PLACERVILLE, Calif. — California had just weeks to get a program that used medication to treat opioid use disorder up and running after receiving $90 million in federal grants in 2017. So officials found a model that was already working in Vermont, and supersized it to fit the sprawling state.
The scaling up of the “Hub and Spoke” system, particularly in rural areas, has presented challenges but also delivered results in locales like this Gold Rush-era city east of Sacramento — and dovetailed with existing efforts to expand medication-assisted treatment to give the state a two-pronged approach to confronting the opioid epidemic.
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Hub and Spoke, first launched in Vermont in 2012, features a system of regional addiction treatment centers or “hubs” that are connected with “spokes” like primary care practices and local clinics. Patients have individual treatment plans. The system allows many patients to get help close to home, at clinics that offer buprenorphine, a drug seen as the gold standard for treating opioid abuse symptoms, and that employ behavioral health providers and nurse case managers. Those with more complex cases, who for example need to be treated daily with methadone, can be referred to a centralized hub.
After starting with 18 hubs and 57 spokes, the California effort has expanded in a year and a-half to include more than 200 spokes statewide. The state has also layered on other programs, including one that treats people suffering from opioid withdrawal in an emergency room with buprenorphine, and then refers them to a nearby spoke, often the next day.
California doesn’t rank with opioid abuse hot spots like West Virginia, Ohio or New Hampshire. But rural pockets, particularly in the north of the state, have experienced alarming overdose death rates.
Beth Tanzman, the Vermont state health official who manages Hub and Spoke there, told POLITICO that while states like Louisiana and New Hampshire have adapted the program, “it’s so important and impressive to see states like California figure out how to scale treatment” for opioid use disorder.
As of last month, more than 13,000 patients in the state have used the model, and the number of physicians prescribing buprenorphine has increased by 82 percent since July 2017, according to the state Department of Health Care Services.
The overarching goal in California is to create a framework for treating a range of addiction disorders, including alcohol, methamphetamines and other substances.
“We know people with addiction are showing up in emergency rooms and clinics and they have mental health issues and they’re getting arrested and they go to jail,” said Kelly Pfeifer, a physician and addiction specialist at the California Health Care Foundation. “Why shouldn’t they get treated wherever they land?”
As it builds out the hub-and-spoke system, California has taken advantage of several waves of federal grants totaling some $266 million to expand the use of medication-assisted treatment. The state may yet have to tap into other sources and find efficiencies once the grants run out.
Despite the short-term nature of the grants, California wanted to take an aggressive approach, said Marlies Perez, chief of substance use disorder compliance at the state’s health care services department. “These federal dollars have been huge in making this happen.”
The money has helped fund an innovative emergency department program, originally called the E.D. Bridge program, which offers patients experiencing opioid withdrawal symptoms immediate access to buprenorphine, also known by the brand name Suboxone. A form that dissolves under the tongue and can resolve symptoms within a matter of minutes is provided right in the emergency room.
The program started a year ago in 12 hospitals and now includes 31 hospitals and one clinic, nearly half of which are located in rural areas of the state.
“We want the entire state,” said Aimee Moulin, an emergency physician at the University of California, Davis who is a regional coordinator for the Bridge program. “Our overall goal is to make this the standard of care.”
Placerville is one of the few places in California where the Hub and Spoke and Bridge programs are being deployed together, offering immediate overdose treatment in the small, rural hospital’s emergency department.
“We’re a small county and a small organization, but we’re going to start seeing this take off across the state because of these two programs,” said Loni Jay, a physician who in November opened a new spoke, Marshall CARES, an outpatient clinic steps from the hospital, Marshall Medical Center in the foothills of the Sierra Nevada.
The county — El Dorado — was quick to establish spokes, due primarily to providers at El Dorado Community Health Centers who were already prescribing buprenorphine well in advance of the hub-and-spoke federal grant. Marshall Medical Center was also one of the first hospitals in the state to sign on to the E.D. Bridge pilot. The hospital recently brought on board a substance use navigator to help guide patients.
“What we’re doing is providing a full integration of care — behavioral health, a MAT [medication-assisted treatment] program, R.N. case managers, licensed alcohol and drug counselors, medical assistants,” said Terri Lee Stratton, CEO of the four-clinic El Dorado Community Health Centers.
The nearest hub still is nearly an hour away, in Roseville. But most providers say they rarely have to refer patients, because they can typically be managed at the clinic level.
Patients suffering from withdrawal who show up at the emergency room get treated on the spot with Suboxone. Then they’re set up with a next-day appointment at a nearby spoke.
Though Marshall providers treat just one or two patients a week in this fashion, they say the program is already starting to have an effect.
“We treat them quickly and effectively, and that doubles the likelihood of them being in treatment in 30 days,” said Arianna Sampson, a physician assistant who helped set up the Bridge program.
For the 49 weeks starting in August 2017, 92 percent of the patients treated at the hospital with Suboxone followed up by seeking care at a spoke, according to Sampson, with the nearest one 15 miles away. After a year, 26 of those patients were still in treatment, accounting for a 74 percent success rate.
Meanwhile, buprenorphine use in El Dorado County increased 89 percent from 2015 to 2017, according to state public health statistics. Statewide buprenorphine prescribing increased just 14 percent over that period.
California still faces barriers to getting these programs up to speed around the state, including stigma from health professionals and resistance from traditional substance-abuse providers. To prescribe buprenorphine, doctors have to get special training and a federal license known as an “X-waiver.” Though that’s created bureaucratic hurdles, the opioid legislationl Congress passed last October expanded who could prescribe it.
The experience has professionals optimistic the region will have the infrastructure to treat other forms of substance abuse, including methamphetamines.
“I truly believe we’re reversing this opioid epidemic,” Sampson said. “But what we know about the history of humankind, there will be something else.”