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Addiction Treatment Gap Hinders Fight Against Heroin Abuse

Andrew Chambers is one of five addiction psychologists in the state of Indiana.
Andrew Chambers

Containing the nation’s growing heroin addiction and ongoing prescription opioid abuse epidemic, is often presented as a law enforcement problem. But behavioral health specialists say the addiction treatment side of the equation is equally urgent. And it’s an uphill battle in many states where addiction psychiatrists are few and funding is lacking.

According to recent research, there’s a shortage of qualified addiction specialists in many states. While the average state has 32 behavioral health specialists per 1,000 addicted adults, some states have far fewer, such as Indiana which has only 20, placing it 47th among the states.

Reporter Andrea Muraskin spoke with Indianapolis-based addiction psychiatrist Dr. Andrew Chambers about the problem, which he calls “the massive public health need.” Chambers sees patients at Ezkenazi Health’s Midtown Community Mental Health, and he directs the addiction psychiatry fellowship at Indiana University School of Medicine.

Andrea Muraskin: We’re seeing a rise in heroin-related deaths around the country. What accounts for this trend?

Andrew Chambers: Heroin has been around for a long time, and there are epidemics that come and go. There have been several over the last hundred years. But I think it's fair to say this one is potentially the largest, most ominous outbreak.  And what's most interesting about this one is that it was caused by an initial wave of prescription opioid overuse and addiction. 

AM: How did that happen? How did we get from a doctor prescribing a painkiller to someone who’s addicted to heroin?

AC: With any addiction, when an individual is suffering with addictive disease, it takes a progressive course. That means that over time as the addiction grows, the individual will devote more time and energy to acquiring the drug, but there's also an escalation to the amount of the drug that's being used, and also the intensity. 

Because of its chemistry, when you take heroin intravenously it gets in the brain very, very quickly. And therefore it’s very potent both in its high and its addictive properties. So what we see is, people who often begin their addiction with lower potency opioids, often taken orally, they will progress to a more intense high and addictive format of that drug class.

The second factor is that the medical profession has finally become aware of the crisis, and there's been a great deal of education and physician efforts to curb the over-prescribing of these drugs. We've kind of leveled off in putting so many prescription opioid pills into public circulation. That means black market street value prices are going up, and they're getting harder to find. And so there's a vacuum in which heroin can fill the market so to speak. 

AM: What’s the demand like for your services at Midtown Mental Health? Do you have a waiting list?

AC: The time to see a physician in our clinic can be anywhere from four to eight weeks.

We have three addiction psychiatrists in the Midtown Mental Health system, and that represents 60 percent of Indiana's workforce in addiction psychiatry. And we're pretty busy. It could improve here but it's a lot better than it is in most places in the state, quite frankly, and probably in the country as well. 

AM: What would a typical treatment regimen look like?

AC: Typically someone would need to be assessed for co-occurring mental illness, which is typically there. So with someone with opiate addiction, you need to know the details of that person's history. It matters how old they are, it matters how long they've been using, it matters what routes they've been using. To what extent have they had to break the law to acquire? What are their resources for treatment? When we're assessing patients psychiatrically we have to take all those factors into consideration to design the best strategy for their care. 

AM: You say one of the factors you consider when putting together a treatment plan is the patient’s resources. Is addiction treatment covered by health insurance?

AC: Unfortunately in the American healthcare system it's much easier to get care and reimbursement for the treatment of medical illnesses—that is illnesses that involve the body from the neck down—but when it comes to taking care of the brain and behavioral health problems, there really is not adequate reimbursement for healthcare services. That's in part why we're in this epidemic in the first place. When you treat one set of illnesses and ignore the others, then of course the others are going go out of control.

One prime example of that is, ironically, methadone. Treating pain with methadone is almost universally supported by Medicaid, but the use of methadone to actually treat opioid addiction is not covered by insurance at all or Indiana Medicaid currently. 

AM: Does poor infrastructure for treating behavioral health have other consequences to the community’s health? 

AC: I think the entire medical community is now beginning to wake up to [the idea that] when you have poor behavioral health, it's pretty much equal to poor public health. You can have state-of-the-art hospitals and state-of-the-art surgery. But if you have that without behavioral health, you're not going be there in terms of an overall high standard of general healthcare and public health in the population. And the reason for that is behavioral health conditions, especially addictions, actually generate a great deal of medical illness, premature death and injuries.

AM: Are there any steps that you think are being taken in the right direction in Indiana to address the treatment problem? And what’s still missing?

AC: There is movement in a very positive direction. After a longstanding moratorium against methadone programs expanding, the state legislature passed a law [in 2014] that would allow them to expand, as long as they are expanding within a community mental health center that also provides addiction and mental health care. And I think that's a very good idea, because it encourages the integration of opiate addiction treatment with other mental health treatment.

But those are baby steps. We're talking about a massive public health need, a massive epidemic. Really there are three legs to the stool that desperately need support. And that is a) workforce development, b) making sure the treatments are covered by insurance and c) physical infrastructure. Even the buildings we're working in are often falling apart or there are not enough buildings to provide the care in. I think progress is beginning to be made, but in terms of resourcing it, that's another question.