Providers say more access to evidence-based treatment for substance use disorders needed

Oregon consistently ranks near the bottom of the country in terms of access to treatment for substance use disorders. Portland-based Boulder Care seeks to address that by providing telehealth and medically assisted treatment options. The company launched in 2017 and has been based in Portland since 2019. Its aim is to normalize this kind of treatment and make it available in the first days or hours when a person with substance use disorder decides they want to get help.

Dr. Honora Englander, who directs the Improving Addiction Care Team (IMPACT) at Oregon Health and Science University, says access to telehealth and medication for opioid use disorder is an important part of addressing the huge and multifaceted problem of substance use disorder.

Englander and Boulder Care CEO Stephanie Strong both participated in the industry-wide AMERSA conference held in Portland last week, and they join us in studio to discuss more about evidence-based approaches to in-patient and out-patient care for people dealing with addiction.

Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.

Dave Miller: From the Gert Boyle Studio at OPB this is Think Out Loud. I’m Dave Miller. Oregon consistently has one of the highest rates of substance use disorder in the country. It also ranks near the bottom of the country in terms of access to treatment for addiction. We’re going to hear now about efforts to make that treatment more widely available. Honora Englander is an addiction medicine physician at OHSU, where she is a founder and director of the Improving Addiction Care Team. Stephanie Strong is the CEO of Portland-based Boulder Care, which provides substance use disorder treatment via telehealth. It’s great to have both of you on the show.

Honora Englander: Great to be here.

Stephanie Strong: Thank you, Dave.

Miller: Honora, first, what drew you to addiction medicine?

Englander: I started my career working as a hospitalist, which is a hospital medicine physician, and I was taking care of more and more young people or really people across the age spectrum who were coming to the hospital and getting admitted with medical or surgical complications of addiction. At the time, we really didn’t have systems or structures in place to support people and their needs. There were sort of a series of people, really young people, who were getting admitted maybe with an infection on their heart valve requiring cardiac surgery, or other really serious life-threatening conditions. Ultimately it was my patients and their needs that took me to the space of addiction medicine. Young people were dying without the necessary supports, and it was a time where we really just had to do something different.

Miller: And what were you doing then that was different?

Englander: What we ended up doing was really starting to understand from our patients, what were their needs? In fact, did a study – which was sort of a first of its kind study – to understand from patients what their needs were. Did they want care for addiction? Did they want that to start in the hospital? What did it look like to try to get care outside of the hospital? We did a needs assessment, then we convened a group across settings and across disciplines, stakeholders to understand what could a care model look like.

That was the foundations for IMPACT, which is the Improving Addiction Care Team, which includes care from an addiction medicine physician or a nurse practitioner or PA. It includes a social worker with a specialty in caring for people with addiction, and it also includes a peer, which is someone with lived or living experience. The model has changed a lot over the years, but essentially providing that care in the hospital, meeting people at this really vulnerable moment, supporting them to treat their withdrawal, treat their pain, offer medications for addiction, support them to link to care after. That’s kind of a quick, high-level summary.

Miller: The two big focuses of your career have been addiction medicine, as you’re talking about, but also evidence-based medicine. It was a surprise to me some number of years ago to find out that that’s not the norm, that evidence-based is not always a focus of medical practice, even if we think it is, but that’s a long aside. What does the evidence say right now is the best treatment for people specifically with opioid use disorder?

Englander: That’s a great question. We have decades of evidence supporting that medications, methadone and buprenorphine, are the most effective treatments and really the cornerstone of treatment for opioid use disorder. There is evidence that shows that they reduce rates of HIV and hepatitis C. They allow people to really reclaim portions of their lives, reconnect with loved ones, resume work, reduce criminal activity, and these are lifesaving medications. People are less likely to overdose. They’re less likely to die, and they’re less likely also to die of other medical causes that are treatable. So methadone and buprenorphine are the standard of care. In the U.S. and also in Oregon, we have a lot of work to do to make these medications broadly accessible, such that people are really drawn into care and engaged in care.

Miller: I want to hear more about that and more of your experience. Stephanie Strong is with us as well, the CEO of Boulder Care, which provides substance use disorder treatment via telehealth. Can you describe the treatment model that you’ve been doing for nearly a decade?

Strong: Absolutely. Boulder Care provides telemedicine services for addiction, and the mainstay of our program, as Honora described, are evidence-based treatments like medication. Clinicians who can prescribe these medicines and peers with lived experience, social supports, all together under one roof. What’s unique about our model, being telehealth enabled, is that patients can get access in their urgent moment of need. While many programs are trying to get people in in a matter of weeks, we’re measuring access in hours, and the privacy, the ability to connect with a care team on your own terms, these are really important ways that we offer a low barrier access to care, and importantly, keep people in it long term. We know this is a condition where there are ebbs and flows and that the longer someone is in care, the better they do, which is why we are so pleased to see that it’s working when folks are staying in care with us for opioid or alcohol use disorder three times longer than the industry benchmark.

Miller: You have big billboards with messages like, what if addiction treatment wasn’t so rigid? What if addiction treatment didn’t expect perfection, and what if addiction treatment didn’t punish you? What led you to that particular messaging? What is it about the way addiction care treatment has sometimes been provided, that you were specifically addressing in those billboards?

Strong: These messages are elevating the direct feedback that we heard from people who use drugs and people who are in treatment today in Portland. Listening to patients is exceedingly rare, actually, across traditional medicine, but in addiction where there’s sort of this premise that you’re starting off with someone untrustworthy, that addicts need a lot of rigid rules and structure at the expense of autonomy and self-worth when people really need support and compassion. We listened to patients and to people who said, I want a treatment program that can help me stay in my job or maintain the childcare that I have to offer my kids and my grandkids.

There are so many reasons that people aren’t able to get into care who want it. It’s a relatively simple notion that if we listen and trust patients, that we can help them, but there’s a lot of rigidity and outdated practices in addiction medicine. Asking someone to come physically to a facility every single day, how can we expect them to get back into work or doing the things that they love if they’re constantly having to find access to transportation, leave their kids with a babysitter they can’t trust? Low-barrier care is really important, as is elevating patient centricity and giving people a voice in what recovery strategies we should be trying for them.

Miller: Honora, what do you think is getting in the way in our country, or perhaps Oregon in particular, of better addiction treatment?

Englander: I really appreciate what Stephanie said about the importance of flexibility and low-barrier care. It’s sort of another term for that, and I think a lot of the structures and policies that are underlying the health systems and structures really are built on a notion of control and controlling, not the individual having their own control, but in fact that the system has control. There’s a lot of mistrust and there’s a lot of fear of diverting medications, etc. When you look at methadone clinics, again, there are clinicians and individuals working in methadone clinics who are really trying to help folks, and the overarching structure of a methadone clinic or an opioid treatment program really is one of social control.

Miller: Can you give us a sense for what that actually means for a patient?

Englander: Stephanie alluded to it a little bit, which is this idea early on in treatment that people have to come every day. The federal rules have changed, so methadone clinics, or opioid treatment programs, are the sole structure within health systems right now that can provide methadone, and methadone has to be dispensed, it can’t be prescribed. Methadone is regulated unlike any other medication, including methadone for pain, methadone for opioid use disorder. I often talk about the work of being a patient in these systems, how challenging it is.

Then as Stephanie alluded to that often if somebody misses several doses or if they have a urine drug screen – again, this may not be the case at all OTPs, or opioid treatment programs – but there are opioid treatment programs that cut people off. For example, if they’ve had a drink of alcohol, even though methadone doesn’t treat alcohol use disorder and even though somebody may have a drink of alcohol and it may not have anything to do with their opioid use disorder. This idea that abstinence is the underlying driver versus wellness and engagement is a huge contrast, and a huge opportunity for us across the United States.

Miller: What we’re talking about here is both federal law and then having the DEA say this is what you should do with medicine. We’re also talking about state practices or individual office practices. I’m just curious how much change you’ve seen in the last 10 years, at a time when fentanyl has burst on the scene and destroyed so many lives and it’s the intensity of this opioid [that] also has just put an exclamation point on everything. I’m curious if you’ve seen improvements and a more understanding medical system or if things are more or less the way they were 10 years ago.

Strong: There’s been a tremendous amount of positive change. There’s a patchwork of laws and policies that govern federal and state and local practicing of addiction medicine, prescribing of controlled substances of these really proven drugs and in telehealth, all in the right direction, but nowhere near at the speed and scale of fentanyl. We’ve seen in just the last few years, the ability for medications for opioid use disorder to be prescribed by more people, nurse practitioners and a growing workforce, when they used to be very restricted and there used to be a limit on the number of prescriptions you could write for any given community where this problem is exploding.

There are structural constraints that while the policies have changed and been lifted to pace with the evidence, we’ve already created a problem that we now need to expand access to treatment rapidly in order to keep up with the drug supply, which is also changing and becoming more lethal as the transition from OxyContin to black tar heroin to fentanyl is more deadly. That’s where innovation, like the programs that we’re discussing, and in telehealth being able to expand access much more quickly so that we can get out of the dearth of treatment providers and the lack of access in so many communities across the country and in Portland.

Englander: It used to be that a physician or a nurse practitioner or PA needed what’s called an X-waiver to write a prescription for buprenorphine. The X-waiver is x-ed. Now anybody with a DEA who can prescribe metoprolol for high blood pressure can prescribe buprenorphine. That doesn’t mean that everyone is, but some of those limitations are gone. And the methadone rules have changed. SAMHSA is the Substance Abuse Mental Health and Addiction Services, at the federal level put out new regulations in, I believe it was April of 2024, and that has expanded access to methadone at the level of the federal law. Whether or not states or individual clinics adopt those full flexibilities remains to be seen.

I think the important thing, though, is that it’s really critical that we get methadone outside of opioid treatment programs and we start exploring pharmacy-based methadone, primary care-based methadone. These regulations really are far outdated. They precede by decades the experience of the fentanyl era that we’re in now, and there’s many, many people locally and across the U.S. that are advocating to liberate methadone.

Miller: Honora, a couple of years ago you got a Fulbright and went to study addiction and addiction medicine in France. We could probably spend hours talking about the differences between the French system and the U.S. system. In the big picture, what were the cultural differences in the way doctors there treated opioid use disorder and the practice here?

Englander: When I was there, one of the big questions I had was how do clinicians think about methadone and buprenorphine? And the reason that I was so interested in that in part was because 87% of people with an opioid addiction in France at the time were on methadone or buprenorphine, and these are just stunning numbers. In the U.S., numbers are estimated around one in five people, about 20%.

Miller: So 20% versus nearly 90%.

Englander: Exactly. And again, just stunning, stunning differences. There are a lot of structural issues that are related to that methadone policy, as we’ve talked about. In terms of regulating how often somebody has to go to a methadone clinic, how high the dose is, etc. that’s different across the two countries. Also in France, people can start methadone either in the hospital or in a specialty addiction center, then with the transition to primary care-based methadone. So there’s these large structural differences.

However, one of the things that I think was really surprising to me – though in retrospect, maybe shouldn’t have been so surprising – is when I interviewed physicians, nurses, pharmacists, policymakers, and asked, what is the purpose of these medications? Almost universally, people described that the goal of medication was to bring people into care. That engaging people in care, that methadone was a powerful tool to treat cravings, to help people feel better, to stabilize their lives, and bringing people into care was the goal.

In fact, nowhere in these early conversations did the idea of abstinence even emerge. I would bring up abstinence and ask, well, what about abstinence as the goal because our systems here really do focus on abstinence as the primary goal, and I think that is sort of some of what Stephanie was referring to about punishment. If engagement is the goal, engagement is the outcome. And again, for life saving medications, it’s really quite remarkable.

Miller: Is that division you’re talking about, abstinence versus engagement, is that a medical theory or a moral one?

Englander: I think it is more a moral theory. Now, I don’t have a problem with abstinence. If someone wants to be abstinent, of course, my goal is to support them there. The difference is expecting abstinence and that abstinence is a condition of care that becomes highly problematic because for many people, abstinence may not be their goal, it may not be attainable. If we build systems around supporting people to stay engaged in care and connect to care and having care be engagable and engaging and accessible, then we can achieve these kinds of outcomes.

Miller: Stephanie, what have you learned about that last part? We’ve been focusing a lot on the provider side. But what have you learned about the ways to encourage somebody who is dealing with substance use disorder to make the decision to engage with care?

Strong: We’ve learned so much now, having treated over 30,000 patients across five states, from rural and frontier Oregon to Cleveland and barrier islands of North Carolina. It’s been fascinating to gather insights and learn what people need in their recovery and what challenges they faced in other treatment settings or is causing them to be reluctant to seek care. One key way that we do that is by having peer recovery specialists who can build a trusted relationship with patients from their own empathy. They not only are able to meet patients with that ethos, they also help us as a care team. They help their providers learn, well maybe if I ask that question differently, I can build trust with my patient instead of what they’ve experienced perhaps before, which is judgment and scrutiny, or even being discharged from care and having medications withheld because they didn’t “pass a urine drug test.”

Or there are three strikes policies at clinics where if a person just isn’t ready and they’re struggling and returning to use, a very normal part of addiction as a disease and a symptom really of what they’re there to treat, they could be told they can’t come back. To really be offering what we call unconditional support and the peer as a liaison to understand what someone is going through, it’s really been illuminating about how we can keep people in care longer and build therapeutic trust. We know that addiction by definition means that you’re using continually despite unintended, unwanted consequences. When we try to impose all of these consequences, threats and punishment as a way of trying to help someone get better, it just hasn’t worked.

Honora mentioned harm reduction and the idea that you can give people really the goals that they want to set for themselves that might be related to use and moderation. I want to drink less. I want to use more safely or less often. Or it might be related to the goals they have for their lives, regaining custody of children or obtaining a driver’s license or a job. Part of our care team, again, not just the clinical and not just the peer, but the social support to help with some of those other social needs as someone is rebuilding the parts of their life and their community that matter to them. To be able to offer all of that in one place with consistency, I think makes a huge difference for the people we serve.

Miller: Honora, what have you found that helps to keep people in treatment?

Englander: I think that I see people, and our team sees people in the hospital and then support linkages to care. Stephanie touching on this issue of trust is so critical. We really work to build trusting systems and trusting relationships. And again, letting the people we’re working to support sort of guide the way.

Miller: Honora Englander and Stephanie Strong, thanks very much.

Englander: Thanks for having us.

Strong: Thank you.

Miller: Stephanie Strong is the CEO of Boulder Care. Honora Englander is the founder and principal investigator of the Improving Addiction Care Team or IMPACT at OHSU.

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