Changes to Spoke: X-Wavier Requirement is no longer in effect.
Vermont’s Opioid Use Disorder Treatment System
Hub and Spoke is Vermont’s system of treatment for opioid use disorder (OUD). Nine Regional Hubs offer daily support for patients with complex addictions. At over 75 local Spokes, doctors, nurses, and counselors offer ongoing OUD treatment fully integrated with general healthcare and wellness services. This framework utilizes medication for opioid use disorder (MOUD) for treatment and efficiently deploys OUD expertise to help expand access to OUD treatment for Vermonters.
Medication Assisted Treatment: The Evidence-Based Approach to Opioid Use Disorder
Although MOUD can involve only medication, in the Hub and Spoke program it is actually a whole-patient approach that includes counseling and behavioral therapies along with medication such as methadone and buprenorphine. MOUD is not the only treatment for OUD, but it is the most effective treatment for most people. It is supported by the American Medical Association, the American Academy of Addiction Psychiatry, and the American Society of Addiction Medicine. Federal regulations designate two settings where MOUD can take place, Opioid Treatment Programs (OTPs) and Office Based Opioid Treatment (OBOT) settings. Vermont takes this structure as a starting point and strengthens and connects the elements.
Hubs Offer Intensive Treatment for Complex Addictions
Hubs are Opioid Treatment Programs, with expanded services and strong connections to area Spokes. There are currently 9 Hubs in Vermont. Each Hub is the source for its area’s most intensive OUD treatment options, provided by highly experienced staff.
- Hubs offer the treatment intensity and staff expertise that some people require at the beginning of their recovery, at points during their recovery, or all throughout their recovery.
- Hubs provide daily medication and therapeutic support.
- Patients receiving buprenorphine or vivitrol may move back and forth between Hub and Spoke settings over time, as their treatment needs change.
- Hubs offer all elements of MOUD, including assessment, medication dispensing, individual and group counseling, and more.
- Additional Health Home supports are made available at Hubs through the Hub & Spoke staffing and payment model. These include case management, care coordination, management of transitions of care, family support services, health promotion, and referral to community services.
- In addition to treating their own patients, Hub staff offer trainings and consultation to the Spoke providers.
Spokes Provide Ongoing Treatment in Community Settings
Spokes are Office Based Opioid Treatment settings, located in communities across Vermont. At many Spokes, addictions care is integrated into general medical care, like treatment for other chronic diseases.
- The Spokes are mostly primary care or family medicine practices, and include obstetrics and gynecology practices, specialty outpatient addictions programs, and practices specializing in chronic pain.
- Prescribers in Spoke settings are physicians, nurse practitioners, and physician’s assistants federally waivered to prescribe buprenorphine. They may also provide oral naltrexone or injectable Vivitrol.
- People with less complex needs may begin their treatment at a Spoke, other patients transition to a Spoke after beginning recovery in a Hub.
- Spoke care teams include one nurse and one licensed mental health or addictions counselor per 100 patients. These Spoke staff provide specialized nursing, counseling and care management to support patients in recovery, this staff assures team-based care and helps primary care providers balance MOUD patient care with the needs of their full patient panel.
State Oversight, Supplemental Funding, Quality and Measurement Support
- The Hub & Spoke concept was first introduced by John Brooklyn, MD and the model was designed and operationalized by the State of Vermont through the Blueprint for Health, the Department of Vermont Health Access, and the Vermont Department of Health’s Division of Substance Abuse Programs.
- The State of Vermont pays for Hub and Spoke services via Medicaid. The Hub programs bill a monthly bundled rate, and the Blueprint distributes funds to support Spoke staffing through its existing Community Health Team payment infrastructure.
- The State of Vermont provides oversight for the program, helping communities monitor treatment needs, waitlist length, average time to treatment, and program performance.
- The Blueprint for Health provides each Vermont community with a data profile showing Hub & Spoke patient demographic data and key program measures, to support data-driven quality improvement.
Evidence of Program Impact
- Access to treatment has grown since program inception, with more than 6000 people now participating.
- The Blueprint for Health uses claims and clinical data to evaluate program impact and program costs. The Blueprint is working with other state agencies to incorporate additional data, such as Corrections data, into its evaluation.
- A peer-reviewed article published in the journal Substance Abuse Treatment showed that health care costs for Vermonters receiving "Medication Assisted Treatment" (A term that has been used in the past but has now been replaced by MOUD) were lower than for Vermonters with opioid addiction not in Medication Assisted Treatment, even when including the substantial treatment costs. The article is available here.
- An evaluation by Dr. Richard Rawson shows significant positive impact from the point of view of Hub & Spoke patients and their families. Dr. Rawson's report also provides an in-depth description of the Hub & Spoke model of care including regional variation. It is available here.
More About Hub & Spoke
- A two-page description of the Hub & Spoke system, similar to the text above, is available for download here.
- Each health service area has a single point of contact for information about the area's MOUD resources. Contact information is available at the bottom of the page here.
- The X-waiver requirement is no longer in effect. It was removed with the passage of the MAT Act. All health care providers with a standard DEA controlled medication license are now able to prescribe buprenorphine for opioid use disorder without separate registration. This Flyer highlights the changes implemented through the MAT Act and please see the updated State Regulations governing MAT. VDH is doing an emergency rule change for the MAT Rules to remove references to the MAT waiver, linked here.
The proposed telemedicine rules also further DEA’s goal of expanding access to medication for opioid use disorder to anyone in the country who needs it. “Medication for opioid use disorder helps those who are fighting to overcome substance use disorder by helping people achieve and sustain recovery, and also prevent drug poisonings,” said DEA Administrator Milgram. “The telemedicine regulations would continue to expand access to buprenorphine for patients with opioid use disorder.”
The full text of the proposals may be found here and here. The public has 30 days to review and comment on the proposals, which DEA will then consider before drafting final regulations. DEA is appreciative of the public’s feedback.
For more information on DEA’s continued efforts to expand access to medications used in treatment for those suffering from opioid use disorder, visit: DEA’s Commitment to Expanding Access to Medication-Assisted Treatment.