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By Liora Engel-Smith
As coronavirus tears through North Carolina, upending nearly every aspect of life, some experts are focusing on another ongoing crisis that has gotten less attention in recent weeks: opioid overdoses.
Overdoses of both prescription and illegal opioids killed an average of five North Carolinians a day in 2018, according to data from the North Carolina Department of Health and Human Services. By comparison, 53 North Carolinians died of COVID-19 since March 25, which seems like a lot, but remains less than the average daily toll from opioids.
A collaboration between University of North Carolina at Chapel Hill School of Medicine and Mountain Area Health Education Center (MAHEC) aims to help people with substance use disorders find the care they need with an eye for making a dent in North Carolina’s opioid deaths in the long run.
The partnership is funded by a more than $1 million, two-year grant, from the national Foundation for Opioid Response Efforts and western North Carolina-based Dogwood Health Trust. The idea is to create stronger connections between clinics that care for low-income people with experts at MAHEC and University of North Carolina at Chapel Hill so patients receive seamless care, said Dr. Shuchin Shukla, physician at MAHEC and clinical assistant professor of medicine at UNC. It will also give MAHEC resources to help providers in community centers and health departments better care for patients with opioid use disorders.
Addiction care across the state tends to be sparse and fragmented. Patients typically need some level of specialty care when they first enter recovery, especially if they require medications such as methadone or buprenorphine, which reduce opioid cravings.
When patients stabilize later on, a primary care provider can continue to monitor them and prescribe their medication. But there’s a shortage of doctors who have the training and licensing requirements to prescribe such medications. As of March 9, North Carolina had 3,351 providers who can prescribe opioid replacement medication, according to the Federal Substance Abuse and Mental Health Services Administration, and many of them tend to congregate in cities. A JAMA analysis released last summer found that 41 counties in North Carolina had high rates of opioid overdoses and not enough providers who can prescribe these medications.
The “hub and spokes” model addresses some of these challenges.
‘What a referral system should be’
In traditional referrals, patients may remain with a specialist for a long time and their family physician may or may not be involved in the treatment plan.
The hub and spokes model closes the referral loop between the “spoke” — primary care providers at a community health center, for example — and the “hub” — a clinic with addiction specialists.
“[It’s] really the ideal of what a referral system should be,” said Melinda Ramage, medical director of Project CARA, a MAHEC program that uses the model to help pregnant women with opioid addiction. “ … What makes the hub and spokes model work is the idea that it is alive and it is a network where the providers that deliver care have to understand and have relationships with each other.”
The idea of such integrated care is not new. Other states, including Vermont, New Hampshire, Washington and California have used the model to increase access to opioid treatment, and Shukla, who is involved with the new UNC-MAHEC effort, said both institutions are eager to eventually scale up the project to include eastern North Carolina.
But first, MAHEC will work with community health centers and health departments in western North Carolina to develop the hub and spokes relationships, Shukla said.
It’ll take at least a year before the network is robust enough to begin taking new patients in the western part of the state, he added. The rise of coronavirus cases may prolong the timeline because many health departments and health centers are busy responding to the outbreak. The program’s other hub in Chapel Hill is already running.
Addressing a mismatch
Dr. Robyn Jordan, assistant professor at UNC Chapel Hill, came to the hub and spokes model a couple of years ago. Jordan, medical director of addiction medicine at UNC, said their clinic had a resource problem.
“Our clinic was full of stable patients that we couldn’t transition to the community, which meant that we couldn’t take on new patients,” she said.
That meant that patients who needed an addiction specialist couldn’t get one, and the clinic’s existing patients were seeing addiction specialists when they didn’t need that level of care.
To fix the mismatch between what patients needed and what they got, Jordan said, the clinic had to reconfigure how it provides care and create strong referral relationships with clinics from other agencies.
Staff now tell patients from the outset that the goal is to stabilize them and refer them to a permanent medical home after a time, Jordan said. Clinical care managers help with that transition and specialists at the clinic follow up on patients throughout and after the referral. Even once patients settle at their medical home, providers from the clinic keep in touch, monitoring and lending expertise as needed.
The collaboration with MAHEC, Jordan said, will help UNC solidify its hub. The funds will allow them to hire peer support specialists, who will keep in touch with patients and make the transition to another medical home easier. UNC will also assist MAHEC in setting up its hub, while MAHEC will help support and train providers in community health centers to care for patients with opioid use disorders.
Jordan said the clinic is still collecting data on how patients fare with the new system, but the hub and spokes model helped the clinic at UNC to see more new patients.
Last year, the clinic took on 42 new patients without adding any new physicians, she added. This year, they’ve seen more than 60 new patients.
Stronger medical homes
A robust referral system is only part of the equation: in order to leave a specialist clinic, patients need a medical home that can help them maintain their recovery.
That’s where community health centers come in, said Alice Pollard, director of health access at the North Carolina Community Health Center Association. The state’s 42 community health center organizations already work with patients on many of their medical needs, including dental, mental health and primary care, she said. Of those organizations, 15 to 20 have some degree of expertise in treating opioid addiction, she said. But that expertise varies from having a robust program with numerous providers to a single provider who can prescribe buprenorphine.
A partnership with experts at MAHEC and UNC could help more centers create such programs, she said, or expand the substance use programs they already have.
“That’s one of the reasons we’re so excited to work with MAHEC and UNC,” she said. “ … But we also think health centers really bring a lot of expertise in helping people navigate some of those social barriers that they have to engaging in care.”