In this lull between Hanukkah, Christmas and the new year, substance abuse, particularly opioid use disorders, is once again the topic. The holidays are a particularly stressful time for people battling addiction, and those who love and want to support them.
The hospitals of Hancock County, in partnership with Healthy Acadia, are working to coordinate a program to help. It is known as a “hub-and-spoke” plan. A centralized location will provide intensive treatment with counseling and medication on a daily basis, to stabilize those with substance use disorders.
After a typical 30-day stabilization period, participants will move to treatment through the “spokes,” where local providers closer to home will continue treatment, gradually decreasing the frequency of counseling and the amount of medication. Eventually, patients will be on a maintenance regime, receiving monthly counseling and very low doses of medication long term.
A hub-and-spoke model has been implemented in Vermont with encouraging results. In an article published in the Journal of Addiction Medicine in July 2017, the authors summarized their findings in this way: “Adoption of this model has been associated with substantial increases in the state’s OUD [opioid use disorders] treatment capacity, with Vermont now having the highest capacity for treating OUD in the United States.”
County hospitals have recruited several dozen primary care providers to serve as the spokes. Their participation is contingent on a fully developed hub, a work still in progress. In Vermont, as the program became fully implemented, both patients and providers signed up in increasing numbers.
In Maine, there were 378 drug overdose deaths in 2016, a 40 percent increase over 2015 (Source: Maine Attorney General’s Office), with 313 of those caused by opioid use, including prescription painkillers. In 2015, one of every 11 babies born in Maine was drug-affected (Source: Maine Medical Association).
Maine’s Department of Health and Human Services and the Maine Legislature are the main sources of programming and funding to address public health problems. This is surely one of the most pressing. How have they responded?
The DHHS directed $2.4 million to medication-assisted treatment (MAT), the basis for the hub-and-spoke program. This, said DHHS, would create 359 new treatment slots for uninsured Mainers. It is notable that the administration has resisted the expansion of Medicaid in Maine, which also would help to provide treatment for those currently uninsured. In fact, Mount Desert Island Hospital closed a drug treatment program a few years back because the lack of Medicaid coverage for its clients left the hospital without a funding source for most patients.
Legislators and the administration have been slowly inching toward the same page. Former DHHS Commissioner Mary Mayhew touted an “opiate health home” model with the basic hub-and-spoke principles. Both Mayhew and the Governor got behind MAT. Legislators submit a slew of bills to address the crisis every year, but so far Maine has not created the coordinated, sustained, “best practice” effort that would begin to reverse the trend of deaths or social and economic impairment resulting from opioid addition.
Sen. Eric Brakey, co-chairman of the Health and Human Services Committee, sponsored a bill to add addiction to opioids or prescription drugs as a qualifying condition for the medical marijuana program. LD 411 was carried over to the coming winter. Studies about the efficacy of such an approach are ongoing, but last year the DHHS denied a caregiver’s petition to allow marijuana prescriptions for opiate addiction.
Commissioner Mayhew consulted with the state health officer and state epidemiologist, both physicians, before she gave the thumbs down. There has been just one clinical trial so far, and the “lack of rigorous human studies” left the consulting physicians unable to support the use of medical marijuana for treatment of opioid addiction.
Maine is one of only 10 states that limit by law the length of time a patient may receive methadone treatment. Maine has the lowest reimbursement rate in the country for treatment providers. (A bill passed last year would allow, but did not mandate, higher reimbursement.) Other barriers to treatment include physician concerns such as a lack of training for MAT, fear that their practices would be overwhelmed with patients seeking treatment and lack of funding for care.
Patients face obstacles, too. The initial need for almost daily treatment raises problems with transportation, child care, work responsibilities and cost. The widespread availability of opioids makes healthy living a daily battle.
The latest in a string of state task forces issued its report earlier this month, recommending a wide-ranging and generalized set of actions that the treatment community quickly labeled more of the same old, same old. Even some task force members panned the report they helped construct, with Rep. Anne Beebe-Center saying she “didn’t hear about anything concrete that would save … lives.” The task force did recommend the hub-and-spoke model and LD 1430, a bill that provides the vehicle, has been carried forward from last year for consideration in the coming session.
We have passed the shortest, darkest day of the year, and in Maine we know the world is always turning toward the morning. Let’s hope the Legislature can take action to make those mornings the start of a new day for addicted Mainers.