Small clinics in rural Minnesota are embracing medication-assisted treatment (MAT) to combat the opioid crisis, and Sawtooth Mountain Clinic in Grand Marais already is seeing positive results since adding a MAT program this spring.
Kate Surbaugh, CEO at Sawtooth Mountain, says a primary reason for adding MAT at the clinic is to provide local service without the need for long commutes.
“We knew people were successful staying sober on Suboxone,” a brand name opiod-addiction prescription, she said, but having to travel to Duluth or farther to obtain the medication was impossible for many people.
Given the need, and the timing of a new doctor coming on staff with MAT experience, Sawtooth quickly enrolled about a dozen patients in its program. Now two of their physicians have completed the extra training to receive the necessary federal waiver to prescribe buprenorphine, a tightly regulated opiod that also has been prescribed for opioid-use disorder.
Buprenorphine, which is in Suboxone, is used in addiction treatments because as a “partial agonist” opiod it is more difficult to overdose when using it than when taking a “full agonist” opiod. Suboxone further mutes buprenorphine by blending it with naloxone, which can be used to block the high effect of the buprenorphine to reduce the risk of it being abused.
“Buprenorphine is safer in that you can’t get the same high,” said Surbaugh. “The high plateaus at a certain point, and it is very difficult to overdose on.”
Calling it a life-changing treatment, she says one doctor noted that physicians are seeing light in the eyes of addicted patients for the first time after treating them for years.
“They are working, taking care of their kids and living their lives. This is a necessary service, and it is extremely gratifying to see how helpful it can be for patients,” Surbaugh said.
While the federal waiver requirement is an extra layer of work, it is a well delineated process accessible online and can be completed in three to five days.
Some, though not all, insurance companies require prior authorization to obtain buprenorphine, a process that can take 72 hours or more. In 2018, the Minnesota Department of Human Services changed its policy to remove prior authorization requirements for Medicaid patients on some buprenorphine prescriptions, though it still limits certain brands. To make it more complicated, there is fluxuation among brands that have those limits. Prescribers may be taken off guard, leaving patients with gaps in their prescriptions and vulnerable to addiction relapse.
While implementation of its own MAT program has not been simple, Surbaugh said it has been a relatively seamless transition with the support of other MAT-experienced clinics. Sawtooth used St. Gabriel’s Health in Little Falls as a template to learn how to deal with prescriptions of such a tightly regulated drug and how to deal with insurance coverage issues.
It was four years ago that Little Falls physicians Kurt DeVine and Heather Bell developed new criteria for their clinic physicians to prescribe opiates. Almost immediately, opiate prescriptions went down by 60 percent, a reduction of 600,000 pain pills per year. They moved on to adding MAT with Suboxone to the clinic for patients with opiate and heroin addictions, something that practically no one in rural Minnesota was doing at the time.
Through the use of an internet platform called Extension for Community Healthcare Outcomes (ECHO), DeVine and Bell have been able to reach a wide and eager medical audience throughout Minnesota. Averaging 80 participants in their weekly virtual clinic consultations and training, DeVine says it’s a unique opportunity for rural doctors to train other rural doctors.
“We have been able to move from being virtually the only rural clinic in the state doing MAT to mentoring many other small community healthcare teams around the state to use Suboxone and help them navigate the waiver training. This has become an online community for MAT prescribers,” said DeVine.
He estimates about 90 percent of his patients are insured through state programs, and working within that system has challenges. Each year, changes are made to what precise drug is approved without prior authorization.
“One of the biggest issues is when a prescription for a MAT patient is suddenly not approved. It is enormously time consuming when one year a brand name is paid for, then suddenly it’s only generic. A prescription can get denied, and a patient can’t run out or we’ve got a problem,” DeVine said.
Some 60 percent of his clinic’s patients using MAT are employed, Devine said. That number excludes retirees and stay-at-home parents.
“These patients on Suboxone are very reliable, good workers. We have patients in all different lines of work: landscapers, teachers, roofers, nurses. I can go anywhere in my town and run into a MAT patient because they are working,” said DeVine.
Matt Johnson, staff at St. Louis County’s Substance Abuse Prevention & Intervention Initiative, says that MAT using buprenorphine, methadone and naloxone is now accepted as a critical tool in the field of opioid addiction treatment.
“Regardless of which medication is used for MAT, when done properly, it is the best practice for opioid dependence. We see it used a lot, and it helps tremendously to help maintain and live normal lives.”
Johnson is aware of considerable bias against MAT, especially among employers, and attributes that to the misconception that workers will nod off or be unable to function on the job while on treatment. That is absolutely not the case, he said, and when done under medical supervision, a maintenance dose of Suboxone keeps the patient from becoming sick from withdrawal and manages cravings.
Furthermore, Johnson does not believe that employers need to know whether employees are receiving MAT for addiction.
“MAT information about a person can oftentimes fall into the wrong hands with a lot of bias behind it,” he said, “but it’s really no different than taking a medication to control blood pressure or diabetes. It is personal medical information for a medical condition, and really that is nobody’s business but the person taking the medication and their prescriber.”
Lake View Hospital in Two Harbors is considering the addition of MAT to its services. The hospital’s President/CEO Greg Ruberg sees MAT as potentially fitting well with their expanding focus on behavioral health under the primary care umbrella. Lake View has added a behavioral health nurse practitioner to staff and will add two new physicians this fall who have experience with MAT.
“Lake County, just like across the country, needs more comprehensive care for opioid abuse disorder, and we are evaluating how we can offer the most complete service,” Ruberg said. Lake View also is looking to the ECHO online program as a model.
State Rep. Dave Baker (R-Willmar) has led the charge on legislation addressing the opioid crisis. He lost his son to an opioid overdose in 2011.
Baker was instrumental in advocating for state legislation passed in July that will bring more financial resources to address opioid addiction. The law requires drug makers and distributors to pay annual fees of $20 million into a fund that would be used for prevention and treatment of opioid use disorders.
“We are nowhere near spiking the ball on this issue,” Baker said, “but we are the first state to get pharmaceutical and distribution companies to help with the problem after they lied about what was going on.”
Recent data released by the Drug Enforcement Agency revealed that more than 1 billion pain pills were prescribed in Minnesota between 2006 and 2012, enough for each resident of the state to have 156 pills. More than 1,600 deaths in the state are attributed to opioid overdoses during that period, with 1,776 opioid related deaths in Minnesota between 2013 and 2017. Nationwide from 2006 to 2012, more than 100,000 deaths are attributed to opioid overdoses.
Despite common perception that addiction to heroin and illegal fentanyl is the most deadly, statistics show that more deaths resulted from prescription painkillers than street drugs.
According to Eileen Smith with the Minnesota Council of Health Plans, an agency representing seven major health insurance providers in Minnesota, private insurance plans have moved in the direction of removing barriers for MAT.
For the companies that the council represents, Smith said, “There is no prior authorization for the medications that assist. It’s important people get the help they need right away when they are ready.”
However, co-pay amounts vary by insurance plan and can be very stiff.
U.S. Sen. Amy Klobuchar (D-Minnesota) cosponsored a bill introduced to the Senate this year that would require private insurance plans to cover prescription drugs related to opioid-use disorder without cost-sharing or copayments by consumers.
“As a former prosecutor, I’ve seen firsthand the devastating impact addiction has on families and communities,” she said in an email statement. “I don’t think that treatment should just be limited to the people that have good insurance or can afford it. When people continue to be turned away when they seek treatment for addiction, more must be done.”