Editor’s note: This commentary is by former Vermont Gov. Peter Shumlin.
[T]he United States currently faces an unprecedented opioid overdose epidemic. In 2016, 42,249 deaths were linked to opioids nationally. Overdose deaths were five times higher in 2016 than in 1999, and many states saw significant increases in overdose deaths from 2015 to 2016.
The epidemic has additionally worsened following the increasing presence of fentanyl, a powerful synthetic opioid created for medical use that is sometimes manufactured illicitly. Fentanyl can be combined with heroin or cocaine either with or without the user’s knowledge. The United States experienced a 265 percent increase in fentanyl-related deaths from 2012 to 2015. Vermont’s overdose epidemic mirrors broader national statistics:
In 2016, 112 people died from opioid-related causes, a 41 percent increase from the year prior. Also in 2016, Vermont experienced an equal number of deaths from heroin and fentanyl for the first time. The opioid epidemic is dynamic and devastating, both nationally and in Vermont.
Vermont has implemented a novel approach in response to the rise in opioid use called the “hub and spoke model.” The hub and spoke model provides medications for addiction treatment (MAT), such as methadone and buprenorphine, alongside wraparound counseling services. MAT programs have shown strong efficacy in clinical trials in treating opioid use disorder, and use of the medications cuts the risk of death by 60 to 75 percent. The model uses over 75 spokes, or office based opioid treatment settings, as a point of contact for people with opioid use disorder. Patients receive linkage to nine centralized hubs. Spokes include settings such as primary care practices, outpatient addiction centers, and practices that see patients with chronic pain. They use doctors, nurses and counselors with specialized opioid use disorder training. Hubs offer more intensive treatment including all elements of MAT that people may require at the beginning of their recovery or upon relapse. People receiving MAT may move between hubs and spokes as their recovery needs change. Hubs additionally serve as knowledge centers that dispense trainings to spokes.
The hub and spoke model has shown success in increasing uptake of MAT services among people with opioid use disorder. For instance, Vermont now has the highest capacity for treating opioid use disorder in the United States with 10.56 people per 1,000 in treatment in 2016. More than 6,000 participants have enrolled in the program since implementation. The model has also been associated with reductions in health care expenditures, even after accounting for MAT program costs. In a study of medical claims among Vermont Medicaid beneficiaries with opioid use disorder between 2008 and 2013, patients receiving MAT were less likely to utilize costly services such as emergency room visits and hospital admissions than patients using traditional abstinence and detoxification-based recovery programs. While program success has bolstered access to MAT, one area in which the hub and spoke model has not yet expanded is into criminal justice settings such as prisons, jails and other community supervision settings.
Criminal justice settings represent opportunities to reach populations who may be at the intersections of risk for opioid use disorder. It is estimated that more than half of individuals in criminal justice-involved populations meet criteria for substance use disorder nationally. Additionally, risk for death among recently released individuals may be up to 12 times higher than in the general population in the two weeks following incarceration with overdose as a leading cause. Reasons for vulnerability to overdose are varied but include: 1) lack of tolerance to opioids after incarceration; 2) lack of social support from disruption in social networks; and 3) high stress upon re-entry. Correctional settings therefore may function as sites to engage individuals with opioid use disorder and provide necessary harm reduction for vulnerability to overdose after release.
Gov. Gina Raimondo of Rhode Island has recently followed Vermont’s lead in developing a statewide hub and spoke model, and further expanded it to help address people passing through the correctional setting. In 2016, the Rhode Island Department of Corrections, the state’s unified prison/jail system, launched a model of screening for opioid use disorder and initiating or continuing MAT treatment. If inmates screen positive for opioid use disorder they are referred to MAT with wraparound counseling services and linked to community MAT programming upon release. Preliminary findings published this week in JAMA Psychiatry showed increases in MAT participation and a 61 percent reduction in overdoses among recently incarcerated individuals from corresponding periods in 2016 to 2017 following program implementation. At the general population level, Rhode Island experienced an over 12 percent reduction in overdoses during the same period. These reductions occurred despite increased proliferation of fentanyl in 2017 and a widespread overdose epidemic.
Criminal justice-involved populations, who are among the most vulnerable to fatal overdose and face enormous challenges during re-entry, remain underserved by current public health approaches. Results in Rhode Island may serve as a model for other regions. In Vermont and across the nation, policymakers and health advocates should redouble efforts and expand MAT, especially into correctional settings. The hub and spoke framework serves as an opportune launching point for treatment and for intervening in criminal justice settings to rapidly reduce mortality from opioid overdose.
