Recently, Governor Peter Shumlin devoted his entire State of the State address to one critical issue: the rise of heroin addiction. As advocates for people struggling with substance abuse in Vermont, many of us were cheering. Now, here’s a politician who gets it. Governor Shumlin correctly argued that addiction is a chronic disease, requiring “treatment and support, rather than…only punishment and incarceration.” He pointed out that treatment costs the state far less than jail, and it produces lasting results.
I was grateful to see the problem of heroin addiction—and the need to invest in treatment—get the attention it deserves. As the governor discussed, opiate abuse and overdose in Vermont has increased exponentially in recent years, in keeping with nationwide trends. As prescription opioid abuse continues to rise, many are switching to heroin as a cheaper alternative. And as the demand increases, dealers are flocking to our region, where a $6 bag of heroin in New York City can be sold for as much as $40.
This growing epidemic has been the driving force behind a new treatment system for opioid addiction. In 2012, Vermont approved the creation of a “hub-and-spoke” model in which five “hubs” administer methadone and buprenorphine, providing a more intense level of care with the goal of stabilization. The surrounding “spokes” are primary care teams, which can also administer buprenorphine as well as ancillary services. While the implementation of this system hasn’t been smooth sailing, I applaud the effort. In the words of Deputy Health Commissioner Barbara Cimaglio, “It’s bringing together traditional medical providers and specialty substance abuse providers to address a very serious public health problem.”
Still, while opiate addiction is clearly a major issue in Vermont and elsewhere, this doesn’t mean that other substances have faded from view. Let’s not forget Old Faithful: alcohol. At Phoenix House Vermont, 13 percent of adult treatment admissions listed heroin as a primary drug of choice last year, while more than 50 percent listed alcohol. Nationwide, alcohol was a primary problem for about 44 percent of Phoenix House adult admissions, heroin for about 18 percent, and other opiates (mostly prescriptions) for six percent. I believe our data mirrors that of treatment programs across the country.
This speaks to the need to nourish the whole treatment and recovery system, rather than simply focusing on one class of drugs. We live in a small state, with a population a little larger than Staten Island’s, and we’re fortunate to have a recovery center in most of our counties. These centers receive a small grant from the state to have a building in which they host AA meetings, recovery coaches, and other key support services for the recovery community. However, the centers are responsible for their own fundraising to support their programs; they could do so much more with greater funding.
Additionally, we need to invest more in outpatient treatment. This means more resources devoted to training primary care physicians in addiction medicine. Across America, the Affordable Care Act is bringing addiction treatment into the realm of mainstream medical care—an important step toward closing the gap between the many who need help for substance abuse and the few who receive it. Vermont’s hub-and-spoke model is an example of this new push toward integrated care. But this system will only be effective if doctors understand how to spot the signs of addiction and address it appropriately. Our state, for example, has the most doctors per capita who are authorized to prescribe buprenorphine, but many have found themselves out of their element given that they have had no prior experience in addiction therapy. Some have been willing to prescribe the medication to existing patients, but are unwilling to take on new patients struggling with addiction. Only with better training will doctors be able to shift their perceptions of addiction, intervene early, and when necessary, make appropriate referrals to a higher level of care.
We must also open the treatment system to allow people in need to choose any qualified and licensed substance abuse clinician to provide their care. A recent JAMA study found that people living in rural areas, like many of the counties we have in Vermont, are less likely to have access to a substance abuse facility that accepts Medicaid. Currently, the treatment for Medicaid recipients can only be provided by a limited number of agencies selected by the state. While the expansion of Medicaid under the Affordable Care Act may make a difference, we must also focus on building the infrastructure to serve more Vermonters across our communities.
Now, I know budgets are tight and I don’t claim to know how to increase funding for these and other areas—although increasing a tax on alcohol and cigarettes and dedicating the revenue to treatment could help. But my point is that we can’t put all our eggs in one basket by focusing on one piece of a complex issue. If we really want to combat addiction and overdose—which, the governor noted, kills more Americans than car crashes—we can’t afford to place key priorities on the back burner.
Director, Vermont Programs
Phoenix House New England