The LePage administration is making the case for its proposal to end methadone treatment as a MaineCare benefit, insisting that transitioning thousands of patients to Suboxone – another medication that treats opioid addiction – is scientifically sound, superior to methadone clinics, and less expensive in the long run.
But medical experts dispute those claims, saying that the science behind how the two drugs affect the brain means that for many patients, Suboxone cannot replace methadone.
“There is not research to support what they’re saying,” said Dr. Meredith Norris, a Kennebunk physician who treats both Suboxone and methadone patients.
Norris said a minority of the 4,500 patients currently being treated in methadone clinics across the state would be candidates to transition to Suboxone, in part because Suboxone would not be as effective in reducing cravings for those with more acute addictions.
Her view is supported by the American Association for the Treatment of Opioid Addiction and other medical professionals.
“This is not a good plan. I would say a small percentage being treated by methadone could transition to Suboxone,” said Dr. Rob McCarley, medical director at Spring Harbor Hospital in Westbrook, which treats patients who need methadone or Suboxone. “For many who are on methadone, they already tried Suboxone and failed at it, so I would say they are not good candidates for Suboxone.”
Maine is one of 33 states that reimburse for opiate treatment, which includes methadone services, according to the American Association for the Treatment of Opioid Addiction.
If Gov. Paul LePage succeeds in convincing the Maine Legislature and the U.S. Centers for Medicare and Medicaid Services that methadone should not be a reimbursed drug under Medicaid, known as MaineCare in the state, thousands would effectively be forced to switch medications.
While MaineCare patients would be permitted to pay out-of-pocket for methadone service, the $90-$100 per week costs would be too expensive for many low-income patients.
The proposal, which is in LePage’s budget, would save the state about $800,000 per year.
DISAGREEMENT ON EFFECTIVENESS
David Sorensen, spokesman for the Maine Department of Health and Human Services, pointed to a number of studies touting the benefits of Suboxone.
“The bottom line is that at some point, people in recovery are going to have to experience withdrawal,” Sorensen wrote in an email response to a question. “There are individuals on methadone for five, 10, or more years, simply replacing one addiction with another.”
But Norris said Suboxone, while effective for some people who are addicted to opioids such as heroin, has a “ceiling effect,” which means that for some acute addicts, Suboxone does not satisfy cravings. Also, the “ceiling effect” means that higher doses of Suboxone do not reap benefits for the patient, whereas higher doses of methadone do reduce cravings.
“For some chronic, long-term heroin users, there are permanent changes to brain chemistry, and Suboxone is not going to work for them,” Norris said. “It’s kind of like if you had diabetes, there are some diabetics that no matter how much they change their lifestyle, they are still going to need medication or insulin. It doesn’t matter if they exercise a lot or never eat another carbohydrate.”
According to a 2012 study published on the U.S. National Institutes of Health website, Suboxone is not as effective for those with severe addictions.
“Due to its weaker efficacy, buprenorphine (Suboxone) is probably best restricted for those with mild-moderate dependence, whereas methadone can be used with all levels of dependence,” according to the study.
Sorensen referred to a 1997 study funded by the National Institute on Drug Abuse that shows Suboxone and methadone have similar effectiveness for those taking doses of 60 milligrams or less.
At the CAP Quality Care Clinic in Westbrook, the average dose for patients is 110 milligrams, officials said. McCarley said an accepted standard by physicians is to transition a patient from methadone to Suboxone only if they have successfully tapered to 30 milligrams of methadone, and not all patients are able to take such low doses of methadone.
VARIATIONS IN TREATMENT
Kristan Hilchey, 41, of Rockland, and a methadone patient at the Westbrook clinic, said she takes a “high dose” of methadone and is not considering switching to Suboxone. She said methadone is working for her. It allows her to live a normal life and hold down a good job as a medical technician.
“You can’t just hop from one drug to the other,” Hilchey said. “I’m kind of flabbergasted that this is even a proposal. I don’t understand why (LePage) thinks that he knows better than our doctors how to treat us.”
Sorensen wrote in his email that Suboxone has other benefits, including that patients are not as likely to overdose, it’s better for women who are pregnant, and it’s dispensed in a primary care doctor’s office, as opposed to a stand-alone methadone clinic. Sorensen said getting treatment at the family doctor allows for more integration of care.
“Primary care treatment yields better health outcomes for individuals, in contrast to back-and-forth referrals between behavioral health and primary care offices that leave up to 80 percent of individuals without care,” Sorensen wrote. “In addition to having substance abuse disorders, many of these individuals suffer from interrelated physical illnesses and/or co-morbid conditions that are not addressed when methadone dosing occurs at a treatment center.”
But McCarley said while Suboxone is effective for some patients, the potential for abuse of a take-home drug is higher than with methadone, which most patients take in a liquid form at a clinic, with none allowed to be taken home.
“These are struggling patients, and to ask them to take 30 pills home and only take one per day, that’s a difficult task for many of them,” McCarley said. “At the methadone clinic, as a physician I can be sure they are getting their correct dose every day.”
SPECIAL TRAINING REQUIRED
McCarley and Norris both said that there’s a dearth of physicians willing to prescribe Suboxone. Doctors need to acquire special training from the U.S. Food and Drug Administration before being permitted to prescribe Suboxone. Sorensen identified 118 physicians who currently prescribe Suboxone in Maine, but Norris said even if that list was up-to-date, they wouldn’t be able to absorb thousands of extra patients.
“This idea that there are all these physicians ready and willing to prescribe Suboxone is just pure fiction,” said Norris, who treats 100 patients taking Suboxone, the maximum permitted by law. “The doctors don’t want to do it, and they are adamant that they don’t want to do it.”
The cost of Suboxone is another factor, with Norris saying that Suboxone costs at least twice as much as methadone.
Sorensen said that while Suboxone as a medication costs more, if patients are not on the drug long-term – as many stay on methadone for years – it would save the health care system money in the long run.
But McCarley said there are costs to society to leaving many people untreated, which would happen if some methadone clinics closed, a likely scenario under the governor’s plan.
“You would have a very high rate of relapse from people who were not able to transition to Suboxone or who were abusing Suboxone. You would see more hospitalizations, not to mention crime,” McCarley said.