Listen to the ECHO
University of Nevada, Reno program aims to expand addiction treatment services in the Eastern Sierra and Northern Nevada
The University of Nevada Reno is working to expand access to mental health counseling and addiction treatment services in Nevada and the Eastern California through its Project ECHO Nevada program.
According to Mono County Behavioral Health Director Robin Roberts, all addiction patients who request medication assistance in their recovery in Mono County are currently referred to providers in Reno. This is because there are no licensed Medication Assisted Treatment (MAT) providers in Mono County. She said her department is working to change this, but that the region’s limited number of mental healthcare providers poses a challenge.
Project ECHO provides free, specialized online training and consultations to licensed physicians, nurses, and physicians assistants in MAT and other commonly requested treatments that are often unavailable in small communities. The goal is to prepare primary care physicians in rural communities to deal with a host of common afflictions that would otherwise require a patient travel to see a specialist–something that may not be covered by their insurance provider.
According to Project ECHO Director Chris Marchand, this model has proven to be effective in treating Hepatitis C and diabetes. Now, Healthcare professionals hope it will expand rural access to medication assisted treatment (MAT) for opioid and alcohol abuse.
According to Danica Pierce, a LCSW Licensed Social Worker and Behavioral Health Coordinator for the Reno-based Northern Nevada Hopes clinic, MAT is most effective when paired with counseling and therapy. There are two phases of treatment where medication is administered:
First, a patient must be stabilized. During this phase of treatment, medications are used to mitigate the symptoms of withdrawal. According to Pierce, Nevada Hopes typically administers Suboxone during this period, which is a combined dose of buprenorphine, a synthetic opioid, and naltrexone, an opiate blocker. “Naltrexone sits on opiate receptors in the brain… that wig out and say, ‘we need opiates!” said Pierce. “It tells the person, ‘we’re good, we’re covered.”
“Like a door with a lock on it”
Once a patient is stabilized, they are weaned off of Suboxone, and prescribed a form of isolated Naltrexone, which Pierce said prevents opioids from binding to receptors in the brain, “like a door with a lock on it,” keeping the user from getting high when they use.
Vivitrol, a form of naltrexone that is administered via a monthly injection, is the most common form of the medication. It’s popular because a patient only has to use it once to prevent themselves from getting high for an entire month. Vivitrol can also be used to treat alcoholism. “It is super effective for people who are stable,” said Pierce. “However, it is really expensive.”
Pierce said that, without insurance, a single dose of Vivitrol costs about $1,200. “Nobody can afford that… and it can get in the way sometimes if someone is a good candidate [for MAT] but can’t pay for it.” Her clinic is federally funded, and as such is eligible for grant funding that can supplement the cost of expensive medications for uninsured, low-income patients. “It is so much harder for a little provider, such as a primary care doctor in rural areas,” said Pierce. “You’re giving people this medication which can be really helpful, but if you don’t have other services [drug and alcohol counseling, a psychiatrist, behavioral therapy]… they have to be really motivated.”
Dr. Tom Boo, Mono County Public Health Officer and a MAT provider at Toiyabe Indian Health Project, said that most insurers, particularly those available in Mono and Inyo counties, do not reimburse clinics for patient visits to substance abuse counselors. “Medication Assisted Treatment should be accompanied by counseling, it is the standard of care. But you have a situation in which MediCal, for example, may reimburse Toiyabe for my time with a patient as a prescriber of buprenorphine, but not for the equally important intensive support provided by our substance abuse counselor colleagues,” said Dr. Boo in an email this week. He said Toiyabe fills in the funding gap for low income patients with grant funding that is not available in the private sector. “Despite the national spotlight on the opioid epidemic, about half of insurance companies still don’t accept substance abuse as a primary billable reason for a visit,” said Dr. Boo.
Furthermore, many doctors are turned off by the prospect of prescribing an opioid to a known user without a broader support network of other healthcare professionals to monitor their progress.
More work, no pay
Marchand said that one of the biggest reasons primary care physicians don’t seek out training in MAT is that the current billing protocol does not compensate them for the additional time and effort involved in offering those services to patients. He said that Medicare and Medicaid typically set the standard for how treatments and services are billed, and that neither program has a separate code for MAT. Often, a doctor administering MAT must spend more than the time with a patient than what Medicaid and Medicair allow them to bill for.
Furthermore, in order to provide MAT, providers have to participate in eight to 24 hours of training, then apply for a federal license to prescribe opioids, and then undergo an audit by the District Attorney’s Office under whose jurisdiction they operate. All for little or no financial gain, and a lot more work.
Additionally, treating addiction patients comes with increased emotional and legal liability. “A lot of times, people are scared to work with addicts,” said Pierce. “They may exhibit challenging behavior, especially during withdrawal. They can be loud, agitated, drug-seeking, and often have co-occurring mental health issues.”
Roberts agreed that the stigma of addiction is a very real barrier to providing care in rural communities. “For a rural doctor operating in isolation, without that support, it looks a little scary,” said Pierce of providing MAT, which she called the scaffolding that gets a patient to a place where they can overcome their addiction through therapy and counseling. Roberts emphasized that access to affordable counseling is just as important as access to Vivitrol and Suboxone.
Roberts said Mono County “provides whatever is needed to those who seek services for substance abuse” through MediCal, but that other insurers such as Anthem which is available in Mono county through the Affordable Care Act, are not required to do so.
“There is a perceived stigma,” said Marchand. “When a provider says, ‘I don’t want that kind of patient in my office,’ the reality is that today, you already have those patients in your office, and that opioid addict could be your neighbor. You could work with a professional who is addicted to opiates and you’d never really know.”
Dr. Boo said that Toiyabe’s Mono County Satellite clinic in Coleville-Walker will soon be able to offer buprenorphine MAT, and that he expects that in the near future, all three Toiyabe locations will provide MAT.
Roberts said access to MAT in isolation won’t be enough to help the County’s addiction patients. “My concern is that even if we have some places where MAT is available, if the general attitude is to see the person seeking treatment as an ‘addict’ who is making a ‘choice to use’ then we are not being user friendly; we are just perpetuating the stigma that maintains the problem,” said Roberts in an email on March 20.
