Suboxone a critical step to treating addiction

Taos County providers describe barriers to providing treatment

By Nick Jebsen
For Taos News
Posted 7/18/19

Doctors say access to Suboxone - a drug that reduces cravings for heroin and other illicit opiates - is crucial to breaking the cycle of addiction. But those seeking …

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Suboxone a critical step to treating addiction

Taos County providers describe barriers to providing treatment

Posted

Corrections and clarification appended.

Doctors say access to Suboxone - a drug that reduces cravings for heroin and other illicit opiates - is crucial to breaking the cycle of addiction. But those seeking treatment face two challenges in accessing Suboxone in Taos County - a shortage of providers able to prescribe the drug and the distances they must travel to reach those seeing new patients.

"We have people coming in from Red River, Costilla, Colorado. We have people from Angel Fire," said Cecilia Rodriguez, an independently licensed family therapist who is intimately familiar with Presbyterian Medical Center's Medication-Assisted Treatment program. "I've been trying for months to refer people to providers in Taos because they're closer, but they're swamped."

Medication-Assisted Treatment is a comprehensive approach to treating addiction in which patients receive therapy, case-management from a social worker and, crucially, medication to reduce their cravings for substances. In the context of heroin and opioid addiction, this medication is often Suboxone, a combination of the opioid Buprenorphine and the opioid reverser Naloxone, which is commonly referred to by its trade name, Narcan. Though highly regulated, it has a significantly lower risk for abuse than methadone, and therefore does not have to be dispensed in specialized clinics.

While MAT is controversial, largely due to misconceptions about the effects of the drug and the science of addiction - and, in part, due to opposition from the for-profit rehab industry - there is a nearly unanimous consensus within the American medical community that MAT is a highly effective treatment for heroin and opioid addiction. The 2018 U.S Surgeon General's Spotlight Report on Opioids referred to it as "the gold standard for treating opioid addiction."

"It's almost impossible to break out of opiate addiction without Medication-Assisted Treatment," said Dr. Jemery Kaufman of Taos Medical Group, who is currently treating 30 patients with Suboxone.

"It's [been] the highlight of my career to see them get control back, to get their kids back, their lives back. You don't get quite that impact with diabetes."

Dr. Gina Perez Baron, a physician working on alternative addiction treatments, echoed this sentiment via email. Of her time in Taos, Perez Baron said, "What I observed working with these patients is, over time, the majority stabilized … so many got better, returning to their families, to school, to entrepreneurship, to activism and advocacy."

Waiver hurdles

Practitioners agreed that the first step of the solution to drug addiction was obvious - that more health care providers in the area needed to acquire their federal waivers to prescribe Suboxone, which in turn would enable patients living in remote areas of the county to receive treatment closer to their homes. And while auxiliary services like case management and therapy are recommended, doctors can treat opiate addiction with Suboxone alone if necessary.

But the process of acquiring a waiver to prescribe Suboxone has its own hurdles. Doctors who seek the waiver are required to undergo an eight-hour training session - a session that is 24 hours for physicians assistants and 30 hours for nurse practitioners - and have their patient records reviewed by Drug Enforcement Administration inspectors, a process Kaufman described as "quite derogatory."

Yet no such training or DEA inspection requirements exist to prescribe Oxycodone and other highly addictive opioid painkillers.

"I'm going to say that MAT was regulated incorrectly by the federal government. It's eight hours of training to get your waiver. You lose a full day of practice, and in medicine, if you're not seeing patients, you're not eating," Kaufman said. "It also created this methadone clinic-like stigma - the idea that people are going to be hanging around your office."

Kaufman also cited the harsh realities of providing health care in rural areas - where many providers are overworked and under-resourced - as a source of practitioner reluctance to obtain the waiver and add to their caseload.

"In private practice we have other patients we need to see for diabetes, for congenital heart disease. We have a shortage of health care across the board," Kaufman said, noting that, like Rodriguez, she too had MAT patients from Colorado. "There's a fear that if you get licensed, everyone in the state is going to know and you're going to be mobbed."

Matthew Probst, the chief quality officer of El Centro Family Health in Española, cited this as a concern for El Centro. "We don't want to enable other providers, we don't want to say, 'Just send them to El Centro,'" said Probst, when asked why his El Centro doesn't accept referrals for MAT. "We need the other 90% of the practitioners in the community to join us in this battle." Probst estimated that El Centro already had about 180 MAT patients in Taos County, making them by far the largest provider of the treatment services currently operating in the area.

Overwhelmed

On Tuesday (July 16) Holy Cross Medical Center and Taos Alive, an anti-drug coalition, held a Substance Misuse Summit in Taos titled "A Practitioner Call to Action." The event sought to educate practitioners and the greater community about Suboxone, as well as to encourage those eligible to acquire their waivers. Held at El Monte Sagrado, the evening included a two-and-a-half-hour presentation on Suboxone and the science of addiction, followed by a panel discussion featuring psychiatrists Snehal Bhatt and Daniel Duhigg as well as Kaufman.

All of the doctors on the panel described treating their patients with Suboxone as an immensely rewarding experience, and that their patients with Opiate Use Disorder were no more challenging to work with than their other patients. They spoke of seeing a majority of their patients stabilize over time, reunite with their children, of even seeing people formerly in the throes of heroin addiction embark on careers in business and activism. The panel then asked the practitioners present to share their apprehensions about offering MAT as a part of their practice, as well as their reasons for not having acquired their waivers yet.

"I don't have time - my workday is about six days longer than it should be," said Robert White, a primary care doctor with Taos Medical Group, was visibly exasperated by the implication that his lack of a Suboxone waiver was the result of some kind of oversight on his part. "There are hours and hours of every day that we're doing everything else people want us to do!"

After one doctor said he wasn't sure how he could integrate MAT into his practice, White cried out from across the room, "We are up to our eyeballs in alligators!" Others around him nodded in agreement.

Afterward, the panel asked how many of the estimated 100 practitioners present were in the process of acquiring their Suboxone waiver.

Only two raised their hands.

Next week: Transportation and poverty are two of the hurdles people struggle with in seeking help to overcome addiction.

Corrections: This story originally misspelled Jemery Kaufman's name. A previous version of this article misidentified Robert White as a physician with Holy Cross Medical Center.

Clarification: Holy Cross Medical Center sponsored this event, along with Taos Alive.

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