September 25, 2017
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Maine’s ‘opioid health homes’ are so intricate there will probably be only a few

By The BDN Editorial Board
Troy R. Bennett | BDN
Troy R. Bennett | BDN
A pharmacist holds the generic version of Suboxone at Community Pharmacies in Gorham.

Maine saw some positive movement this winter with the LePage administration and the Maine Legislature agreeing on an anti-addiction initiative and putting money behind it.

In a supplemental budget bill, lawmakers devoted $3 million to pay for medication-assisted treatment for those with opiate addictions but without health insurance. The federal government is expected to chip in an additional $1.8 million to help the state form “opioid health homes” for those struggling with addiction.

The idea is that someone with an addiction, but without health insurance, can access treatment at a primary care provider’s office that offers a full complement of anti-addiction services. Lawmakers were pleased to allocate some resources toward fighting Maine’s deadly addiction epidemic; the LePage administration was able to act on one of its desires — to shift more addiction treatment to primary care offices.

The consensus is encouraging, but details matter. And the opioid health home details developed by the LePage administration appear to make it more difficult to deliver treatment to those who need it, instead of making it easier for them to access it.

“The core concept is, anything that creates an excessive need for structure presents a significant barrier to treatment,” Dr. Mark Publicker, an addiction specialist in the Portland area who recently was awarded the American Society of Addiction Medicine’s Lifetime Achievement Award, said in an interview.

The opioid health homes are heavy on structure. According to details recently released by the Maine Department of Health and Human Services, a medical office that applies to become an opioid health home would need at least six people on staff who have some level of addiction expertise:

— A nurse practitioner or doctor who can prescribe buprenorphine, known commercially as Suboxone.

— A “clinical team lead” who is a “licensed clinical professional with opioid addiction treatment expertise.”

— A “nurse care manager” who could be a “registered nurse with expertise in addiction treatment” or a credentialed “psychiatric and mental health nurse.”

— A “certified clinical supervisor” licensed as a drug and alcohol counselor.

— A “licensed alcohol and drug counselor” who provides counseling.

— And a “peer recovery coach”: someone in recovery who can provide mentoring.

With these six people on staff, the medical office would qualify for $500 per month for every uninsured patient served.

The medical office can receive $1,000 per patient per month for “directly administering” the medication. This option would require a pharmacist on site, and it would require that patients visit the medical office daily for their medication if they’re prescribed buprenorphine.

“To have the full complement of listed personnel, plus a pharmacist, is a very bad idea, which will not result in any increased access to care,” Publicker said. Few primary care practices have the full complement of staff required, much less the infrastructure of a licensed pharmacy on site, meaning only a select group of practices will be able to apply to become opioid health homes.

Unlike methadone, where clients generally need to receive a daily dose at a clinic, buprenorphine — the drug that would be most commonly prescribed at opioid health homes — is meant to be prescribed and taken at home daily so a patient can maintain a normal life. Buprenorphine attaches to the brain’s opioid receptors, reducing cravings and stopping withdrawal symptoms without creating a high.

“There’s a large group of working people who can’t go to some place to have medicine dispensed every day,” said Publicker, who said many of his patients are fishermen who drive long distances to his Portland office because of a lack of local access to treatment. “Unless we address this in a more thoughtful manner, we’re excluding this whole population of coastal fishermen.”

Plus, most doctor’s offices don’t have pharmacies on site. “It would require primary care providers to maintain a stock of buprenorphine in their office, which, of course, no one is going to do,” Publicker said, because “it requires an additional level of DEA regulation that would be so burdensome.”

In the absence of state leadership, Maine has been slow to react to a burgeoning addiction epidemic. Under the LePage administration, the state has cut access to health coverage whereas expanded access would provide more people with addictions a way to pay for treatment.

Small initiatives aimed at people without insurance are better than nothing, but they’re a woefully insufficient response — especially when they’re designed in such a way that drastically limits their benefits.


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