WESTBROOK, Maine — As lawmakers debate the future of a treatment for opiate addiction in Maine, Andrea of Gorham desperately hopes her voice cuts through the clamor.
The 50ish woman receives methadone treatment at a clinic in Westbrook, paid for by MaineCare, the government health insurance program for low-income Mainers. She’s one of nearly 4,000 residents who would lose coverage for the therapy if Gov. Paul LePage’s plan to cut state funding for methadone clinics succeeds.
Andrea, who declined to share her last name, described in no uncertain terms her fate without methadone.
“If my MaineCare won’t cover this place anymore, I know for sure — 100 percent, if not more than 100 percent — I will die,” she said, fighting back tears. “I know that. And I don’t want to die.”
Addiction hooked her years ago, beginning with a prescription for painkillers after surgery for injuries she suffered in a car accident. Without methadone, she’ll start using again, she said.
She tried buprenorphine, an alternative to methadone that’s prescribed in doctors’ offices rather than dispensed at clinics. The LePage administration favors buprenorphine — known under the brand names Suboxone and Subutex — as part of what it views as a broader effort to address drugs abusers’ overall health instead of their addiction alone.
Suboxone didn’t work for Andrea, failing to stem her cravings and withdrawal symptoms, she said. She ended up cutting herself to cope with the stress, leaving gashes in her arms that often required stitches.
Andrea returned to methadone, and now she’s no longer abusing drugs or cutting herself, she said, sitting at CAP Quality Care, the clinic she credits with saving her life.
“[Buprenorphine] doesn’t work for some people, and I’m one of those,” she said. “But this place works for me. Methadone works for me.”
She wants LePage to know her story.
“I wish he was here, because that’s who I would love to talk to,” Andrea said. “I hope he hears me.”
Dr. Kevin Flanigan, medical director for MaineCare, thinks Maine can do better than methadone. He sees a fractured system rooted in the 1970s that isolates patients seeking treatment for addiction and puts them at risk of dangerous drug interactions.
“After 40 years of treatment for addiction, it is time for an improvement,” he said.
In making its case against methadone, the LePage administration has highlighted a stark divide in the ways patients access two medications for the same affliction. Federal regulations treat methadone and Suboxone completely differently, creating a split system for addiction treatment that’s at the heart of the debate over his proposal.
LePage proposes to cut $727,000 in state funds in fiscal year 2016 and $868,000 the year after. Dropping that funding would mean Maine also relinquishes annual federal matching funds of $1.2 million and $1.5 million, respectively. Lawmakers must approve the cuts, which Democrats have labeled as too drastic, before state funding for methadone would cease.
The governor’s budget plan casts methadone and Suboxone in competing roles.
Substance abuse experts say addicts should have access to both. Research amassed over decades shows that each therapy, combined with counseling, helps opioid abusers return to productive lives without illicit drug use, though methadone has a stronger track record for patients with long-lasting and severe addiction.
Both are time-tested therapies for addiction to opioids, a class of drugs that includes illegal narcotics, such as heroin, as well as the prescription medications OxyContin, Percocet and Vicodin. Methadone and Suboxone are opioids themselves, working in different ways to appease the addicted brain in safer doses.
A third option is Vivitrol, a monthly shot that prevents users from getting high. Only a tiny fraction of MaineCare patients are prescribed the medication, which requires drug abusers to completely detox from opiates for at least a week before their first injection.
Unlike addiction to some other substances, such as alcohol, opiate addiction nearly always requires treatment with medication, explained Dr. Mark Publicker of Mercy Hospital Recovery Center in Westbrook, a nationally recognized expert in addiction medicine.
“We all know alcoholics who can just stop drinking,” he said. “They may be miserable cusses, but they can stop drinking. People with opiate addiction, it isn’t elective.”
Brain scans of people with longtime opiate addiction show impaired function in parts of the brain that control judgment, impulse control, decision-making and management of stress, he said. Those changes typically remain even after an addict stops using, making sobriety hugely challenging, Publicker said.
“Opiate addiction, more so than other addictions, changes the brain in a way that — after somebody’s been using the opiates for more than a year or two years — tends to be permanent,” he said.
For many addicts, living a productive life and abstaining from illicit drugs while taking methadone or Suboxone qualifies as success.
MaineCare patients on Suboxone tend to be both healthier and more integrated into society, Flanigan. Instead of visiting methadone clinics that treat solely their addiction, Suboxone patients regularly check in with doctors who oversee all of their care, he said.
“They’re becoming employed, they’re reuniting with family, they are no longer having engagement with law enforcement around issues related to their addiction behavior,” he said.
Methadone, at the right dose, blocks both cravings and withdrawal symptoms.
“The studies go back over 30 years and they’re international and they’re unequivocal that methadone is an extremely effective treatment,” Publicker said.
Buprenorphine is very effective at blocking withdrawal, but may fall short for patients with severe addiction, he said.
Methadone can provide a high at certain doses. Buprenorphine is much less likely to, though some drug abusers report getting high from the medication, recovering addicts and substance abuse professionals say. Patients on buprenorphine also won’t get high if they take other opiates, though they can still crave drugs, Publicker said.
Suboxone is a combination of both buprenorphine and naloxone, a drug that under the brand name Narcan is gaining wider use as an overdose antidote. In Suboxone, however, naloxone serves a different purpose — to prevent misuse, Publicker explained.
If patients take Suboxone as prescribed, orally or dissolved under the tongue, the naloxone has no effect. But if patients inject Suboxone in an attempt to get high, the naloxone leads to the painful process of withdrawal.
Patients are less likely to overdose on Suboxone than on methadone, research shows. Buprenorphine has a “ceiling effect,” meaning after a certain point taking more of the drug won’t increase its effects.
Still, patients who require methadone are much more likely to overdose on other drugs if they can’t access the medication, Publicker said.
Most of the overdose deaths from methadone don’t involve doses dispensed at clinics. Methadone is also prescribed as a pain medication, and it’s that form turning up in the majority of drug deaths involving methadone in Maine, said Dr. Marcella Sorg, an associate professor at the University of Maine who analyzes statistics on drug fatalities. In 2013, 37 of the 176 drug deaths in Maine involved methadone, she said.
Both drugs wind up on the streets, though police say Suboxone is becoming a bigger problem.
Drug users may illegally buy Suboxone to stave off withdrawal, though some use it to treat their addiction because they can’t find a doctor to prescribe the medication, Publicker said.
“We see people walking in the door who have been clean and sober for two years buying buprenorphine on the street,” he said.
Different care models
Under federal regulations, methadone administered for substance abuse treatment must be dispensed at licensed clinics, which are subject to strict oversight by both state and federal agencies. Doctors can prescribe the medication only to treat pain.
Patients must take their doses — dispensed either as a liquid or a wafer — in front of clinic staff to ensure they don’t smuggle it out of the building. Patients can earn the right to take a bottle home if they avoid illicit drug use and remain committed to treatment. They also undergo regular drug tests and must participate in counseling.
The approach effectively “ghettoized” methadone treatment, Publicker said. Past efforts to integrate methadone therapy into primary care fizzled out when Suboxone came on the scene more than a decade ago, he said. But the daily visits to a clinic provide needed structure for many patients, Publicker said.
Flanigan believes the system puts patients at risk. Doctors can check the state’s prescription monitoring program to learn which medications a patient is taking, including Suboxone. But while methadone clinics can check the system, they’re barred from submitting information under federal regulations designed to protect the privacy of substance abuse patients. That means doctors unaware of a patient’s methadone treatment could unwittingly prescribe drugs that increase the chance of an overdose, including medications used to treat anxiety, he said.
Doctors may prescribe Suboxone after undergoing special training through the Drug Enforcement Administration. Patients can take home up to a 30-day supply.
With regular visits to a doctor, patients receive more comprehensive care, Flanigan said.
“Many if not all of these patients have a host of other physical and behavioral health conditions that need to be addressed,” Flanigan said. “We know that methadone can interfere with other treatments.”
Kathy Alarie, program director at CAP Quality Care, said many methadone patients visit doctors regularly. They’re asked to sign releases allowing the clinic to disclose their treatment and coordinate their care with other providers, she said.
“I think that’s part of the myth, that they don’t have other doctors,” Alarie said. “They do.”
For Andrea, disclosing her methadone treatment to doctors has led to judgment and some physicians refuse to treat her at all, she said.
“To this day, I have not found a doctor that I can be completely honest with,” she said.
The BDN will look further into Maine’s methadone debate. Future reports will focus on transitioning away from methadone — a delicate process for patients, why few doctors are prescribing the alternative and questions about relative costs of treatment.