Health Care

Some still wait for opiate treatment, despite progress

BRISTOL — Last month Therese Giles watched a nightly news report in frustrated confusion. The governor and other officials were saying opiate addiction treatment was now readily available to those seeking it.

At a Sept. 14 news conference in Burlington, Gov. Phil Scott told reporters, “Today we can say Vermont now can quickly meet the demand for treatment services in all 14 counties.”

Phil Scott
Gov. Phil Scott. File photo by Bob LoCicero/VTDigger

Though the governor and other speakers cautioned that there was still more work to be done, several media outlets, including VTDigger, understood his statements to mean there were no longer treatment waiting lists in the state.

Giles is a registered nurse and the case manager for the opiate treatment program at Primary Care Bristol. That program has a waiting list of close to 90 people. She said Tuesday that the next person on her list had been waiting to get into the program since February 2016.

Most people on that list are active drug users, Giles said, who face a greater risk of overdose if they don’t get help.

The reality she sees at work doesn’t match the recent public impressions, according to Giles.

“We feel like that message is one that’s not completely accurate, because we have a lengthy waiting list here in Bristol,” Giles said.

Scott spokeswoman Rebecca Kelley said the governor and members of the administration were simply joining local officials in Burlington to mark an important milestone, the elimination of the waiting list at the Howard Center Chittenden Clinic, which for years had the longest queue in the state.

“I don’t think it was ever presented that there were not waitlists across the state,” Kelley said. “This was about recognizing there was no longer a waitlist for the Chittenden Clinic and being able to move people quickly into treatment throughout the state.”

Kelley said she could not speak to the specific situation of Primary Care Bristol, which is operated by Porter Medical Center, a recent affiliate of the University of Vermont Health Network.

Giles said she is concerned that the governor’s message, despite its acknowledgment that more needs to be done, could leave physicians in Addison County, or other underserved areas of the state, with the impression the situation is under control.

Too many physicians are already reluctant to get certified as opiate treatment providers because of a persistent stigma that the patients will be disruptive, Giles said.

Waitlist, Opiates
The Chittenden Clinic in South Burlington. File photo by Morgan True/VTDigger

The Chittenden Clinic is one of six “hubs,” or large clinics that offer methadone and serve patients who need more support than can be provided in a doctor’s office. A wider range of providers — from primary care practices like Bristol, to health centers and standalone psychiatric offices — known collectively as “spokes” offer less-intensive care to recovering addicts alongside patients with other medical needs.

Vermont has seen a marked increase in the number of spoke providers certified statewide, thanks in part to recent federal legislation allowing physician assistants and some nurses to become certified as opiate treatment providers.

In September 2014 there were 128 certified spoke providers. As of June this year, the most recent figures available, there were 203, according to a Health Department report.

But in some pockets of the state, most notably Addison County, there is still a dearth of providers.

A major reason the Chittenden Clinic was able to eliminate its waiting list was a concerted effort by the UVM Medical Center to get more of its doctors certified in opiate treatment.

The Vermont Department of Health closely monitors waiting lists at the six hubs. Far less is known about who is waiting for spoke services. That’s partly because there are 77 spokes, and unlike the hubs, they’re overseen through a Department of Vermont Health Access program known as the Blueprint for Health.

The blueprint offers money for spoke providers to hire support staff, nurses and counselors to help administer drug treatment services based on the number of Medicaid patients served.

“There is no centralized way of tracking waiting lists for spokes, because there are so many,” said Beth Tanzman, executive director of the Blueprint for Health.

Still Tanzman, who was aware of the waiting list at Bristol Primary Care, said she doesn’t share Giles’ concerns about providers becoming complacent after the governor’s recent announcement. Tanzman said she’s not aware of any other areas with similar waits to what exists in Addison County.

“We have much more contact with physicians and prescribers, and people understand the importance of access across the state’s network,” Tanzman said.

There is also no way to know how great the demand ultimately will be for spoke services, or medication-assisted treatment generally, because there are few estimates of how many people are addicted to opiates, Tanzman said.

When the acting head of the Office for National Drug Control Policy visited Vermont earlier this year, praising the state’s progress in expanding opiate treatment, he cited a figure that nationwide 8 out of 10 opiate-addicted people aren’t seeking treatment.

What the state does track, when it comes to spokes, is the number of certified providers in 13 regions across the state. The latest figures, from June, show that Addison County, the Springfield area and the Upper Valley have the fewest spoke providers.

Mountain Health Center in Bristol will begin offering medication-assisted treatment Oct. 16 with two prescribers, which is expected to reduce the waiting list at Bristol Primary Care.

However, it’s challenging for spokes to scale up their programs, said Susan Bruce, Blueprint for Health coordinator for Porter Medical Center. Prescribers can treat up to 30 patients during the first year and up to 100 at any given time thereafter, but figures from the state show 78 percent have fewer than 10 patients.

“It’s a slow building process,” Bruce said. “For each provider that has their certification to take on 30 patients would be difficult.”

That’s because programs need to hire qualified support staff to handle administrative and case management work. But Blueprint payments to hire support staff only follow Medicaid patients, which for Primary Care Bristol is just two-thirds of its caseload.

As patients at the spokes stabilize, improve their lives and find jobs, they may lose Medicaid benefits or get private insurance through their employer. That means less money for the spoke. “Basically by having our patients become successful, we sort of shoot ourselves in the foot,” Giles said.

Still, seeing people get healthy, find jobs and move forward with their lives is what makes the work she does rewarding, Giles said. “You can’t imagine how gratifying that is,” she said.

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