Behavioral health care provider Centerstone Kentucky launched a first-of-its-kind pilot program in Bullitt County one year ago to treat patients addicted to opioids like heroin. In addition to intensive outpatient services involving clinical case managers, peer support specialists, counseling and behavioral therapy, the program took new steps to offer medication-assisted treatment (MAT) — expanding its use of the non-narcotic Vivitrol and for the first time utilizing Suboxone, a partial agonist of opioid receptors in the brain.
Scott Hesseltine, the vice president of addiction services for Centerstone Kentucky (formerly Seven Counties Services), recently spoke with IL about the successes and challenges of the pilot program — a program expected to be replicated in Jefferson County by this summer — as well as new detoxification protocols, which began including Suboxone in July.
The MAT program now utilized in Bullitt County was first created and tested by Hesseltine when he worked for the Hazelden Betty Ford Foundation in Center City, Minn., where the number of post-treatment deaths of opioid dependent patients was reduced to zero. While the large majority of programs treating opioid addiction in America rely on an abstinence-only model eschewing partial agonist medication such as methadone or Suboxone, a growing number of addiction specialists, researchers and public officials are touting MAT as a successful model.
Vivitrol is administered through monthly injections and contains naltrexone, a non-addictive drug that blocks opioids from attaching to brain receptors, thus blocking any euphoria from taking heroin or powerful prescription painkillers. Suboxone is prescribed and taken orally daily by patients on their own; the medication is largely comprised of the drug buprenorphine, which is itself an opioid providing a milder high, but also partially blocking these same receptors and reducing withdrawal symptoms. Suboxone also contains a small amount of naloxone — the drug used to revive those who overdose on opioids by sending them into immediate withdrawal — which is meant to deter patients from abusing the drug by melting it down and injecting it.
Hesseltine shared statistics from the Bullitt County pilot program’s first fiscal year beginning last July and nearing the end of its third quarter, saying it has “gone well” overall but has significantly improved over the last six months as the program has refined and enhanced its use of peer support and case management. Perhaps the best sign of all — amid a heroin and fentanyl epidemic that is claiming the lives of an escalating number of overdose victims — is that just like in Minnesota, Hesseltine said there have been no fatalities among the program’s patients
Of the 205 people who have come in for an assessment in the current fiscal year, 92 were admitted and roughly 50 percent of those patients have “successfully completed” the program. Patients are deemed successful when “they’ve completed the intensive outpatient programming and they’ve remained engaged with us,” said Hesseltine. “Those people that have moved on beyond treatment and into recovery, where they’re in their own mutual aid group and they’ve completed continuing care group with us.”
According to Hesseltine, the individuals not admitted into the program “either went to a higher level of care, a lower level of care, or they decided that the rigor we were asking them to commit to was just not what they were interested in.” Admitted patients who were not deemed successful includes people who stopped coming or repeatedly relapsed by returning to opioid use, though he added that “of that 50 percent, there’s quite a few that have come back and been re-engaged… but if it’s repeated and it’s evident that we’re not the most appropriate level of care, we’ll transfer them to a more appropriate level of care, and it counts those people, as well.”
The rate of success has increased even more in recents months as outpatient services have been enhanced, said Hesseltine, noting that since July their patients have had “over 1,100 different formal structured interactions with case management and peer support.” While approximately 70 percent of the patients primarily use Suboxone and 30 percent use Vivitrol, Hesseltine has found that patients are having success transitioning from one medication to another.
“What’s nice is we’re seeing the use of multiple medications, knowing that it’s not just buprenorphine (Suboxone) or Vivitrol,” said Hesseltine. “It’s that buprenorphine can often lead to stepping down onto Vivitrol, and then you go off of Vivitrol and into sustained recovery. That’s been really kind of a neat piece of it, having that transition work. They complement each other.”
Through a grant, Hesseltine said the program has also made use of a limited number of “bridge” devices — a small neurostimulator that is placed behind the ear and has just been cleared by the FDA to relieve patients of the pain associated with opioid withdrawal. He says the devices have proven successful, though “the challenge is it’s not covered by insurance, and it costs about $750 for the device. But we do have a small number with this grant that we can use, and then we’re working to try to find ways to offset some of that expense for people who could benefit from it.”
While this intensive outpatient pilot program has only been available in Bullitt County since last March, Hesseltine said Centerstone will begin its first program of this kind in Jefferson County “within the next 60 to 90 days.” The program already has its facility ready — the downtown site once known as the Jefferson Alcohol & Drug Abuse Center — so it isn’t running into any licensure or “not in my backyard” problems common with drug treatment centers. Instead, the delay is simply due to the lack of available medical providers to work at the facility, though he is “very hopeful” that Centerstone will find such professionals in the next couple of months.
While Jefferson County may have to wait a few more months for this intensive outpatient program, Centerstone has been putting Suboxone to use for patients who are in their short-term inpatient detox facilities since last July — to what Hesseltine said is great success. While only 40 percent of patients had previously been able to successfully complete their detox, once Centerstone changed its withdrawal protocols to include the short-term use of Suboxone, this completion rate saw a “dramatic jump” to 65 percent — enabling hundreds more patients to move on to the next phase of recovery process.
“We see about 85 percent of all the people who come in have opioid abuse disorder as the primary diagnosis, and of those people the majority utilize the Suboxone protocol,” said Hesseltine. “So hundreds of more people have remained and completed detox successfully, absolutely.”
While Centerstone has been joined in the past year by several other addiction treatment providers who’ve added MAT via Suboxone or Vivitrol, access to such care has not increased at the same pace as the opioid epidemic, as Louisville has witnessed record-high overdose runs and fatal overdoses connected with opioids. Hesseltine said that putting a dent in the region’s opioid problem will take more than just additional law enforcement interdiction of the increasingly present and dangerous opioid fentanyl, or a dramatic increase in a wider variety of treatment resources — as city officials need to find more innovative ways to connect those abusing opioids with treatment options.
“We also need to have multiple access points with linkage into those treatment services,” said Hesseltine. “As you have the overdose reversals (by EMS personnel with naloxone), try to embed peer supports and other types of linkage to treatment. So you’re making it even easier to get from either a hospital into treatment, or from an overdose reversal site into treatment. I think that’s really important.”