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New addiction medicine coalition formed to address addiction problems in SE Utah - Medically Speaking, Volume Two, Number Nice, 3/19/15

Affiliations between Blue Mountain Hospital, Utah Navajo Health System and University of Utah Health Care have fostered exciting healthcare opportunities, including a new collaboration to help address the challenge of substance abuse and addiction.

The Southeast Utah Addiction Medicine Coalition met for the first time in late February with representatives from Blue Mountain Hospital, UNHS, San Juan Counseling, San Juan Health District, Moab Regional Hospital and Four Corners Behavioral Health. BMH CEO Jeremy Lyman, who helped bring the parties together, said University of Utah Health Care also sent six representatives to the initial meeting, mostly from the University Neuropsychiatric Institute (UNI). He said UUHC and UNI were willing to be part of the coalition because of their affiliation with BMH and UNHS. Both have committed to continue providing support and resources to help bring this idea to fruition, Lyman added.

UNHS CEO Michael Jensen echoed Lyman's sentiments, adding that the affiliation was a major factor in securing the participation of Dr. Elizabeth Howell, M.D., M.S., who attended the initial meeting. Dr. Howell specializes in Psychiatry, Adult Behavioral Health and Addiction Psychiatry at UNI. She is also one of the few doctors in the State of Utah qualified in Neuropsychiatry and addiction medicine treatment.

"There's no doubt about it," Jensen said. "The affiliation allowed her to come down. She wants to come down and serve the people of this area."

One objective of the coalition is to find an answer to the overwhelming challenge of substance abuse and addiction. Not only addiction to street drugs and alcohol, but also addiction to pain medicines, which may be an even greater challenge for medical providers and behavioral health specialists, according to Rick Hendy, Director of Behavioral Health at UNHS.

"Doctors in our community are faced with the challenge of helping patients with chronic pain but, at the same time, concerned about the addiction potential of many of these medicines," Hendy said. "It's hard because I think many of our doctors, if you were to interview each one, would say it's one of the most frustrating parts of their practice. They want to help their patients. They don't want to harm their patients. Personally, I think any human being taking narcotics-based medicine would eventually become addicted to it. Not just because of their personality or life style but because of the physiological effects on the brain. Some people, when they get tapered off, don't think about it again. Other people start a cycle of seeking drugs."

According to Jen Sadoff, Director of Community Relations and Marketing for Moab Regional Hospital, a 2013 Community Health Assessment for the Moab area indicated the number one concern of that community is alcohol and substance abuse in general. She said that ties into a lot of challenges in that area, including physician satisfaction with their job.

"The Department of Rural Health identified the number one reason for physician dissatisfaction was a lack of mental health and substance abuse services in rural areas. Mental Health and substance abuse go hand in hand," Sadoff said.

Robb Austin, CEO of Moab Regional Hospital, initially approached Lyman and introduced the idea of establishing the new coalition. He said his vision for the group would be ensuring that people who need the attention and the medical care, are getting it in the appropriate setting at the appropriate time with the appropriate provider.

"It's all about helping those people who need the help," Austin said. "It's kind of our challenge to come up with devising that strategy for southeast Utah. "

Austin said the idea for the coalition struck home with him, after listening to physicians talk about this issue in a couple of meetings and asking, 'What do we do?'

"It's a clinic issue and then it becomes an emergency room issue and then it's certainly a societal issue; and they all see that and they keep telling me, we don't know how to solve this problem," Austin explained. "The patient will go from physician to physician to physician and initially, if I remember the first discussion, it was on pain medicine, and pain management. And it didn't take long to say it's not pain, it's an addiction problem and man that just stuck with me. If you solve that issue, you will have addressed most of the problem. So it's really listening to the providers. We administrators need to step up. That's our job."

Jensen said the hope for UNHS is to get help for pain patients and addiction patients, but the line there is a little blurred.

"The challenge is, we only have one provider at UNHS that is able to really treat these patients," Jensen explained. "He's the only one qualified to prescribe addiction medicines. So Dr. Fisher is providing a real service by doing this.

Dr. Mahana Fisher is the only physician in southeast Utah qualified to prescribe addiction medicines to treat patients, suffering from addiction to pain medication, street drugs and alcohol abuse. Dr. Fisher said there are quite a few benefits that can come from this coalition. But, he stressed, it's time for everybody in this region to get on the same page in dealing with, and treating addiction problems.

"The problem with our geographical location is, everybody is doing something different in different areas. Yet people will travel to get what they want. They also pit everybody against each other, while trying to get the medications they want. It's time everybody gets together and we all get on the same page. It's actually mandatory that we do this," Dr. Fisher explained, adding that the problem is very frustrating for provi-ders.

According to Fisher, medications like Suboxone and Subutex are used to help get people off opioids of any sort, whether heroine or prescribed medications.

"They are opioids but a different type of opioid. They're used for maintenance," he explained. "Part of the problem with opioids is they use them to get a euphoric effect, to get high basically, but the doses escalate. That's the problem. It takes more and more and more of the medication to cause the same effect. After a while, people who have been on opioids for a while have to take them or they get severe withdrawals. Severe, severe withdrawals. And that's kind of the problem.

"Some people who actually want to get off of their medications, and are motivated, cannot because they can't tolerate the withdrawals," he continued. "Subutex, during the induction phase, helps to get through those withdrawals," he continued. "That's why we use it to get them off medications. But then they also have to be on maintenance because they can get withdrawals from Subutex, and subsequently they still have the addiction problem. Suboxone is a pain medication but it's not a very strong pain medication," he added. "Some people do prescribe it for pain, yes. But people get so tired of taking it, and they're so afraid of going through withdrawal from opioids, they come and see me."

Fisher said most providers don't want to deal with addiction medicines, like Suboxone and Subutex, because the patients who need them are the toughest population to deal with. He said treating patients with addiction medicines is only part of the process. It needs to involve medical and psychiatric treatment. He said straight addicts need long-term psychological treatment and medical doctors are not normally trained as psychiatrists.

"I think physicians are frustrated with people coming into their clinics, yelling and screaming for pain medication and they don't know what their resources are. They don't know where the tools are to help them," Sadoff said. "They're trained to help people and, in the patient's eyes, the only way to help them is to give them a pill they don't need and that they're addicted to. And that's frustrating for the physicians."

Vicki Gigliotti, RN, is the Chief Clinical Officer at Moab Regional Hospital. She said one of the reasons her organization is involved in this coalition, is that this issue has been a major challenge, from a physician's standpoint, in Grand County for many years. But, she adds, the problem has to be addressed on a larger scale than has been attempted in the past.

"The entire reason we are working on addressing this from a collaborative, regional perspective is because in a rural setting you can't do it piecemeal. You have got to join together for your region," Gigliotti said. "It's not just the providers or just the hospitals or just UNHS or San Juan Counseling. It has to be all these people. And we still have more people to bring into it. The problem is multi-facetted so the solution has to be multi-facetted. This was a fantastic start. I couldn't believe the commitment and involvement by all these different people and organizations. It was wonderful."

Dr. Fisher said realistically, he'd like to see a couple of things accomplished with the coalition. First, provider education about what the problem is.

"Most providers know what addiction is, but they don't want to deal with it," he said. "We can't treat it psychiatrically because we're not psychiatrists. Medically we can treat it. We can start diagnosing with the help of UNI. Addiction is medical. UNI can deal with the psychiatry part."

The second thing Fisher would like to see accomplished is an added interest by local providers in dealing with addiction medicine. He said providers need to recognize that addiction is a medical problem.

"We need to diagnose the problem and not sweep it under the rug," he said. "It can be treated. Once we recognize that addiction is a medical problem, and it can be diagnosed and treated medically, more doctors might be interested in addiction medicine. The patients I'm seeing now are the tip of the iceberg. They've recognized what the problem is and they've decided to come in on their own."

UNHS does not currently operate a Medication Assisted Therapy program that addresses both the addiction medicine and behavioral supports with a shared treatment plan. The efforts of the coalition may result in both of those resources being created.

"The approach needs to be, first, prevention and second, treatment," Hendy said. "None of the members of this coalition have these resources alone. Hopefully, together we can find ways to develop the resources to comprehensively aid members of our community suffering with addiction."

Gigliotti said one of the biggest things to come out of the first meeting was that instead of each respective practitioner and individual, thinking about their own bubble, no one is thinking about their own bubble any more.

"Every step we take from now on, I think, is a regional effort not just a local effort, and I just think that's huge," Gigliotti said. "I think it's such an overarching need. The baby step would be, what if addiction went from the number one concern on the community health needs assessment to the third or fourth?"

Jensen said he'd like to see UNHS with the ability to provide the care addiction patients need, but right now UNHS doesn't have the ability to really take on any more patients.

"So if we can find a way to increase the number of providers, services and programs, or, on the flip side, down the road, we'd love to decrease the demand for this type of treatment," Jensen said. "But that's a problem everywhere. I don't know if anybody has found a way to decrease that demand yet. These are dedicated patients and sadly they will do anything to get their pills."

The next meeting of the entire coalition is scheduled for May 15. In the meantime, additional education and information meetings might be held, Austin noted. He said he's excited to see so much interest in the coalition.

"Dr. Howell applauded us for bringing this together the way that we did. I think it shows the incredible need for this program, by having that kind of a right-off-the- bat summit to address this issue. It really shows the need for this," Austin said.

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