MONTPELIER >> Rick Rawson grew up on a dairy farm in Whiting but spent much of his professional career in Los Angeles, where he co-directed the UCLA Integrated Substance Abuse Programs.
He's conducted addiction research and training programs in places including Iran — which he says has one of the worst heroin problems in the world — Israel, Egypt, the United Arab Emirates, Saudi Arabia and Vietnam.
In the 1980s he helped set up a series of methadone clinics and behavioral treatment centers across California. He's written several books and hundreds of academic research papers.
But none of it prepared him for what he encountered when he moved back to Vermont last summer. Rawson, who graduated from the University of Vermont with a doctorate in experimental psychology, followed events in his home state and heard about Gov. Peter Shumlin's 2014 State of the State address, which focused on the opiate crisis and attracted national attention.
Still, Rawson says he was astonished by the extent of the problem. He says he regularly meets friends and colleagues whose children have struggled with heroin.
"It's everywhere," he says. "It really did catch me off guard."
Although Rawson had plans to retire — he lives in a house overlooking gentle hills and farmland in Sudbury — and perhaps write a book based on his research and travels, he was asked to help Vermont assess its own heroin epidemic and evaluate the state's progress in combating it.
Rawson cites two key epistemological challenges facing the state. The first is figuring out how many people are dependent on opiates, for which he says there is no solid data. The second is taking a close look at the treatment methods being used and determining if they're working.
In June, Rawson facilitated a meeting with public health researchers from UCLA, the Pacific Institute for Research and Evaluation, and the University of Texas at Austin to help Vermont's Department of Health determine how many opiate users there are in the state.
He's also set to begin a six- to nine-month research study that will look at how effective Vermont's "hub-and-spoke" treatment model has been. The system relies on a handful of regional treatment centers, or hubs, and the evolving network of physicians throughout the state who are treating opiate addiction in their private practices — the spokes.
"We're trying to look at the model we've set up and ask the question: Is this working?" says Erin O'Keefe, the Health Department's opioid treatment program manager. "Are people's lives improving?
Measuring the problem
One percent of the population — or roughly 6,500 people — currently is being treated for opiate addiction in Vermont, Rawson says. But that's only a fraction of the total number of users.
The figure doesn't include those who are on a waiting list for treatment or are participating in needle exchange programs.
Rutland's West Ridge Center, a methadone clinic and treatment center, has seen more than 1,000 patients since it opened in 2013. It currently has 400 in active treatment and at any given time between 40 and 50 on its waiting list. In Chittenden County the number of people on the waiting list is much higher.
According to Rawson, the Department of Health is still working on coming up with an overall number, but his guess is that something like 3 percent and possibly 4 percent of the population has an opiate addiction. That's about 20,000 people.
This has far-reaching implications. Rawson says past research into opiate addiction, particularly among the population affected during the last heroin epidemic in the late 1960s and '70s, shows that opiate users tend to have chronic health problems and are often in and out of jail and treatment programs.
There are public health issues including higher rates of hepatitis and in some places HIV. Indiana, for example, recently experienced the largest outbreak of HIV cases in the state's history, attributed directly to injection drug use. With its needle exchange programs and regional treatment centers, Vermont is unlikely to see a similar outbreak, Rawson says, but the risk is there.
Moreover, Rawson says, there's little good data on the number of new users, especially young people, who will need treatment in the decades to come.
Gauging the response
Even without those numbers, the state still needs to address the opiate crisis, and it is largely doing so through its hub-and-spoke model.
Beginning later this year, Rawson and UVM will conduct a research study to evaluate how well that system is working. Eighty patients currently in treatment will be interviewed over the course of several months about their experience.
Twenty people not in treatment — 10 who have dropped out and 10 who have an addiction but have not sought help — will also be interviewed. The researchers also will conduct focus groups with family members of addicts.
Rawson says they hope to get a better sense of what's working and what's not, what's keeping people from seeking treatment, and how the state can improve access to care.
The hub-and-spoke model will be effective only if more physicians in private practice begin to treat patients for opiate addiction, Rawson says. That means understanding addiction not as something that should be treated in isolation but as a public health issue.
Rawson was recently observing Dr. Richard Baker, a family physician in Rutland, who incorporates addiction treatment into his daily practice. Rawson says that when he told Baker that what he was doing was actually cutting-edge, the doctor replied, "They're my patients. Why wouldn't I treat them?"
While Rawson acknowledges the challenges Vermont faces, he also says the state is "three to five years ahead of the rest of the country" when it comes to treatment of opiate addiction.
For example, according to O'Keefe, Vermont's overdose rate is significantly lower than the neighboring state of New Hampshire's. O'Keefe attributes this in part to greater access to services and the fact that services for opiate addiction are covered by Medicaid in Vermont. In many states that is not the case, O'Keefe says, and people seeking treatment cannot afford it.
"What's happening in Vermont is important and noteworthy," Rawson says.