First Posted 11/26/2013
As I read about the moratorium on buprenorphine treatment programs in Bangor, Maine, I thought about the scene from the movie Titanic where the people who found safety in lifeboats struggled to keep those in the water from climbing aboard. The Bangor city council recently voted to impose a moratorium on expanding buprenorphine treatment programs for 180 days, at least in part because of concern that Bangor had become ‘port in the storm’ for heroin addicts with nowhere else to turn.
I haven’t been to Bangor, but I live in Bangor-like conditions. Bangor clinics treat more than the city’s share of people addicted to opioids. The city has three methadone clinics, treating a total of 1500 people, many of whom travel from outside the city for treatment. Numbers on buprenorphine treatment were not provided in the articles I’ve read, and so I don’t know if buprenorphine/Suboxone prescribers in Bangor carry the same heavy load. Some editorials about the Bangor situation have suggested that buprenorphine treatment is unfairly targeted because of the large number of methadone patients. The two types of treatment are often confused, especially since methadone clinics now dispense buprenorphine to some patients and methadone to others. But buprenorphine-based products differ from methadone in that they can be prescribed for addiction treatment, whereas methadone can only be dispensed—initially on a daily basis. The medications are similar in that both are the most reliable methods to cut the number of overdose deaths from pain pills or heroin.
By ‘Bangor-like’, I’m referring to the lack of buprenorphine-certified physicians in northeast Wisconsin and the Michigan Upper Peninsula, and the need for residents of those regions to travel in my direction to see a buprenorphine-certified provider. There are also regions of the Upper Peninsula where pharmacies have stopped providing Suboxone. The exit of one pharmacy created greater pressure on remaining pharmacies, creating a death spiral that ended with no pharmacies dispensing Suboxone across a wide region.
To people without addictions, I suspect that large numbers of opioid addicts lining up for care look like the people who tried to climb into the Titanic lifeboats. People who have lost everything to addiction can seem a bit desperate with their dated clothes and late-model cars. Newcomers to treatment look rough after weeks of lousy sleep and the lack of toiletries that go with living in a car. A group of patients outside a methadone clinic are less picturesque than a Starbucks shop.
But there is nothing pretty about blocking treatment facilities that could save lives, out of concern that the good city of Bangor is doing too much good for the surrounding area. It is always revealing to apply attitudes toward addiction to other diseases. If Bangor was a Mecca for cancer treatment, with several hospitals to attract patients from miles around, would the city council be concerned? Success rates with buprenorphine rival cancer treatment success rates; is it more important, or more rewarding, to save the life of one patient over another?
I am frustrated that the regulations for treating opioid dependence keep more doctors from helping carry the load. I’m frustrated that the ‘systems’ that have taken over much of the healthcare landscape discourage buprenorphine-certification of their employed physicians. I find it ironic that almost all hospitals requires ACLS certification for their staff physicians, but none require buprenorphine certification—even though most doctors will rarely if ever have to run a ‘code’, while patients seeking help for addiction are plentiful—and ignored.
But a surplus of doctors willing to navigate the maze of regulations to offer methadone treatment or willing to sign on to random DEA inspections to prescribe buprenorphine medications is a good thing. An even better thing would be for a city council to take pride in not turning away people struggling with an epidemic that has become the number one killer of young adults in much of the country. We all agree that opioid dependence is a disease. Let’s hope that in 180 days, Bangor will decide to treat it like one. The solution, in 1912, wasn’t to have even FEWER lifeboats.