Editor's note: This is Part 1 of our 5-part "State of Withdrawal" series. Click here for the other stories in the series.
AUGUSTA, Maine - Maine is in the grip of an opiate epidemic, and has been for the past 15 years. Heroin is firmly entrenched in the most rural parts of the state.
Drug overdose deaths have soared. They now equal or surpass fatal car accidents each year. Pharmacy robberies still make headlines.
Demand for drug treatment has more than doubled during that time. Between 2008 and 2012 enrollment in methadone programs in Maine jumped by more than 20 percent. And now comes a proposal to end MaineCare insurance coverage for methadone patients.
Susan Sharon begins a series of reports on what's at stake and why some Mainers could be left in a "state of withdrawal."
For Tim, who asked that we not use his last name, everything is at stake. A wife. A three-year-old daughter. A job. He's 50 years old, determined to be a good parent. But he says he wasted four years chasing an addiction that drained his bank account and made him sick.
It all started when he fell down the stairs.
"I broke my back about six years ago," he says, "and I was prescribed opiates. And it turned out I liked them, and when I got shut off, I continued buying. It gets worse and worse. A little bit more and a little bit more."
Tim says he got plugged into a vast under-the-radar network of other addicts buying and selling drugs just to keep from going into withdrawal, an experience that he describes as a very bad case of the flu. He tried to quit on his own - just go cold turkey. He says he lasted three days.
"And I never understood it 'til it happened to me," he says. "I have known people in the past that were addicted and I thought they were crazy. I thought after four or five days that they'd be all set, that they were just being babies about it. But it's bad. It's tough."
Eventually, Tim sought help. He's been in methadone treatment for the past six months. He pays for it out of pocket, $90 a week. "And this was an easier way for me to go. And it's working good for me," Tim says. "Even though this is hard on my budget, it's a lot better than the alternative."
When it comes to proven strategies to combat opiate addiction, the National Institute on Drug Abuse and other health organizations agree: Combining medications with behavioral therapy is the most effective treatment; and methadone, Suboxone and Vivitrol are the best drugs for the job. Though very different, they suppress withdrawal symptoms, reduce cravings and block the effects of other opioids.
Of the three, methadone has the longest track record. It's been studied for more than 50 years. "It's been shown to be effective by any measure," says Dr. James Berry. "And the measures of effectiveness are continued participation in treatment, better function in the community, less crime in the community, less illness."
Dr. Berry is a member of the addiction medicine team at Mercy Recovery Center in Westbrook. He says ER visits and costly diseases, including Hepatitis C and HIV, which can be contracted by shared needles, are also greatly diminished when patients are given methadone in a clinic setting.
"And we see better function in terms of patients having stable family lives, being able to regain custody of their children, have jobs, participate in recovery," Dr. Berry says, "whereas patients who don't have access to either methadone treatment or Suboxone struggle."
Woman at desk: "Can I have your patient number please?"
Woman at desk: "You need to make an appointment with your counselor."
At methadone clinics like this one in Lewiston, patients must be seen every day. They get referrals for mental health, and other, services. There are support groups. Counseling is mandatory, as is drug testing.
Patients are also required to swallow their liquid medication in front of a dispensing nurse and speak to her afterward so she knows that it's not being smuggled out of the building.
Roy McKinney of the Maine Drug Enforcement Agency says there's a reason for all of this caution. "A number of years ago law enforcement was responding to unattended deaths - drug overdoses - and methadone was the drug of choice that was causing that," McKinney says.
Now, Maine's methadone clinics, 11 of them, are regulated, certified and audited by half a dozen state and federal agencies. Despite these controls, and what addiction doctors say are the benefits for hundreds of patients like Tim, the drug, the clinics and even the addicts, carry a stigma.
"What's happening with methadone - and we're being told this daily - methadone is being sold on the streets," Gov. Paul LePage says, "and the revenue from the selling of the methadone is going into buying heroin."
In his proposed budget, Gov. LePage wants to spend more money on drug enforcement, end MaineCare coverage for about 3,000 methadone patients and steer them toward Suboxone treatment instead.
Department of Health and Human Services Commissioner Mary Mayhew says there's a reason the administration prefers Suboxone to methadone. "We do know that Suboxone is far less susceptible to abuse and to overdose and why we believe it is in the best interest of the Medicaid program," Mayhew says.
But MDEA'S Roy McKinney says the facts on the street don't support that finding. He says when it comes to abuse and diversion, methadone is not his biggest headache. "And now we're seeing a shift to Suboxone as being predominantly what we, at MDEA, seize that's been diverted."
Unlike methadone, Suboxone can be prescribed in a doctor's office, and patients can take home as a much as a 30-day supply. Methadone still contributes to overdose deaths, but data from the Medical Examiner's Office show its involvement is on the decline.
And Dan Coffey, president and CEO of Acadia Hospital, says the form of methadone that is being diverted is different from the liquid doses dispensed in a clinic. "Methadone is also a pain medication," Dr. Coffey says. "So, it's not unusual for cancer patients to be receiving a pill form of methadone and that tends to be diverted."
Acadia treats about 500 opiate addicted patients with methadone, and 150 with Suboxone. Many of them will need treatment for years. But Coffey says methadone is typically prescribed for longer-term addicts who need higher doses of maintenance medication. He says one drug can't simply be substituted for the other.
"We don't believe that legislatures or municipal governments should remove coverage for addiction treatment, anymore than for treatment of hypertension, diabetes," Coffey says. "When legislatures start messing around like that, usually unintended consequences result."
Those unintended consequences include withdrawal, relapse, overdoses and crime. And in the worst-case scenario Coffey says Acadia's Narcotic Treatment Program, which treats a large number of MaineCare patients and is currently losing money, might be forced to close.
Correction: An earlier version of this story incorrectly called Dan Coffey a doctor. And Acadia Hospital might be forced to close its narcotic treatment program should the Maine Legislature remove coverage for addiction treatment, not be forced to close altogether.