Program Aims to Meet Addicts' Health Needs Long Term
As early as 2010, they began to see the signs of the coming epidemic.
Patients came in for primary care with needle tracks on their arms and full-blown cases of undiagnosed hepatitis C.
Pregnant women waited until well into their third trimester to seek prenatal care — afraid to keep taking the drugs they were on, afraid to quit.
People, hurting, no longer able to afford the prescription opioids that dulled the pain, stooped to buying heroin on the street.
They’d come in, see a doctor or nurse practitioner, then disappear for weeks or months. Some would get clean, only to relapse. Some would come back with their parents or their children — multiple generations of families hooked on drugs.
Providers at Cherokee Health Systems spent those years trying to plug the dam, to pull together resources to stem the tide of addiction that threatened to wash over Knox and 13 surrounding rural counties where Cherokee operates primary and behavioral health clinics. But the funding wasn’t there for a full-fledged addiction treatment program. The disease that had already taken root in East Tennessee wasn’t yet on the national radar.
That’s changed. About a year ago, Cherokee unveiled a plan, supported by a $325,000 federal government grant, for a comprehensive addiction treatment program integrated with the primary-care and mental-health services it’s long offered. In August, the federally qualified health center hired retired U.S. Army Col. Dr. Mark McGrail to direct the clinic.
McGrail, a 34-year Army veteran and family physician who last served at Fort Campbell and overseas, worked at Cherokee during a 2013-14 fellowship at the University of Tennessee Medical Center. So he was already familiar with the health center’s patient population — about a third on TennCare/Medicaid, about another third uninsured — and its mission to treat physical and mental health issues at the same time.
Therapy and meds
McGrail’s primary task was to head up a medication-assisted therapy program, which Cherokee hasn’t had.
The center has a state grant to help cover some of the cost of buprenorphine, a replacement drug used to gradually wean addicts from opioids, and naltrexone (Vivitrol), which blocks the nervous system receptors that get pleasure from opioid use. As an MD, McGrail can write those prescriptions, which he began doing a month after his hire.
“Cherokee has long had its intensive outpatient programs, which were run by psychologists and non-prescribing providers,” said McGrail, who said those therapy programs will not only continue but expand. “But we know that medications are a valuable adjunct in the treatment of addiction.”
Under obstetrician Dr. Michael Caudle and psychologist Suzanne Bailey, director of integrated services, Cherokee had been one of the few providers that would treat pregnant women with addiction issues and whose babies might be born drug-dependent. Now those women also will be under McGrail’s care; seven of his patients so far were pregnant when they came in, and five still are.
But even those who aren’t pregnant usually come in with untreated psychological trauma as well as other health issues, such as diabetes, hypertension or serious dental problems. The federal Substance Abuse and Mental Health Services Administration estimates nearly 40 percent of people addicted to drugs also have a mental disorder.
“As you can imagine, many of them have had little to no health care for the last few years,” McGrail said. He envisions his clinic as both directing patients to primary-care and behavioral-health services, and accepting patients whose primary-care doctors or therapists catch their addiction problems during visits for other issues — “an addiction ‘medical home,’ if you will,” he said.
“I think we’re going to be able to address all their needs in one setting — that’s our program,” he said. “We have yet to really open the doors. We’ve written referral guidelines to share with our sister health-care organizations, but we haven’t been brave enough to put them out there yet because I think once that happens, the floodgates are open.”
Preparing for a flood
State data showed last year Tennessee was second only to Alabama in the number of opioid prescriptions written, with more prescriptions than state residents. Studies suggest as many as a fourth of people prescribed opioids become addicted, often in a matter of weeks.
In 2015, according to the state health department, 1,451 Tennesseans died of drug overdoses, significantly higher than the number who died in motor vehicle crashes. According to Regional Forensic Center data, Knox County alone saw 170 drug-related deaths in 2015 — nearly double the number from just five years earlier — and that number doesn’t take into account those still alive but addicted. SAMHSA estimates at least 4.5 percent of the state’s entire adult population — more than 193,000 — abused prescription opioid drugs in the past year.
McGrail is seeing more than 60 patients. He said 90 percent of those are addicted primarily to opioid drugs, the remaining 10 percent primarily to alcohol. About 80 percent of those who used IV drugs also had untreated hepatitis C, poised to become a public health burden because it’s so easily spread through shared needles and so costly to treat effectively.
“So we’re looking at significant risk down the road for them for their health,” he said. “We’re looking at trying to get a hepatitis C program here … but we’ve got to work through the finances,” an obstacle also for Knox County Health Department because the newer medications that “cure” hepatitis C can exceed $80,000 for a 12-week course.
A second obstacle is finding a gastroenterologist willing to work with Cherokee’s uninsured and TennCare hepatitis C patients; there’s not one on staff.
Four of the opioid addicts McGrail is seeing now have returned to IV drug use, he said. That means the other 95 percent are, at least, not increasing the spread of hepatitis C through shared IV drug use. Those who have relapsed are still receiving treatment by Cherokee's care team, he added.
McGrail is realistic that the clinic is “a marathon, not a sprint,” as Cherokee’s chief clinical officer, Dr. Parinda Khatri, has said. Relapse rates are higher for opioid addicts than for users of other drugs. Some studies put opioid relapse at 85-90 percent. Research suggests the use of medications could reduce that rate, but widespread use of the newer medications in opioid addicts is still relatively new. McGrail said he’ll evaluate the length of time patients need those medications on a case-by-case basis.
After months of searching, Cherokee last month hired a registered nurse for the clinic. The challenge to find qualified staff willing to work with opioid addicts is magnified in rural areas; Jellico’s Dayspring Family Health Center, in Campbell County, received a grant identical to Cherokee’s to start a similar program but hasn’t found a behavioral health specialist.
"We have been looking for licensed clinical social workers, clinical psychologists or licensed professional clinical counselors to develop our program but have not been successful in locating them,” despite running ads continuously, said Chief Medical Officer Dr. Geogy Thomas. “As soon as we find the right fit, our hope is to have a fully integrated model that offers a holistic approach to addiction.”
SOS cites success
But Nashville’s Neighborhood Health federally funded health center has seen success with its comprehensive opioid addiction program for which it received a $231,1931 grant last year.
Known in the community as “SOS,” Neighborhood Health’s program began in July and includes a dedicated physician along with a case manager, licensed practical nurse and two full-time behavioral health therapists, said Pam Brillhart, chief operating officer. It combines medication-assisted treatment with individual and group therapy and referrals to outside 12-step programs such as Narcotics Anonymous, she said.
Like Cherokee, Neighborhood Health does a full physical and behavioral health assessment for those entering the program, to catch other issues, Brillhart said. Those in the addiction program who were not already Neighborhood Health patients are assigned a primary-care treatment team and get preventive services and medical management of chronic conditions, she said, while patients who come in for primary-care and behavioral health services are screened for substance abuse and referred to SOS when appropriate. The center hopes to serve 100 SOS patients this year.
Brillhart said SOS’ rate of retaining patients in its addiction program is 83 percent, compared to the national average of 45-50 percent. Like Cherokee, Neighborhood Health attempts to schedule appointments with multiple providers back-to-back at the same location on the same day, to increase both the odds of patients keeping appointments, and their investment in the program, she said.
The SOS program also is open to pregnant women, who can get prenatal services at Neighborhood Health or through an outside provider of their choice, she said.
“We have found that obtaining OB services for addicted women is yet another barrier for them,” she said.
Striking while hot
Cherokee has found scheduling appointments around pediatrics is effective, Khatri said.
“Women will notoriously miss their postpartum follow-up visits, but they will keep those well checks for their babies,” she said. “So we can have mom’s gynecological visits, psychological visits and addiction visits with baby’s well checks. We’ve really patched together a network of support for this woman and a health-care home for the family.”
Too often, if a patient can’t get addiction services immediately after making the decision to get clean, the desire passes, Khatri said. Cherokee’s ultimate aim is to get people care instantly, with grant money filling the gaps between insurance approval or the ability to self-pay.
“Otherwise, we lose them,” she said.
McGrail said when word of the program spreads, he expects Cherokee will soon need “another one of me.”
“Once we fully open the doors, we will not be lacking in business,” he said.