Distribution of Narcan to emergency responders is part of a two-pronged federally backed effort to help counties combat the opioid epidemic.
The other piece aims to support local physicians with medication-assisted treatment for people who want to break their addiction to heroin or narcotic painkillers. That effort has yet to gain traction.
A year ago, Stanislaus and San Joaquin counties were targeted for $4.2 million in funding for Narcan distribution and a hub-and-spoke system for supporting local physicians in providing medication-assisted treatment for addicts.
Thus far, no physicians have chosen to participate in the project in Stanislaus County. There’s no record that any primary care practices in the county are certified to administer buprenorphine, an addiction treatment drug that can be prescribed for addicts by a physician’s office.
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The state awarded the grant funds to Aegis Treatment Centers, which runs the methadone clinic on McHenry Avenue in Modesto. If Aegis had any takers for the hub-and-spoke project, a Manteca center would provide support to primary care practices in smaller communities like Oakdale or Patterson, said Dr. Lyn Raible, medical director for Aegis.
Raible said a physician’s office in Turlock or Modesto could also serve as a “spoke” for prescribing Suboxone and managing treatment for people addicted to opioids. Suboxone is a more widely known form of buprenorphine.
“We have gone through the list of every known prescriber that you can get on a state website,” Raible said. “The only doctors who prescribe buprenorphine are not prescribing it for addiction. They’re prescribing it for pain.”
Top health officials have pushed medication-assisted treatment for the 2 million people addicted to opioids in the United States, partly due to the high relapse rates of recovery programs that rely on support groups and abstinence. A study in Massachusetts found that overdose survivors placed on addiction medications, combined with counseling and recovery supports, were 50 percent less likely to later suffer a life-ending overdose.
The National Institute on Drug Abuse cites a 2009 study, which found that patients on methadone combined with psychosocial therapy had a 33 percent lower rate of failed drug tests and were almost 4 1/2 times more likely to stay in treatment than those on a placebo with counseling.
In a study in Sweden, all of the participants treated with a placebo and counseling support had positive drug tests compared with 25 percent of patients given buprenorphine and counseling. The death rate was 20 percent among patients who dropped out of treatment.
Raible said she’s aware of patients who can’t get to the Aegis clinic on McHenry, where methadone is a mainstay of therapy to help people overcome opioid addiction. It’s estimated that 80 percent of Americans with opioid substance abuse disorder are not getting treated, she said.
The Aegis center, which is the largest addiction services clinic in the county, is not permitted to dispense Suboxone, even though it’s safer than methadone and has less potential for misuse.
Suboxone does not produce a desirable high and any effects level off with every dose, which discourages people from misusing the drug. New patients can fairly quickly receive a take-home supply so they don’t have to visit a clinic several days a week, Raible said.
Stanislaus and other counties are waiting for a state approval before treatment centers can prescribe Suboxone, Raible said.
She said that physicians elsewhere who are trained in Suboxone treatment fear there are not enough supports and may feel isolated in dealing with addiction patients. Some patients may have mental health issues and doctors participating in the hub-and-spoke program are responsible for referring all patients to counseling.
The program provides nursing staff and clinical support for urine testing and legal compliance. It can also help doctors with arranging counseling for patients, said Aegis Grant Manager Sarah Khawaja.
Dr. Silvia Diego, a family practice physician in Modesto, said there’s a need for addiction treatment options for patients who need to stop long-term use of opioid pain medications. Starting in the late 1990s, doctors were compelled to prescribe stronger pain meds for patients before the addiction risks were known, and now are expected to decrease the medications, she said.
“It’s a very difficult problem,” Diego wrote in an email. “A lot of patients start out with legitimate pain that becomes unresolved. ... When they are addicted they don’t realize they need help. Having somewhere to send them with support, for those who really want to try, would be amazing.”
Raible said assistance is not available for large numbers of pain management patients who will need to be weaned off narcotic pain relievers. Rarely is there teamwork between pain management doctors and addiction treatment.
She said many patients with chronic pain have sought addiction treatment from Aegis after their doctors cut them off and they started buying opioids on the street.
“We are not transitioning them in the right way,” Raible said.
Khawaja said she’s had an initial discussion with a county staff member about holding an opioid summit where some training for local physicians could be offered. The first meeting of a newly formed county opioid coalition will be held later this month.
Definitive information is lacking on the severity of the opioid crisis in Stanislaus County but there are indications the problem is significant. A state Department of Public Health dashboard shows that 527,832 prescriptions for opioid painkillers were issued in the county last year, almost equal to the county population.
Khawaja said the Aegis center in Modesto, with 800 patients and 300 people on a waiting list, is the largest of the company’s 33 clinics in Northern and Southern California, and there’s need for a second Modesto clinic. There’s also enough people with substance abuse disorders to keep a county methadone clinic in business.
A tally of overdose deaths handled by the county Coroner’s Office is considered to be incomplete because some opioid-related deaths that occur in hospitals may not be reported to authorities.
According to an annual survey done for the High Intensity Drug Trafficking Area, the Coroner’s Office attributed 35 overdose deaths to opioids last year (24 prescriptions and 11 heroin). Heroin was a factor in four accidental deaths.
Those survey numbers were down from 48 opioid overdose deaths in 2016 (37 prescriptions and 11 heroin) and 76 fatal overdoses in 2015 (50 prescriptions and 26 heroin).
Raible said she will keep looking for physicians to add addiction services to their practice.
“We would love to find somebody who wants to do this and maybe has not started because they don’t have support,” she said.
The Aegis clinic in Modesto can be reached at (209) 527-4597.