Opiate addiction and how best to treat it continues to be a focus in Vermont. And that includes the question of where to provide medication-assisted treatment.
Often, people are seen in one of Vermont’s five main treatment centers, or "hubs." But lately, physicians are being encouraged to see such patients in their own local practices.
Physicians like Dr. Alicia Jacobs, whose office is in Colchester. “I think that, in the end, we all understand that opiate addiction — or ‘substance use disorders,' as they’re now called — really is a chronic relapsing, remitting illness that needs attention in a medical home,” Jacobs says.
“Medical home” means your doctor’s office. And that’s where Jacobs says she’s seeing a “significant shift” – with many physicians now willing to take on patients whose health issues happen to include addiction.
The idea seems pretty straightforward. Jacobs says physicians are being called on to treat people with addiction disorders like they would any other patient in their practice.
“We want to take care of them in their medical home, in their primary care office – just like we take care of everyone else," she says. "That's the aim and goal is to normalize this care. However that’s not what we’ve been doing. These patients have had to go elsewhere to receive this kind of treatment – most specifically at the Chittenden Center – which is the Howard ‘hub', for this kind of care.”
One of those patients is James Rebinskas, who recently shared his addiction story at a medical conference in Burlington.
Rebinskas says he’s been in recovery for six years and has been receiving Suboxone – which helps reduce cravings for opiates – at the state’s busiest hub: the Chittenden Center in South Burlington. Until recently.
“One day I was at the clinic," he says. "And my caseworker came up to me and she said, ‘Hey, if you're interested we’re starting this new program where we're taking the stable people, and we’re moving them to local doctors. Would you be interested?' And I was like of course! That’s always been my goal.”
Rebinskas has been seeing Dr. Jacobs for about four months now. He says his overall health has benefited from having a one-on-one relationship with a physician, and getting a Suboxone prescription is just part of the visit.
“I’ve got to do a urine screening of course every month, but as long as I'm not relapsing, I should just be treated like any other patient," he says. "I come in, she takes care of my overall health problems, and then just, you know, prescribes the Suboxone. I mean it's as easy as that. Why they make it such a big thing to ... prescribe Suboxone … it’s beyond me.”
But Dr. Jacobs says it has been a big thing for physicians because it involves a whole new way of thinking about substance abuse disorders. The new idea is that failure to stay clean is often part of the recovery.
“In the past we have really thought about it in a disease-model concept, where we're aiming for abstinence and we don't tolerate relapse. And really the truth is — moving towards a ‘harm reduction model,’ where we can minimize use and help these patients get wrap-around services to help with a lot of the social determinants of health and all of the challenges in their life," Jacobs says. "If we move toward that it elevates the calling.”
So in laymen’s terms, what does this mean for physicians?
“I think it is a significant mindset shift," she says, "where physicians understand that this might even feel like uncomfortable care. It is uncomfortable to be prescribing and wonder if it might be diverted. It is uncomfortable to have someone relapse – that can feel like a failure both to the patient and the physician. And so really, it's complex to understand and know how to respond to those kind of relapses in this chronic disease."
Uncomfortable, perhaps. But Jacobs says doctors in Vermont have been responding to the call to provide greater access to treatment.
And that, she says, is the most important concept of all.
"Understanding that substance use disorders are chronic," she says. "And that people will have relapses, people will struggle along the way but also that when they are in treatment — and that can range from being on methadone replacement to vivitrol to Suboxone — if they are in treatment they have better outcomes and this is the most important concept. So if we can have them in treatment and accessing services that will help them with this issue, then their outcomes are so much better, mortality is so much lower and that's what we want.”
And while treatment can be costly, Jacobs says it's less expensive than paying for overdoses or incarceration or hospital stays. It is, as she describes it, "a worthwhile investment."