Caregivers Face Agonizing Decisions

Front Page / Feb. 27, 2014 11:09am EST

By Donna Olsen

I n his State of the State address about heroin and opiate addiction in Vermont, Gov. Shumlin stressed the need for treatment.

“Let’s start treating drug addiction as the immediate health crisis that it is by dramatically increasing treatment across Vermont,” he said.

“Right now we have hundreds of Vermonters who are addicted and are ready to accept help but who are condemned to waiting because we still do not have the capacity to treat the rising demand,” he said

Laurina Holt is coordinator of Medically Assisted Treatment (MAT) at the Clara Martin Center. Daily she sees people coming through the door asking for inpatient treatment or asking to get on the Suboxone and Methadone programs for their addiction to opiates or heroin.

“That’s a huge problem we have as a state, not having enough beds or treatments available for people,” said Holt.

“People will come in here and want in-patient or want to be put on the program and have to wait a long period of time. And during that time most of them are still continuing to use because they can’t stop.”

Heroin is an opiate, and there are a lot of other opiates used such as Oxycodone, Percocet, and Vicodin. If someone is addicted to opiates they can go to Clara Martin Center or one of the other treatment centers in the county.

They can either go in-patient or attend out-patient groups. “Intensive out-patient” groups meet three times a week. Central Vt. Hub “How it works for the Clara Martin Center is, somebody comes in and they meet with me. If they say they want to go on and be assessed for the Suboxone Program, then I refer them to Central Vermont Addiction Medicine (CVAM) in Berlin,” said Holt.

CVAM is a joint effort between Central Vermont Abuse Services and Bay Area Addiction Research and Treatment (BAART) to provide comprehensive assessment, evaluation, induction and treatment for those 18 or older who meet the criteria for opioid and the clinical and physical criteria for agonist therapy. A collaborative effort with BAART health services also does Methadone maintenance.

Once it is decided that someone is appropriate for either program, the patient has to go through an induction process. The patient is started off on a dose of Suboxone and they are monitored by a nurse and a doctor at CVAM. It is all outpatient and people have to go daily to get their dose of Suboxone in the beginning until they have established the appropriate dose for them. Everybody is on different amounts.

Methadone treatment is also through a doctor but patients remain at CVAM. Suboxone can be prescribed by local doctors once the patient completes the induction process.

Under Vermont’s Blueprint for Health, CVAM is considered a hub, where all the doctors have their patients go to be assessed. Then there are “spokes” across Vermont. Clara Martin Center and Gifford Medical Center are spokes and so are the doctors who prescribe Suboxone.

Physicians Speak Out

The Herald did a joint interview with Dr. David Pattison, an internist at Gifford Medical Center and Dr. Kevin Buchanan, a psychiatrist at Clara Martin Center. They are the two doctors in Orange County who prescribe Suboxone to opiate -addicted patients.

“We are both prescribing Suboxone for maintenance purposes, meaning once people are off their illegal drugs and stabilized and they’re in a good place in their recovery, they’re ready to come out to the community and rebuild their lives,” said Pattison.

Dr. Pattison is an adult primary care doctor and a pediatrician and treats the whole family spectrum. He sees patients in their twenties who say they started on opiates in their teens.

“There is definitely a wish that if some young person, teenager, is trying and getting started on drugs, you wish you could get them off everything and not even have to have them on Suboxone.

“And I think that a lot of people succeed in getting clean,” said Pattison.

The doctors have been prescribing Suboxone since 2006. Their numbers have been increasing over past several years. Those numbers, however, reflect only the ones seeking treatment. There are a lot of people who are not seeking treatment.

“People are telling me that they have no trouble getting opiates on the streets in all our surrounding towns. That it’s very easy,” said Pattison.

“We see our numbers have only been going up and up and up. There is no down trend,” said Buchanan.

As the legal system sees more and more crime related to drugs, these doctors are seeing more patients in need of opiate addiction treatment.

“It just seems like there has to be more and more people getting involved in this as time goes on,” said Buchanan.

A Lot of Debate

According to Buchanan, there is a lot of debate about Suboxone and the treatment of opiates. There are a lot of young people getting on opiates and then trying to get off opiates by getting on Suboxone. They get their life back, get off the street and quit getting into legal trouble.

But then Suboxone itself becomes an issue. It is very hard to get people off of it, so patients become tethered to the medical system. There is no limit on how long a patient can be on Suboxone.

“It can be very hard to get them off, but this is known for Methadone too—that when you try to get people off methadone, a high percentage relapse,” said Pattison. “And the same thing happens with Suboxone. The same thing happens with Oxycodone and heroin. You try to get them off. You get them to zero by tapering, and a lot of them relapse. It’s a bad problem; a big problem,” said Pattison.

According to Pattison, it is very hard to overdose on Suboxone and kill yourself. The drug has a long half-life which means people are not needing to be dosed multiple times a day. They can be dosed every day or even every other day. It also blocks the effects of other opiates: If someone takes a heroin overdose on top of their Suboxone, they are less likely to die.

Hard To Resist

However, Suboxone itself is hard to resist.

“I believe it’s the strongest affinity for the receptor of any of them,” said Buchanan. “It is a very powerful med that satisfies the brain, but when you try to take that away from the brain it’s very hard; the brain has a harder time adjusting. So people stay on it because of that.

“The second thing is I think people are just scared to death that they are going to relapse (to heroin) and be back on the street.”

The opiate addicts come in all shapes and sizes and situations, the physicians noted. Some need to be on a long program of Suboxone or Methadone, if they have had years of hard use and it would be too risky to take them off.

“The biggest concern for me is these young people, 20 something, getting on this and then some of them might be on Suboxone for years. I think that’s some sort of moral,” said Buchanan.

“We both feel uncomfortable with that, but the alternative for a lot of people is very destructive illegal drug use. In Paradise no one would be on Suboxone either,” said Pattison.

A Way Out

Both doctors agree that when someone’s life is falling apart with opiates, Suboxone is a way out and very effective. But to get it, they must sign a contract that they could be on for years, agreeing to meet with a counselor at least once a month. They are required to submit to tox screens and surprise drug counts. If they break the contract they could be referred to a higher level of treatment.

Currently Dr. Buchanan and Dr. Pattison are the only two doctors prescribing Suboxone. A lot of doctors don’t want anything to do with opiate patients.

“We all came up through our practices being deceived and taken advantage of and screwed around by drug seekers and opiate addicts,” said Pattison.

There are 100 people on the waiting list for the Suboxone program at the hub. But when the governor creates more staff at the treatment centers, as he has proposed, it creates another problem. There would not be enough spokes.

And this population takes up a lot more time of Buchanan’s and Pattison’s practices than the average patient.

“It’s tremendously time consuming, because there is always something that is going on,” said Buchanan. “It comes down to how you are going to have to deal with all these different things. The problem is that there are not enough resources. There is more demand than supply at both the hub and the spoke,” he said.

“Right now I spend a quarter of my time doing this. And do I really want to do more than that? I have regular patients too,” said Pattison.

Still, both doctors agree that it is good work. People have problems and they are asking to get better. They have a treatment that has potential for making them better and a lot of them do get better.

“That’s why we are in medicine— to help people,” said Pattison.

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