When Courtney Hasse was diagnosed with melanoma, she immediately received referrals to the region’s top doctors and within weeks had a plan of attack for the cancer that could have killed her.
“We didn’t have to make any appointments,” said her mother, Katrina Sauerwein. “They would call to tell us what time there and where to be. It was almost like the red carpet had been rolled out for us.”
The experience contrasted starkly, however, with the search to find help for her daughter’s heroin addiction.
“I begged for six years to find doctors that could help us,” she said. “Once you’re dealing with addiction, you get treated totally different. No one was knocking on my door to save my daughter.”
In a region flush with nationally rated hospitals and doctors, addiction remains a deadly disease that continues to stump medical professionals and the family practices and health systems they work in.
“The current opioid issue is terrible, and it’s helped us focus on what we haven’t done well in our health care systems in the past – which is treat substance abuse disorders,” said Dr. Shawn Ryan, chief medical officer at Brightview, a Norwood-based outpatient addiction medicine practice.
The problem isn’t unique to Greater Cincinnati.
"The health-care system wiped their hands of treating addiction a long time ago," said Emily Feinstein, director of Health Law and Policy at the National Center of Addiction and Substance Abuse in New York.
"It's barely on the curriculum for physician training, and doctors themselves can place the same stigmas on the patients that the general public does," Feinstein said. "When they face a patient dealing with addiction, they either don't recognize the symptoms, or they're scared they'll do the wrong thing and they just ignore it."
But unlike the past waves of crack or methamphetamine abuse, the heroin epidemic is forcing attention from countless medical providers as emergency rooms are flooded by overdoses and a host of costly complications that come with IV drug use.
“What’s new about heroin is that it’s cheap, it’s readily available, and the lethal effect is more immediate,” said Dr. Richard Lofgren, president and CEO at UC Health. “You have overdoses and you have a high rate of infectious diseases that you don’t have with other addictions.”
But as the growing number of addicted receive and seek medical care, they face glaring gaps in treatment options, insurance coverage and physician know-how.
“We need to develop a system of care for substance abuse disorders in our health-care system. Period," Brightview’s Ryan said. “We’re starting to see a shift, but we have a long way to go.”
As Greater Cincinnati and Northern Kentucky wrestle to curb the heroin and opioid epidemic, here are five big changes that local health-care leaders have told WCPO are needed across our local health systems to tackle the challenge.
Better Care in the Emergency Room
In August – as emergency medical crews responded to a record 174 overdoses in four days – a "light bulb” went off for Tim Ingram, Hamilton County’s top public health official.
“Once these folks have been transported to an emergency room – it’s an opportunity,” Ingram said. “We have to come up with a standardized protocol across our health systems so that we’re not just stabilizing them in the (emergency department) with Narcan and then pushing them back out on the streets. We’re better than this.”
Reviving someone from an opioid overdose “and just letting them go is the worst thing you can do,” said Feinstein of the National Center of Addiction and Substance Abuse.
“That’s equivalent to giving someone who just had a heart attack the shock paddles to revive them, and then sending them home,” Feinstein said. “If you don’t find a way to treat them, then they’re going to be back with the same problem or worse.”
Instead, she said, research shows that people addicted to heroin who receive buprenorphine – a medication that reduces opioid cravings – show better results than those who received other treatments.
A Yale School of Medicine study of 300 patients found that those who received buprenorphine and were then referred to ongoing treatment by primary care doctor were twice as likely to stay in treatment compared to those who received just a consultation or intervention by physicians.
“When they come into the emergency room, that’s really the moment they need comfort care, which is why buprenorphine is so important,” she said.
Better Access to Medicine That Can Help
But prescribing buprenorphine is no easy task.
Federal regulations put caps on the number of patients a doctor can treat with the drug, and require doctors to go through additional training and a lengthily waiver process before they can prescribe.
Although rules allow emergency room doctors to prescribe up to a three-day supply, the federal rules have kept many other doctors from going on to prescribe the drug longer term, Feinstein said.
“Medications like buprenorphine are still really misunderstood, and it comes from this long-held belief that medication-free treatment is the best,” Feinstein said. “Research is proving that it’s not.”
Better Insurance Coverage
As Katrina Sauerwein searched the region for treatment options to help tackle her daughter's heroin addiction, she found few options that any medical insurance plan would cover.
“She went to several local rehabs here, and most are self-pay – you pay all the money up front,” she said. “It didn’t matter if she stayed 10 minutes or the whole program. There was no refund.”
One program offered a 10-day detox plan for $2,000. It didn’t work. The family’s biggest expense: A $35,000 program that spanned 35 days.
“Through everything we’ve been through – we saw so many missing links,” Sauerwein said. “There was no system that could take her from step one through the rest of her life. It’s all just bits and pieces here and there.”
Under the Patient Protection and Affordable Care Act, also called Obamacare, health insurance plans are now required to offer coverage for substance abuse disorders. The law requires plans to offer the same type of comprehensive coverage for addiction as they do medical and surgical benefits.
However, as many as 88 percent of insurance plans across the U.S. lack the details needed to know whether they’re providing the coverage required by law, according to a June report by the National Center of Addiction and Substance Abuse in New York.
“If your kid has a broken arm, it might take three calls to figure out who’s the best surgeon your insurance covers,” Feinstein said. “If you’re kid has an addiction, that’s not the case.”
In Ohio, for example, most plans lack coverage for care that takes place in a treatment or residential center. The same is true in Indiana, according to the report. In Kentucky, methadone is excluded from coverage by most plans as a maintenance drug for opioid abusers.
But there are other reasons treatment can be hard to find.
“Even if you do have insurance, often there’s a lack of providers,” Feinstein said. “Sometimes, the reimbursement rates are so low for this work, health systems don’t want to take it on.”
More physician education
Just this year, the Accreditation Council of Graduate Medical Education recognized addiction medicine as a new subspecialty. That move paves the way for countless universities to begin crafting courses for future doctors to become experts in substance abuse.
It’s a long time coming, Feinstein said.
“For a long time, addiction was not seen as a disease, but as a moral failing and many medical systems wiped their hands of substance abuse work decades ago,” she said. “That’s led to very few schools in the country that are teaching this right now.”
In Northern Kentucky, Dr. Mike Kalfas said too many physicians still don’t recognize addiction as a chronic disease.
“There are always excuses as to why doctor’s don’t see this as a disease,” said Kalfas, a family medicine doctor and addiction specialist. “They say things like, ‘Well they’re doing something illegal.’ That’s why we’ve got to go back to medical education and start there.”
A 2012 report of Feinstein’s center found:
Addiction counselors, who make up the largest share of providers of addiction treatment services, are not required to have any medical training and most states do not require them to have advanced education of any sort.
Physicians and other medical professionals, who make up the smallest share of providers of addiction treatment services, receive little education or training in addiction science, prevention and treatment.
Locally, the University of Cincinnati's College of Medicine includes an Addiction Sciences Division, which offers courses to medical students and fellowships for physicians and researchers.
In October, UC Health opened its first intensive outpatient program, where individuals receive both medication-assisted therapy and group-based therapy. The health system also recently opened a walk-in clinic where individuals can meet with physicians and addiction specialists to talk about treatment options.
The new programs are still "ramping up," said Christine Wilder, director of UC's Addiction Services Division.
"I think there is still a perception that if people have the willpower, they can overcome addiction," Wilder said. "History and science tell us, that doesn't work out too well. That's why more training for physicians is so important."
More compassionate care
Across the region, local health-care leaders have been meeting regularly to discuss ways to provide more seamless care for patients battling addiction.
“There is a lot of discussion about better ways to provide initial medical stabilization and then linking that with ongoing care with other providers in the community,” said Nan Franks, director of the Addiction Services Council.
But lifting the stigma associated with addiction and treatment is critical.
“The problem we have so often is that even when someone wants help they don’t know how to ask for help or they're afraid,” said Garren Colvin, CEO at St. Elizabeth Hospital in Northern Kentucky.
Brightview’s Ryan agreed.
“There’s not a whole lot of care for them today when they do ask for help,” said Ryan, a former emergency room doctor. “When they show up, they’re mistreated by 90 percent of the emergency room staff. We may be seeing a shift, but we have a long way to go.”
In September, Courtney Hasse was released from prison after serving nearly a year for a minor parole violation.
“She’s working to get a job, and her life back,” her mom said. “I think there is more community awareness today than there was three years ago, but we’re still loosing people every day and we don’t have system in place to do anything about it.”
Hopefully, that will change, Franks said.
“Everyone is coming together now to really focus on solutions,” she said. “It doesn’t feel fast enough, but I think as we decrease the stigma, and increase knowledge we have a better chance at more seamless care.”