Credit: George Danby / BDN

Heroin has become a major problem in Maine. But for as serious as the heroin epidemic is, far more Mainers each year seek treatment for alcohol dependency.

In 2014, alcohol was the most common substance for which Mainers sought treatment, with 3,589 Mainers entering treatment, compared with 2,538 for heroin and morphine. The need for treatment, however, is much greater. An estimated one in seven Mainers needed but did not receive treatment for alcohol dependency, according to the Maine Office of Substance Abuse and Mental Health Services’ 2015 substance abuse trends report.

The state has a chronic shortage of treatment and detox facilities for Mainers addicted to alcohol, a shortage worsened by the closure of Mercy Hospital’s Addiction Recovery Center in Westbrook last August.

“The opiate epidemic has sucked all the oxygen out of the room,” Dr. Mark Publicker, a nationally recognized addiction expert who practiced at the Westbrook center, said. “When we talk about addiction treatment, there’s never a mention about treatment for alcohol.”

Not enough beds

When Mercy’s Addiction Recovery Center was open, it served as a statewide resource for alcohol and drug detox. Hospitals as far north as Bangor routinely transferred patients who needed to withdraw from alcohol to Westbrook, Publicker said.

Only a handful of centers across the state provide inpatient detox services for Mainers who need to safely withdraw from alcohol, including MaineGeneral Medical Center in Augusta, St. Mary’s Regional Medical Center in Lewiston and Milestone Foundation in Portland. North of Augusta, however, there are few detox services.

“That’s a real challenge our state is confronted with. It’s not a rural problem; it’s a statewide issue,” Pete McCorison, program director for substance abuse services at Aroostook Mental Health Center, said.

Most hospitals still will admit someone going through acute alcohol withdrawal, McCorison said, but few offer dedicated inpatient detox programs.

The growing rate of opioid addiction has left several detox facilities with fewer beds available to help Mainers safely withdraw from alcohol.

Until recently, Milestone’s 16-bed detox program in Portland, the only nonhospital detox center in Maine, almost exclusively served patients withdrawing from alcohol. But a couple of years ago, the program began to see a spike in admissions for opioids, which now account for nearly half of all admissions, according to Milestone Executive Director Robert Fowler.

“So the impact of that is that it’s becoming more and more difficult for people with alcohol addiction to find treatment beds at any level of care,” Fowler said. “Every day we have people we are unable to accommodate because of program capacity.”

Alcohol withdrawal, unlike withdrawal from opioids, can be fatal. In regular and chronic drinkers, the body ramps up production of hormones to offset the depressive effects of alcohol. When someone abruptly stops drinking, the body continues to pump out these hormones.

“That’s something that distinguishes it from a heroin withdrawal. In heroin withdrawal, people feel as though they’ll die, they feel horrible and they feel as though they won’t be able to survive the process, but it’s not fatal in the way that withdrawal from alcohol can be,” Fowler said.

Every year about 226,000 patients are treated in a hospital for a condition related to alcohol withdrawal, according to a 2004 study in the journal American Family Physician. Only 10 percent of patients with alcohol dependence are treated as inpatients, so it’s possible that as many as 2 million Americans go through alcohol withdrawal.

Most drinkers will experience mild symptoms and can safely wean off alcohol outside a medical setting. Minor symptoms, which begin within six to 12 hours, include anxiety, insomnia and tremors. Within 12 to 24 hours, some patients may begin to experience hallucinations.

But people with a history of heavy alcohol use, those who have undergone multiple detoxes and older drinkers are at risk for more serious complications. Within 24 to 48 hours after their last drink, chronic alcohol users can have seizures that without supervision can result in falls and death.

In the most severe cases, people can experience a condition called “ delirium tremens” that is fatal in about 1 to 5 percent of cases. Delirium tremens, which can set in 48 hours after the last drink, is characterized by confusion, fever and seizures. Unattended, it can cause dehydration, hyperthermia and irregular heartbeat, all of which can be fatal.

“As a medical emergency, alcohol withdrawal is more serious,” Fowler said.

Treatment that works

If someone in Maine needs treatment for alcohol dependency, odds are low they will be told there is an effective medication that can curb cravings for alcohol. A shortage of doctors who prescribe anti-craving medications is arguably one of the biggest challenges to providing treatment for alcohol dependency in Maine.

When he headed the Mercy’s Addiction Recovery Center, Publicker and his staff regularly incorporated anti-craving medications, such as naltrexone or its injectable form, Vivitrol, to help patients sustain their recovery as they progressed through the center’s outpatient treatment program.

“Time after time, we’d be sitting in the recovery center with patients in detox as demoralized as can be who had never been prescribed an anti-craving medication and who always expressed shock that no one told them these medications existed,” Publicker said.

Even after a patient was started on an anti-craving medication, few primary care physicians would be willing to continue providing it to patients after they completed the program, Publicker said.

One reason that access to this medication is low is the prevailing bias against viewing alcohol dependency as a chronic disease that needs to be managed with medication. Another reason is that few physicians and few patients know about the effectiveness of naltrexone, even though the U.S. Food and Drug Administration in 1994 approved its use for treating alcohol dependency.

Only 10 percent of patients nationally seeking treatment for alcohol dependency are prescribed available anti-craving medications, according to a 2014 study in the Journal of the American Medical Association.

Instead, most patients are referred to group-based substance abuse counseling or 12-step support groups. These programs may work for some, but they largely ignore the underlying chronic nature of alcohol dependency that makes relapses common.

Alcohol dependency is a chronic disease, not a behavioral disorder. Overtime, chronic alcohol use leads to changes in the brain’s chemistry that lead to severe compulsion, which makes it hard to resist the urge for another beer. And this is where medication steps in.

When someone takes naltrexone, for instance, it blocks the alcoholic high and reduces the impulse to continue to drink. Naltrexone, unlike methadone, has no risk for addiction because it doesn’t cause a high.

A growing body of research suggests that naltrexone coupled with substance use counseling helps reduce alcohol cravings and relapses into dependency, allowing patients to focus on therapy and goals to sustain their recovery, according to the study in the Journal of the American Medical Association. A patient’s odds of avoiding relapse are almost doubled with the use of anti-craving medication than with counseling or 12-step programs alone.

“Medications exist and believe me they work,” Publicker said. “They take people who have been demoralized by relapse after relapse after relapse and restore to them the ability to build their recovery.”

Coverage gap

Another challenge to addressing alcohol dependency is that many Mainers can’t afford treatment because they don’t have health insurance. Even as the Affordable Care Act expanded options for insurance, the number of Mainers without health insurance has held steady at 15 percent, according to a 2015 report by the Maine Health Access Foundation.

Cuts to MaineCare eligibility left thousands of Mainers without health insurance, many of whom suffer from an alcohol or drug dependencies. Substance abuse programs have fought to remain open in the wake these cuts, and the state’s decision against accepting federal funds to expand MaineCare coverage.

Mercy’s Addiction Recovery Center struggled under an uptick in charity care for addiction treatment following MaineCare cuts to the point where the model became unsustainable, Publicker said.

“Sometimes 20, 30 or 40 percent of patients in our inpatient program were uninsured,” he said.

Back at Milestone in Portland, Fowler said that more than half the people who enter into the detox program have neither private health insurance nor MaineCare. A state block grant, however, helps cover the cost of providing uncompensated care for the uninsured.

But the real problem for those patients is that their options for outpatient care and counseling after detox are limited because there are few free care programs for people without health insurance.

“It very much impacts what their aftercare plan might look like and their access to treatment options,” Fowler said.

Milestone offers a high-intensity residential treatment program in Old Orchard Beach for people who have struggled to stay in recovery. But only one of the 16 beds available in the program is available to patients without MaineCare. The waitlist for that one bed is years long, Fowler said, even though the program almost always has empty MaineCare beds.

“That’s really unfortunate because people are seeking treatment out of state or people are going without treatment,” he said.