The Spokane area needs more physicians willing to treat patients for opioid use disorder, local providers say, as barriers continue to exist for both patients and prescribers alike.
The impacts of the opioid epidemic continue to be felt in outpatient clinics, emergency departments and doctor’s offices statewide, as providers and patients face obstacles to offering and accessing treatment.
In Spokane County, 40,331 patients have at least one opioid prescription in the county, 2019 data from the Spokane County Health District show. That’s 1 in 13 residents.
Opioids are typically prescribed to treat pain, but can be addictive. A nationwide epidemic resulted in billions of opioids being prescribed in Washington state alone. Opioid use disorder, which happens when a person relies on opioids, is treated primarily with medication.
That medication requires a prescriber and in some cases, the medication must be accessed in a controlled environment every day.
Those who access such medication-assisted treatment are sometimes shut out of sober or abstinence-only programs, reducing their options for assistance.
When access to medication becomes a roadblock for those seeking treatment, it can lead them to use illicit substances like heroin that offer the same effects and can be easier to get.
Some providers are trying to overcome those barriers.
Compassionate Addiction Treatment, a relatively new nonprofit, serves anyone on a walk-in basis.
Trudy Frantz, a nurse and the nonprofit’s medical program manager, said not having appointment times is crucial for many clients who are homeless.
“What we know is that when somebody comes in – especially our homeless population – and says, ‘I can’t do this anymore, I’m done, I need to go and do treatment,’ we may not see them again if we say, ‘OK, our next appointment is in three weeks,’ ” Frantz said.
But while assessments are available whenever Compassionate Addiction Treatment is open, the nonprofit relies on volunteers to prescribe medications for clients. One nurse practitioner comes in after work two days a week, Frantz said, and a retired physician will start volunteering one night a week in March.
The use of medication to treat opioid use disorder contrasts with the abstinence-only philosophies that only work for a small percentage of the population. Research shows that using medication to treat opioid use disorder can work, with harm reduction as the goal.
“The validation in medication-assisted treatment for addiction comes with an acknowledgment that reducing harm is the goal,” said Matt Layton, clinical education director at the Washington State University College of Medicine. “That means moving the person away from IV heroin, homelessness, jail and problematic relationships and having them come into a clinic every day.”
For Frantz’s clients, that means coming in for an assessment and then having prescribers order them medications, like buprenorphine, which is a partial opioid agonist that can treat a person’s pain without creating a high. Suboxone is a common buprenorphine product with a small dose of naloxone, which acts as an opiate blocker.
Frantz’s treatment focuses on reducing overdoses and deaths.
“Suboxone reduces overdose deaths – that’s the big thing it does,” Frantz said. “It also helps people when they can’t get heroin, and instead of going through withdrawals, they’ll take Suboxone.”
From 2014 to 2018, 205 people died from opioid overdoses in Spokane County. Heroin-related opioid overdoses have increased during those five years, health district data show.
Some buprenorphine products are offered as pills or injections.
For Dr. Lora Jasman’s patients at MultiCare Rockwood Clinic, buprenorphine products are the most popular. Naltrexone, another treatment option, is administered as a monthly injection that is not an opiate at all, but patients have to be off opioids for a week before starting that drug treatment, which can be incredibly challenging, providers say. As a result, buprenorphine is a more popular treatment, Jasman said, and patients can start that treatment from home with prescriptions.
Methadone, a more potent narcotic used for treatment for opioid use disorder, is prescribed and dispensed from only two locations in Spokane: the Spokane Regional Health District and Spokane Treatment Solutions.
More than 1,000 people receive opioid treatment at the health district, with the majority of patients taking methadone. Typically, a person starting methadone treatment will need to come in to take it six days a week, with a take-home dose for Sunday. Patients can then gradually take more doses at home. The health district has access to the county jail to offer treatment there as well.
Misty Challinor, the health district’s director of treatment services, said there is a “significant shortage” of treatment counselors.
The stigma around offering treatment for opioid use disorder represents a significant barrier to more treatment resources being available.
Jasman, with MultiCare Rockwood Clinic, said everything from the perception that it’s not a fun population to take care of to the perception that it is hard to do can keep doctors from offering treatment.
But Jasman, whose roster is capped at 275 patients, said it is easy to get the hang of and that the need is urgent, especially in the primary care setting.
There are 80 doctors within 50 miles of Spokane who can prescribe buprenorphine, the Substance Abuse and Mental Health Services Administration directory shows.
To prescribe buprenorphine, a doctor must finish an eight-hour training and then apply for a waiver that could take up to 45 days to receive. Nurse practitioners, physician assistants and other prescribers must complete even more training to apply for a waiver.
If approved, a prescriber can only have 30 patients in the first year, unless they apply for an exception. In the second year, they can have up to 100 patients. There is pending federal legislation to loosen these tight buprenorphine regulations, but it has not moved beyond being introduced.
Luis Manriquez, a professor at the WSU College of Medicine, said he encourages students still in medical school to get their buprenorphine prescribing waiver. Manriquez got the prescriber waiver during his residency program, and he thinks the elimination of the waiver would remove barriers for providers.
“I think that would help a lot, because once you actually deal with any of these patients, you find out that they’re just like anyone else and extremely grateful for help and support,” Manriquez said. “There’s none of that doom and gloom. It’s just not there.”
Addiction is a chronic medical disease, and Jasman said it should be treated as such.
“I think part of it is there’s a belief out there that it’s a behavioral problem, that you (can) just stop doing that, rather than there being a problem with the brain where the brain cannot stop doing that,” Jasman said.
Overexposure to addictive substances, like opioids, can reorder how the more rational part of the brain controls decision-making, Jasman said. If the brain begins prioritizing its part that experiences pleasure instead of rationality, addiction to that pleasure feeling begins, all as a response to direct exposure of the brain to the drug.
Addiction, as Jasman points out, is “no respecter of persons.”
She has had patients who went from making high salaries to being homeless due to opioid addiction, she said. Increasingly, providers see patients addicted to multiple substances and patients who have co-occurring mental health and substance-use disorders.
A 2019 WSU study found that 56% of patients who frequent hospital emergency departments had a substance use disorder and that 24% of those patients had co-occurring substance use disorder and psychiatric diagnoses.
“It’s a polysubstance world, and we’re dealing with a lot of different substances,” Jasman said. “I think the other thing that people are not terribly aware of is that there’s a pretty big relationship between any substance-use disorder and adverse childhood experiences, so the more we can figure out ways to keep our children safe, the more we’re going to be able to do about the substance use problems.”
While Spokane County is seeing far fewer overdose deaths related to opioids, with the peak in 2006 at 83 deaths that year, there were still 1,210 hospitalizations with opioid-related diagnoses in 2017. People ages 18 to 34 years old had the highest rate of hospitalization.
“It’s a whole generation of young people that are overdosing,” Jasman said.
But Jasman said she does see people improve and get better.
“I think what we need is more prescribers, we need more of an accepting attitude about having people on medication,” Jasman said. “There’s still a lot of treatment programs that won’t accept them. There’s still a lot of living environments where they’re not accepted. It’s getting better, but (it’s) not great.”
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