Holly Warren was recently leafing through one of her old medical school textbooks, trying to recall how much instruction she’d received in addiction medicine – trying to recall, “Did we even talk about this? Was it even on our radar?”
“And it really just wasn’t,” Warren said. She received an excellent education two decades ago at East Carolina University’s Brody School of Medicine, then at Duke University for internal medicine. “But we just really didn’t talk about addiction medicine very much.”
Today, Warren knows quite a bit about it. She began providing medications for opioid use disorder, or MOUD, at a federally qualified health center in rural Greene County, North Carolina, and now serves as medical director of the health department in Lenoir County, likewise a rural county in eastern North Carolina, where her clinical focus is MOUD.
She’s found support from the NC STAR Network.
In 2023, the federal Substance Abuse and Mental Health Services Administration lifted a restriction on health care providers’ ability to administer buprenorphine, considered a “gold standard” for treating opioid use disorder. Now fully capitalizing on this opportunity, the NC STAR Network is an initiative designed to expand access to addiction treatment for North Carolinians.
The network is a partnership of three hubs – the medical schools at the University of North Carolina at Chapel Hill and East Carolina University, and the Mountain Area Health Education Center, or MAHEC – and health care practices throughout the state. The objective is to train and support primary care providers to administer MOUD.
The network has received funding from the Foundation for Opioid Response Efforts, which cites it as a model of sound investment of funding from the Rural Health Transformation Program: $50 billion in federal money over the next five years to improve rural health care systems.
The Hub-and-Spoke Model
For Claire West, an internist in UNC’s Division of General Medicine and the NC STAR Network’s director, addiction medicine is the “absolute essence of primary care.”
“I think I speak for my colleagues in primary care, whether it’s family medicine or internal medicine,” West said, “that we were drawn to this because of our strong belief in whole-person care.”
Addiction is a chronic disease, she stresses, and should be treated in the continuum of whole-person care.
The NC STAR Network was built using a hub-and-spoke model, inspired by the approach the state of Vermont takes to addressing opioid use disorder. The medical schools and MAHEC serve as the hubs, offering a full range of care and training and support for the spokes, while the spokes provide ongoing care in a community setting.
The relationship between the hubs and spokes has continued to evolve.
“To remove the idea that the hub provides and the spoke receives was really important,” said Gabriela Castro, a family medicine physician in rural Chatham County and the NC STAR Network’s data team lead. “It’s bidirectional communication and learning,” with the community-based practices helping hub staff “understand what’s happening on the ground, what works for their specific community.”
The network now reaches into 88 of North Carolina’s 100 counties. From July 2024 to June 2025, the academic hubs provided MOUD to 1,400 patients, while spike sites reported serving well more than 4,000.
Every Door Open
The NC STAR Network team believes the primary care environment is ideal for administering addiction medicine for a number of reasons.
To begin with, “There’s a longstanding relationship; there’s trust, and there’s continuity,” Castro said. Delivering addiction medicine in the continuum of primary care “helps us frame the treatment of substance use disorder as one of many parts of a complex system of conditions that affect individuals.”
Moreover, she said, “Any door should be the right door when somebody wants treatment.”
Data indicate that patients who receive MOUD treatment in a primary care setting have equivalent retention rates as those who receive specialty treatment and often report greater satisfaction with the experience.
Embedding addiction medicine into primary care practices also helps destigmatize the treatment, Castro said.
“When we separate it from the rest of primary care, it becomes not only difficult to access but shameful for many patients,” she said. In a primary care office, “many patients feel much more comfortable; they’re already being seen for other conditions.”
The visit, West said, then offers her an opportunity to say to her patient, “‘I’m going to start giving you pre-exposure prophylaxis for HIV. I’m going to screen you and treat you for hepatitis.’ I can do all of these things.”
Or, to a patient who’s using methamphetamine, “‘You don’t want to stop using methamphetamines because you’re unhoused and you need to stay awake for your self-protection? I see that. I’m going to work with the case manager to help you find some housing resources.’”
Rural Reach
As has been widely reported, rural America has a shortage of most all health care services. This is certainly the case with the availability of MOUD. MAHEC is playing a critical role in addressing that.
MAHEC serves largely rural Western North Carolina. A primary objective is to place health care professionals in rural communities and provide them with the resources and training to remain there. Addiction medicine has been folded into that.
The Foundation for Opioid Response Efforts has invested in MAHEC’s role in the NC STAR Network. Karen Scott, the foundation’s president, said her organization found the network to be a sound investment not only because of its potential reach but the diversity of access points – MAHEC, the academic medical centers, local health departments, federally qualified health centers – allowing primary care practitioners throughout the state to tap into specialist expertise.
The Mountain Area Health Education Center provides a full range of health care services throughout largely rural Western North Carolina. (Photo by Taylor Sisk / The Daily Yonder)
The MAHEC team, Scott said, has played a critical role in disseminating that expertise across rural Western North Carolina.
When Zach White, MAHEC’s opioid dependence treatment program coordinator, first started providing MOUD, a standard question he asked of new patients was, “Do you have a primary care provider?” And the most common response, he said, was, “No, but I’ve been meaning to get one.”
“We’ve got such a great opportunity, because, as we know, folks are coming in having used substances sometimes for many years and have not been tending to their health,” White said.
Foundation for Opioid Response Efforts program director Ken Shatzkes hopes to see other states looking to the NC STAR Network as a model for investment in the Rural Health Transformation Program funding. While the applications states have submitted for that funding don’t “explicitly say, ‘We need to build hub-and-spoke systems,’” he said, “the elements of what makes this a success are in those applications.”
‘Pretty Cool’
Acknowledging the treatment of substance use disorder as a chronic condition, Castro said, has transformed the way her primary practice addresses other conditions.
“It really helps us think about meeting the patient where they are,” she said. “We can’t push them too soon; we can’t push them any further than they want to go. We’re here to offer consultation and support and work with the logistical difficulties that they encounter navigating the health care system.”
“It absolutely has transformed the way I treat other things,” Castro said, “and I’m a better primary care physician.”
The NC STAR Network continues to expand its reach across the state.
Sandy Thomas-Montilus is an internist who provides MOUD in the rural southeastern region of the state, is clinical director of the N.C. Department of Adult Correction’s MOUD program, and is an NC STAR community partner. She stresses the importance of networking – networking that she believes can, in addition to expanding access to a critical treatment, help chip away at the stigma around addiction and addiction medicine.
“There’s still a lot of stigma amongst my own profession,” Thomas-Montilus said, “the idea that, ‘I don’t want those kinds of people in my practice.’ And to me, that’s very sad.”
Having played a role in the overdose crisis – some unaware of the addictive nature of prescription opioids; others through irresponsible prescribing, “I think we owe it to our patients” to be proactive in addressing it, she said. “The profession does.”
Holly Wilson says that when she was practicing primary care, her first objective was “for my patients to know that I cared about them. I couldn’t always fix their diabetes or their high blood pressure or various chronic conditions they faced,” she said, “but most importantly, I wanted them to know that I care.”
Now in addiction medicine, “I have to say it’s pretty cool,” she said, “to be able to continue to practice that primary objective, and to see lives pretty quickly changed by offering evidence-based care.”
“It’s really rewarding to see people heal and recover from a chronic illness.”
The post The ‘Hub-and-Spoke’ Model for Addiction Treatment in North Carolina appeared first on The Daily Yonder.
