Primary care providers are well-suited to treat patients with opioid addictions

NEIGHBORHOOD HEALTH Plan of Rhode Island Medical Director Dr. Tracey Cohen, left, talks at a Dec. 13 panel discussion about opioid addiction, as CODAC Behavioral Healthcare President and CEO Linda Hurley, and Dr. Josiah (Jody) D. Rich, director of the Center for Prisoner Health and Human Rights at The Miriam Hospital, listen. / PBN PHOTO/NANCY KIRSCH
NEIGHBORHOOD HEALTH Plan of Rhode Island Medical Director Dr. Tracey Cohen, left, talks at a Dec. 13 panel discussion about opioid addiction, as CODAC Behavioral Healthcare President and CEO Linda Hurley, and Dr. Josiah (Jody) D. Rich, director of the Center for Prisoner Health and Human Rights at The Miriam Hospital, listen. / PBN PHOTO/NANCY KIRSCH

WARWICK – The impact of losing 1,000 lives in Rhode Island over four years to drug overdoses is astonishing, said Dr. Josiah “Jody” D. Rich, professor of medicine and epidemiology at The Warren Alpert School of Medicine of Brown University and director of the Center for Prisoner Health and Human Rights at The Miriam Hospital. Speaking at a program sponsored by Neighborhood Health Plan of Rhode Island and the Rhode Island Health Center Association, “A Call to Action: Prevention and Treatment of Addiction in the Primary Care Setting,” Rich said that the many death scene photographs he has viewed “put a vivid face on the epidemic.”

The stigma around the disease of addiction is still troublesome, said Rich, who warned those attending the Dec. 13 conference at Warwick’s Crowne Plaza Providence-Warwick that Fentanyl – 100 times more powerful than morphine – is entering Rhode Island through several distribution channels. Several inmates at the Adult Correctional Institutions had drug overdoses linked to Fentanyl; one inmate required four doses of Naloxone to be revived, when tens of thousands of people typically need only a single dose to revive, he said.

Gov. Gina M. Raimondo’s Overdose Prevention and Intervention Task Force contains four key points: Reversal – of drug overdose effects, with drugs like Narcan that have saved thousands of lives – recovery, prevention and treatment.

Some patients get medication-assisted treatment from primary care practitioners like Dr. Sarah Fessler, chief medical director of East Bay Community Action Program. Initially skeptical, Fessler recognized buprenorphine’s merits after some of her patients died from opioid overdoses. Today, she champions treating patients suffering from addiction in a PCP setting.

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“I think a PCP is a great place to treat addictions; primary care providers ‘get’ chronic diseases, like heart disease and diabetes,” said Fessler. “It’s an ongoing problem that has a lot of psychological and behavioral modification needs that fit really well with the chronic disease model.”

Fessler was quick to acknowledge that PCPs can’t do it alone; there’s a big need for counseling and other supports, which East Bay Community Action Program provides. The state’s opioid toolbox, an initiative of the American Medical Association, the Rhode Island Medical Society, the R.I. departments of Health and of the Behavioral Health, Developmental Disabilities and Hospitals, will provide guidance for providers treating acute pain, opioid use disorders and patients needing overdose prevention education. Originally due to launch in September 2016, Fessler said that the toolbox will be available soon.

As the state’s first “center of excellence” for the treatment of opioid use disorder (a certification from BHDDH), CODAC Behavioral Healthcare is building reciprocal referral relationships with PCPs and federally-qualified health centers, said CODAC CEO and President Linda Hurley. If a PCP is successfully treating someone in the community with buprenorphine who has a crisis and needs support, our responsibility is to see that patient within 24 to 48 hours; once that patient is stabilized, CODAC’s goal is to get that individual back to the PCP, she said. CODAC’s extensive case management wraparound services support patients with substance abuse disorders, who represent all ages and socioeconomic strata. It has a medical hotline number, a 24/7 nurse who can schedule an assessment appointment for an individual in need and its Medical Director Dr. Susan Hart will answer PCPs’ questions and provide guidance, said Hurley.

“It’s a holistic approach … the model only works when the entire community of providers works together,” said Hurley.

Dr. Tracey Cohen, Neighborhood’s medical director, drew applause when she said, “[This] is not willpower, it’s not a decision; it’s an intense disease. Treatment works and we have to … not be apologists. It’s an epidemic.” Decades ago, doctors overcame the stigma of treating HIV patients and people understood that HIV wouldn’t disappear with willpower or by ignoring it; the addiction situation is no different: “Unless we treat it, it’s going to keep killing.”

Among Fessler’s most compliant and responsive patients are those receiving medication-assisted treatment. “Sometimes people fail, but people fail to take their insulin more than they fail to take their buprenorphine … opioid [addiction] treatment in my office is not difficult to do,” she said.

Some 20,000 Rhode Islanders have the disease and need treatment, so there’s plenty of work to do, said Rich, who exhorted attendees to operationalize their practices to get the federal waivers needed to allow them to deliver medication-assisted treatments; communicate with CODAC and seek assistance, as needed. The state and federal governments are committed, and federal money is available.

“We need to step up to the plate; we’re poised in Rhode Island to lead the nation,” said Rich.

Cohen, Fessler and Hurley were among the panelists on a panel, “Addressing the Opioid Crisis in Rhode Island,” which Rich moderated. Earlier in the daylong program, U.S. Sen. Sheldon Whitehouse and Neighborhood President and CEO Peter Marino were among other speakers.

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