Issues with Methadone and Suboxone Treatment in Rural Tennessee, Plus a Comparison of These Two Opio

There are several issues that rural Tennesseans with opioid use disorder like me face in securing medication-assisted treatment program enrollment.

This article details these problems and provides a brief comparison of the most important pros and cons of using methadone and buprenorphine for opioid replacement.

Methadone Programs Are Few and Far Between

As you probably know, the biggest catch-22 related to adopting methadone over buprenorphine as an opioid replacement is that enrollees are required to regularly visit the methadone clinic on a daily basis — at least that’s true here.

Right now, there are only 13 independent methadone clinics across the Volunteer State.

Northwest Tennessee, where I live, is home to nine counties, two of which are Dyer and Henry. Henry and Dyer Counties are each home to one methadone clinic. Henry County is located in the far northeastern extreme of Northwest Tennessee; Dyer County is in the far southwest extreme of Northwest Tennessee.

An hour’s drive separates me, in Martin, from Paris’ methadone clinic. Dyer, on the other hand, is a little closer, but not by much — it’s still a stretch away, Google Maps telling me the trip would be 42 minutes long. Methadone clinics are sometimes closed on Sunday and provide program enrollees with a take-home dose of methadone to bridge the gap between their Saturday clinic visit and their next opportunity to check-in on the following Monday.

While methadone programs may not be excessively inconvenient for people who live in Paris or Dyer, specifically, they are generally out of the question for most Northwest Tennesseans who suffer from opioid use disorder.

Understanding the Costs of Buprenorphine and Methadone Programs — Plus More

According to a 2017 article out of the Johnson City Press, an East Tennessean local newspaper, the average cost of being enrolled in one of the Volunteer State’s methadone MAT programs costs between $10 and $16 daily, equating to $300 to $480 monthly. This same article reports that the average cost of buprenorphine MAT program enrollment costs roughly $300 monthly, or about $10 per day.

At first, I paid $838 monthly to maintain enrollment in a buprenorphine MAT program and fill my Suboxone prescriptions. Now that I’ve found a pharmacy willing to honor discount cards — I went through nine pharmacies before landing on my current pharmacy of choice — I pay $556 monthly for both MAT program enrollment and for the prescription itself.

Not having insurance is tough if you want to be on Suboxone or methadone.

TennCare is the state of Tennessee’s version of Medicaid, which only pregnant women, people under 19 years of age, uninsurable persons, elderly people, those who are legally disabled, and people who take care of entirely-dependent children less than 21 years of age.

Not everybody, including me, is eligible for TennCare, however.

While most Tennesseans, fortunately for them, do have insurance, most buprenorphine and methadone programs throughout the state widely turn down patients’ insurance policies because they tend to return low rates of monetary reimbursement.

Two years ago, the Tennessee Recovery Coalition’s Executive Director, Paul Trivette, was quoted as sharing that, in his personal experience, methadone and buprenorphine MAT program cost reimbursements from TennCare range from $7 to $70 per visit. In other words, a lot less money than they’re able to command by only taking cash payments.

Since the U.S. Department of Mental Health and Substance Abuse Service maintains strict guidelines for who’s able to prescribe buprenorphine for opioid use disorder, costs of securing medication-assisted treatment program enrollment are likely higher here than in places with more MAT programs. Here in Northwest Tennessee, for example, home to some 254,000 people, we’ve only got 19 physicians approved to prescribe buprenorphine for opioid use disorder and two methadone clinics.

Understanding How Buprenorphine Can Be Better Than Methadone

As mentioned above, participants in methadone maintenance programs are forced to check-in daily at methadone clinics throughout the entire length of their treatments. Some people, if they abstain from other drugs for long enough, are given “take-homes,” or take-home doses.

Buprenorphine providers typically start off on a weekly prescription schedule for anywhere between four to eight weeks. After that, they’ll move to biweekly or monthly visits. As visits with these programs become less frequent, costs typically are lowered. For example, I paid $105 each week at the MAT program I enrolled in back in September. After several clean drug screens, I was given the choice to attend monthly, which cost $280.

Even at the beginning, buprenorphine-prescribing medication-assisted treatment programs require far less commitment than their methadone-using counterparts.

Let’s Look at This the Other Way Around

Something else that’s important to know about buprenorphine is that most users do not, in fact, report feeling high from their regular doses.

Methadone, on the other hand, does cause the same euphoric effects that “real” opioids — by “real” opioids, I mean opioids that give us the most recreational potential (e.g., heroin, oxycodone, oxymorphone, morphine) — though many users claim that the methadone high feels “dirty.” The euphoric effect provided by methadone is arguably the single-most valuable upside that methadone brings to the table.

Peering into Pharmacies and Their Role in These Types of Programs

Suboxone programs, for example, require patients to obtain their Suboxone or other formulations of buprenorphine from pharmacies.

Methadone is provided directly by methadone clinics in an on-site, in-house fashion. You don’t have to fill methadone at pharmacies.

Pharmacies often discriminate against people who try to fill one or more prescribed controlled substances. This is especially true here in NWTN, where stigma against drugs encourages pharmacists to exercise significant discretion against filling Suboxone, Subutex, or other buprenorphine prescriptions.

Methadone clinic participants not having to deal with pharmacies at all is another good reason to consider methadone over buprenorphine.

Blocking the Euphoric Effects of Other Opioids

One of the primary selling points of methadone and buprenorphine is that they both bind tightly to the brain’s opioid receptors, preventing users from getting high from other opioids.

Methadone blocks other opioids for anywhere from one to two days, depending on dosage. Buprenorphine, on the other hand, blocks the effects of other opioids for as long as a week, according to anecdotal reports I’ve found online. It’s a safe bet that most people taking buprenorphine won’t be able to successfully “break through,” as it’s called, for at least three to four days.

Patients who feel that they’re likely to slip up and relapse on other opioids may be better off with buprenorphine since its opioid-blocking effects last so long.

Conversely, patients who still dabble in the use of other opioids may want to take less buprenorphine than prescribed to make breaking through easier or just take methadone.

In terms of opioid-blocking capability, buprenorphine definitely takes the cake.

Information About Dosing Methadone in Tennessee

Per the Tennessee Department of Mental Health and Substance Abuse Service’s “Minimum Program Requirements for Non-residential Opioid Treatment Program Facilities,” methadone dosages can’t exceed 30 milligrams, except in “extraordinary circumstances,” when the first day’s dosage can reach 40 milligrams.

In total, daily dosages generally cannot exceed 100 milligrams of methadone. They can, though the program’s physician must provide a clinical explanation for the patient’s particular needs and why upwards of this dosage is necessary.

The State Opioid Treatment Authority, or SOTA for short, may approve dosages above 120 milligrams, though they can only be administered after such methadone programs have received explicit, written permission from the Volunteer State’s SOTA.

A study linked above indicated that patients maintained on 120 milligrams of methadone were the least likely to successfully to get high by using other opioids. This 100-milligram limit within Tennessee may not be conducive to reducing the incidence of relapse of people enrolled in medication-assisted treatment programs.

https://medium.com/@danpgarr/issues-with-methadone-and-suboxone-treatment-in-rural-tennessee-plus-a-comparison-of-these-two-3e6e243b3e97