Opioid addiction is a lifelong chronic condition that can benefit from medical treatment, like diabetes and chronic obstructive pulmonary disease, Ball explained. In addition to supervising pharmacy students during their clinical rotations at the Center for Family Medicine in Sioux Falls, she works on the clinic’s medication-assisted treatment addiction care team, which is led by Dr. James Wilde and includes nurse case manager Cindy Genzler and therapists Daniel Felix and Mary Jones.
The Drug Addiction Treatment Act of 2000 allows qualifying practitioners to treat drug dependence with Food and Drug Administration-approved controlled substances, such as methadone and buprenorphine. “The use of buprenorphine, for instance, diminishes the physical effects of dependence on opioids, including cravings and withdrawal,” she said. “It is a life-changing area of practice.”
However, to prescribe these drugs, providers must receive specialized training. For a licensed doctor, the DATA waiver requires eight hours of training; for a nurse practitioner or physician’s assistant, it’s 24 hours. The Providers Clinical Support System provides free waiver training via online coursework and webinars.
“When we first started in 2016, we were only aware of one other clinic that provided medication-assisted treatment to more than a few patients,” said Ball, noting that some of their patients traveled hundreds of miles to receive treatment. “We felt we needed to a do better job helping doctors obtain waivers and get experience in treating substance use disorders so they would provide these services across the state and country.”
In 2016, less than 20 percent of South Dakota counties had at least one provider who could prescribe buprenorphine for opioid use disorder, according to statistics from the Federal Office of Rural Health Policy.
Increasing waivered providers
First, Ball and Wilde, who serve as faculty for the Sioux Falls and the Pierre Family Medicine Residency programs, focused on training their residents. “All medical residents go through a one-month addiction block in which they spend time with area prevention, treatment and recovery services and as part of our integrated treatment team,” she explained. During this unit, the residents complete PCSS waiver training.
In addition, the CFM team offers opportunities for outside professionals, including doctors, nurses, pharmacists and counselors, to spend a day working with their integrated treatment team. These professionals either have or are earning their waivers.
The team also works with Project ECHO, which connects specialists with practitioners in rural communities.
Since September 2018, Ball and her team at the Center for Family Medicine have received more than $490,000 in funding through the state’s target response and response to the opioid crisis federal grants. Last year, the CFM team helped train 29 family medicine residents and 11 physicians to provide medication-assisted treatment for drug addiction. Of those, 27 have obtained their waivers.
Furthermore, 14 pharmacy students receive MAT training each year during their clinical rotations. “Our goal is to train the next generation to provide this care,” Ball said.
Tiffany Wolfgang, director of the Division of Behavioral Health in the South Dakota Department of Social Services, said, “Through federal funding (from the Substance Abuse and Mental Health Services Administration), we are able to support the CFM program and others who are making sure we have the capacity to provide addiction services across the state.”
In addition, Ball and her team along with others at SDSU in the Department of Pharmacy Practice, Department of Sociology and Rural Studies and College of Nursing secured a two-year, $200,000 Health Resources & Services Administration planning grant. This allows them to assess MAT access in rural South Dakota and to plan a program that combines telehealth, MAT and face-to-face intervention to provide addiction care and counseling through telehealth technologies.
Making a difference in patient’s lives
Since the state-funded project began, the number of patients treated for opioid use disorder at the Center for Family Medicine has grown from 46 to nearly 100. The team has gone from providing team-based care half a day once a month to once a week. In addition, the center has hired a second therapist and a full-time nurse case manager “to provide more consistent care for our patients,” Ball explained.
Since the treatment program started, only one patient has died of an overdose. “These are high-risk patients,” she pointed out. Through state funding, Ball and her team also hope to work with police departments, jails and emergency rooms to identify patients who could benefit from this type of treatment.
“One of the biggest misconceptions about addiction is that it is a choice,” Ball said. “Most people who become addicted do so after the first couple of doses.”
Furthermore, personal history and genetics can increase the likelihood of becoming addicted, she continued. “From 80% to 90% of the patients we see have had adverse childhood experiences, including poverty and sexual, physical or emotional abuse.”
Wolfgang said, “There is not just one story to be told—we see a little bit of everything. Maybe today a patient is using heroin, but it started from a knee injury and then progressed to illicit drugs when the patient became addicted and could not continue on prescriptions. Though the numbers in South Dakota are low compared to the national average, it does not feel like it for those impacted by opioid addiction.”
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