Hub-and-spoke model catching on in battle against addiction

Nov 24 2017

Hub-and-spoke model catching on in battle against addiction

The New England region has been plagued by the highest average rate of overdose deaths in the country. But one state in the region, Vermont, has made impressive strides in its battle against addiction, by focusing on making medication assisted treatment (MAT) widely available, using a “hub and spoke” model.

The “hubs” are addiction specialists who provide MAT. The “spokes” are primary care providers who give continuing, less-intensive care. Vermont has six hubs in 10 locations and dozens of spokes spread out across the state.

Officials say one major benefit of the hub-and-spoke model is removing from primary care providers some of the time-consuming burden of treating addicted patients with a variety of other health needs. The state provides support to doctors with “MAT teams,” a nurse and a behavioralist who handle some related functions, such as counting pills and handling patient check-ins.

The results have been significant. In 2014, Vermont had 1,751 people in treatment, and 513 on a waiting list. In July 2017, there were 3,148 people in treatment and just 110 on a waiting list.

According to figures from the Centers for Disease Control and Prevention (CDC), the drug overdose death rate for New England was about 24.6 per 100,000 people in 2015 (the most recent year state-by-state data is available), which was the highest for any region in the country. However, Vermont was well below the regional average at 15.8, and the national average of 16.3.

John Brooklyn, M.D., a family practice and addiction specialist in Burlington,Vermont, is credited with starting the effort develop a more effective approach to the opioid problem. In 2011, Brooklyn started working on the problem, which led to piloting a local program in Burlington and, eventually, the statewide model.

The program Vermont developed is modeled after the overall U.S. health care system, in which primary care physicians refer patients to specialists when necessary, Brooklyn told 

“The parallel universe would be cardiology or infectious disease, where if you get sick and your primary care doc can’t take care of you, you’d get referred to a cardiologist. The nexus of this was really to try to integrate substance use treatment in primary care,” he added. That way, “if a doctor had a patient that they didn’t really know what to do with, they could refer them to someone like myself who’s board-certified in addiction medicine.”

The new system would not have been possible without the passage of the Affordable Care Act in 2010. Under the ACA, Vermont was able to use a special Medicaid waiver to help pay for the hub and spoke system. With the expansion of the state’s Medicaid program, the federal program now covers most of Vermont’s more than 8,000 opiate addiction patients.

Vermont also developed new rules for prescribing opiates for acute pain, which went into effect on July 1. The new rules focus on prescriptions for “opiate naive” patients – those who have not had an opioid for the past 30 days. The rules limit how much medication that can be initially prescribed, with different limits for four categories of pain: minor, moderate, severe and extreme pain.

The rules also use a “morphine milligram equivalent limit,” to compare strengths of different kinds of opiate pain relievers, such as Oxycontin, Vicodin, Percocet and others, Vermont Department of Health
spokesperson Shayla Livingston told The limits are lower for patients under the age of 18, she said.

In California, a similar hub-and-spoke model is being developed using a $90 million federal grant from the Substance Abuse and Mental Health Services Administration (SAMHSA). The system assembled by the California Department of Health Care Services  will have 19 hubs, each with their own spokes. California has set a goal of treating 20,000 additional addicts over the next two years.