Maine Governor Proposes Dramatic Patient Shift from Methadone to Buprenorphine

Addiction Professional, May 6, 2015
by Alison Knopf, Contributing Writer

Budget cuts proposed by Maine Gov. Paul LePage would eliminate all Medicaid funding for treatment with methadone, which is provided only in opioid treatment programs (OTPs) by federal regulation. There are currently 4,000 patients in MaineCare, the state’s Medicaid program, who are getting treated with methadone in OTPs. Under LePage’s proposal, these patients all would transfer to office-based opioid dependence treatment with buprenorphine.

The proposal follows years of the governor’s efforts to cut back on or eliminate MaineCare funding for methadone and buprenorphine. Maine did not expand Medicaid, which means that there is an even greater demand for treatment than is reflected in the current MaineCare rolls.

But there are huge problems with the proposal, according to treatment advocates. First, there aren’t enough physicians who are authorized via federal waivers to prescribe buprenorphine to the 4,000 patients who might need it. Second, advocates say the proposal wouldn’t save costs, since treatment with methadone is one-third of the cost of treatment with Suboxone, the brand formulation of buprenorphine that Maine is planning to use.

The state’s view

But the proposal is not designed to save costs, according to Kevin Flanigan, MD, medical director of MaineCare. Rather, the rationale for the state’s decision is that patients in OTPs were found to have higher general medical costs than patients in buprenorphine treatment, Flanigan said in an interview with Addiction Professional.

“This initiative is not about cost; it is not about management of a single chronic condition,” says Flanigan. “It is about a comprehensive care delivery model focused on the entire patient and management of all of his/her medical conditions so as to ensure optimal health outcomes.”
The fact that treatment with Suboxone is far more expensive than treatment with methadone “makes our point,” he says. “Yes, methadone treatment centers in and of themselves are less costly than brand name Suboxone, but the global cost of care for patients who suffer from addiction is the same whether they are being treated with Suboxone or at a methadone treatment center. We believe that those on Suboxone have access to a more comprehensive care plan because his/her provider will be engaged in all of their care and not just management of addiction. By definition, methadone treatment centers fragment care, and fragmented care leads to higher cost with worse health outcomes on average.”

OTPs and comprehensive care

But opponents of the state's plan say the opposite is true. OTPs do provide comprehensive care for patients, make sure that they have primary care physicians (PCPs), and in fact see their patients on a regular, often daily, basis, says James I. Cohen, a Portland-based attorney who represents a coalition of OTPs in the state.

“From conversations that I’ve had with members of the [LePage] administration, they believe that Suboxone is a more holistic form of treatment and that it’s better integrated with the overall care of the patient,” says Cohen, who adds that he has not met with the governor himself. “We disagree with that assessment. OTPs assist patients in working with PCPs, want patients to have PCPs, and methadone providers see their patients.”

Many office-based physicians see patients once a month to prescribe the medication, whereas many methadone patients visit clinics on a daily or weekly basis, say OTP representatives.

In addition, there’s a big flaw in the budget assumption, which was “not based on comparing the cost of treatment with methadone and the cost of treatment with buprenorphine,” says Cohen. “That would have been appropriate, but they didn’t do that.” Instead, the governor compared the entire cost of healthcare for methadone and buprenorphine patients and found that total healthcare costs were higher for methadone patients—without taking into consideration differences in the patient population, addiction severity, and other variables.

“You can’t assume changes in behavior based on changes in fiscal policy,” says Cohen. In other words, there is no guarantee that forcing sicker patients (from OTPs) into the treatment modality that has attracted healthier patients (buprenorphine) will make the OTP patients healthier.

Clinically, there are big problems with transferring patients from methadone to buprenorphine, says Cohen. One issue is that patients who need to be maintained on high doses of methadone would have to cut back, because buprenorphine’s “ceiling effect” works only up to a certain level. The withdrawal that these patients would experience in cutting back could lead them to relapse. The other problem is that these patients would lose contact with their comprehensive treatment program, he says.

Not enough physicians

Logistically, there are not enough physicians to provide buprenorphine to the 4,000 patients currently in treatment with methadone, says Pat Kimball, president of the Maine Association of Substance Abuse Providers. In addition, office-based PCPs don’t offer addiction counseling, she says.
According to Flanigan, more than 300 providers have completed the training for the license that allows them to prescribe buprenorphine. Asked how many patients are on buprenorphine in Maine now, Flanigan responded that the only data he has involves MaineCare patients. More than 4,000 MaineCare members receive at least one prescription a year for Suboxone, and about 2,700 to 2,800 receive a Suboxone prescription every month.  

The number of patients a physician can treat with buprenorphine is capped at 30 or 100, depending on the level of training. In addition, many physicians have waivers but are not prescribing up to the level that they are allowed, or are not prescribing at all. One program, Discovery House, offered $5,000 bonuses to physicians to sign up to become buprenorphine prescribers, but it got no takers, according to the Bangor Daily News.

There are other states that don’t allow Medicaid to pay for OTP treatment. In these states, patients have to pay out of pocket. Flanigan says the state doesn’t know how many patients on methadone might choose to stay in their OTP and self-pay instead of being transitioned to buprenorphine.

If people can’t afford to pay for their own treatment—and if they’re on MaineCare, they probably can’t—they probably will end up searching for drugs on the street, says Kimball, who is also director of Wellspring Substance Abuse and Mental Health Services in Bangor.

Ironically, Maine was a leader in recognizing that opioid addiction is a public health problem in the state, says Kimball. “Nationally, we’re known for our approach,” she says, which included the work of former single state authority directors Kim Johnson (now with NIATx) and Guy Cousins, who lost his job when it became clear that his views and the governor’s were in conflict.

More OTPs needed

More, not fewer, OTPs are needed in the state to cover the geographic expanse, says Kimball, noting that some patients travel hours every day—with transportation paid by MaineCare—from rural areas. That would represent a savings, if OTPs are eliminated, of about $750,000. “But when I look at that, I say why can’t we talk about opening up more clinics?” she says.

The NIMBY (Not in My Back Yard) issue has largely prevented that. However, what the communities opposing the OTPs don’t realize is that the people who need treatment are living in their midst, Kimball says. “Communities get scared, and they have moratoriums against clinics opening up in their neighborhoods, but the people they’re scared of are already living in their neighborhoods,” she says.

She adds, “The frustrating thing is that the governor sees this [opioid epidemic] as a problem, but his approach is the war on drugs approach. We know from a historic perspective that this doesn’t work.”

Link to article.
Link to LePage's Proposal.
Link to Bangor Daily News May 31, 2015 article: ‘A system that doesn’t exist’: Without methadone, patients rely on addiction treatment few Maine doctors prescribe.
Link to Bangor Daily News May 31, 2015 editorial: The fight to stop treating addicts as if they’re expendable.