Two-year methadone treatment cap, quietly passed in DHHS supplemental budget, starts Jan. 1

BANGOR, Maine — A new law geared to save taxpayers millions of dollars by placing a 24-month lifetime cap on state funding for MaineCare patients using methadone to treat their opiate addiction goes into effect Jan. 1.

The proposed policy rules to implement the law are under review by the Maine attorney general’s office, according to Department of Health and Human Services spokesman John Martins. They are expected to be signed by DHHS Commissioner Mary Mayhew this week, he said Wednesday.

The rules, which eliminate a controversial retroactive clause that was part of the law, will not be released until they are final, Martins said.

“There is still a two-year lifetime restriction, but it starts Jan. 1,” said Dr. Kevin Flanigan, medical director of MaineCare Services.

“It’s a soft cap,” Dr. Vijay Amarendran, a psychiatrist at The Acadia Hospital in Bangor, said last week. “There are exceptions, if it is medically prescribed.”

MaineCare recipients who are not approved for additional time after 2014 can continue to receive methadone maintenance treatment, but the state will no longer pay for it.

There are 4,760 drug-addicted Mainers receiving methadone maintenance treatment to fight opiate addiction, and 3,119 of those — more than 65 percent — are on public assistance under MaineCare, the Medicare program for the state, Martins said.

The state spent about $9 million for methadone treatment in 2010 and another $7 million to take patients to clinics, Martins said. Maine is expected to save $1.36 million over the next two years for the cost of providers, mental health services and the Office of Substance Abuse. Other costs, such as transportation, also might see reductions, Martins said.

“As we do not know how many patients will still be receiving methadone treatment in 2015, or what the final prior authorization rules will be, it is difficult to estimate savings at this point in time,” he said.

In recent years, more and more Maine residents have overdosed on diverted painkillers, most of the time mixed with alcohol or another drug, and the number of pharmacy robberies, which were nonexistent just a few years ago, has jumped to more than one a week in 2012.

The number of Maine residents seeking treatment for prescription drug abuse also tops the nation, according to a federal Substance Abuse and Mental Health Services report in 2011. The rate has risen steadily from 28 per 100,000 residents in 1998 to 386 admissions per 100,000 residents in 2008, the report said.

State lawmakers considered a controversial bill last spring to create a retroactive two-year cap on MaineCare payments for methadone treatment, but it eventually died in the Senate.

But the bill then was quietly slipped into the supplemental budget for the Department of Health and Human Services and became law when signed by Gov. Paul LePage in May.

Since then — and without any publicized debate — Flanigan, members of the Office of Substance Abuse, methadone and suboxone treatment providers, and others have been crafting rules that will govern implementation of the new law.

“There was a lot of anxiety out there” during the legislative debate, Flanigan said. “[The drug treatment legislation] was passed as part of the Department of Health and Human Services’ supplemental budget and it got lost in the mix.”

The fact that the draft statute was placed in the supplemental budget “gave us time” to work on the rules without public debate, he said of the working group tasked with writing the policy rules.

More than one methadone clinic operator said the legislative changes earlier this year were made for budgetary reasons without input from those who deal with drug addicts, many of whom have been on drug-replacement opioid therapy for years.

“We’re extremely nervous,” Kelly Kenney, director of outpatient services at The Acadia Hospital in Bangor, said last week in response to questions about the new drug treatment rules. “The state made the decision months ago and said, ‘Suck it up.’”

“It created a lot of anxiety,” Susan Sullivan, program director for Westbrook’s CAP Quality Care, the second largest opiate treatment program in Maine, said last week of the drug treatment legislation.

She said legislators made the changes because “Maine has a huge opiate problem and it costs a lot of money.”

“They are MaineCare rules promulgated by legislators against any evidence-based practices,” Dr. Joseph Py, corporate medical director for Discovery House, which has clinics in Bangor, South Portland, Calais and Waterville, said last week.

No one in favor of the changes testified before legislators about the drug treatment changes when the DHHS supplemental budget was passed, he said, adding, “We’re stuck with it, so we have to do it.”

That is one reason Py eagerly worked with Flanigan on the proposed rules.

“Kevin Flanigan has been very open-minded about what should be created,” Py said, adding that he was “encouraged by the process.”

The Discovery House clinics service about 1,500 addicted Mainers, and “85 percent of our folks in methadone treatment are on MaineCare,” he said.

CAP Quality Care serves 480 patients and about 70 percent are on MaineCare, Sullivan said. “A fair number” of patients have received treatment for more than two years, she said. Acadia serves between 650 to 700 patients every month, with about 60 percent on MaineCare. The number of patients at Acadia in methadone maintenance treatment for two years or more was not available Thursday.

Methadone patients also are worried about what the changes will mean.

“I think it’s a tragedy, quite frankly,” Joey Bonaddio, no address provided, said last week shortly after getting his daily dose of the cherry-flavored liquid painkiller at the Discovery House in Bangor, one of nine methadone clinics in the state. “The government, the state, needs to take a much bigger look into it. The people who come here need to be here.”

The changes would not affect him because he’s not on MaineCare, but they are a concern when weighing the consequences, he said.

“Would they like to see those people on the street buying meds or stealing from pharmacies — possibly hurting the public — or coming here for controlled treatment?” Bonaddio said. “I think it’s going to create a lot of problems.”

Breaking free of opiate addiction is the reason Millinocket resident Kyle Bellfleur, a MaineCare recipient, travels 134 miles every day for his methadone treatment. He said it has been a struggle but he is making progress and is trying to reduce the amount of methadone he takes.

“I’ve been at a high dose for so long my taper is about 5 milligrams every week or so,” he said, referring to the amount his dose is being reduced. “It’s going to be another six or seven months. I’ll be here till springtime.”

The methadone legislation mirrors prior restrictions placed on suboxone, another common opiate replacement drug for addicts in treatment. The suboxone rules and others covering opioid pain management also were strengthened as part of the DHHS supplemental budget, Flanigan said.

“In the Legislature, it’s safe to say, there was a three-prong approach to opioids,” he said, referring to methadone, suboxone and opioid pain management changes.

The new rules for suboxone, which is administered through a doctor’s office, place a 24-month retroactive cap for those on MaineCare, he said.

Suboxone patients on public assistance who want to continue to use the opioid replacement beyond the two years must get approval from DHHS “prior to the expiration of the 24th month of coverage” in order to continue, the new law states.

There are 2,875 people taking suboxone in Maine, Martins said. How many are MaineCare patients was not available Thursday because state offices were closed due to the snowstorm.

The new opioid pain management limits require a second opinion for many long-term patients — those taking painkillers such as oxycodone for more than six months — and require MaineCare patients to try other treatments, the proposed rules state.

In addition to the new drug treatment regulations, DHHS on April 1 reduced payments for MaineCare patients attending methadone clinics from $70 to $60 per week.

That was a tough pill to swallow, because some clinics operate in the red, Sullivan said.

“It does add an increased burden for clinics that are not adequately reimbursed for the services we offer,” she said. “I think all the clinics experienced staff reductions.”

With weekly costs averaging around $115 per patient, methadone clinics offer more services than state and federal funds pay for, according Py.

At the same time the payment reduction was put into place, the state also granted a number of waivers that reduce the number of federally required services methadone clinics must offer, Sullivan said.

Reducing the number of drug screens from one per month to eight a year, changing from one-on-one counseling to group therapy, and increasing a counselor’s caseload from 50 to 150 patients are among the waivers, she said.

“It’s not the same quality of services,” Sullivan said. “The quality of services provided to patients has been significantly reduced.”

Every $1 invested in treatment reduces drug-related crime and criminal justice costs by at least $4, according to a recent study by the U.S. Centers for Disease Control and Prevention.

“Recovery support is necessary to help recovery be successful,” Guy Cousins, director of the Office of Substance Abuse, said in a 2009 presentation titled “An Integrated Approach to Prescription Abuse in Maine.”

When Karen Simone, director of the Northern New England Poison Center, heard that services were being cut at methadone clinics, she was not impressed.

“That is the worst thing you can possible do,” said Simone, who tracks drug overdose deaths and other poisonings in Maine. “I understand you have a budget crisis, [but] there are expenses right now and expenses next week and next year. Just giving someone a drug is not going to work.”

Recovering drug addicts need services and support from a wide variety of sources — healthy friendships, counselors, family members, community-based groups and employers, for example — in order to be successful, according to Cousins.

While some patients have been on methadone maintenance treatment for years, the new law and two-year cap were created based on federal guidelines and established best practices, Flanigan said.

“The average length of time for all receiving methadone treatment is 508 days (1.4 years),” Martins said in an email. “The average length of stay for clients who were deemed successful in completing treatment was 852 days (2.3 years).”

What the new law will do is push addicts and providers to seek out alternative treatments to methadone and suboxone, according to Flanigan and Py.

“It’s really going to force that conversation,” Flanigan said.

“It kind of forces you, as a prescriber, to offer alternative forms of treatment for patients,” Py said. “We have to be more creative.”