Editor’s note: This commentary is Stephen M. Leffler, MD, who is is chief medical officer at the University of Vermont Medical Center.
The opioid crisis in Vermont is complex, and it cannot be solved by mobilizing one faction of our community, or pulling on a single lever. All of us – the medical community, law enforcement, local and state government and all of our community stakeholders — must work together to end this epidemic.
At a recent press conference led by Burlington Mayor Miro Weinberger, I joined several leaders from across our region to discuss collaborating to respond to the crisis. These community partners included Burlington Police Chief Brandon Del Pozo and his counterparts from South Burlington and Winooski, Chittenden County State’s Attorney Sarah George, Vermont Department of Health Commissioner Dr. Harry Chen, representatives from the Chittenden County Opioid Alliance, and many others. All of us joined Mayor Weinberger in committing ourselves to – in the mayor’s words – “doubling down” on the opioid crisis.
As a longtime emergency room physician in Vermont and also the chief medical officer at the University of Vermont Medical Center, I believe there are four key areas of focus for the medical community going forward:
Better and safer prescribing practices
The challenge we face in the medical community is to prescribe the right amount of medication – not too much and not too little. That sounds simple, but a one-size-fits-all approach won’t work. In order to decrease the number of people who become addicted through prescriptions, we must understand what the safest amount is to prescribe in different situations, and we must monitor our prescribing practices to ensure we aren’t over- or under-prescribing. The UVM Medical Center collects data on how many narcotics we prescribe in a month across different specialties. Going forward, if we are doing a good job of prescribing just enough to treat the problem, and no more, then we will see the total number of prescriptions and the number of pills per prescription we are writing go down. We have committed to tracking this data and sharing it publicly.
More aggressive and effective treatment
Another focus for the medical community is decreasing the number of people dealing with addiction on the waitlist for treatment and decreasing the length that they are waiting for treatment. A year ago, there were 600+ people on the waitlist for treatment in Vermont, and they were waiting more than 12 months for treatment, increasing their risk of continuing to use illicit opioids, contract an infectious disease, overdose and prematurely die. Today, we have about 130 people on the waitlist, and they are waiting two to three months for treatment. What is our goal? To be successful, we should have no one on our wait list, and anyone who needs treatment should be able to get it immediately. We are working toward that goal by increasing the number of clinicians who are trained and approved to prescribe – not just physicians, but also physician assistants and nurse practitioners. In Chittenden County, we have expanded our “hub-and-spoke” model, increasing the number of people treated in the hub at the Howard Center’s Chittenden Clinic Medication-Assisted Treatment Program and increasing the number of primary care clinicians who are providing medication assisted treatment in what we refer to as the spokes. In between the hub and the spokes lies our Addiction Treatment Program, run by addiction psychiatrist Dr. Sanchit Maruti, where patients continue the treatment started in the hub, and begin the transition to the primary care setting. Throughout this transition, they receive support and therapy from spoke staff and clinicians in support of their outpatient treatment and long-term recovery.
Innovative Research
As an academic medical center, UVM Medical Center and our partners at the Larner College of Medicine at the University of Vermont are committed to research and education to address the opioid crisis more effectively. One example of that is the breakthrough research of Dr. Stacey Sigmon, a UVM addiction research expert and director of the Chittenden Clinic. Dr. Sigmon recently published the results of a study to test an “Interim Buprenorphine Treatment” (IBT) regimen for wait-listed opioid-dependent adults in the New England Journal of Medicine. IBT participants received buprenorphine maintenance dispensed via a small-computerized device. They were monitored daily, and not only did they achieve far more abstinence from illicit opioid use than nonparticipants, but they also demonstrated several other positive impacts such as reduction in anxiety and depression.
Focus on Medical Education
In addition to research, we are also focused on educating our clinicians and learners through a variety of educational sessions and programs. I would cite just one example – the work of Dr. Charles MacLean, associate dean at the Larner College of Medicine at UVM, and his colleagues in the Office of Primary Care and Area Health Education Centers (AHEC) Program. Dr. MacLean led a team that developed “Opioid Prescription Management Toolkits” that collect the best practice strategies for managing prescriptions in primary care and other ambulatory settings. The goal of these toolkits is to identify the most helpful methods used to create predictable and well managed opioid prescribing patterns for physicians, nurse practitioners and physician assistants and their patients.
In conclusion, the UVM Medical Center is committed to working with our partners in Burlington and across Vermont to continue to address the opioid epidemic. There is much more work to be done, and working with our community and state partners we are up to the challenge.
