A Bangor recovery center contacted more than 100 doctors across the state with what sounds like a tempting offer. Desperate to help patients waiting months for one form of opioid addiction treatment, staff at the Discovery House promised each physician a bonus of $5,000.
Contract with the center to prescribe buprenorphine — a medication designed to ease withdrawal symptoms and cravings — the letters read, and the money is yours. Discovery House also offered to handle all the time-consuming paperwork and scheduling.
Nearly a year and a half later, program director Brent Miller recalls immediately how many physicians took the deal.
“No one,” he said. “Not one.”
To Miller, the recovery center’s failed pitch illustrates a longstanding crisis in addiction treatment that budget cuts proposed by Gov. Paul LePage will only exacerbate. The governor seeks to eliminate all state funding for another therapy, methadone, a mainstay of opioid addiction treatment largely paid for by the MaineCare program.
If lawmakers approve the cuts, up to 4,000 MaineCare patients would lose coverage for methadone and begin the risky process of transitioning to buprenorphine.
The LePage administration favors that medication, known under the brand names Suboxone and Subutex. Unlike methadone, which is dispensed at clinics, buprenorphine is prescribed at doctors’ offices. That makes it the treatment of choice under the administration’s broader effort to address the overall health of substance abuse patients instead of their addiction alone, officials say.
“Our goal is to allow these members to access a more comprehensive health care delivery package,” said Dr. Kevin Flanigan, medical director for MaineCare, the government health insurance program for low-income people.
Many substance abuse experts contend patients should have access to both buprenorphine and methadone. Decades of research shows that each therapy, combined with counseling, helps people with a history of heroin and painkiller abuse to return to productive lives. Methadone has a stronger track record for patients with long-lasting and severe addiction.
Substance abuse professionals also warn that Maine already faces a shortage of doctors willing to prescribe buprenorphine, even without the proposed budget cuts. Among the hurdles: Doctors must undergo special training to prescribe the medication and the government limits the number of patients they can treat — 30 the first year and up to 100 after that with a special waiver. MaineCare reimbursement also fails to cover their costs, and patients with substance abuse disorders are often challenging to treat.
“We have patients waiting four, five, six months to get in here and we’re one of the few programs providing the service that’s actually taking patients … We can’t handle what we have now,” Miller said.
Licenses, but not prescriptions
Exactly how many Maine doctors prescribe buprenorphine is difficult to nail down. About 330 have received the required special license from the U.S. Drug Enforcement Administration, according to the Maine Department of Health and Human Services. They could conceivably treat more than 19,000 patients if each prescribed at the maximum.
“There is capacity out there,” Flanigan said.
Opponents of the budget cuts say that view ignores reality.
“How do you shift thousands of people who are successfully managed on a medication into a system that doesn’t exist?” said Dr. Mark Publicker of Mercy Hospital Recovery Center in Westbrook, a nationally recognized expert in addiction medicine.
Another list maintained by the U.S. Substance Abuse and Mental Health Services Administration counts about 120 doctors in Maine who prescribe buprenorphine, along with 37 hospitals, clinics and other treatment programs. But the agency warns that not all are taking new patients.
A group of graduate students in the University of Maine’s social work program reached out to the physicians on the list, finding less than half prescribing Suboxone, according to Mikala Thompson, lead researcher on the project. Forty-three confirmed they’re prescribing the medication, 42 confirmed they weren’t and 27 failed to respond, she said. Two physicians on the list were deceased, she said.
“Maine is proposing policy decisions based on inaccurate data,” Thompson said.
Methadone clinics opposed to LePage’s plan point out that Maine’s most active Suboxone prescribers are psychiatrists, not primary care doctors equipped to handle patients’ broader health needs.
One clinic’s example
Dr. Gary Ross, a Brewer physician, accepts patients for Suboxone treatment, but through a clinic he operates separately from his family practice.
The patients arrive in the evening, which he said provides a safe and private environment. They pay upfront for their visits because Ross doesn’t accept MaineCare. The program fails to fully compensate him for the time he and a nurse spend with Suboxone patients, which includes counseling and drug screening, he said.
“It takes a surprising amount of effort to be able to run down the therapy notes, or the meetings, or prove that they’ve made the meetings,” Ross said. “It’s pretty time-intensive for me to do it the way I think it needs to be done.”
The first visit, lasting about an hour, costs $300, with follow-up visits running $150 to $200, he said. Patients pick up their Suboxone prescriptions at a pharmacy.
“It covers my costs and it feels reasonable for the extra time I put in,” he said.
Some substance abuse professionals disapprove of physicians accepting cash for Suboxone treatment, saying the arrangement is sometimes healthier for a doctor’s bottom line than for the patient.
The bigger issue, according to Ross, is that Suboxone is poorly understood in the medical community as a treatment option. People with substance abuse problems are also notoriously difficult to treat, he said.
“Very few physicians have any training, any education, in addiction. Addiction of any kind,” Publicker said.
Proper treatment for opioid addiction involves more than just medication, whether it’s methadone or Suboxone, Miller said. Those “replacement medications” stabilize patients by blunting withdrawal symptoms and cravings, but long-term recovery depends on changing entrenched behaviors, he said. Patients also need counseling, urine tests for illicit drug use, medication counts and call backs to check on their progress, he said.
MaineCare doesn’t pay for that — reimbursing providers only for the time they spend with patients in the office — and many doctors don’t have the resources to commit to it anyway, Miller said.
“You’re not going to get paid for some of the things that are best practice for monitoring patients,” he said.
Methadone treatment, on the other hand, requires patients to visit a clinic every day for at least the first 90 days, and the additional services are included, Miller said.
Many family doctors are simply too busy to add Suboxone patients to the mix, Publicker said.
“How many primary care doctors in the state take MaineCare, also have waivers to prescribe buprenorphine, and if they do, how many actually use it?” he said. “The answer is vanishingly few.”
Flanigan, who practiced full time in Pittsfield as an internist and pediatrician before taking the MaineCare position, said he never prescribed Suboxone.
“I had a practice that was overwhelmingly busy handling all of the care that I could at the time,” he said.
Still, hundreds of other doctors in Maine sought out training and certification to treat Suboxone patients, he said.
“The question is what leads a doctor to become certified and then not provide services to all the patients they’re authorized to treat?” Flanigan said.
Larry Plant, a Portland psychiatric nurse practitioner who specializes in substance abuse, said policymakers should consider allowing advanced-level health providers like himself to prescribe Suboxone. But even expanding the pool of prescribers won’t fix the discomfort many feel treating patients with addiction, he said.
“You have a patient population who’s dependent on chemicals or substances,” he said. “A lot of medical providers don’t want to deal with that, it’s uncomfortable for them, whether it’s a bias on their part or … just not part of their training.”
Plant, who formerly worked at a methadone clinic, supports the governor’s plan to transition patients to Suboxone, authoring a March 12 OpEd in the Portland Press Herald saying Suboxone is a better, more closely monitored option. Federal privacy laws prevent methadone from being reported on the state’s prescription monitoring program, leaving providers unwittingly prescribing anti-anxiety medications and other drugs that interact dangerously with it, he said.
Plant said he’s seen too many patients overly sedated with methadone and heard stories about clinic clients abusing drugs while waiting in line for their daily dose, Plant said.
The state will work to identify the barriers to prescribing Suboxone and help doctors to overcome them, Flanigan said. He acknowledged the challenges, but noted MaineCare has already managed to remarkably reduce the number of beneficiaries prescribed opioid medications. While he has said the goal was to better manage patients’ pain with other treatments, many individuals’ paths toward addiction begin with a legitimate prescription.
A legislative remedy?
Lawmakers are also focused on facilitating Suboxone treatment. A bill that would create a pilot program to improve access to such treatment recently won bipartisan support during a public hearing in the Legislature’s Health and Human Services Committee. The program would allow patients with moderate narcotic addiction living more than 30 miles from a methadone clinic to receive treatment with Suboxone and methadone.
Flanigan is also confident that methadone patients could safely switch to Suboxone treatment under the governor’s plan. People taking methadone must carefully taper their dose before transitioning to Suboxone, or risk severe withdrawal and a high likelihood of relapsing, substance abuse professionals say.
Publicker sees overdoses and deaths on the horizon if lawmakers approve the governor’s plan. Most methadone patients can’t afford the treatment without coverage through MaineCare, and will turn to heroin without it, he said. With doctors prescribing narcotic medications more cautiously and drug makers producing harder-to-abuse formulations, many substance abusers are turning to cheaper and potentially much more potent heroin.
As demand for heroin rises, so does violent crime, Publicker said.
“Oxycodone is primarily a property crime drug. …You’re shoplifting, you’re stealing from grandma who raised you, but you’re not knocking people over the head,” he said. “Don’t get me wrong, people are holding up drugstores. But heroin is bringing out-of-state drug gangs.”