Nearly a half-century into the "war on drugs," with a new wave of opioid addiction at crisis proportions, a handful of commercial health insurers are beginning to cover methadone maintenance, the oldest and best-researched treatment for addiction to heroin and prescription pain relievers.
Independence Blue Cross, the Philadelphia region's largest insurer, will join the emerging trend in August, offering complete coverage with no co-pays. There are spaces available at local methadone clinics and the treatment is considered highly effective.
But it also is controversial — substituting one drug for another, perhaps for life — and cumbersome, typically requiring daily visits to a clinic. And methadone maintenance, which historically has been publicly funded, long has been stigmatized as serving the most hard-core addicts and the poor. Communities often fight to keep new clinics from opening.
No one has any idea how many middle-class policy-holders — who are more drawn by newer (and much more costly) drugs for opioid addiction that don't require daily clinic visits — will take advantage of methadone coverage. The larger impact, several people who work in the field said, may be to help lift the reputational cloud from methadone maintenance.
Richard Snyder, chief medical officer at Independence Blue Cross, said the need became clear to him as he heard people testify about the horrors of addiction while he served on Mayor Kenney's opioid task force a few months ago. Methadone costs pennies a day. But even the most expensive treatments are cheaper than the consequences of a downward spiral of opioid misuse, Snyder said.
"From a business perspective it's logical to do it, and from a social standpoint, it's imperative that we treat people," he said.
Methadone was developed in the 1930s to relieve severe pain, and is still used that way. Scientists discovered three decades later that it had the effect of blocking addicts' normal reactions to heroin, allowing them to live normal lives as long as they continued taking their daily dose. But crime, not treatment, was the driving force behind its acceptance.
Law and order played a big role in the 1968 election of Richard Nixon, and national anxiety over crime worsened as Vietnam veterans returned home addicted to heroin. The White House recruited a young psychiatrist from Chicago whose work using methadone as a substitute for heroin had gained notice. His charge: Set up a nationwide system for treating heroin addiction that could get junkies off the street and allay public fears.
"The president said to do it as quickly as possible," said Jerome Jaffe, who became the nation's first drug czar and most recently was a clinical professor of psychiatry at the University of Maryland School of Medicine, where he maintains an affiliation.
Jaffe, who was born in Philadelphia and received undergraduate, master's, and medical degrees from Temple University, worked in secret at first to develop from scratch a system of mostly small, independent treatment centers around the country that used various techniques. But he became best known for methadone. Federal grants paid most of the cost.
"The whole system had separate financing because insurance is for 'medical' stuff. And addiction was separate. And within addiction, methadone, oh my God, it couldn't be more separated," said Thomas McLellan, cofounder and chair of the Treatment Research Institute in Philadelphia and a former deputy director of the Office of National Drug Control Policy under President Barack Obama. Methadone clinics "were stigmatized geographically, culturally, financially from the very beginning. Like a little housing project," McLellan said.
Pennsylvania, New Jersey, and most other Northeastern states eventually used Medicaid, created in 1965, to cover treatment for their most impoverished residents. A half-century later, the Affordable Care Act dramatically expanded that option, which would be severely cut under Republican proposals now being considered. Private insurance almost never covered methadone maintenance (and, before the ACA, often did not cover any type of addiction treatment).
Meanwhile, lawmakers in 16 states, mainly in the South, have directed their Medicaid programs not to cover methadone maintenance at all; West Virginia, with by far the worst drug death rate in the nation, has banned the opening of new methadone clinics, regardless of funding, since 2008.
McLellan began his career as a psychologist at the VA Medical Center in Philadelphia, treating addicted soldiers back from Vietnam. He still recalls the furor over replacing heroin with methadone, which is addictive but does not have heroin's psychoactive effects. "The idea of giving opioids to an opioid addict was likened to giving women to a rapist," he said.
It is possible to overdose on methadone, so the federal government early on imposed rigid rules that also prevent diversion. Perhaps the most despised is that patients can get only a single dose a day at their clinic until they meet certain measures of stability and trust, which typically takes months. With clients hanging around outside, many clinics appeared seedy, and the stigma grew. Cuts in federal funding forced clinics to grow larger — and more conspicuous — in order to survive.
When the Food and Drug Administration approved buprenorphine (most commonly sold as suboxone) in 2002 as the second drug to treat addiction, policymakers allowed it be prescribed monthly by certified doctors in their offices. Suboxone is also a maintenance opioid but is much less likely to cause an overdose than methadone, and patients tend to stay on it for much shorter periods before being weaned off.
A third medication, sold mostly as a monthly injection approved in 2010, also can be given in doctors' offices. It is still on patent and heavily advertised; posters popped up on SEPTA a couple of months ago asking "What is Vivitrol?" (It is an opioid blocker rather than a substitute opioid.)
Suboxone and, to a lesser extent, Vivitrol are fast gaining in popularity. The rigid rules of methadone maintenance, however, may be partly responsible for its effectiveness: Daily visits to pick up medication make it more likely that people in recovery will also get the counseling that helps retrain their brains not to respond to cues that can lead back to drug use and, potentially, a fatal overdose.
For that reason, many comprehensive treatment centers impose their own rules for suboxone. At NHS Human Services' centers around the region, "they begin with a seven-day supply" and mandatory intensive-outpatient therapy amounting to three group and one individual session a week, said Laura Murray, chief medical officer for the nonprofit's addiction services. NHS offers all three types of medication-assisted treatment as well as treatment without meds at its several locations, and currently has plenty of openings for outpatient treatment. (It does not have residential treatment, which is in short supply.)
Studies have generally shown that relapse is less likely when treatment includes medication but each one has unique properties. "There is not a one size fits all," said Murray. More than 90 percent of NHS clients are covered by Medicaid, but the organization accepts commercial insurance. People choosing suboxone are more likely to be employed, she said.
Many commercial insurance plans did not cover any type of medication-assisted treatment until several years ago, and just a handful have begun covering methadone in the last couple of years, said Mark W. Parrino, president of the American Association for Treatment of Opioid Dependence, which represents comprehensive treatment programs, most of them exclusively methadone maintenance. But methadone is "an odd fit" for many health insurance plans, he said.
Aetna, for example, covers methadone treatment but bills it like any outpatient visit. A typical $25 co-payment every day would often be more than the full out-of-pocket cost, conceded Mark Friedlander, Aetna's medical director for behavioral health in commercial policies. He said that Aetna, the third-largest insurer in the country by members covered, is looking at other ways to reimburse for methadone maintenance.
"All health insurers are considering this," said Samuel Marshall, president and CEO of the Insurance Federation of Pennsylvania, which represents insurers other than the Blues.
Independence Blue Cross plans to cover all clinic services in one weekly reimbursement, and waive co-pays. Deductibles will still apply, however, as well as in- and out-of-network distinctions.
Per person, methadone maintenance is surprisingly inexpensive, although it is still chronically underfunded. Community Behavioral Health, the agency that handles behavioral health billing for Medicaid managed care in Philadelphia, paid just more than $15 million to cover 6,000 people in 2016, or about $2,500 a person for the year, including therapy, urine tests, and other services at 15 clinics. Contrast that with a monthly injection of Vivitrol, which carries a list price well over $1,000, not counting counseling and other components of treatment.
Commercial insurance coverage of methadone could help lift the stigma and perhaps encourage more people to seek help, said Geoff Neimark, chief medical officer for Community Behavioral Health.
"There often are many unspoken assumptions about methadone being a treatment for 'those people' or certain sorts of people," said Neimark. "I think this really can help change the public perception."
Yet there is a growing gap in who gets what kind of medication-assisted treatment, with buprenorphine more typically prescribed to whites and methadone more to black and Hispanic patients, research has found.
"Methadone is in need of rehabilitation," said Nancy D. Campbell, a historian of science and medicine at Rensselaer Polytechnic Institute in Troy, N.Y., and the author of several books about addiction treatment. "Methadone probably is the best drug for people to be on if they want to lead something like a normal life," Campbell said. "It stabilizes people."