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Strength in Numbers: Treatment Program Helps Addicts Recover, Thrive

  • A participant listens during a session at Groups, a treatment program in West Lebanon, N.H., on October 3, 2016. (Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • At Groups, an addiction treatment program in West Lebanon, N.H. Keith Arnesen, of Canaan, N.H., grabs his journal before starting a group session on Oct. 3, 2016. Participants contribute in their journals during the session. (Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • After participating in a session at Groups, an addiction treatment program in West Lebanon, N.H., Robin Sanville, of White River Junction, Vt., waits for the results on her second drug test on Oct., 3, 2016. (Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • A participant speaks about his struggles with addiction and recovery during a session at Groups, a treatment program in West Lebanon, N.H., on October 3, 2016. He consented to be photographed but did not want to be named.(Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • Dr. C.Tyler Vogt, left, talks with Cody Barton, of White River Junction, Vt., about Barton's dosage after a group session at Groups, an addiction treatment program in West Lebanon, N.H. on Oct. 3, 2016. (Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • At Groups, an addiction treatment program in West Lebanon, N.H. participants must give a urine sample before the start of the group session. Melinda Cass, operations supervisor for New Hampshire, dips a test into one of the samples on Oct. 3, 2016. (Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • Jeff DeFlavio is CEO of Groups, an addiction treatment program with eight offices in New Hampshire (including Claremont and Lebanon), six more in Maine and Ohio and with hopes to expand nationwide. (Courtesy photograph)

  • Inspiring messages are tacked to the bulletin board at Groups, an addiction treatment program in West Lebanon, N.H.(Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.



Valley News Staff Writer
Saturday, October 15, 2016

West Lebanon — “For $65 a week you can get the therapy and medication you need to regain control of your life.”

That’s the promise that greets visitors to the website of Groups, an addiction treatment program founded 2½ years ago by a Dartmouth College student with an unusual resume and no lack of confidence in his ability to change the world.

Jeff DeFlavio was still working toward degrees from the Geisel School of Medicine and the Tuck School of Business when, in early 2014, he and a Dartmouth-Hitchcock doctor with decades of experience treating addiction opened a tiny office in Claremont.

The office was the first in the Groups program, which now has eight sites in New Hampshire, six more in Maine and Ohio and aspirations to expand nationwide with a focus on rural areas.

Each week, patients battling addiction to prescription painkillers or heroin go to those offices to take a drug test and participate in a 60-minute group therapy session.

A patient who shows up, pays, sits through the session and passes the test gets a prescription from a Groups’ doctor for a week’s supply of Suboxone, a combination drug that includes a synthetic opioid called buprenorphine that reduces an addict’s craving but doesn’t produce a high. The program lasts for up to two years.

Patients seeking recovery from addiction have found medication to be a powerful tool. As an addict, said Cody Barton, a 26-year-old painter from White River Junction, “there was never one day where I could just be OK and not have to do heroin to be able to function.”

At Groups, his medication “just completely took over the routine of doing the heroin. I just take the Suboxone every day.”

Buprenorphine has been available since 2002. Its effectiveness in treating addiction has been proven and recognized by doctors, scientists and government officials.

But countless addicts who need treatment — with buprenorphine or other medications — have nowhere to go to get it.

That is an especially daunting problem in the rural areas of northern New England. About 27,000 residents in New Hampshire and 14,000 in Vermont need treatment but don’t get it, the U.S. Substance Abuse and Mental Health Services Administration recently estimated.

DeFlavio wrote an academic paper looking at the barriers to expanding the use of buprenophine, then went to work addressing the problem — big time.

“I knew from the start that I didn’t want to form another organization that would treat a few people well,” he said. “I wanted to form an organization that was going to meet the size and scale of the opiate epidemic.”

And even though DeFlavio, now 30, once worked for a well-known nonprofit and spoke out against the privatization of public education, he believes that private business offers a better way to address the mushrooming public health crisis in opioids. “We are a for-profit medical practice because it’s the best way to bring this solution to the most people possible,” the Groups website declares.

But succeeding as a for-profit venture requires performing well for investors as well as for patients. Only time will tell how well the company can serve both sets of masters.

Pursuing a Social MissionAnd a Profit

In some ways, DeFlavio, who received his medical and business degrees in 2015, seems an unlikely candidate to formulate a response to the fast-growing epidemic of heroin and painkiller abuse.

DeFlavio grew up in a Boston suburb. While still in high school, he served as a student representative on the state Board of Education where, he recalled, he expressed “a lot of concerns about standardized testing and charter school systems.”

DeFlavio attended George Washington University, where he was active in supporting refugees from the embattled Sudanese province of Darfur. After he graduated, he worked for a year in The Gambia at a hospital run by Partners in Health, the nonprofit medical relief organization co-founded by Harvard physician Paul Farmer. “I wanted to work in the developing world doing health care, building health care systems,” DeFlavio said.

Instead, he enrolled in medical school. He chose Dartmouth in part because Jim Yong Kim, a Partners in Health co-founder, was president. He also was drawn by the college’s program that allows a student to simultaneously earn a doctorate of medicine and a master’s in business administration.

Opiate addiction was “a problem I was not sensitive to” before starting medical school in 2010, DeFlavio said. But then, as a medical student visiting “all these rural primary care facilities in Vermont and New Hampshire ... I just couldn’t believe how many people I was seeing who were struggling with opiates. It was mind-boggling.”

Consider the numbers. During a recent year, 10.7 million Americans — including 48,000 in New Hampshire and 18,000 in Vermont — misused prescription painkillers, according to estimates by the U.S. Substance Abuse and Mental Health Services Administration, based on the 2013 and 2014 National Surveys on Drug Use and Health.

The death toll has been staggering: 36,000 nationwide in 2014, according to the U.S. Centers for Disease Control and Prevention. In 2015, there were 75 accidental or undetermined-cause deaths in Vermont involving fentanyl, heroin or prescription painkillers, according to the state Health Department.

In New Hampshire, fentanyl, heroin or prescription painkillers were involved in 397 of the 439 drug overdose deaths in 2015, according to the state Medical Examiner’s Office.

DeFlavio said his awareness of the opioid problem grew during his third year of medical school, when he was doing an inpatient rotation at Mary Hitchcock Memorial Hospital overseen by Don West, an expert on addiction treatment: “We had like 20 patients, and 18 of them had a diagnosis of opioid dependence.”

Outside of the hospital, DeFlavio saw a dearth of treatment options. He moved to fill that need with Groups, which now employs 80 people, treats more than 1,200 patients and has raised $4 million from venture capitalists.

“We’re scaling it fairly rapidly,” said Heather Prebish, Groups’ New Hampshire clinical director.

DeFlavio emphasizes the humanitarian aspect of his work with Groups. “I believe that health care is a human right,” he said. “In a privatized medical system, obviously, people can’t get it a lot of times. You have to create affordable options.”

That’s where his business training comes in. “In the United States, most of our medical care is privatized, either formally or functionally,” DeFlavio said. “All the nonprofits run like for-profits.”

Groups aims to offer treatment at prices that are “drastically less than what other people are charging,” DeFlavio said. Being the most affordable provider of counseling is “at the heart of the mission,” he added.

The ways Groups cuts costs include finding economical ways to provide therapy — to 15 patients at a time with a nonprofessional counselor, rather than one-on-one with a doctor — and do drug testing.

Insurance rules that reward “high-cost, low-value physician interactions” or mandate expensive test protocols can be avoided because patients pay out of pocket, according to DeFlavio.

Typical northern New England buprenorphine providers charge $500 to $1,000 for an initial appointment, frequently collect “hidden fees” for things such as urine testing and have high initial dropout rates, DeFlavio said. At Groups, 84 percent of patients remain in the program after a month, and more than 50 percent are still in after six months, he said.

West predicts the Groups formula could work on a larger scale. “They’ve got a model that they can replicate and they know how to do it, and there’s enough physician interest,” he said.

Ending suffering gives Groups its social mission, according to DeFlavio. “We can save a lot of people’s lives, (people) who have been victimized and given very dangerous medication without education,” he said. “We can help them get their lives back.”

DeFlavio said the company’s commitment to that mission is anchored in the personal experiences of most of its board members. He said the company does not make board members available for interviews.

The composition of the board and the company’s executive team make clear that Groups’ devotion to its social mission does not preclude an equally strong commitment to business growth and success. The company has veterans of McKinsey & Co., the global business consulting firm, as its chief operating officer and board chairman, respectively. Its board also includes a director of Kindred Healthcare, a Fortune 500 company that operates nursing homes; a venture capitalist; and Gregg Fairbrothers, the founder of Darmouth’s Entrepreneurial Network.

Financial backing came from RRE Ventures, DeFlavio said. RRE is a $1.5 billion New York City-based venture capital firm that invests in startups in markets that are “large, growing, and attackable,” according to its website. RRE Principal Steve Schlafman is the venture capitalist on the Groups board.

Such backing wouldn’t have been available to a nonprofit, DeFlavio said. Groups was established “as a business and as a for-profit, not as a nonprofit, because I wanted to be able to access capital markets,” he said.

“I think it’s really important to access capital markets to solve social problems,” he added. “We got $4 million in venture financing that would have gone to something else worthy but it would have gone to another app or something like that. Instead, we’re spending it building an organization that’s helping people recover from heroin addiction.”

The Groups Model

DeFlavio spelled out the rationale for the Groups approach in his paper, “Analysis of barriers to adoption of buprenorphine maintenance therapy by family physicians,” which was published in the journal Rural and Remote Health in 2015. DeFlavio was the lead author.

Noting previous research showing that medication-assisted treatment was effective but underutilized, DeFlavio and some Geisel colleagues surveyed more than 100 primary care doctors in New Hampshire and Vermont.

The study, which began in September 2012 and ended the following March, found that front-line primary care doctors believed that diagnosing addiction was part of their job. “They feel a responsibility to treat these people,” DeFlavio later said. “What they say is, ‘I don’t know how to do it. My staff doesn’t know how to do it. I don’t get paid enough money. It takes too much time.’ ”

To reduce the time, cost and red tape associated with prescribing buprenorphine, Groups relies on skilled administrative staff and brings together in each weekly session up to 15 patients, a counselor and, periodically, a doctor.

“The group is the core functional unit of the clinic,” said Silas Howland, a boyhood friend of DeFlavio and a Groups co-founder. While each patient is an individual in a unique circumstance, there is “a bit of overlap,” Howland said.

“In a group setting you have a lot of peers who are ... able to bond and create a group cohesion,” Howland added.

The approach combines “the power of community with the power of medical science,” DeFlavio said. Groups offers a spiritual element to care similar to that found in 12-step programs but also uses evidence-based medication-assisted treatment, he added.

West, the addiction treatment expert, said the Groups approach resembles one used for more than a decade in the addiction treatment program at Dartmouth-Hitchcock.

“Jeff really took the model that we started at Dartmouth clear back at the beginning: in order to get Suboxone, everybody had to come to group,” West said. “Groups is sort of the son of the Dartmouth program in many ways.”

DeFlavio pointed to the group obstetric appointments for pregnant mothers he observed in the obstetrics department at D-H’s Keene clinic as another inspiration. “The patients already know 90 percent of what they need to know,” DeFlavio said. “You bring together people who have a much better understanding of what they’re going through than doctors (do), and you allow them to share with each other.”

Within a year of seeing that approach working in Keene, DeFlavio had joined with West to design a program and open a Claremont clinic for drug addicts.

DeFlavio said he reached into his own pocket for $1,000 to pay for the insurance coverage and renovations necessary for Groups to open in February 2014: “It was just me and Don (West). I was the counselor. I did all the administrative stuff. And Don was the doc.”

West, who still works with the company, recalled Groups’ early days. “My office to do intakes was in the closet,” he said. “We were sort of feeling our way in the dark.”

There was plenty of light, inside and out, as Groups patients and staff members waited for a recent weekly session to begin. Attendees were casually dressed, and talked easily among themselves. Later, in the formal session, they raised their hands and spoke quietly in response to counselor Wayne Miller’s gently probing questions about the stages of the recovery process.

The discussion flowed freely. Some comments touched upon the loneliness that several participants felt. A doctor warned them of the dangers of mixing prescription painkillers with sedatives, which are known as benzodiazepines. There were friendly exchanges about what constituted recovery.

After the session ended, the patients lined up to get their test results and prescriptions.

The groups are more than just a low-cost way of treating many patients, some caregivers say. “People in groups are able to validate each others’ worth,” said Peter Mason, a retired primary care doctor from Lebanon who writes prescriptions for some Groups patients.

“In Groups, I feel like I’m with other friends,” said Keith Arnesen, 28, of Canaan, who has been in the program for eight months. “We’re all in the same boat.”

“The support is nice,” said 23-year-old Damean Prenticz, of Canaan, who has been in the program for 18 months. “I had a slip-up. No one judged.”

The gatherings also foster a sense of responsibility, said Prebish, Groups’ New Hampshire clinical director: “Patients hold each other accountable in a group setting.”

Groups so far has grown despite requiring patients to pay upfront — $50 initially, $65 currently — for each session. But the hope is to get reimbursements from private insurance companies and from Medicaid.

“We are actively negotiating with half a dozen insurance companies” and expect to start accepting Medicaid coverage for New Hampshire patients by the end of the year, DeFlavio said.

West has mixed feelings about that. “Having Medicaid would be nice, but in some ways having to pay for their own visits for most (patients) is a hell of a lot less expensive than (what) they were spending on drugs when they started, and it really means that they’ve got to be motivated to stick with it, so it’s somewhat of a motivator,” he said.

Meanwhile, DeFlavio seems comfortable with the role of the profit motive in his fledgling venture with a social mission. “To say that drug addiction treatment should be delivered for free or delivered by the government when all of the rest of health care is in a for-profit, fee-for-service system is really just confining people who struggle with opiate addiction to another ghetto,” he said. “It’s saying to them that you can’t go and buy health care that you need to get well, that you know is good for you.

“To confine this work to the realm of government and charity means we will never catch up, forever (be) one step behind.”

Rick Jurgens can be reached at rjurgens@vnews.com or 603-727-3229.