The Upper Peninsula (UP) of Michigan is a beautifully unique and isolated part of the country, with Lake Superior lying to the north and Lake Michigan and Lake Huron to the south. The Mackinac Bridge, a five-mile suspension bridge and the third largest in the world, is the UP's only connection to the rest of Michigan. The UP holds one-third of the land mass for the state yet only 3 percent of its entire population. Those who call the UP home (nicknamed “Yoopers”) are spoiled with fresh water, fresh air, wilderness, wildlife and space. Many have lived here for a lifetime without ever crossing the Mackinac Bridge to the Lower Peninsula, or finding it necessary even to contemplate it.
What isn't so unique about the UP is a recent increase in prescription drug and opiate addiction. While Michigan finds itself well above the national average for past-month illicit drug use and past-year drug dependence or abuse, rates in the UP are even higher.1 Resources for the treatment of opiate addiction in the UP have always been extremely limited, but this has never been more apparent than now. There are no methadone programs anywhere in the UP; the closest methadone program is out of state and 175 miles from Marquette, the UP's largest city.
It is against this backdrop that Marquette General Behavioral Health opened its doors to opiate addicts for treatment with buprenorphine in June 2007. With no clear indication of what was to come, one brave psychiatrist completed the necessary training to become eligible to prescribe buprenorphine. Within minutes of receiving his newly assigned DEA number, the psychiatrist saw his phone begin to ring off the hook. Callers were desperate and anxious for access to what sometimes is called a “miracle drug.”
Although attempts were made to screen callers for appropriateness, within months our outpatient staff was positively overwhelmed (and not in a positive way). The demand for the time and resources needed to manage this service quickly grew beyond the capacity to reasonably provide it.
In addition, it wasn't clear whether we were truly “helping” anyone. Suddenly we were confronted with a steady stream of complaints of stolen meds, names of our patients in the local media for drug-related offenses, and a host of callers reporting that a patient was selling or abusing this drug. We also had a high volume of clients dropping out of service.
The good intentions we had been infused with at the beginning had begun to wane. Our local peers in the addiction field were looking at us with both curiosity and skepticism. In April 2008, only 10 months and 29 admissions into our venture into buprenorphine treatment, we closed the door to new admissions.
It would have been easy at that point to throw in the towel, shrug our collective shoulders and sigh, “We tried,” but if we hadn't learned anything else, it was that the UP had a very serious drug problem. And despite what seemed like an overabundance of failures, we had experienced a handful of remarkable successes. Some of our patients were not only in recovery, they were going back to school, getting jobs and raising children. Several of our recent customers had a previous history of multiple, traditional treatment attempts and/or failures. The addition of buprenorphine to their recovery program had provided them with the first real success they had ever experienced.
We decided not to be discouraged by the dropouts and to focus on expanding the handful of successes. We needed to figure out how to offer buprenorphine treatment in a way that it could remain available to those who could benefit from it. The “open door” policy we had started with had nearly caused our demise. With the demand for buprenorphine therapy unmanageably high, the questions on the table were both simple and complex: How do we manage a limited resource? How do we make this service available to the best treatment candidates in the UP, keeping in mind that there is no methadone program or long list of physicians prescribing buprenorphine in our rural area? How do we reduce the “hassle factor” (requests for early refills, lost scripts, calls from jail, and general non-compliance) and therefore prevent burning out our staff? How do we maintain our credibility with other local agencies, treatment providers, law enforcement and, most importantly, our patients?
After wrestling with these questions, researching what other providers were doing, and taking a painstaking look at the errors we had made with our first efforts, we decided to slow down the entire screening process by requiring potential clients to complete an application prior to acceptance and admission into our program.
The rationale for an application was twofold. First, completing and mailing the application would require effort. Those who were not willing to complete the application were most likely not going to be willing to meet other more demanding requirements of our program (i.e., responding to requests for drug testing and pill counts, participating in substance abuse counseling, etc.). Second, the application would give us a better opportunity to screen applicants and potentially fill the limited treatment slots with those in the best position to benefit from buprenorphine.