Over the last few years, Washington state has funded five “health engagement hubs” to help treat people with fentanyl addictions. The model offers drop-in buprenorphine or methadone at no cost to people suffering from opioid addiction, as well as harm reduction services and other health care. The idea is to make treatment as easy to access as the drugs themselves, says Caleb Banta-Green, a researcher at University of Washington who has championed the model. Washington U.S. Sen. Maria Cantwell, a Democrat, has recently introduced a bill in Congress that would fund health engagement hubs through Medicaid. Banta-Green joins us to explain the impact the centers are having in Washington.
This transcript was created by a computer and edited by a volunteer.
Dave Miller: From the Gert Boyle Studio at OPB, this is Think Out Loud. I’m Dave Miller. Over the last few years, the state of Washington has funded five “health engagement hubs” to help treat people suffering from fentanyl addiction. They offer medication at no cost to drop-in patients, in addition to harm reduction services and other health care. Caleb Banta-Green is a research professor at the University of Washington’s School of Medicine who has championed this model. Democratic U.S. Senator Maria Cantwell wants to take it nationwide. The overall idea is to make treatment as easy to access as the drugs that are fueling this overdose epidemic. Caleb Banta-Green joins me now. It’s great to have you on the show.
Caleb Banta-Green: Thank you so much for having me.
Miller: I want to start with that last line I mentioned because when Washington Senator Maria Cantwell introduced legislation to make these hubs possible nationwide, she said this: “Access to treatment must be easier than access to fentanyl.” So let’s start with that. What is access to treatment like in general?
Banta-Green: Great question. By treatment, I want to be really clear what we’re talking about. The most evidence-based treatments for opioid use disorder are the treatment medications buprenorphine, often a brand name Suboxone, or a long-acting form Sublocade, and the medication methadone. So that’s very important to understand we’re talking about treatment medications as the primary evidence-based gold standard treatment.
So, if you think about both of those … we’ll start with methadone. I did my training almost 30 years ago in an opioid treatment program with folks using heroin. And that process of getting on methadone has gotten better, but it still often requires a fairly intensive assessment, a waiting list to get in there, you have to have multiple medical and counseling evaluations, and then getting the medication. There are some side notes and ways to actually make that much faster. But historically, and in many areas it’s variable across agencies what the policies are, it can take days, weeks or even months to get on that medication methadone.
Buprenorphine is a slightly different medication that can be prescribed, often provided out of a doctor’s office and picked up at a pharmacy. But that, too, like any health care that we’re trying to seek, can take weeks or months to get. So that’s kind of the traditional historical approach to getting access to the main treatment, which are those medications.
Miller: Are there any good medical reasons for those delays, or is it kind of bureaucratic or I don’t know, maybe moral friction that society has put in the way?
Banta-Green: Well, on the methadone front, it’s very much around bureaucratic delays. It’s a model of care that started over 50 years ago and it just has extreme regulatory burdens. For my physician colleagues, there’s just no other medication in the United States that has that barrier to access. And there’s a lot of historical reasons for that, tied up in race, and class, and place and such for why it was so restrictive, and almost punitive, really, in the way it’s been administered.
For buprenorphine, there are less regulatory barriers for that. But what we find even as it came on line in 2002, and it just slowly increased the access to that medication, a major policy change was put into place that removed additional training requirements for providers that were in place for two decades. And that’s had very little impact. And part of that is because … there’s sort of two elements to that. The health care systems and those providers are really not incentivized to care for a population that may have fairly high care needs. They may have multiple behavioral health issues and may miss a lot of appointments. So there are a lot of those things – the health care system is not set up well there.
At the same time, via survey work we’ve done with folks who use opioids across Washington state, we asked them, “have you needed health care in the last year and not gotten it?” 60% said yes and it was mostly because of how they were treated by a provider. So you have the systems that are not really designed and often don’t even want these clients. And you have clients who are picking up on those signals and really not feeling welcome in those environments as well.
Miller: Before we get to the model that you’ve been championing – not alone, but you’re, you’re most well known as the champion for it – I still want to learn a little bit more about why it is that these medications are the gold standard. What is it about them that makes them the best version of care we have right now for opioid addiction?
Banta-Green: I think I’ll share with you the opioid addiction, the formal diagnostic terminology is opioid use disorder. And that “disorder” is very important. It has to do with sort of a chaos and lack of balance in a person’s life. And so it’s important to understand opiate use disorder as a starting place. People often are very confused, understandably, about what opioid use disorder is. If 10 people take opioids every day for a month, they’re going to become physically dependent upon them. So the physical dependence part is integral. There are many people who have medical conditions – whether they’re respiratory conditions or pain conditions – that are physically dependent upon opioids, but they don’t have chaotic or disordered use. They don’t have an addiction.
A small proportion of people are sort of predisposed to like those opioids and that may either be physiological, it may be a trauma response, it may be dealing with issues in their life for which opioids make them feel better, emotional or physical pain. So some small proportion of folks may actually become addicted.
When a person is addicted, they’re both physically dependent to that medication and it’s really this disordered use. And what happens in the brain is an actual change in brain chemistry. It gets rewired. I’ve heard providers talk about the fact that the reward system in the brain is hijacked. So from the outside, we might see a person … hey, they made a choice to use an opioid. They’re making a bad choice to keep using opioids. They should stop using opioids. They should make a good choice. What they can’t see is the change in brain chemistry and that the endorphin system in the body is really getting distorted.
So for the vast majority of folks with obedience disorder, what they need to do is get on these treatment medications for some period of time. For some people it’s months, for some people it’s years. But the point is, think about fentanyl. Fentanyl is a very fast acting, very potent, very short acting opioid. What that means is, it’s like a wicked roller coaster whipping you up and down 10 to 20 times a day. Those medications, methadone and buprenorphine, they just get you on a steady state for one day, to up to 30 days for injectable forms of the medication. So a person is still dependent on opioids and that’s because the body has been rewired to respond to opioids in that way. But they can be out of the chaos of use disorder.
So with those medications on board, not only do they get a person out of disorder, not only do they support recovery, but for different physiological and pharmacological reasons, they reduce mortality – your chance of dying – by over 50%.
Miller: So let’s turn to “health engagement hubs.” I gave a one-sentence version. Can you give us a fuller sense for how they work?
Banta-Green: So the idea of a “health engagement hub” for people who use drugs, and there’s different names and different models of care, but fundamentally, the idea is to have drop-in access to, certainly, those treatment medications I mentioned. And then I should say that the Washington State Health Care Authority has a specific model of care. And if people are interested in that they should look at their webpage. It has additional elements like primary care, wound care, other things like that.
The model that I’ve been working on over the last eight years is a little lighter touch than that. So that’s really what we call a community-based medications first model. It’s sort of a predecessor to “health engagement hubs.” And we tested that in six sites across Washington state – urban and rural, Eastern and Western. And in that model of care, sort of the predecessor to “health engagement hubs,” is low barrier access to buprenorphine. It is the ability to meet with a care navigator, a mental health care manager. And we’re also working with folks who have methamphetamine or cocaine use disorder, and offering them referrals and trying to get access to mental health care, as well as using a behavioral intervention, a reward program called Contingency Management.
So that’s kind of the model we have right now operating in Washington state in several places. It is this low barrier model of care. This thing that is working on coming online by the Washington State Health Care Authority is a somewhat more intensive model of care that also brings in primary care and wound care, also harm reduction care, and services and counseling are integral in that. And that is the model of care that Senator Cantwell and Senator Cassidy from Louisiana have been putting forth as a potential national model.
Miller: What are the preliminary results at this point from a number of years of experience at these first few hubs?
Banta-Green: The very first model I mentioned was in downtown Seattle at the Syringe Services program and that was called Buprenorphine Pathways. That was a nurse care manager model with drop-in access to care. And that was really exciting. One measure of success was people, within a couple of months, were lining up two hours early to get medications. If you build it, they will come. We also found very significant reductions in illicit opioid use, even as people continue to use some other substances. And this is very important as well for folks to understand. Many people use multiple substances and they don’t just use a cold turkey stop. That is a rare phenomenon that happens and that often is a barrier to people starting or engaging in care.
So that initial model of care showed dramatic reductions in illicit opioid use. This newer model of care brought in care navigators and was done in more locations around the state. What we found was that there were dramatic increases in the amount of buprenorphine that folks used, huge increases, about a two[fold] to threefold increase in how long they are on those medications. And we know that matters, because every day they’re on medications, they’re more likely to be on medications the next day, supports recovery and reduces mortality.
To the mortality point, what we found in our study – these are preliminary results and the research is under review in a peer review journal now – is we saw about a two-thirds mortality reduction. That’s what we would expect for buprenorphine, but what’s even more exciting for those results is this was in a group that was largely unhoused and in a low barrier model of care. So the fact that we were able to find comparable things that we would find in a traditional health care setting in nontraditional healthcare settings, where there’s higher risk population, was very exciting.
Miller: For the system that Senator Cantwell would like to see nationwide, she says that these health care centers that want to become hubs, they can’t just offer medication for opioid use disorder. They also have to offer harm reduction services, physical and behavioral health care services, and social services like housing support. And there are also requirements for different kinds of providers that they have to employ.
I think I understand the reasons for all of these requirements, but they do add to the cost and complexity of what a health center would have to do. If we are in an emergency where access to these medications is an urgent problem, does it make sense to you to add on these required extra layers?
Banta-Green: Yes and no. I mean, people need and deserve that additional amount of care. They really do. It’s really important to be able to do HIV and Hepatitis C testing and treatment. That’s a very important thing to do. People have really horrific wounds. People absolutely need connections to housing support. But I take your point as well, that kind of a lighter touch model of care that is a little more nimble. It’s a little more easy to deploy, particularly as in the Pacific Northwest where we have some big urban areas that are very well-resourced but many rural areas that are not so well-resourced.
I do think it will be very important to figure out how to scale these properly so that you can actually find the staff that you would need to work on these programs, particularly in more rural areas. I think there are ways to partner with different providers within a community so that all of the services are offered, and they’re bundled and accessible. But I do think it is a challenge to sort out how comprehensive we make these services.
Miller: You’ve said that one of the features of this model is that they take people in over and over. If they start using, and stop and start again, in a sense, that they’re always welcome. Why is that important for this particular health issue?
Banta-Green: Let me start with an anecdote one of our nurses shared with us with our first program. He said a client came back to them and said, “I’ve been on a program a few weeks. Last week I had a slip and I used heroin again. And every other time I’ve been in a treatment program, when I had a slip, I kept using because I knew I was gonna get kicked out of treatment. But I knew you weren’t going to kick me out. So I didn’t stop, I didn’t keep using heroin and I came back to stay in care.”
Miller: It’s a paradox. I mean, I imagine that the reason those other places for decades had that rule was just because they intended the opposite to happen. You’re saying that the system did not have its intended effect of coercing people into stopping so they would get treatment.
Banta-Green: Right. I mean, I think it is a big change. And again, I was trained in that model of care 30 years ago. And it’s just a really abstinence-oriented model of care. It is about you having to want care, you have to deserve care. Perhaps you had to have hit rock bottom in order to earn care. And that’s all BS. Everybody deserves access to care every single day. That care might be harm reduction services. It might be treatment medications. Our goal is ongoing engagement.
You need to remember that many folks with opioid disorder, not only do they have opioid disorder, they often, either before or during the course of the opioid use disorder, had substantial physical and emotional trauma. Their ability to engage in trusting relationships with folks is understandably really damaged. So the ability to know, “you’re going to welcome me back no matter what,” is really fundamentally important to this model of care.
It also is why this idea of what we call harm reduction means something. It means meeting people where they are and working with them every day to help improve their health in any way that they’re able to that day. This is confusing. It is antithetical to many people who have a very much an abstinence orientation to what addiction treatment should look like. And perhaps that worked for them and perhaps it worked for their alcohol use disorder. But when it comes to opioid use disorder, it is clear that we need to get people started on medications and maintained on medications as long as we can and as long as it is benefiting them, and that’s really what we’re aiming to do, that ongoing engagement.
Another way to say it is, I want something for everybody every day. If today I wake up and today is the day I want to stop using, I should be able to get access to medications. If today is the day I wake up, it’s a terrible day and I need to use it because I’m feeling terrible, I should still deserve not to die or get HIV that day. So I want to make something for everybody every day.
Miller: Caleb, thanks very much.
Banta-Green: You bet. Thank you.
Miller: Caleb Banta-Green is a research professor at the University of Washington’s School of Medicine. He joined us to talk about a relatively new approach to treating opioid addiction. Now, Democratic U.S. Senator Maria Cantwell wants to take a more robust version of this hub model nationwide.
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