What are hubs and spokes and how can they help fight the opioid epidemic?

Treatment model for opioid use disorder in Washington based on successes in other states

Cheryl Shifflett’s story of opioid addiction starts in way that may sound familiar: She was prescribed opioids for chronic pain and began taking more than she needed. She tried to stop misusing her medication multiple times, but could not do it on her own.

She lost her job, she lost her home, and she damaged important family relationships.

Cheryl’s story of recovering from opioid addiction, however, is not so typical.

The University Place woman is one of the first Washingtonians to receive treatment for opioid use disorder through the state’s new hub-and-spoke treatment model, which helps make addiction medications more available, including methadone, buprenorphine (brand name Suboxone), and naltrexone (brand name Vivitrol).

Cheryl Shifflett

Meeting the treatment demand for opioid addiction — also known as opioid use disorder — is part of Washington’s strategy for fighting the opioid epidemic, which kills two people a day on average in the state.

The hub-and-spoke program is about networking, and it gets its name from the way it creates a help network within a specific community. There is a hub, which is a facility where staff are certified to administer addiction-treatment drugs such as Suboxone, and there are a variety of nearby spokes, which are other places a person might find help for opioid use disorder. Spokes within a community could include a residential treatment facility, a therapist’s office, drug court, a tribal medical facility or an emergency room, for instance.

The hub and spokes work together to serve as many patients as possible, and to tailor treatment to each individual. A person might first access the system when an overdose lands them in the ER, one of the spokes. From there, they could get a referral to the hub to access addiction-treatment medications. Once stabilized at the hub, they could transfer to services at another spoke — be that outpatient treatment or therapy.

As part of the program, a care navigator is stationed at each spoke to help with patient intake and referrals for medication-assisted treatment.

For Cheryl, her recovery journey began in September when she visited a therapist at Greater Lakes Mental Healthcare and was diagnosed with a substance use disorder. Through the hub-and-spoke network, she learned of a new treatment program at nearby Northwest Integrated Health, the hub in Pierce County.

“I was actually the first patient to go to Northwest Integrated Health and start the Vivitrol shot,” the 52-year-old said during an interview with the governor’s office in February. “It literally has saved my life. Without this, without a doubt, I’d still be using.”

The shot, received about every four weeks, helps control her cravings, allowing her to focus on the underlying emotional and mental health problems that triggered her to use. Vivitrol also blocks the feeling of being high if opioids are used. Understanding that substance use disorder is a treatable medical condition rather than a moral failing also helped her work through the shame and guilt she had about her behavior.

Washington’s hub-and-spoke system is modeled in part after a successful program in Vermont

In Vermont in 2013, after a decade of providing medication-assisted treatment for opioid use disorder but experiencing a backlog of patients, public health officials launched a new approach. They designated hubs in each of the state’s five regions, all staffed by addiction specialists.

Specialists from the hubs worked with health care employees in the spokes to train them to administer medication-assisted treatment, allowing the system to serve more patients.

In its first three years, the hub-and-spoke system in Vermont saw a dramatic increase in the number of patients served — from about 900 patients served in hubs to about 2,800, according to a peer-reviewed study published in the Journal of Addiction Medicine. In several regions, the new system nearly eliminated or significantly reduced wait lists for treatment, the study found.

“This system may serve as a model for other states grappling with the current opioid use epidemic,” researchers concluded.

Near the conclusion of President Barack Obama’s second term, the federal government distributed State Targeted Response grants to help fight the opioid crisis. Washington state received $11.7 million in STR money, using a portion of those funds to help launch its own hub-and-spoke treatment network.

Since beginning in the summer of 2017, Washington’s hub-and-spoke program has treated nearly 1,600 patients as of February. The program was launched in the state with federal State Targeted Response (STR) dollars granted by the Obama administration. (Washington State Department of Social and Health Services image)

The Washington State Department of Social and Health Services received the money in May and launched the new program by August in several communities in Western Washington. It was modeled in part on successes in Vermont, as well as in Massachusetts, which trains nurse care managers to administer medication-assisted treatment.

Medication-assisted treatment for opioid use disorder

Treating opioid use disorder with medication — known as medication-assisted treatment or “MAT” — is a fundamental part of the hub-and-spoke system. This treatment approaches addiction as a disorder requiring medicine rather than a problem of self-control, said Dr. Asif Khan, CEO of Northwest Integrated Health. MAT may be combined with other traditional substance use disorder treatment, such as counseling.

Thanks to federal State Targeted Response (STR) grants, the hub-and-spoke program is available in 12 of Washington’s 39 counties, but the hope is to expand these networks to more parts of the state. (Washington State Department of Social and Health Services image)

When people begin abusing opioids, it might start with a desire to get high, but soon a dependency can develop, Khan said. Going without the drug increases stress hormones and causes physical withdrawal symptoms similar to the flu, including a runny nose, stomachaches, diarrhea and sweating. At that point, patients have a compulsive disorder in which they seek the drug to avoid withdrawal.

“You cannot blame the patient anymore,” Khan said. “You cannot say he’s just doing it to get high. They have a disease now where there is damage in the brain, and there are Food and Drug Administration-approved medications, and those medications actually help.”

Patients can stay on the medication for as long as they need, which could be months or years, Khan said. Meanwhile, they receive behavioral health care and help with life skills.

Dr. Asif Khan, CEO of Northwest Integrated Health

Medication-assisted treatment for opioid use disorder is covered for patients enrolled in the state’s Medicaid program, and thanks to behavioral health parity rules in the state, every private insurer in Washington covers these treatments.

Cheryl’s struggle with opioid use disorder lasted about five years before she found help, and she tried to quit on her own about three to four times each year. When she couldn’t, she felt like a failure, which led her to want to take opioids even more. She called it “complete chaos and hell.”

Vivitrol is “not a cure-all, that’s for sure,” Cheryl said, “but it certainly puts you on a path for greatness.”

She said her recovery has helped her reestablish relationships with family members and be a better mom to her two teenage sons.

Next steps for Washington’s hub-and-spoke program

So far, the hub-and-spoke networks in Washington, which are available in 12 of the state’s 39 counties, have treated approximately 1,600 patients.

The plan is to use new funding available in this year’s state supplemental budget to add more hub-and-spoke sites across the state, including in Eastern Washington, said Michael Langer, office chief with the DSHS Behavior Health and Recovery Division.

Michael Langer, Washington State Department of Social and Health Services

“We’re reaching more lives this way,” Langer said, adding that the hub-and-spoke system is “quicker and more comprehensive.”

In Pierce County, officials hope to create new spokes in neighboring Thurston County and work closer with organizations that offer wrap-around services, such as housing and employment help, to people recovering from substance use disorders.

Hubs are also working to train more providers within some spokes to prescribe and administer medication-assisted treatment themselves, expanding the availability of these treatments. In Pierce County, for example, Northwest Integrated Health is training physicians at five nonprofit Community Health Care clinics and at the Puyallup Tribal Health Authority to offer MAT.

The hub-and-spoke system is just one part of Washington’s approach to fighting the opioid epidemic. In 2016, Gov. Jay Inslee signed an executive order to combat the opioid crisis, and in 2017, he signed HB 1427 to enact several recommendations made by the King County Heroin and Opioid Task Force.

This year, state lawmakers included more than $10 million to support opioid abuse treatment, including growing the hub-and-spoke program; $69.3 million for behavioral health enhancements statewide; and more than $1 million for new Assisted Outpatient Treatment programs, which will allow more patients to receive treatment in their own communities. The budget also includes $1.2 million to increase Medicaid reimbursement rates for medication-assisted treatment, which will make treating Medicaid recipients more affordable for providers.

“A significant part of solving our state’s opioid epidemic is connecting people who suffer from opioid use disorder with treatment they need,” Inslee said. “Building a strong hub-and-spoke network in communities across our state will help make sure patients know what’s available, and that they get quick access to the treatment options best for them.”

Any Washingtonian who needs help with substance abuse can call the state’s 24-hour hotline

Need help? Call the Washington Recovery Help Line at (866) 789–1511 for around-the-clock help for substance abuse, problem gambling and mental illness. The help line is anonymous and confidential, and its trained volunteers and staff can provide intervention and referral services.

Suboxone, shown above, is one of the medications administered to people battling opioid use disorder. (via Wikimedia Commons)