It sounds like a great idea: Stop treating recovering addicts with a therapy that requires daily trips to a clinic and instead set them up with primary care providers who can prescribe medication they can take at home. The problem is there aren’t enough physicians qualified and willing to prescribe the take-home drug.
Yet, this is the proposal in Gov. Paul LePage’s budget for the next two years — eliminate state funding for methadone treatment and have MaineCare recipients get buprenorphine, which also goes by the brand name Suboxone, through a primary care provider instead.
An incentive program, reported in the recent analysis of opioid treatment options by Jackie Farwell, highlights the shortcomings of this approach.
About a year and a half ago, Discovery House in Bangor offered more than 100 area physicians a $5,000 bonus if they’d contract with the recovery center to prescribe buprenorphine. Discovery House would handle the time-consuming paperwork and scheduling.
Not one physician has taken Discovery House up on the offer.
Recently, three University of Maine graduate students conducted a telephone survey to find out how many of the 112 doctors included on a federal list of buprenorphine prescribers actually prescribe the medication. Less than half those listed, 43, confirmed that they prescribed it, and 42 said they had stopped prescribing the addiction treatment drug. Another 27 didn’t respond.
The students found only two prescribers in Aroostook County.
“Our goal is to allow these members to access a more comprehensive health care delivery package,” Dr. Kevin Flanigan, medical director for MaineCare, said of the plan to move recipients of the government health insurance program for low-income people away from methadone. This is a laudable goal, but members can’t be transitioned to a package that doesn’t exist.
Sen. Geoff Gratwick, a Bangor physician, has a better plan. Building on the work of a Bangor group that took a hard look at drug abuse and addiction in the city, he proposes a pilot project to test the effectiveness of using drug treatments other than methadone to deal with opioid addiction. The test sites would be outside Bangor, which is home to three methadone clinics, involve primary care providers and offer peer support.
His bill, which is under consideration by the Health and Human Services Committee, would offer a good way to identify — and, more important, rectify — problems with Suboxone before mandating that MaineCare patients move to that treatment with no access to methadone if they can’t get Suboxone treatment or if it doesn’t work.
Dr. Gary Ross offers Suboxone treatment in Brewer. He meets patients in the evening, and payment is made up front to keep this work separate from his family practice. He said he doesn’t accept MaineCare because the program fails to fully compensate him for the time he and a nurse spend with Suboxone patients, which includes counseling and drug screening.
“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.
The bigger issue, Ross told the Bangor Daily News, 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.
Suboxone has many benefits. But not all addicts can be treated with Suboxone. Those with the most severe addiction are generally best treated with methadone, which also is less likely to be diverted or sold. To ensure proper treatment, MaineCare recipients should not entirely lose access to methadone.
Most important, if physicians aren’t available to prescribe Suboxone, it’s not a viable alternative. If the LePage administration is serious about this transition, it must first build up a system of Suboxone providers and the accompanying supports, as Gratwick’s bill would do.