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MAPP Testifies Before Appropriations Committee Regarding Two Year Limitation in Prescription Suboxone Support in Proposed DHHS Budget Cuts
Submitted to the Appropriations Committee in support of testimony by
David A. Moltz, MD
Chair, Clinical Practice Committee
Maine Association of Psychiatric Physicians
Chief, Outpatient Behavioral Health Services
Mid Coast Hospital
Brunswick, Maine
Response to the proposed two-year limit on prescribing of Suboxone
The Maine Association of Psychiatric Physicians (MAPP) is opposed to the two-year limit on prescribing of Suboxone proposed in the Governor’s budget. Our opposition is based on several factors:
Maine has one of the highest rates of prescription drug abuse in the United States. Admissions to substance abuse treatment for prescription opiate abuse increased from less than 500 in 1999 to 14,000 in 20081, and Maine has the highest per capita rate in the United States.
Buprenorphine is one of only two drugs which effectively treat prescription drug addiction. Methadone and buprenorphine are both FDA-approved and effective in eliminating withdrawal and craving from prescription drug abuse. However, they are not interchangeable. Each is effective for different populations and different circumstances; for example, methadone treatment is not practical in rural areas, because of the necessity to travel long distances on a daily basis. There is no evidence that a person doing well in one treatment can successfully transition to the other.
Addiction is a chronic condition, with a high rate of relapse when treatment is stopped. Suboxone regularly allows individuals to return to improved social functioning. Patients return to work, to their families, and to school. Some are able to discontinue medication and continue functioning well. However the scientific literature demonstrates a high rate of relapse for patients as a group when treatment is stopped. For example, a recent government-funded study showed a success rate of 49% for individuals taking Suboxone, but a relapse rate of almost 92% when it was discontinued2. While many individuals can lower the dose over time, and some can successfully stop completely, this must be done carefully and on an individual basis, not on an arbitrary time frame that is not supported by evidence.
With the likely decrease in other services, Suboxone will be even more essential. Under the current budget proposal, residential treatment programs that are funded through PNMI will be eliminated. Hospital outpatient programs will have treatment visits cut in half. Treatment with Suboxone will be even more essential as other services are cut.
The decision to limit Suboxone prescribing was made purely on financial grounds. Senior staff of the Office of MaineCare Services stated in a presentation to the MaineCare Physicians Advisory Group that clinical considerations were not included in the decision to limit buprenorphine prescribing, which was based solely on considerations of cost. This decision will have profound effects both on individuals and on society, and it is not acceptable that the clinical and social impact is not taken into consideration.
The cost analysis is flawed. The decision to limit prescribing of Suboxone was based on the rate of increase of cost to MaineCare, and a comparison to the costs of methadone treatment. However the rate of increase parallels the rate of admissions to substance abuse treatment noted above. Suboxone only became available in 2003, and is so effective that its use has increased steadily since then.
In the comparison to methadone, only the cost of the drug and of transportation to methadone programs was taken into account. A more rigorous analysis, in the journal Health Affairs, included the total cost to the health care system of each treatment, rather than simply pharmacy cost, demonstrating that treatment with Suboxone actually costs less than treatment with methadone3. If the comparison is to no treatment, the social and financial costs are immense including the costs of incarceration, hospital and emergency room treatment, unemployment, criminal activity and deaths by overdose, amongst others.
For all of these reasons, the Maine Association of Psychiatric Physicians urges the elimination of the proposed time limit on Suboxone prescribing, and the preservation of full access to this essential treatment.
References 1. Maine Treatment Data System, 2010. Quoted in Maine PMP presentation to the MaineCare Physician Advisory Group, 12/8/2011.
2. Weiss, et al. Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence. Arch Gen Psychiatry 2011; 68:1238-1246.
3. Clark, et al. The evidence doesn’t justify steps by state Medicaid programs to restrict opioid addiction treatment with buprenorphine. Health Affairs2011; 30(8):1425-33.
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