Editor's note: This is Part 2 of our 5-part "State of Withdrawal" series. Click here for the other stories in the series.
AUGUSTA, Maine - Under his proposed two-year budget, Gov. Paul LePage wants to end MaineCare coverage for more than 3,000 methadone patients. They would still have the choice of continuing to pay for their medication out of pocket, or - under the governor's plan - they could switch to two other treatments that involve the opiate replacement drugs Suboxone and Vivitrol.
Tonight, in part two of our series, "State of Withdrawal," Susan Sharon takes a look at what the state hopes to accomplish and why many in the treatment community say it's a bad idea.
According to the Maine Department of Health and Human Services, there were just under 4,000 MaineCare clients receiving methadone in 2013, and just over 5,000 receiving Suboxone. Fewer than 300 were prescribed Vivitrol.
Methadone costs much less than the other two medications, but it can only be prescribed in a federally-approved clinic, and it has to dispensed to the patient daily. So, that year, DHHS says it spent almost as much transporting clients to methadone clinics in the state as it did on the treatment itself - about $15 million all together.
Compare that to the $11 million spent on Suboxone, which can be prescribed by a doctor and taken home in a 30-day supply, and you can see an emerging debate.
"I think we can all agree that the ideal medical care is a comprehensive package where a person receives all of their care, the wholistic package, through a single primary care provider," says Dr. Kevin Flanigan.
Flanigan is the medical director at the Office of MaineCare Services. He says the state believes that it can achieve better outcomes for low-income addicts by switching them from methadone to Suboxone treatment and getting them a more complete range of medical services, and save money at the same time - about $2 million over the next two years.
"It is not that much money," Dr. Flanigan says. "It is about getting these people the comprehensive services they need, because many of these members also suffer from other medical and behavioral health conditions. And, again, once you get to where you can get the entire package of health care services in one location, the literature is unquestionable: There is going to be improved health outcomes."
"There's no scientific basis to what he's doing, and it's not medically appropriate for probably the vast majority of people that he's trying to do that for," says Kim Johnson. Johnson is the deputy director of NIATx, a research collaborative at the University of Wisconsin that works to increase access to treatment. She previously worked as the director of the Maine Office of Substance Abuse under Govs. Angus King and John Baldacci.
Johnson says some states, like Vermont and Rhode Island, are working to integrate primary care with treatment for opiate addiction but they aren't doing it at the expense of methadone. In fact, Johnson says, they're expanding access to methadone and Suboxone because they're the best treatments available, and because, she says, patients need to have a choice.
"People need to work with the physician to figure out what is the best treatment, given their particular circumstances, just like you would with any other disease," Johnson says. "There's not one antibiotic. There's not one cancer treatment."
Specifically, there's the problem of dosing. Dr. James Berry, an addiction specialist at the Mercy Recovery Center in Westbrook, says Suboxone has a ceiling. It can't be prescribed in a high enough dosage to cover the needs of many methadone patients who tend to be long-term addicts.
"First of all, it's difficult to transition patients from methadone to Suboxone," Dr. Berry says. "Methadone is a stronger opiate, and the doses that most patients on methadone maintenance are on do not translate over to any dose of Suboxone. We can admit them here and get them on Suboxone, but most of the time they don't do very well. They don't stick with the program. They tend to relapse."
As for Vivitrol, Berry says it's not widely available in Maine and only appropriate for a limited number of patients who can tolerate it. It's also expensive - about $1,000 for a once-a-month injection. The governor's proposed budget includes a $300,000 pilot program for Vivitrol.
Larry Sexton, who works with addicts at Crisis and Counseling in Augusta, is a fan of the medication. He's treated about 100 patients with it over the past five years. "We've had very good success with it," Sexton says. "For everybody that's completed the entire course of six months to a year-and-a-half, I don't know of any that have relapsed, at this point."
Sexton, who has also worked with methadone and Suboxone, is less enthusiastic about those opiate replacement drugs because of what he says is their potential for abuse. And while Gov. LePage is now showing signs that he might be more interested in that treatment, Dr. Kevin Flanigan wants to make it clear that the state is not doing away with access to methadone treatment - it just doesn't want to pay for it.
"For those members who suffer from addiction and are covered by MaineCare, if they choose to continue to receive methadone treatment services, they can do so and they can pay directly to the methadone treatment center, whatever the sliding cost would be for them," Flanigan says.
But even the cheapest of the three medication replacement therapies, methadone, costs about $90 a week. And treatment providers have already witnessed what happens when clients lose MaineCare. In January of last year, hundreds of people known as "non-categoricals" lost MaineCare insurance under a LePage administration directive.
At Discovery House in Bangor, Marketing Director Brent Miller says 60 methadone patients were affected.
"They could not bridge into the Affordable Care Act," Miller says. "It was too expensive and there was no alternative ways in which they could continue their treatment on this disease."
Jennifer Minthorn, program director for Merrimack Medical Services, says it was the same story at other methadone clinics where MaineCare recipients account for well over half of the clients. Merrimack runs methadone clinics in Portland and Lewiston, and treats just under 500 patients.
"You know, initially what they tried to do is self-pay," Minthorn says. "The problem is, these folks don't usually have high-paying jobs and what we have found is, like, within the first couple of months they just couldn't maintain that."
The loss was compounded by cuts to the MaineCare reimbursement rates for methadone and Suboxone providers, and by a move to increase the patient-counselor ratio at methadone clinics from 50 to 150, something those who work in recovery say is not recommended.
"I just think this is kind of, you know, a broad shot across the bow," says Gordon Smith. "You know, this is kind of more of the same, but this is much more drastic." Smith is executive vice president of the Maine Medical Association, which advocates for both physicians and their patients. Smith says it would not be medically appropriate to move 3,000 methadone patients on MaineCare out of their preferred treatment and into Suboxone or something else.
"These are people who are trying to get better. They are trying to get off drugs," Smith says. "Why would we punish them by taking away their treatment options when are so few options available?"
Dr. Kevin Flanigan of the Office of MaineCare points out that 17 other states do not provide insurance coverage for methadone or Suboxone. But at a time when other states, like Vermont and Massachusetts, are expanding drug treatment, Flanigan acknowledges that he's not aware of any state that has chosen the treatment plan Maine is in the midst of crafting.
