Not long after MaineCare cracked down on the availability of narcotic prescriptions early last year, police reported a spike in heroin abuse.
Maine addiction specialists agree: They say the restrictions, while working to prevent some Mainers from getting hooked on painkillers, also squeeze the drug supply to fuel addiction elsewhere.
Enter Maine’s growing heroin problem, and the state’s ongoing distinction as one of the worst in the country for drug addiction.
State officials view the MaineCare changes as a positive step, leading to a 30 percent drop in the number of opiate prescriptions since 2011. Patients with chronic pain are benefitting from alternative approaches, such as physical and occupational therapy, and MaineCare’s also saving money, they say.
To Dr. Mark Publicker of Mercy Hospital Recovery Center in Portland, however, such prevention efforts amount are small victories in Maine’s existing drug crisis.
“At this point, focusing on prevention is like having a family sitting in their living room and teaching them fire prevention when their house is burning down,” he said. “It really is important that the family know in the future how to prevent fires, but first they’ve got to put the fire out.”
As doctors prescribe opiates more cautiously, the street supply dwindles, driving up prices and spurring some addicts to turn to cheaper and potentially much more potent heroin, said Dr. Andrew Kolodny, a psychiatrist, public health advocate, and spokesman for the group Physicians for Responsible Opioid Prescribing.
Restricting prescription practices can help in the short term, but “the answer is to do something about the many people who are already addicted,” he said. “If you only curtail the overprescribing, without seeing that the people who are already addicted have access to treatment, then you’ll just see people turning to heroin. You have to do both.”
Emerging from the country’s opioid addiction epidemic are two groups, Kolodny said.
One is young adults who use the medications recreationally, often getting hooked on drugs they found in their parents’ medicine cabinet or scored through friends and family. Those addicts, who tend to be young and otherwise healthy, always faced obstacles convincing a doctor to prescribe the drugs and turned to the black market, he said. Now that prescription opiates are drying up on the street, they’re switching to heroin.
Alarmingly, younger addicts appear to be first experimenting with heroin by shooting up, Publicker said. Most don’t know about the dangers of sharing needles or where to get clean ones. “We’re going to see [HIV],” as a result, he said.
The second group Kolodny describes is middle-aged and older adults, more often prescribed opioids for medical treatment and less likely to turn to heroin in desperation.
“Believe it or not it’s that second group that’s much more likely to die of an overdose death,” he said.
Fatal heroin overdoses in Maine jumped from seven in 2011 to 28 in 2012.
While Maine has seen a rise since 2012 in the number of people seeking treatment for heroin and morphine addiction — for individuals on MaineCare and other types of health coverage — there’s no way to know if they’re abusing those drugs because they were shut off from opiates, said John Martins, a spokesman for the Maine Department of Health and Human Services. Opiates remain the top culprit in addiction treatment in Maine, he said.
Kolodny argues Maine should rapidly expand access to substance abuse treatment, much like Vermont. MaineCare has instead pulled back, capping methadone and buprenorphine treatment to two years and dropping coverage for thousands of childless adults, steps Republicans contend are needed to avoid bankrupting the program.
“That’s a very bad idea,” Kolodny said. “They should be expanding methadone, and they should be expanding buprenorphine. That’s the only way out of this mess.”
A reformulation of OxyContin — “our state drug,” Publicker says, as the chickadee is Maine’s state bird — also has contributed to the heroin problem. While it’s still kicking around as a street drug, the painkiller dropped off in use after its manufacturer made it more resistant to abuse, Publicker said.
Heroin, on the other hand, is a “more antisocial drug” tied to violent crimes and skyrocketing overdose rates, he said.
“We’re seeing murders that we never saw here,” Publicker said.
He questions whether Maine has sufficient pain therapy options such as those touted by the state. And, he points out, just because MaineCare limits doctors in prescribing opioids doesn’t mean patients can’t pay for the drugs themselves, outside of their government health coverage.
“This concept of having people take alternative therapies if you don’t make them available is a fallacy,” he said.
Publicker, also president of the Northern New England Society of Addiction Medicine, describes Maine as the most regressive state in the country for providing access to substance abuse treatment.
“Opiate addiction in the state is a metastatic cultural cancer, and we’re trying to treat symptoms of the cancer,” he said, such as by arresting people and removing children from their homes. “If you just treat the symptoms of cancer — nausea, hair loss, — the cancer is going to kill the individual. We’re not treating the disease, but we have treatment that works.”