More than 15 years ago, state health officials warned that New Hampshire’s struggle with alcohol and drug addiction far outpaced available treatment options.
Fourteen treatment programs across the state had shut their doors in the 1990s, and they had not been replaced.
“Current alcohol and other drug needs exceed the existing capacity (for treatment) within the state by 2-10 times,” said a state report from 2001.
Those warnings are eerily familiar in light of New Hampshire’s unprecedented epidemic of opioid-related deaths. Today, frustrated patients and their families continue to question why there are waitlists for treatment even after yearly death counts continue to surge and countless others struggle with addiction.
“These services have been underfunded for decades,” said Lindy Keller, resources and development administrator for the Bureau of Drug and Alcohol Services at the state Department of Health and Human Services. “As horrible as it is that people have to die, we know that when these crises happen, people start paying more attention to the issue.”
State officials and treatment providers are racing to fill the gaps. While it is still a work in progress, officials say they have made substantial gains making treatment affordable and expanding outpatient and medically assisted treatment programs.
“Are we the first in the nation for treatment access? Obviously not,” said Jaime Powers, administrator for the Bureau of Drug and Alcohol Services.
However, Powers said the state’s treatment capacity has “grown hugely” in a short amount of time.
“There’s a lot more coverage at least for outpatient services,” she said. “It’s certainly leaps and bounds past where we were a couple of years ago.”
New Hampshire has roughly the same number of residential treatment centers that accept state Medicaid patients as it did a few years ago – 15 – but the state is also developing more outpatient services.
With the Legislature’s reauthorization of Medicaid expansion, thousands more New Hampshire residents are now able to access a substance-abuse benefit Powers calls “one of the best in the country.”
Health officials and treatment experts are also pushing back against the idea that everyone needs a bed at an intensive residential treatment center.
“Usually when people talk to me about treatment capacity, they want to know about beds,” Powers said. She admits those services are needed for severely addicted and disadvantaged people, but many others “don’t need that high level of care.”
In fact, there’s a push to get more addicted individuals cared for in a community setting rather than residential centers.
There is also emphasis on using medically assisted treatment – the maintenance drugs buprenorphine (the active drug in Suboxone) and methadone – to help addicts focus on staying sober without first having to go through withdrawal.
Methadone must be dispensed at federally overseen clinics, but buprenorphine can be prescribed by licensed primary care doctors.
“Primary care is a perfect setting,” said Dr. Molly Rossignol, an addiction medicine doctor at Concord Hospital.
The U.S. Department of Health and Human Services recently expanded the number of patients a single buprenorphine doctor can treat from 100 to 275.
“Potentially, it’s huge,” Powers said. “The question becomes though, do doctors want to take on more people?”
A lot of indicators point to no. Rossignol said many New Hampshire buprenorphine providers are wary about even caring for 100 patients because they need to be thorough to treat addiction well.
In the first few weeks of buprenorphine treatment, it’s recommended for patients to be seen weekly to make sure they are stable. Some patients relapse in the beginning and need careful monitoring.
Buprenorphine treatment is more than administering the drug; patients are supposed to get psychiatric counseling and case management services.
“Even though it sounds great, some practices are going to say, ‘We don’t have the resources to prescribe that,’ ” Rossignol said.
Another barrier to treatment with buprenorphine is the prior authorization needed for New Hampshire’s expanded Medicaid population, Rossignol said.
Doctors have to jump through extra hoops to prescribe those patients buprenorphine, documenting whether the patient is in counseling and, in some cases, writing about their strategy to taper the patient off the drug.
Rossignol’s staff have spent up to five hours on the phone with insurance companies for just one patient. It usually takes two days for prior authorization to go through, meaning patients have to pay for their first dose out of pocket.
Rossignol said the policy is misguided. “It’s not a standard of care to talk about tapering patients within a year. I think it’s an absolute barrier to care.”
Rossignol said another big part of improving access to treatment comes with educating medical students about addiction so they are prepared when they start practicing medicine.
“I think that things are moving in the right direction,” she said, adding, “it still feels slow.”
Workforce development with substance abuse counselors is one of the biggest challenges New Hampshire still faces. The profession is experiencing shortages – a combination of a low-paying job and an often-stressful work environment.
Addiction counselors make $40,000 on average, according to the Bureau of Labor Statistics. Keller said she doesn’t have New Hampshire-specific salaries for the community mental health centers the state partners with, but she said she’s heard of difficulty recruiting new counselors because some neighboring states pay more.
However, recently passed state contracts went to increasing counselor salaries. Longer term, Keller said recruiting efforts for new counselors are going ahead at full speed.
Many of the state’s contracts with treatment centers were very recently passed, meaning it will take some time before they are up and running on the ground. The challenge is daunting, but Powers said she is optimistic.
Her phone has been ringing off the hook with people interested to open up more treatment programs.
“I don’t think it’s going to be this year we’re going to see . . . and it’s not going to be (that) we’re back to 2010 levels with overdose deaths,” Powers said. “But we’re making progress.”
People seeking treatment can search for programs at nhtreatment.org.
(Ella Nilsen can be reached at 369-3322, enilsen@cmonitor.com or on Twitter @ella_nilsen.)