A year of treatments: Addiction clinic offers medication, support

ST. ALBANS – A year ago, the BAART treatment clinic opened near the southern point of St. Albans City, tucked at the far end of a lot rung by hedgerows and trees.

The location, BAART Regional Director of Operations Jason Goguen said, was perfect – the clinic was still on the city’s major thoroughfare but secluded enough to allow patients some privacy.

The clinic also sits atop a bus route maintained by Green Mountain Transit (GMT), a strict prerequisite for the clinic site.

Having a St. Albans clinic means the 140 patients BAART used to have bused from Franklin County to clinics in Burlington and Newport can be treated locally.

A year after opening, BAART now tends directly to 60 patients seeking medication assisted treatment (MAT) – a kind of treatment pairing measured doses of medical opiates like buprenorphine and methadone with counseling – and coordinates another 350 to 400 patients receiving attention from other healthcare providers around the county.

There’s also no longer a waiting list for treatment access in Northwest Vermont, Goguen reported.

It’s a system that, according to some experts, has helped Vermont meet the opiate epidemic head-on and, according to numbers recently published by the Center for Disease Control and Prevention (CDC), stand as one of the few states to actually see a reduction in drug overdoses.

“We wanted to tackle it head on,” Goguen said. “We didn’t hide from it.”

The St. Albans BAART clinic is classified as a “hub” in a statewide model known as the “hub and spoke.”

The model was built off of the traditional healthcare structure, where primary care providers provide general care for patients, but may send patients on to a hospital when their condition required more technical and immediate attention from specialists.

Instead of hospitals, the “hub and spoke” model addressing the opioid epidemic is centered on clinics, which serve as regional hubs. People seeking treatment begin the process in the clinics before being referred to more locally sourced primary care providers, the “spokes” of the hub and spoke model. Should the recovering patient need something more intense, the spoke may refer the patient back to the hub at the clinic.

Examples of spokes in Franklin County would be primary care providers at the Northern Tier Center for Health (NOTCH) clinics dispersed around the county. The BAART treatment center also functions as a spoke in St. Albans.

The primary care spokes are allowed to prescribe buprenorphine, an opioid that can be used to control more painful symptoms of opiate withdrawal before being tapered off. The St. Albans BAART clinic’s Treatment Center Director, Shannon Rodgers, called it a “total opiate blocker,” due to the drug’s interactions with the body’s opioid receptors.

A second drug, methadone, can only be administered from the hub. To imagine the effects of methadone, Rodgers asked the Messenger to “picture a blanket” that covers the opiate receptors.

“It’s there to help control the cravings in a monitored and safe environment,” she said. “It takes care of the need to want opiates.”

Patients seeking treatment will meet with BAART officials to discuss which treatment would best serve the patient and, following a prescription, counselors will start a patient at a lower dose before gradually building up the dosage. They’ll set a ceiling once the patient stabilizes before eventually working to a point where they can trim down the use of methadone or buprenorphine.

“Sometimes when people taper out of the program, it can be as long as six months,” Goguen said. “It could be as little as a couple weeks.”

Patients undergoing those drug treatments aren’t given a hard deadline to be weened off of the treatments, by BAART or state Medicaid.

In Vermont, Medicaid pays for the treatments indefinitely, something that sets the state apart from other places in the U.S. and something that Goguen says lends to the model’s success.

He compared it to Maine where, until recently, patients being treated for opiate addiction were only allowed two years of coverage under Medicaid. Two years after that deadline was initially set, a number of patients were forced to stop treatment and Maine saw a spike in relapse and overdoses.

In addition to medication, MAT patients also take part in individual or group counseling.

BAART patients also receive support for other pieces of their life. Tapping into a network of healthcare providers and social services, BAART may connect patients to local groups and healthcare services to address some the needs of patients outside of the clinics.

The idea, Goguen said, was to help fix the parts of a patient’s life that either led them to opiate addiction or could keep them there.

“It’s not just ‘stop using’ – that’s not the answer,” Goguen said. “We have to dive in and go back to the beginning. Figure out when? How? Why did you start using? What got you down on this road?

“I’m still a firm believer that no one wakes up in the morning and says ‘I want to put a needle in my arm and put these drugs in me to see how it feels.’ It doesn’t start that way.”

A lot of that work is placed on the clinic’s counselors, who Goguen and Rodgers admit have a lot expected of them.

“When we hire our counselors, we always tell them that 50 percent of their job is counseling, 50 percent of their job is case management,” Goguen said. “It’s a lot.”

The state has granted funding for a pilot program in BAART’s St. Johnsbury, Berlin and Newport clinics to establish full-time employment case managers to help patients look for work, a challenge for many of those recovering from addiction.

Should the program work, Goguen suggested it could be moved to St. Albans.

“If it goes well, I hear there may be additional funding for that,” Goguen said.

The challenges

Earlier this year, when Gov. Phil Scott visited the St. Albans BAART clinic as a part of his “capitol for a day” tour of Franklin County, the state’s health commissioner, Dr. Mark Levine, admitted that, even though it appeared the “hub and spoke” were impacting the opiate epidemic, he estimated as many as 10,000 Vermonters were still struggling with addiction who hadn’t come to a clinic yet.

Experts have attributed some of the difficulty in taking in those 10,000 Vermonters to the state’s more rural environment that leaves some communities isolated between mountains and forests. For clinics elsewhere in the state, Goguen said there might only be one spoke.

The effect of population loss in large parts of the state is also felt, making staffing difficult in some places where trained nurses and counselors may be hard to come by. It’s a challenge compounded by a greater, nationwide shortage of medical professionals.

Some Medicaid-assisted busing courtesy of GMT has allowed for transportation from some of the more distant towns in Northwest Vermont, a system that, according to Goguen, might not be able to reach everybody, but puts Franklin County in a better position than some of its counterparts in the eastern and southern parts of the states.

In other parts of the state, public transportation links were completely absent.

“It could absolutely be better, but it could be a whole lot worse,” Goguen said. “I think it’s always going to be a problem to get to these outlying towns.”

Goguen said that clinics also had to overcome a stigma attached to them in their respective communities, a side effect of an opiate epidemic that’s narrowly imagined as a problem afflicting criminals and the poor.

“We battle stigma even at the professional level,” Goguen said.

While the opiate epidemic is largely painted along demographic lines, with commentators regularly defining it as a problem for America’s white, rural poor, the tone has begun shifting. National data collected by the CDC has challenged that narrative as the epidemic spreads to the cities and takes a heftier toll on minority communities.

The epidemic also isn’t tailored to economic class, something that Goguen and Rodgers can both speak to.

“We see some folks who are battling housing issues and food scarcity,” Rodgers said. “Sometimes we see folks with a college education with good family support – maybe professionals or business owners in our community.”

“Not everybody that comes here is at the poverty level,” Goguen confirmed. “We have many patients who are financially stable and do quite well, but they’re battling this disease.

“Many of our patients… had a broken arm or had back surgery, and then they’re prescribed these powerful opiates.”

The stigma has started to fade in recent years, however, as Goguen said it’s increasingly harder to shun opiate addicts as the epidemic becomes more entrenched and familiar.

“These are small communities,” Goguen said. “If you don’t know someone in treatment, unfortunately you will.”

A success story

In St. Albans and Vermont at large, BAART says they’ve held the line on the opiate epidemic.

Rodgers doesn’t have hard data on St. Albans in particular, but anecdotally says that the impact on those who’ve sought treatment is noticeable.

“Folks come in for treatment and, three months, six months, nine months later, you’ll be looking at a different person,” Rodgers said. “It works. For the people it works for, it really works.

“We see the bad side too,” she adds before clarifying that there’s been more good news than bad.

Calls to the treatment center have reportedly slowed since it opened a year ago, Rodgers said.

The BAART clinic at St. Albans recently took to offering group classes like yoga, meditation and anger management, which Rodgers and Goguen hope can help patients as they leave the clinic and wrestle with recovery.

One of the classes Rodgers seemed the proudest of related to the clinic’s gardens. Gardens trace the treatment center’s parking lot, tended to by some of the patients receiving treatment at the clinic.


Opiate treatment needs ‘leveling off’: Local clinic has 360 patients