Maryland Switches Opioid Treatments, And Some Patients Cry Foul

Jul 19, 2016
Originally published on July 20, 2016 4:34 pm

Maryland Medicaid officials have made what appears to be a small change to the list of preferred medications to treat opioid addictions. The agency used to pay for the drug in a dissolvable film form. Now it's steering patients to tablets, which some doctors say are not as effective for their patients.

Those doctors say the change is having a profound effect on some people struggling to stay clean.

Starting on July 1, Maryland's Medicaid program removed Suboxone film — a drug that can be used by people addicted to opioids to keep their cravings at bay — from the state's list of preferred drugs and replaced it with a tablet form of the medication called Zubsolv.

State officials say the change was made to stop the illicit flow of the drug into jails and prisons.

"Those Suboxone strips were diverted and smuggled into jails and later were sold or traded in criminal activity that was happening in jails," says Shannon McMahon, deputy secretary of Maryland's Department of Health and Mental Hygiene. "The numbers were frankly staggering, the amount of diversion that was happening in the jails."

So far this year more than 2,300 hits of Suboxone have been seized in Maryland jails and prisons, according to Gerald Shields of the state's Department of Public Safety and Correctional Services. That's about 40 percent more than at this time last year, Shields says.

The drug helps people control their opioid habit. But it is also an opioid itself. It doesn't produce a high as strong as many opioid painkillers that have turned into popular street drugs, but it does stave off cravings and can create a mild sense of euphoria.

It comes as a tiny, dissolvable film — about the size of a Listerine breath mint strip — that's transparent and easy to hide.

"They have been cut up into multiple different pieces," McMahon tells Shots. A single strip can be worth as much as $50 on the street and they are often divided into several "hits" that are sold individually, she says.

"They were coming into prisons through letters — backs of stamps, corners of folks' eyeglasses," she says. McMahon says the strips were causing problems in prisons because of illegal sales and trade.

So at the recommendation of the Department of Corrections, along with a panel that advises the state's Medicaid program on medications, officials decided to replace the Suboxone strip with Zubsolv, made by a Swedish company called Orexo AB.

The choice is raising eyebrows because Maryland's health secretary Van Mitchell used to work for Manis Canning & Associates, the lobbying firm that represents Orexo. Mitchell's spokeswoman says he left the firm before Orexo became a client.

Mitchell and Steven T. Moyer, Maryland's secretary of Public Safety and Correctional Services, argued in an article in the Baltimore Sun that the change would save lives. They said Maryland's correctional system, since 2010, "has seen 13 fatal overdoses." However, a spokeswoman for the state's health department acknowledged that those were overdoses on opioids in general, and not specifically overdoses on Suboxone film.

Doctors say Suboxone film, as well as the Zubsolv pill that replaces it, actually protect against overdoses because they contain both the opioid Buprenorphine and a drug called naloxone that reverses the effects of an overdose. Naloxone is used by emergency responders to revive people who overdose.

The change has drawn broad opposition from doctors who treat people with substance abuse problems and from advocates for people who are recovering from addictions. Those include the Behavioral Health System of Baltimore, a nonprofit that oversees the city's behavioral health system, and the Maryland Association for the Treatment of Opioid Dependence.

The change has wreaked havoc on some people with substance abuse problems who, until a few days ago used Suboxone film, says Adrienne Breidenstine, vice president for policy and communications at the Behavioral Health System of Baltimore.

One of them is Nicole, a mother of two who has been in recovery for about eight years. Nicole became addicted to painkillers after she was injured in a car accident. She was stable on Suboxone strips but switched to Zubsolv 10 days ago. She asked NPR not to use her full name because her history of addiction is not common knowledge.

"When I got on Suboxone I didn't even have custody of my son," she says. "After I got clean, I got put on Suboxone. I've got both my kids now, we have our own house, I'm working, they're doing good in school, I finished school, and that's why it's so scary to me that they completely switched me over."

Since the change, she says, she's been feeling sick, having trouble sleeping, having cravings and symptoms of withdrawal.

"It hasn't been working for me," she says. "I don't know what I'm going to do if they don't cover it again. I just don't want to go back to that life and I don't want my kids to go there."

Nicole's doctor, Michael Fingerhood, has a primary care practice at Johns Hopkins Bayview Medical Center in Baltimore. His practice, which overlooks downtown Baltimore from across the water, welcomes people with substance abuse problems. The group treats about 450 patients who, until this month, were using Suboxone strips.

He says just two weeks into the change many of his patients, like Nicole, are struggling.

"This is taking patients who are stable, who are doing really well, and saying we're going to do something to disturb how well you're doing," he tells Shots.

Fingerhood says Zubsolv is supposed to be the equivalent of Suboxone. But not all patients react the same to different medications. Many, like Nicole, have been clean for years and for the first time, they're feeling sick again and some, he says, are in real danger.

Feeling even the slightest bit of withdrawal symptoms can be awful for someone in recovery, he says.

"In the midst of addiction people are searching for a high, they're having withdrawal, they're running the streets. Their lives were horrible," Fingerhood says. "Having withdrawal brings back all those memories of how terrible life had been and it's a terrible feeling to be in withdrawal."

Shaking up all the Suboxone patients across the state to keep a relatively safe drug away from a handful of inmates doesn't make sense, Fingerhood says. And the numbers are indeed pretty small.

If those 2,300 Suboxone hits seized in prison were whole strips — and prison officials say they weren't — that's still only the equivalent of about 10 prescriptions from January through last week.

Instead, Fingerhood says, "We should be providing treatment in the prison system."

He says if someone who was on Suboxone gets arrested, it makes sense that family members or friends would try to get them the drugs in prison.

The only place in Maryland that inmates can legally get any medication to help get or keep them off opioids is in the Baltimore City Jail, according to Shields, the Department of Corrections spokesman. He says the system provides methadone to some inmates to help wean them off opioids before moving them to another prison.

State officials say Medicaid patients can still get Suboxone if they really need it. Doctors just fill out a form requesting a waiver, known as a prior authorization, and get an answer the next day.

Fingerhood made that request for Nicole. Five days later, he still had no response.

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KELLY MCEVERS, HOST:

The Medicaid program in Maryland used to pay for a drug to treat opioid addiction that comes in the form of a dissolvable film. The program is now steering patients to the tablet form of the drug which doctors say isn't always as effective. NPR's Alison Kodjak reports the change is having a profound effect on people who are struggling to stay off opioids.

ALISON KODJAK, BYLINE: Last month Maryland told doctors that Medicaid will no longer pay for Suboxone strips, a drug that's used by people addicted to opioids to keep their cravings at bay. The reason...

SHANNON MCMAHON: Those Suboxone strips were diverted and smuggled into jails and then later sold or traded in criminal activity that was happening in jails.

KODJAK: That's Shannon McMahon, who runs Maryland's Medicaid program.

MCMAHON: The numbers were frankly staggering of the amount of diversion that was happening in the jails.

KODJAK: She says that so far this year, more than 23 hundred hits of Suboxone have been seized in Maryland's jails and prisons. That's about 40 percent more than at this time last year. You see, Suboxone is itself an opioid. It doesn't produce a high as strong as many opioid painkillers that have turned into popular street drugs, but it does stave off cravings and can create a mild sense of euphoria. It comes as a tiny dissolvable film that's transparent and easy to hide.

MCMAHON: They have been cut up into multiple different pieces. They're about the size of a Listerine strip, if you can use that as a visual. They were coming into prisons through letters, or they were, like, on the backs of stamps. They were coming in in the corners of folks' eyeglasses.

KODJAK: So at the recommendation of the Department of Corrections along with the panel that advises on medications, Medicaid officials decided to replace the Suboxone strip with a tablet called Zubsolv. The choice is raising eyebrows. That's because Maryland's health secretary, Van Mitchell, used to work for the lobbying firm that represents Orexo Pharmaceuticals which makes Zubsolv. Mitchell's spokeswoman says he left the firm before Orexo became a client.

The change has wreaked havoc on some people with substance abuse problems who use the Suboxone film like Nicole, a mother of two who has been in recovery for about eight years. She doesn't want us to use her full name because her history of addiction is not common knowledge.

NICOLE: When I got on Suboxone, I didn't even have custody of my son. And after I got clean, then I got put on Suboxone, and I have both my kids now. We have our own house. I'm working. They're doing good in school. I finished school. And that's why it's so scary to me that they just completely switched me over.

KODJAK: Nicole became addicted to painkillers after she was injured in a car accident. She was stable on Suboxone strips but switched to Zubsolv 10 days ago.

NICOLE: It's been a nightmare ever since. I haven't been feeling good, and I cannot sleep at night on this certain medicine. I'm actually having cravings again.

KODJAK: Nicole's doctor, Michael Fingerhood, has a primary care practice at Johns Hopkins in Baltimore. It welcomes people with substance abuse problems and treats about 450 patients who until this month were using Suboxone strips. He says just two weeks into the change, many of his patients, like Nicole, are struggling.

MICHAEL FINGERHOOD: These are taking patients who are stable, who are doing really well and saying, we're going to do something to disturb how well you're doing.

KODJAK: Many have been clean for years, and for the first time, they're feeling sick again because Zubsolv is not exactly the same as Suboxone. He says some are in real danger.

FINGERHOOD: So in midst of addiction, people are searching for a high. They're in withdrawal. They're running the streets. Their lives are horrible. So having withdrawal brings back all those memories and flashbacks of how horrible life had been, and it's a terrible feeling to be in withdrawal.

KODJAK: Shaking up all the Suboxone patients across the state to keep a relatively safe drug away from a handful of inmates doesn't make sense, Fingerhood says. And the numbers are pretty small. If those 2,300 Suboxone hits seized in prison were whole strips - and prison officials say they weren't - that's still only the equivalent of 10 prescriptions from January through last week. A better strategy, he says...

FINGERHOOD: We should be providing treatment in the prison system.

KODJAK: But for now that's not happening. So Fingerhood and other doctors across Maryland are trying to keep their patients clean while they adjust to the change. State officials say patients can still get Suboxone if they really need it. Doctors just fill out a form and get an answer the next day. Fingerhood made that request for Nicole, and five days later, he still has no response. Allison Kodjak, NPR News, Baltimore, Md. Transcript provided by NPR, Copyright NPR.