Medication and More

The circumstances that bring Vermonters with opiate addiction to the doors of Synergy Counseling Group's clinics in Montpelier and South Burlington all differ to some degree. Some are longtime heroin users who have attended a more conventional treatment program in the past, while others have developed a pain medication dependency and never have pursued treatment in the past.

But nearly all of the agency's patients can relate a similar pattern in their thinking about the Vermont program. First, word on the street about a medication called Suboxone initially attracted them. Then, once they arrived, they found that the rest of what the program offers proves to be as important as the medication.

James Hamel, LADC, CADC James Hamel, LADC, CADC, and his innovative multidisciplinary practice offer a striking contradiction to the notion that addiction treatment agencies cannot effectively integrate biomedical and psychosocial approaches to healing. And in fact, Synergy doesn't stop at that. Plans are in the works to incorporate acupuncture, movement therapy, and yoga into program offerings that already include a variety of holistic approaches, with the overall goal of placing as many recovery-affirming services as possible under one roof.
Hamel says the private-practice structure of the Synergy operation, which was launched in early 2007, is critical to its success because it attracts professionals who value the flexibility of designing services without concern about dictates from a board of directors.

“I wanted to look for a way in which to develop a program that would alleviate the anxiety of providers about working with opiate addicts,” says Hamel.

Program's origins

Opiate addiction treatment issues weren't even on Hamel's radar until 2000, when the addiction counselor relocated from Texas to Vermont. Suddenly, at least 90% of the clients he was seeing were dealing with a primary opiate addiction—with these individuals relatively evenly split between those using heroin and those using prescription opiates.

As Hamel began to learn about the potential of the medication buprenorphine to help opiate addicts in recovery maintain sobriety, he also began to see some of the concerns physicians had about becoming regular prescribers of the medication. Some didn't appear to want opiate treatment patients sitting in the same waiting room with the families in their practices. Even many of those who enrolled in the process to be certified as prescribers turned out largely to be “certified non-prescribers” because they weren't working with many or any new patients, Hamel says.

His goal was to establish a new setting in which medical professionals could spend part-time hours meeting with patients while still maintaining their off-site practices. The idea was for clients in the program to receive a comprehensive assessment followed by medication, scheduled group counseling, and whatever other support they might need. “We would also introduce other applications of the recovery process, such as exercise and wellness,” Hamel says.

Synergy now has a staff of 18 medical, addiction, and mental health professionals. The medical staff generally works part-time, while the program employs a full-time alcohol and drug counselor. It is exhilarating for Hamel to see these professionals from different disciplines working together in the same building, accustomed as he was to attending seminars in Texas where physicians in suits would occupy one side of the room and counselors in sandals the other, feeling worlds apart.

The two Vermont clinic sites can serve up to 150 patients at a time, although only a maximum of 90 can be on Suboxone at one time because that is the patient limit for the program's medical director, Tim Wargo, MD. For Wargo, the Synergy effort represents an ideal fit, as he always has looked to venture beyond conventional practice in his career.

“The conventional stuff doesn't go far enough,” Wargo says. “It doesn't answer all the questions people have. What we stress to patients is that they have to do something else in addition to the medication.”

Medication procedures

What the program finds is that the Suboxone gives addicts in recovery the stability to make them amenable to the counseling and the other support services, according to Hamel and Wargo. From their first encounter with the program, clients learn that the medication isn't a cure-all. “Wayne,” a 21-year-old client who entered the program for treatment of an addiction to OxyContin, explains that he visited the clinic four times for comprehensive assessment interviews before he finally received a Suboxone prescription.

The assessment process generally involves a full physical exam, a mental health evaluation, and a substance use evaluation. The medical doctor talks to the client about diet, exercise, and other lifestyle issues in addition to the medication. “People will say they have never had a doctor talk to them about these things before,” Hamel says. “It's their first ‘a-ha!’ experience.”

As clients begin in the program, they are scheduled for multiple on-site counseling sessions for each week in a variety of groups. They pick up their dosages of Suboxone at each visit, so they never take home more than a couple of days' worth of the medication at a time until they have been in the program for a longer period and are visiting the clinic less frequently. Even though the Suboxone formulation of buprenorphine is designed to combat diversion, clinic leaders say there would be many temptations for clients to sell the medication on the street if the controls from the clinic site weren't in place.

“It's too easy and too tempting to have a pile of this in a closet somewhere,” Wargo says. “Having it on site really helps the process.” Again, this practice of administering the medication dosing from the clinic is something that a multidisciplinary private practice without a board of directors has an easier time putting in place.

Payment issues have not been a major concern for Synergy up to this point, as most clients are in the state Medicaid system and their coverage encompasses most of Synergy's services. Program leaders are well aware that they will need to evaluate their success over time, and they believe they will be held to a high standard in furthering client abstinence.

Wargo says that at present about 30 to 40% of the Suboxone clients who have come in are staying in the program and staying off their drug of choice. “People are doing well in counseling,” he says. “If you can hook and engage them, eventually it will sink in.” That's why use of a medication that promotes sobriety is central to the program.

Making an impression

Ironically, many of Synergy's clients seem to want to talk more about the non-medication aspects of the program—as if the drug opens the front door but the real excitement lies with what's inside.

Wayne explains that the medication helps him with his daily obligations, including multiple jobs. “If I don't take it, I wake up with sweats and have no motivation,” he says. But he says the program also has shown him the importance of lifestyle changes to his well-being. “It's huge to eat healthy and regular,” he says.

“Stephen,” an artist in his 30s who became dependent on pain medication after a back injury and had used illegal opiates in the past, has found the physician and therapy staff at Synergy to be more thorough than were professionals in a hospital-based program he previously had attended. “The groups are really, really good here,” says Stephen. “I feel really safe here. There's a real strong sense of community.”

“Derek,” 34, a client who had used mainly morphine since his late teens, sees the Synergy program as more comprehensive than other treatment experiences he has had. “People are closer and more open and honest here,” he says. “They really try hard to do things right for the patient.”

Hamel has several short-term goals for the program, such as fully integrating the complementary therapies and bringing on another physician in order to increase the number of clinic clients who can be on Suboxone at one time. But otherwise, the program will go forward with the flexibility to make improvements as they present themselves, he says.

He summarizes, “Without hesitation, I am convinced that the future for our field is dependent upon a closer relationship between traditionally disparate components of the healthcare field.”