23 minute read
Beyond Opioids
Story by Kristen Munson
Photos by Andy Duback
It seems like an old story now. Painkillers prescribed by a well-meaning doctor that lead to addiction and a deadly downward spiral. In the early days of the nation’s opioid epidemic, it seemed everyone knew someone who lost someone to a bottle of little white pills. Two decades later, the storyline has changed, and yet stubbornly remained the same—people are dying, and they don’t have to.
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It starts with a flood. In the mid-’90s, the introduction of oxycontin, a narcotic painkiller heavily—and falsely—marketed to physicians to treat patients without the risk of addiction, set off a cascade of death. Regions of the United States blanketed with prescriptions quickly became plagued with addiction. And when prescriptions ran out, people turned to illicit sources like heroin.
In Vermont, Governor Peter Shumlin devoted his 2014 State of the State to address the rising rates of opiate addiction. That year, there were 63 overdose deaths in Vermont. Shumlin called for treating addiction as a chronic illness and expanding drug treatment. He cited Vermont’s innovative huband-spoke model—developed in 2011 by John Brooklyn ’79—as a path forward. The model integrates medication for opioid use disorder (OUD) into primary care settings using a system of hubs—sites that could distribute methadone, an effective but highly regulated medication— and spokes—providers in general medical settings who could prescribe buprenorphine, a medication with fewer restrictions. The move helped eliminate waitlists for treatment in Vermont.
“Within four years of Shumlin’s speech Vermont had the highest per capita number of people on medications in the country,” says Rick Rawson ’70, Ph.D. ’74, a research professor at the University of Vermont’s Center on Behavior and Health. “Vermont really is viewed nationally as a leader in how aggressively opioid use disorder was addressed.”
It still is. Vermont ranks first in the nation for the percentage of adults with OUD on either methadone or buprenorphine.
“No other state comes close,” Brooklyn says.
But it may not have been enough. In recent years overdose rates have risen as subsequent waves of addiction became more complex. And the arrival of the COVID-19 pandemic didn’t help. People lost their housing and jobs. Some individuals in treatment had to scramble and shift clinics. Overdose rates soared. Last year, 244 Vermonters died of opioid overdoses—the most ever—and 2023 appears to be another record-breaking year.
So, after a decade of taking the problem seriously, why are we here?
“I like to think we built a system that could survive a hurricane,” Brooklyn says. “We have access points all over. We weren’t prepared for a tsunami.”
The pandemic overlapped with another killer wending its way to Vermont—the introduction of fentanyl, a narcotic pain reliever 50 times more potent than heroin, into the illicit drug supply.
“With fentanyl, the margin of error is just so small that two milligrams will get you high, three milligrams will kill you,” Rawson explains. “It looked like the hub-and-spoke turned the numbers down … then fentanyl changed the rules. ... We’ve had to recalibrate.”
Last year, 93 percent of Vermont’s opioidrelated overdoses involved fentanyl compared to just 11 percent in 2011. And increasingly, street supplies are cut with harmful fillers like xylazine, a powerful sedative for veterinary uses, and gabapentin, an anticonvulsant, that reduce the effectiveness of drugs like naloxone (also called Narcan) that can reverse a person’s overdose. The side effects range from depressed breathing to skin sores that rot flesh.
The pervasiveness of fentanyl in the drug supply has also made gold-star medication treatments less effective. People who use fentanyl while on buprenorphine, for example, can go into painful withdrawal.
“Buprenorphine—which was highly effective against heroin—is much less effective in the fentanyl era,” Brooklyn says. “So, for many people, methadone becomes their only option. And then it’s a lot more difficult because you have to go to a hub. You can’t go to your primary care provider or do a televisit and go to a pharmacy to pick it up.”
The timing is unfortunate. We are in the fatigue phase of the current drug epidemic, Rawson explains. The early overdose fatalities were often tied to prescription opioid misuse, and the problem affected the old and young. People with successful careers. Kids with bright futures.
“The people dying [now] are the more chronic, long-term, unhoused, mentally ill people who have been wrestling with their addiction now for a long time,” Rawson says. “The folks who aren’t the children of leaders in the community. And it’s [easier] to ignore the fact these folks are dying.”
But they deserve to live, too.
Capitalizing On Emergencies
This is what drives Roz King ’14, M.S.N.’19, a clinical nurse and director of research in the UVM Department of Emergency Medicine. She has witnessed dozens of patients take their first steps towards recovery in the emergency department through the Start Treatment and Recovery (STAR) program. The idea is to capitalize on moments when a person is receptive to treatment.
In 2018, the Substance Abuse and Mental Health Services Administration (SAMHSA) awarded King and Dan Wolfson, M.D. ’00, an associate professor of medicine at UVM’s Larner College of Medicine, a grant to develop STAR, to initiate patients onto buprenorphine in the emergency department and funnel them into treatment in their community upon discharge.
“Initially we did envision that the people we would enroll would be patients who overdosed and were brought into the emergency department,” King says. “And we did have some of those patients. But this is where the teaching hospital aspect comes in.”
Most STAR patients came from referrals by hospital staff or surfaced by research coordinators like Jackson Lyttleton ’22 who screen patient medical records for eligibility in studies. In the past, people who wanted medication-assisted treatment made appointments with providers or walked into clinics. But for some people, the moment they decide to seek help may not occur during regular business hours.
“Addiction is messy and difficult,” King explains. The STAR program addresses the gap outside the hours of 9 to 5. “What is more low-barrier than an emergency department? We are always there.”
In 2022, SAMHSA awarded King’s team a five-year, $3.7 million grant to expand STAR treatment to include prescribing methadone. The goal is to enroll 312 people by the end of year five. At year one, they are already far ahead of their goals.
“It’s a much bigger need than we anticipated,” she says. “[Overdose deaths are] continuing to rise, and so that is why programs like this are so important to get people the help right when they need it.”
The STAR team brings peer recovery coaches, addiction specialists, psychiatrists, physicians, and nurses together to find ways to streamline intake processes and improve outcomes in a population where successes can be a long time coming. Lyttleton spends his days scanning medical records, visiting patients, and connecting with study participants. His job is to make starting treatment as easy as possible. And he stays in touch with participants for months after they are discharged from the hospital. Lyttleton’s role is critical because of the personal interactions and trust he builds with patients.
“What I try to convey to the patient is that no matter what has gone on before … all I care about is helping them get into treatment, if that is what they want,” he says.
Participants receive harm reduction kits— drawstring bags with Narcan, sharps containers, tourniquets, alcohol wipes, antibiotic ointment, toothpaste, and information about where to go for further help. STAR 2.0 puts peer recovery coaches in more of a starring role.
“It’s all well and good for me to go in there as someone with a ton of privilege … saying ‘you can do this! Just take this medicine and come back!’” King says. “What do I know? I’ve read about it in textbooks, and I’ve written about it myself, but I can’t speak to that. Whereas our peer recovery coaches have that lived experience. There is nothing more authentic than someone who can genuinely say they’ve been there.”
The STAR team tries to reduce barriers to treatment however they can. They have sweatpants available. Snacks. Comfort items so people stick out long wait times. Success stories have begun to surface.
“People have gotten custody of their children back. People have gotten jobs again. People have been able to see their family again,” King says. “A lot of it has been eye-opening how grateful patients are for being heard and feeling seen.”
Long-term outcomes are trickier to measure. Recovery from OUD is measured in years and often includes setbacks. But programs like STAR are one link in a long chain. King knows some patients will never show for their first treatment upon discharge. She knows that some will relapse.
“Dream success is they enter recovery, and they never relapse again,” King says. “But that is not the most realistic. Harm reduction is what we are going for. This might be their first, third, one of seven attempts at recovery—that’s okay. ... The first measure of success is that they show up and they engage in treatment in our hospital.”
The STAR program has also helped change the perceptions about substance use by clinic staff, too. People like herself, King admits.
“I remember when we first started giving out Narcan in the emergency department,” she recalls. “This is way before STAR, and I am embarrassed to say I was one of those nurses who said, ‘Why should we be giving that?’ And the reason is because these are human beings, and we should be saving their lives.”
An Old Problem Resurfaces
When Rick Rawson graduated from UVM with his Ph.D. in experimental psychology in 1974, he began studying drug addiction at UCLA. It was not considered glamorous work. Drug users were viewed as sociopaths. Criminals. Meeting people with addiction issues changed his mind.
“These are regular people,” Rawson says, adding that they often have families and kids and jobs. “They’re not doing it because they are mutants or some kind of aberrant human beings. Something happened to them, and they can’t get out of it.” He has spent the last 50 years trying to find that way out.
At UCLA his research focused on stimulants like cocaine, which unlike opiates, does not have a pharmacological treatment available. Progress appeared stalled. Then a promising behavioral treatment emerged from UVM in the early ’90s—research Rawson initially dismissed. But that treatment, contingency management, remains underused across much of the country even though it could make a difference in the newest wave of the opioid crisis. Last year, nearly half of Vermont’s fatal opioid overdoses involved cocaine.
“I think it’s a big enough contributor, that if you … get contingency management distributed out throughout the state and accessible to people, it could actually have a measurable impact,” Rawson says.
Steve Higgins, professor of psychology and psychiatry at UVM, agrees. He directs the Vermont Center on Behavior and Health and developed the contingency management program for cocaine use disorder that Rawson couldn’t believe worked. He’s been waiting for the policy world to catch up.
Contingency management uses small sums of money or gift cards as incentives for a person not to use drugs. And it works. The small rewards have been shown to get women to quit smoking during pregnancy. It works to promote exercise in individuals with heart conditions. And it works to curb stimulant drug use. It works, Higgins says, because of our biology. “We are all sensitive to the allure of the immediate reward, and some more than others.”
Contingency management is derived from the behavioral learning theory of “operant conditioning”—the idea that one’s behavior is shaped by rewards and punishment.
“Your brain didn’t evolve to find drugs,” Higgins says. “But it’s sensitive [to drugs] just because it’s neurochemistry based. So, contingency management uses that same reward system to try and provide rewards for making healthy choices. And it works. It’s immediate. It’s reliable. You come, you give me a negative urine, you get a voucher today.” The goal is to get individuals to adopt healthier behaviors while they build more natural substitutes. It’s a bridge, Higgins says.
But even as clinical trials demonstrate its efficacy, there remains broad hesitancy to adopt it. However, the landscape is changing in Vermont, where the state legislature recently earmarked $840,000 for contingency management to combat stimulant use.
“Paying people to stop using drugs might to some look like, my god, you guys have gone crazy,” says Mark Levine, Vermont’s health commissioner and a UVM professor of medicine. “Contingency management is an evidence-based treatment that we should be embracing and that actually will end up costing way less than some of the downstream effects of having a severe addiction.”
Over the next decade, Vermont is slated to receive upwards of $47 million from a set of class action lawsuits against pharmaceutical distributors and drug makers for their role in the opioid crisis. Levine heads the state’s Opioid Settlement Advisory Committee, composed of addiction researchers, healthcare providers, prevention experts, and survivors, to advise lawmakers how to spend settlement money—legal atonement for the dead. From the outset, the mandate has been to balance prevention programming with efforts to help people swept up in opioid addiction stay alive and recover. The 2023 legislative session was the first time funds were awarded, and the message was clear: throw out more lifelines.
Flood The Streets
Before Mark Levine became health commissioner in 2017, he practiced internal medicine in Burlington. He gave up his practice to help more people through health policy, an action underscored during the pandemic when his weekly address reassured Vermonters that the path forward involved following the science. He's using that same approach to the state’s overdose problem. When Levine took office, overdose trajectories were declining. The pandemic created a storm where, just as the drug supply got deadlier, our collective mental health crashed, and there were fewer people around to notice.
While Levine intends to spend more on prevention in the future, the 2024 spending cycle will focus on the immediacy of keeping people alive. The settlement committee recommended increasing the number of medication units— satellite hubs that expand capacity for and access to medication for OUD, including at the Department of Corrections, where about 60 percent of inmates receive medications for OUD. Individuals on methadone often must travel—sometimes hours—to qualified sites for their medication. For many folks, that is simply a barrier too high to hurdle. Satellite medication units lower the bar.
The committee also budgeted $2.2 million to hire more than two dozen outreach workers to find individuals struggling with substance use and connect them to health services. The move came after reporting found that 75 percent of Vermonters who died from opioid overdoses had no prior connection to the state’s treatment system.
“We want to at least identify people who haven’t been able to access the system, for whatever reason,” Levine says. “Because having the greatest treatment system in the country isn’t good enough if you still can’t get everybody into it.”
The committee also proposed investing heavily in harm reduction strategies like flooding the streets with naloxone as well as with xylazine and fentanyl test strips. The aim: make contact with people. “That is a way to get people into the system,” Levine explains. “Hopefully it opens the door to other kinds of treatment as well.”
Some of the committee’s proposals require significant capital investment and will take months to enact. But Levine is hopeful because there are pieces in place that do work—like the hub-and-spoke model—that they are building on and out. “These problems are not unsolvable,” Levine says. “And it’s not just a matter of just trying to wipe out every cartel in Mexico and disrupt the supply chain because we know that has never worked and it probably never will work. It’s much more these fundamental public health approaches.”
Tweaking The Formula For Success
Stacey Sigmon, professor of psychiatry, understands the power of following the science.
She directs UVM’s Center on Rural Addiction (CORA) and serves on the settlement task force with Levine where she advocates for evidence-based practices. Her specialty involves finding barriers to drug treatment and removing them—whether by collapsing intake times to trim waitlists or devising workarounds so medical providers feel more comfortable prescribing medications.
For instance, in 2015 Sigmon developed a technology-assisted treatment protocol that involved a Med-O-Wheel, a small computerized device that dispenses medication in set intervals, after learning that many providers worried about buprenorphine prescriptions being diverted. The Med-O-Wheel allows patients to securely store and take their medication at home. Sigmon conducted a pilot study that showed nearly 80 percent of subjects using the protocol screened negative for illicit opioids, compared to none in the control group. That study was published in the New England Journal of Medicine in 2016. She and her colleagues recently replicated the study in two randomized clinical trials and published their findings in the Journal of the American Medical Association in September.
“And the exciting thing is we are then poised to take this out to the masses,” Sigmon says.
That is the purpose of CORA. In 2019, it was one of three centers founded by the Health Resources & Services Administration to bring tools and treatments to traditionally underserved swaths of the country. As of August, CORA has disseminated more than 153,000 fentanyl test strips, nearly 13,000 doses of naloxone, 200 wall-mounted naloxone dispensers, and 500 xylazine test strips, and approved four sites across New England for vending machines where people can access naloxone any time of day, no questions asked.
CORA experts also hold virtual online office hours to counsel rural providers across the country with complex medical cases. The center hosts an annual scholarship program that brings rural providers to UVM for intensive training to care for patients with OUD using best practices. And while the center’s initial mandate was to focus on New England, funding was renewed with the intention for it to go national, Sigmon says. “I think there is still a lot of untapped potential.”
Even small tweaks can make a big difference. At the Chittenden Clinic, the largest hub in the state, which both Sigmon and Brooklyn help to lead, federal changes during the pandemic expanded telemedicine options and loosened restrictions around prescribing methadone. This allowed clinic providers to give people ‘take homes’ to reduce the burden of travel—now a standard part of its practice.
“With all those things in place, we cannot compete with the Amazon-like delivery system that the dealers have to deliver drugs right to people’s homes,” Brooklyn says.
That’s why he and others continue to innovate. The pandemic opened the door to changes that have made the remote monitoring of medications possible. In May, both the Chittenden and St. Albans hubs launched the Wheels and Wave project, an intervention that allows patients to take methadone from home. The one-year project stems from the success of a recent study Brooklyn ran that paired a medication device with a smartphone app that patients use to record themselves taking methadone. The entire process takes five minutes. And it works. The retention rate for the study was nearly 100 percent—a rarity in OUD treatment programs.
“We had a number of people that had to wake up and go to work at 4 o’clock in the morning. Well, the first opioid treatment program doesn’t open until 5:30,” Brooklyn says. “[They were] never going to be able to work and be in treatment at the same time.” Remote dosing made it possible.
“It’s a game changer,” he says.
Bringing People Towards Safety
Caroline and Geoff Butler know a little something about transformation.
The couple runs the Johnson Health Center, a two-year-old clinic specializing in primary care and addiction medicine that is an offshoot of the Vermont nonprofit called Jenna’s Promise. Since November, the center has grown from 36 patients to 280, and nearly 100 are in the clinic’s substance use program. The startup has a lean staff with a big mission—low-barrier care and an open-door policy where people feel safe coming. Every patient has Caroline’s cell phone number. Every patient knows she cares what happens to them.
“The most important voice in anybody’s treatment is their own,” says Geoff, executive director of the center, about his wife’s philosophy. “You really have to listen to the person. Find out how they are feeling, what they are thinking, and really come up with a plan from there.”
Their patients run the spectrum from active use to well into recovery. For individuals struggling with addiction, Caroline listens “for those places where we can start working,” she says. Maybe they are open to addressing their hepatitis C. Maybe they will get a vaccine or have an infected leg wound treated.
“The whole philosophy around it is just bringing people towards safety,” Caroline explains. “From there we can kind of open more doors.”
Last spring, the Butlers enrolled in CORA’s scholarship program. They frequently use CORA’s office hours for complicated medical cases, and the clinic now houses Vermont’s first naloxone vending machine, available to the public on its front porch.
“It was really something that came out of tragedy,” Caroline explains. “We lost a 17-yearold to an overdose in this community last year and so that was where that idea came from.”
The vending machines allow people to access the opioid agonist any time of day and without a prescription. CORA is working to place three additional machines in New Hampshire and
Maine—something Caroline says can’t happen fast enough. “Those will save somebody.”
The Butlers specialize in caring for patients with substance use issues. In part, because it’s a population they know well—both are in long-term recovery.
For years Caroline hesitated about disclosing her status because of the stigma around substance use disorders. But she understands the importance of being able to advocate using that life experience. Caroline serves on the state’s settlement task force and is determined to channel funding into innovative projects that address the state’s drug problems as they shift.
“It is easy to just think of it as money,” she says, “when it's really—it’s people. It’s people.”
After The Flood
On July 10, the Johnson Health Center survived a setback of its own.
The historic flooding that devastated communities across Vermont hit Johnson especially hard. It wiped out the town’s water treatment plant. Low-lying houses were swamped with agricultural runoff and sewage. The Johnson Health Center wasn’t spared.
In mid-July, office furniture was piled by the side door. A film of silt coated edges of the parking lot. On the pavement, a small gray sign, the kind that typically rests on a shelf, takes a minute to notice—four small capital letters that spell HOPE. The Butlers are both wearing T-shirts with the clinic’s logo. Their arms are etched with intricate tattoos of the natural world—moths, peonies, honeycombs, and bees.
“I love moths because they fly towards the light,” Caroline says. “And sometimes they burn themselves up in flames because they get a little too close to it.”
Before the flood, Geoff removed the vaccine fridge and laptops, and Jenna’s Promise staff set computer towers on countertops. It didn’t matter much in the end. They lost everything. Then the community showed up to help muck out. That is the philosophy of Jenna’s Promise in practice—the village model. The organization was started by Jenna Tatro’s family to address the gaps she fell through in her journey to recover from opioid abuse. Jenna, a native of the town of Johnson, died February 15, 2019, from an addiction she developed in college after getting beaten up by a boyfriend and prescribed painkillers for relief. The Tatros used the money from her life insurance to fund treatment that would be less likely to fail people like their daughter—including things people in recovery often need to thrive: housing, employment, easily accessible healthcare, therapy, and a safe community. And now the health center was underwater.
As they did during the pandemic, the Butlers pivoted to telehealth. The health center operates out of a temporary space at Jenna’s Promise. And even as construction crews work to rebuild the clinic, the Butlers are considering if, and how, to add a mobile health unit.
“It’s not dissimilar as how the drug world is changing,” Caroline says. “It gives us a chance that we didn’t want and wouldn’t have taken before, but it gives us a chance to sort of look at how do we evolve? How do we as providers work to really meet these new needs?”
While FEMA teams interview residents near Jenna’s Promise coffee shop, Daniel Franklin, COO of Jenna's Promise, sits in the window seat. He looks tired. Franklin has been focused on relocating some of the nonprofit’s residents who lost their homes in the flood and getting the café where they work back up and running. He knows displacement is often a precarious moment. And he knows a new tidal wave is coming that he fears the state isn’t ready for.
“We are at the dawn of the age of methamphetamines and cocaine in our region, and xylazine and other polysubstance use, that will bring and has brought with it in many parts of the country, a mental health emergency, a homeless emergency that will necessitate change in our system of care,” Franklin says. “I hope we will get ahead of this. Because our system is not built for this.”
He lauds the state’s move to support contingency management and disseminate harm reduction supplies. But he urges for additional investments in more holistic centers of care. Jenna’s Promise can accommodate just 17 residents. “We can’t stay five years behind,” he says.
This is something Gregory Tatro worries about, too. He is Jenna’s brother and a chief evangelizer for Jenna’s Promise. Tatro believes the current system for treating people with substance use disorder is inadequate.
“It didn’t work for my sister,” he says. “It failed her consistently. She would at times try to get into recovery. And she would at times stumble all on her own, but also sometimes the system would throw obstacles in front of her.”
Tatro wants to mow obstacles down. He points to the town of Johnson. It was struggling, Tatro says. Since Jenna’s Promise opened, once-empty buildings now have businesses staffed with people reimagining a different path. People invested in that vision. And then the flood came. Tatro sees how the water management system built for the past failed to meet the current moment. He worries this is the case for the opioid crisis.
“We can’t do the work without the pumps pulling the water out,” Tatro says. “But we need more to actually make this place a place to live. And metaphorically that applies to people in recovery. Recovery centers are incredible. Treatment centers are important. The other supports we have—access to suboxone for example. We have been trying to limit the supply of addictive pills by law enforcement—all that is critical. And we need more to actually change the trajectory.
