CINCINNATI — In the midst of a heroin epidemic that’s sweeping across the United States and hitting Greater Cincinnati hard, there are not enough medical providers equipped to treat drug addicts, substance abuse experts said.
There are more social workers and counselors treating addiction than there are physicians trained to provide medical-assisted treatment or recognize when their patients are abusing substances. The issue is complicated by a longstanding societal debate about whether addiction is a disease or a choice.
Today, a local doctor is calling for more addiction treatment that combines medical and social services, and his work with the American Medical Association could lead to that national change.
In December, the association tapped Shawn Ryan, 38, of Cold Spring, to serve as the vice-chairman of its Payer Relations Committee. Now, he’s recruiting a team to help develop a new national treatment model that would make it more commonplace for addiction to be treated as a medical issue, in addition to the counseling and social service treatment that already exists. Ryan's team will also explore innovative ways to fund it.
“Every one of our patients needs both the medical treatment as well as the psychosocial services — not one or the other,” said Ryan, who’s also the president of the Cincinnati-based substance abuse recovery center, Brightview, and an emergency medicine physician at University of Cincinnati Medical Center.
He knows it will likely take more than a leading medical group's position paper for that model to see the light of day. It’ll take a change in philosophy about the cause of addiction — an issue that divides much of the country, including the medical community.
Ryan's in the camp of people who believe addiction is a disease — a choice the first time a user tries it, but a chronic-relapsing brain disease once they're hooked. There's another massive group in this country that believes users have complete control of their addiction.
“Most current treatment organizations have very few medical professionals because it has historically been treated as a social, psychological problem. Now we have a real divide or a gap in the availability and presence of medical professionals who handle cases of addiction. We struggle to find (them),” Ryan said.
'It's Not Just A One-Factor Disease'
Addiction experts said involving doctors in an addict’s treatment plan is essential — and not just because they can prescribe medication to addicts that eases symptoms of withdrawal.
“(It's) very helpful because their health is monitored — things like heart disease, which may come, or lung cancer or Hepatitis C — all of which are effects of addiction,” said Ann Barnum, vice president of community strategies at Interact for Health.
The cause of drug addiction is complex. That's why experts said it's critical to rely on both doctors and counselors to treat it.
"(Treating) addiction is not only about staying away from drugs, but it's about changing a lifestyle. It deals with housing. It deals with case management. It deals with medication that may be needed, in addition to counseling. It's not just a one-factor disease," said Margo Spence, president of First Step Home, a 24-hour residential treatment program for women.
Many Tri-State residents addicted to opiate drugs, like heroin, enroll in nonprofit treatment organizations, such as First Step Home, that rely on social workers, counselors and psychiatrists. Those organizations often keep the lights on through grants. They contract out with medical providers, instead of staffing them in-house.
“They were never designed to treat a medical problem — especially a complicated one. They’re really only historically designed to deal with social issues for the most part,” Ryan said.
At First Step Home, which serves 75 female addicts and their children, the recovery center has a contract with Good Samaritan Hospital, which gives opiate-addicted soon-to-be moms access to medical care at the hospital.
Spence said the treatment center has tried to start its own medical department, but has never been able to sustain it.
“It’s always better for us to have as many services on-site (as we can) than clients having to leave our environment and go to another location. It streamlines the process,” she said. “But we do not have the funds currently to be able to pay for nursing care and doctor care and those kind of things on-site."
At Brighton Recovery Center for Women, a 100-bed treatment facility in Boone County, addicted women have access to contracted nurses 16 to 20 hours per week, said Anita Prater, Brighton Center director.
She, too, sees the benefit of having medical staff on-site and available all the time. Prater said an in-house medical staff be best equipped to react to an addict's behavior.
“You need to understand how addicts think and how they manipulate. (They’re) seeing issues they’ve ignored for years, and now all of a sudden because they are sober and can feel feelings, they want to manipulate you for time, attention and medication when they need to be focusing on other stuff,” Prater said.
Some local grant-funded treatment organizations do have medical providers on staff, but Ryan said those organizations could always use more.
“They have some, but there’s just not not enough to go around. It’s no fault of the Talbert House or the Center for Addiction Treatment or anyone else," he said. "They’re not health systems. They were not designed to treat a disease. They’re doing their very best.”
Why There’s a Shortage of Addiction Specialists
The addiction treatment industry struggles to find medical staff trained to treat addiction as a disease because their services are often not heavily reimbursed through Medicaid, experts said.
“It’s never been paid for. The medical world moves slower than anything else I’ve ever dealt with in my life. After you declare (addiction) to be a disease, you have to get people to believe it. You have to train people to deal with it. Simultaneously, you have to reimburse it because (otherwise) no one is going to go through years of training,” Ryan said.
Barnum said that’s why there’s a shortage of people with addiction expertise across the country.
“No one going to college was going to say, ‘I want to be an addiction counselor because that’s going to give me a good living.' Because you’re not getting paid. You only got into that because you wanted to help,” Barnum said.
Because funding isn't easy to find, many Tri-State physicians are forced to charge their addicted patients out-of-pocket in order to keep the lights on, Ryan said.
Dr. Mike Kalfas, a local family doctor and addiction specialist, said his patients battling addiction in Kentucky are routinely denied by Medicaid. He said he relies on digging up samples for the patients who desperately need treatment medication, like shots of Vivitrol — an injection used to treat addiction.
"(Medicaid doesn't) hardly pay or anything….They’re rubber-stamp denying me and sending me on,” he said.
To Barnum, the issue stems from the health care industry putting addiction in the same payment category as a broken leg.
“It’s not an acute illness. It’s not like having a cold or even the flu or a broken leg. It’s more like having diabetes or heart disease. It’s an ongoing, chronic illness that has to be monitored. You have to have checkups," she said.
But not everyone is blaming health insurance for a lack of doctors equipped to treat addiction.
"I would really argue against any notion that insurance policy or practice is even a limiting factor in identification or treatment of behavioral health concerns,” said Jonas Thom, vice president of Behavioral Health at CareSource, who’s working with Ryan on the American Medical Association committee. "We cover everything."
“I think there’s a stigma out there and still a lot of blaming and anger and a misconception in the public mind that addiction isn’t a disease. I agree with the sentiment that it’s a problem but not a problem that’s perpetuated by insurance policies. It’s a cultural problem that insurance companies are trying to address desperately by increasing our network, increasing access to care.”
Training Every Doctor to Handle Addiction
While some are concerned about the lack of addiction specialists available, others think the real issue stems from not enough family doctors who understand addictive behavior.
"Trying to cover all the addiction patients in the United States with board-certified addiction specialists is like saying we need enough endocrinologists to cover all diabetics in America,” Kalfas said.
“This (heroin epidemic) is such a ubiquitous problem that every primary care doctor wants to find somebody to send their addicts to. There’s not enough, and theres not going to be enough. If we start now it’s going to take 10 or 15 years to train enough doctors to treat all these people. This is primary care disease,” he said.
Spence said she worries that an improperly trained doctor -— or one who's not trained at all in addictive behavior — may over-prescribe pain medication without realizing the dangers of someone becoming addicted.
“If you notice, if you go to a physician, you’re asked a question: ‘Do you smoke? If you smoke, how often do you smoke? Do you drink?' We don’t go ahead and say ‘Do you take drugs that aren’t prescribed to you by a physician?’" Barnum said. "We need to ask those questions, and then we need to have a response.”
Prater, the Brighton Center director, said that society will begin to change its philosophy about addiction as a disease once treating addiction as a medical issue becomes more commonplace.
"The one silver-lining in this heroin epidemic is that I think it's propelling this discussion more often, and it's probably going to get us there quicker than I ever dreamed possible. I think it's forcing us to talk about it as an addiction, and I think it's forcing us local, state and federal levels to think about making changes."
Ryan, who's working on developing solutions to improve the quality of addiction treatment, said his committee hopes to publish their findings within about six months.