mental health providers that could deal with the depression or other mental disorders that often accompany opiate addictions. Without the help from behavioral health specialists, many felt ill-equipped to handle such complex patients on their own in a primary care setting.
While treatment centers in Central Oregon generally don’t have waiting lists for addiction treatment, Rick Treleaven, executive director of Redmond-based BestCare Treatment Services said there aren’t nearly enough methadone clinics to meet the need.
“The number of providers in the state hasn’t changed in 15 years,” he said. “We added Bend Treatment Center here but Ontario lost theirs.”
Insurance coverage
Recent data shows about 50 percent of those on the Oregon Health Plan who have an opiate addiction are receiving treatment. Commercial plans, on the other hand, continue to place severe limits on access, particularly to medication assisted treatment, despite parity laws that require equal coverage for physical and behavioral health services. Veterans Affairs and Medicare, which covers individuals with disabilities as well as the elderly, also have significant barriers for accessing treatment and for treatment providers to get paid.
“So it’s not the poor people, it’s the middle class that often have more limited access,” Treleaven said. “If someone gets into an accident at work and is disabled, and then they get strung out on painkillers and they want treatment for that, well, they’re on Medicare so no access.”
The federal parity law for mental health and substance abuse treatment was passed in 2008. The Affordable Care Act passed in 2010 also listed substance abuse treatment as an essential health benefit that all plans must cover. But health plans still use a variety of tactics including prior authorization, requiring patients try other less expensive types of treatments first or limits on the number treatments or the duration of therapy.
“None of this has been tested in courts of law,” said Dr. Dennis McCarty, director of the Substance Abuse Policy Center at OHSU. “I think the insurance companies are vulnerable, but they’re going to make it difficult to access the benefit, until they are told they can’t.”
In other areas of the state, the limited supply of treatment slots is already leading to longer wait times.
“People try to get into treatment and they say come in for an intake appointment in four weeks, or if you try to get into residential treatments you can go on a waiting list for two or three months,” said Eric Martin with the Addiction Counselor Certification Board of Oregon. “That in and of itself is evidence of the need. You double or triple the number of your heroin addicts, but you don’t double or triple the number of methadone clinics.”
A national study published earlier this year, found 40 percent of individuals with addictions waited three to seven days for an initial appointment, and 12 percent waited longer than a week. The wait time for treatment averaged 43 days, and more than a third had not been linked with treatment after three months. Many simply gave up.
“One set of challenges stacks up on the other,” said John McIlveen, a policy analyst who serves as Oregon’s State Opioid Treatment Authority.
Expanding capacity
Methadone clinics are expensive to open and require a critical mass of patients nearby to justify the costs. Increasing the number of physicians with waivers could bring treatment to underserved areas faster, but doctors have not been enthusiastic about signing up.
To obtain a waiver, physicians must undergo an eight-hour training and adhere to a number of regulations that make it more complicated to prescribe than a cholesterol or diabetes medication.
“It doesn’t fit into the clinical workflow very well,” said. Dr. Amy Kerfoot, with Northwest Permanente and a member of the Oregon Medical Association. “The patient population can sometimes be challenging … They don’t always play well by all the rules.”
Many doctors say they fear losing their regular patients if they apply for the waiver and wind up with a waiting room full of drug addicts.
“The reality is they already have the waiting room full of addicts,” McCarty said. “If they’re prescribing opioids, they have patients addicted to opioids in their practice.”
Dr. Todd Korthuis, an addiction medicine specialist with Oregon Health and Science University, said doctors need more support to incorporate addiction treatment into their practices. He recently spoke with a rural physician seeing more than 1,000 patients in his primary care practice. Although the doctor was nearing retirement, he obtained a waiver and now treats 15 patients with buprenorphine.
“For him to go to the 30 patients he’s allowed to see, and still take care of all his little old ladies with diabetes and heart disease, it’s just overwhelming, so he feels like 15 is kind of his limit,” Korthuis said. “But that’s a success story. A lot of doctors don’t want to do the training, because they don’t want to see those patients in their waiting room.”
Increasing access, he says, needs to start with medical training. Most doctors had little training in addiction during medical school, and the field of addiction medicine is relatively new. OHSU is approved to train four addiction specialists per year, and has a surplus of applicants. But the medical school only has funding for one slot.
OSHU also has an addiction consult medicine line, which doctors can call to get help managing their patients. Starting this winter, addiction specialists will meet via video link with physician practices to go over their cases and help resolve problems funded by a federal grant.
Local efforts
That could help physicians in Deschutes County, which remains one of the hot spots for opiate abuse and overdoses within the state.
“If we could connect all the people who were motivated or willing to get engaged, who could benefit from medication assisted treatment, we would probably be woefully inadequate in our current supply,” said Dr. Mike Franz, medical director of behavioral health for PacificSource Health Plans, who chaired a medication assisted treatment workgroup for the Central Oregon Health Council.
The group is now working to increase capacity in the region through a hub and spoke model. Bend Treatment Center, as the hub, would start patients on medication assisted therapy and treat the more complex cases. Established patients would be handed over to the spokes, primary care providers and specialty behavioral health providers in the community with waivers.
Wyden is pushing for Congress to provide $920 million in funding to increase treatment capacity. The Comprehensive Addiction and Recovery Act passed earlier this year included a number of initiatives that would reduce the supply of opiates and increase the capacity for treatment and prevention. But Congress recessed this summer without passing the spending bills to fund the act’s provisions.
A continuing resolution provided $7.1 million in funding for the opioid addiction efforts, including $3.27 million in treatment grants. Oregon would get about $11 million of the $920 million. The state was also recently awarded a targeted capacity enhancement grant that will focus on underserved areas including Central Oregon.
“We looked at the places that have the toughest access, the highest hospitalizations and the highest death rates,” McIlveen said. “That’s where we went to focus our efforts in those areas.”
(Editor’s note: This article has been corrected. The original version misidentified John McIlveen’s title. He works for the Oregon Health Authority Health Systems Division and serves as the State Opioid Treatment Authority. The Bulletin regrets the error.)