BRATTLEBORO — For people ready to seek treatment for substance-use disorder, timing is everything.
The more quickly someone receives support, the more likely they are to enter a recovery program, said Kurt White, director of ambulatory services at the Brattleboro Retreat as he and a number of colleagues introduced the Rapid Access to Medication Assisted Therapy (MAT) program.
The program, a collaboration among the Retreat, Brattleboro Memorial Hospital, and Turning Point of Windham County, will provide another pathway to recovery.
“I have often colloquially said that we need to 'strike while the iron is hot' - and work to capture the person's moment of readiness,” White said. “It is in the nature of addictive disorders that moments of willingness can come and go, and in a very real way, there is always a pull toward use and relapse.”
This program aims to provide fast, low-barrier access to treatment through BMH's emergency department. The 24/7 program surrounds people in active withdrawal from opioids with a variety of services.
These services include trained recovery coaches; emergency access to medication, if appropriate; and urgent next-day referral to the Retreat's Hub program, which provides outpatient suboxone treatment services.
The program, which quietly launched in June and has moved nine people through, is designed to serve those experiencing an emergency or dangerous withdrawal. For others, the Retreat's HUB program should be their first call.
Matthew Dove, a nurse practitioner in the BMH emergency department, has been involved with the program from the beginning.
“The emergency department gives a platform - it gives a place - to provide access to a medication that can be lifesaving for many people,” he said.
The program builds off the synergy of existing collaborations - specifically, with Turning Point of Windham County and the recovery coaches the Brattleboro nonprofit has embedded in the emergency department.
“That work has been transformative for not only patients, but also our emergency department in looking at trauma-informed and trauma-responsive care and how to really meet the needs of someone struggling with substance use,” Dove said.
Recovery coaches are available around the clock in the emergency department, where patients can ask to speak to them regardless of whether they enter a recovery program.
“Coaches provide compassionate and active listening, resources, and referrals,” said Susan Walker, executive director of Turning Point. “Their experience in recovery provides hope that recovery is possible and makes it easier for emergency department patients to share their stories.”
Representatives from BMH, the Retreat, and Turning Point formally unveiled the program during a press conference at BMH on Nov. 6. The partners started discussing the program in 2018.
According to a report by the Vermont Department of Public Health, “Opioid-Related Fatalities Among Vermonters,” issued in February, Windham County had the highest per-capita rate of fatal opioid overdoses in Vermont for two years in a row. In 2017, 13 people (30.3 per 100,000) died from fatal opioid overdoses. In 2018, that number increased to 21 (49.0 per 100,000).
“These days, we are especially concerned about people remaining in a state of relapse or using substances, because negative consequences [including, but not limited to, overdose and death] are ever-present risks,” White said.
“If someone knows they are in crisis and can get help right away, there is at least some chance we can make a connection that changes the trajectory of the person's life and recovery for the better,” he added. “If we miss the moment, who can say what will happen next?”
Building the program
The new program based at BMH is modeled on efforts of other Vermont emergency departments. Locally, the partners made some adaptations so the MAT program can match the services available here.
The partners also worked hard to create a unified workflow across all the organizations - not an easy feat for system and regulatory-heavy organizations such as hospitals.
“Usually it's a workflow in each organization and then we try to mesh it together, but we really looked at a workflow algorithm cross-organizationally,” said Becky Burns, RN, Director of Community Initiatives at BMH.
“It was a pretty impressive process, I think,” she said.
Burns said the recovery coaches are vital because they can accompany a patient through the whole recovery process, helping them in a number of ways, including taking them to appointments or navigating programs.
The medication used by the program to help reduce the physical symptoms of withdrawal is buprenorphine, an opioid that is also an opioid partial agonist.
“This means that, although Buprenorphine is an opioid, and thus can produce typical opioid effects and side effects such as euphoria and respiratory depression, its maximal effects are less than those of full agonists like heroin and methadone,” explains the website of the National Alliance of Advocates for Buprenorphine Treatment.
“At low doses Buprenorphine produces sufficient agonist effect to enable opioid-addicted individuals to discontinue the misuse of opioids without experiencing withdrawal symptoms.”
Using the medication, however, requires a daily protocol. So, while people can start the medication in the emergency department, they must continue the protocol through the Retreat's Hub.
Dr. Geoffrey P. Kane, chief of addiction services at the Retreat, explained that buprenorphine has shown to be a safer alternative with a lower chance of negative side effects for people using medication-assisted treatment, he said.
Kane cautioned that the drug isn't a golden ticket on a one-way train from dependence to recovery.
It's like wearing cleats to walk across a frozen lake, he said. The cleats provide extra traction, but the person still needs “to do the work” by walking.
Kane noted that in most emergency departments that offer medication-assisted treatment, the program operates from doctor to doctor. A doctor prescribes the medication in the emergency department and then follows up with the patient within their own office, Kane said.
The rapid program, however, operates institution-to-instituion.
“Which gives the services to the community more legs than when it hangs on a single practitioner,” he said. “And the possibility here for handling a higher volume of patients is there as well.”
“A trend noticed on the statewide level is that there seems to be an increased need [for] but a decreased utilization of [recovery programs],” White said.
He sees evidence that, in the last couple of years, Vermont has done a good job of getting people living with opioid-use disorder into treatment.
“But as the epidemic has worn on and become ever more lethal with fentanyl entering the mix - the population that hasn't gotten treatment yet has gotten more complicated and not so easy to reach,” White said.
With complicated cases, patients might need to interact with a coach or doctor dozens of times and build a level of trust before they're ready to enter treatment.
“Peer recovery coaches have lived experiences themselves with these issues,” said Walker. “[Patients] may push away help at first, but when there is somebody there who can identify with them, it just makes it easier to start a conversation.”
Kane said that addiction does not come with a typecast or a specific demographic. Yet research has shown that some life experiences - hunger, low income, trauma, or a lack of housing, for example - can increase people's risks of developing an addiction.
“People who have more advantages in society, if they do develop addiction and start in treatment, have a better prognosis; it's easier for them to get better,” Kane said.
“By reducing the disadvantageousness in the population, we reduce the risk of addiction, and when people in [other] populations have addiction, if we counteract their disadvantages, we improve their prognosis,” he said.
Barriers
Creating a program with as few barriers as possible required the partners to jump several hurdles of their own.
For example, they needed to create systems that moved seamlessly between the three organizations, especially when it came to inter-organization information sharing.
“That was huge - how can we help this person get to the next step with the least amount of resistance?” Burns said.
Walker added, “Everything is about relationships.”
Another challenge: providing services for a chronic condition in a medical setting that is squarely set up to look only at the short term.
As Dr. Alison P. R. Kapadia, site director of BMH's emergency department, explained, emergency medicine is meant to be a quick stop where a patient's emergency condition is evaluated and stabilized before the patient is transitioned “to more definitive care,” such as a primary-care doctor or the intensive-care unit.
Emergency departments are not set up to manage chronic issues, she said. For example, if someone is admitted to the department in diabetic shock, the staff will stabilize the person, but managing diabetes long-term is handled by an outpatient program or by one's personal physician.
“There is not a lot of training in how to manage addiction in the emergency department because it's not really effectively managed in the emergency department,” she said.
Furthermore, opioids, and their use in something like an MAT program, are highly regulated by both the state and federal governments.
For example, doctors who prescribe buprenorphine must obtain a federal waiver, called an “X waiver,” from the U.S. Drug Enforcement Administration. The process requires eight hours of training.
“In my mind, this is completely unnecessary and is a barrier to care that is left over from a time when opiate addiction was even more stigmatized than it is today,” Kapadia said.
She is particularly frustrated by this extra work for a medication like buprenorphine, considered safer than all the other opiates on the market.
As a result, many physicians felt that getting the waiver would be a waste of time, she said.
“We had to emphasize [to staff] the importance with addiction,” Kapadia added. Program organizers had to convince their colleagues that although drug-dependency issues are not treated in the emergency department per se, “when somebody presents to the ED seeking help, if you can start their robust outpatient therapy in the emergency department, that can save their life,” Kapadia said.
All of the hospital's 17 emergency physicians are allowed to administer buprenorphine, but to date, only seven are “X waivered” and can write prescriptions.
Kapadia added that BMH shares its emergency physicians with Cheshire Medical Center in Keene, N.H., which is also part of the Dartmouth-Hitchcock health-care system.
Funding for the program comes from the partner organizations. Some of the services are covered by health insurance.
“There has not been a large injection of money to help us fund this process,” White said.
Walker said the state funds nine recovery coaches in emergency departments throughout Vermont.
It's not all about opioids
The Rapid Access to MAT program specifically focuses on supporting people struggling with opioids. Yet, opioids are only one addictive substance among many - and Vermont struggles with all of them.
Approximately one third of the cases that recovery coaches work with dealt with opiates., but alcohol is the number-one issue coming into the emergency room, said Taylor Wellington, director of emergency services at BMH, who referenced recent data gathered through the nine statewide emergency department coaching programs.
Often an alcohol-related death is called something else, like a “slow cardiac disease” or a “GI bleed,” Wellington said.
“We're at a fairly unfortunate moment in our society where we have a serious opioid problem, a serious and ongoing alcohol problem, and a burgeoning problem with people getting into trouble with cannabis,” White said.
“We seem to be at the beginning of a stimulus epidemic, so we really need to think about how we can all work together to help the individual and a little bit less about the substance.”