By Meg Haskell
It’s hardly a rapid solution to a deadly epidemic that last year claimed 418 Maine lives, but lawmakers and advocates in Augusta moved closer this week to establishing a coordinated, statewide response to the state’s growing opiate crisis.
Legislators gave preliminary endorsement to a measure to create and fund a “hub-and-spoke” model of addiction care in each of Maine’s eight public health districts.
The model aims to expand the availability of health care providers who prescribe medications such as buprenorphine, also known by the brand name Suboxone, to treat opiate addiction, while also providing free treatment for low-income Mainers who lack health coverage through MaineCare or private insurance.
Critics say the state needs to move swiftly to stem the crisis by making the overdose drug Narcan more readily available, eliminating arbitrary caps on medication-assisted treatment and making it easier for addicted Mainers to enter treatment when they’re ready.
Portland addiction medicine specialist Dr. Mark Publicker says the model is a bureaucratic solution, too cumbersome to implement at a time when opiate deaths in Maine are spiraling upward.
“We need to act now, treating [the opiate crisis] as the emergency that it is,” Publicker wrote in an email. “We need to change the focus of response: not to build new programs and systems of care but instead remove barriers to buprenorphine,” he said.
But while some say the plan fails to respond to the crisis, supporters say it has the flexibility to build efficiently on the existing treatment infrastructure while laying the groundwork for the future.
“It all comes down to how quickly we respond and how seriously people take this health crisis,” said Rep. Karen Vachon, R-Scarborough, as she introduced her bill to the Legislature’s Health and Human Services Committee at a work session on Tuesday. Though some regions are presently served better than others, Vachon said Maine needs a statewide system that integrates prevention, emergency response, acute-care treatment with medications and counseling, and support for long-term recovery.
And, she said, Mainers need to know how to access care when they need it, using the existing 2-1-1 service hotline, marketing tools and other means.
“Nobody knows where to go with this crisis. This is a statewide blueprint, so people will know where to go when they need help,” she told the committee.
Vachon’s bill, LD 1430, would establish a statewide network of treatment “hubs,” one in each public health district, equipped to provide rapid — even same-day — access to comprehensive addiction treatment, including medications, intensive mental and behavioral health counseling and other services. Hubs might be situated in regional hospitals or other existing health facilities.
MaineHealth in southern Maine and Brewer-based Eastern Maine Healthcare Systems provide addiction-management expertise to some primary care practices in their networks, setting up what could become the first of the eight hubs in the model. Spokeswomen from both organizations took part in the work session and affirmed support for participating in the development of a broader system.
Patients stabilized through treatment at one of these hubs would transfer to a community-based “spoke” closer to home — such as a local primary care practice or other medical program — for ongoing care and referrals, including medication management, counseling and support services such as peer guidance, job training and housing assistance.
The hubs would also provide educational resources and support to health care providers, including primary care prescribers looking to incorporate medication-assisted addiction treatment into their community practices.
The bill, reworked in Tuesday’s committee session, directs the Maine Department of Health and Human Services to seek federal grant funding to support the development of the hub-and-spoke system. It also includes a $6.6 million fiscal note for each of the next two budget years to make addiction treatment, including medications such as Suboxone, available to uninsured Mainers.
Hub-and-spoke models for treating substance abuse have been established in several other states, including Massachusetts, California and Vermont.
A 2017 paper published in the Journal of Addiction Medicine shows a 64 percent increase in the number of primary care doctors in Vermont who prescribe Suboxone for addiction, and a 50 percent increase in the number of addiction patients receiving care since the model was implemented there about five years ago.
In Maine, upwards of 600 providers are certified to prescribe Suboxone, according to the Maine Medical Association, but it’s unclear how many actually use the drug to treat addiction in primary care practices. Nationally, according to data from the Substance Abuse and Mental Health Services, only about half of approved primary care providers prescribe Suboxone, and those who do typically treat fewer than five patients in their practices, though they are typically approved to treat 30, 100 or more.
At The Acadia Hospital in Bangor, addiction specialist Dr. Vijay Amarendran said stigma remains an issue for many primary care doctors who resist treating opioid-addicted patients and their sometimes frustrating relapses and other behaviors.
In addition, he said, reimbursement for medication-assisted addiction treatment often does not adequately compensate providers for the time spent managing their care.
“There’s a huge need [for medication-assisted treatment ] in the community,” he said. “We all agree we need more primary care providers in our area who are qualified to prescribe Suboxone.”
At Tuesday’s work session, HHS committee members agreed to incorporate DHHS’ “opioid health home” model, which has enrolled just one medical practice and only a handful of patients since it started about one year ago, into the developing hub-and-spoke system. With all eight members of the committee who were present at the session voting in support of passage, the measure now heads to the appropriations committee for additional consideration.
The hub & spoke model is a good one for addiction treatment; care MUST be comprehensive. Buprenorphine alone is not the answer. Integration with existing 12-Step programs is another essential step that has worked well in my practice experience.