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Stuck in the Middle: Barriers to Treatment for the Middle Class

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Most of us with addictions are well informed of the many types of treatment available.  This is due to the countless times we are desperate to change and get help while we are likely suffering in withdrawal, our addiction is ruining our life at home or work, we are tired and depressed or we simply know we need help and we want the help.  So we look online, we search for hours, we read up on all the latest treatments and clinics, treatment centers, rehabilitation facilities, psychiatric hospitals that treat addiction, outpatient programs, we find meetings near us and plan to try and go, we may even have the energy to get books and try treating ourselves with spiritual or motivational materials, access pharmaceuticals from the street because we are still too ashamed to ask for treatment from a professional, and definitely, we read online about all the medications that are available for treatment. We are well-informed before ever seeking help, as to what options are out there.  Yet we are still confused and overwhelmed by which options would work best for us; who we should see, where we should go, when we should make this decision. 

It is personal for every addict and I have had my fair share of working every part of the traditional healthcare system for 5 years ongoing, to try and be well, and have come upon innumerous roadblocks on the way.  The barriers for the middle class is something I have found appalling yet it is almost never discussed in media reports, political conference press releases, treatment reform groups, no, it is only discussed on recovery websites and forums from the very people like I, who have encountered such difficulties.  We reach a point when we truly want help so badly, and somehow muster the energy to look for help, meanwhile chasing & feeding our then-active addiction, every day in order to maintain what our body requires to be sane and functional.  It is exhausting just writing this to think back on what I personally went through while desperately seeking help, crying out for what I knew I needed to save my life. 

My opiate addiction began in 2009.  It rapidly spun out of control within 9 months, when I decided I needed help for the first time.  I spent hours online looking for a suboxone doctor in my area, meanwhile suffering tremendously in the worst withdrawal I had ever experienced.  I was told I could be seen that same night (which after years of experience searching for help, I find this now to be miraculous).  The cost was $450 cash for the first visit, then $250 per month for each subsequent visit, in cash.  I found out afterward that my insurance, which is through a labor union in Boston and is one of the best insurance programs for everything BUT addiction, would only cover the cost of 2 months of treatment and I'd have to pay first and then be reimbursed, as the suboxone office did not bill insurance directly.  2 months of suboxone treatment is far below what experts and professionals recommend as a length of time for treatment, but I was at the mercy of the insurance company's decisions and I knew after 2 months I would have to pay out of pocket for this expense. 

At the time it did not seem like an excessive amount and I knew my husband would gladly pay the $250 every month out of pocket, because it was far cheaper than my addiction was costing me, which was about $90 per day  But then I went to the pharmacy that 1st night with my prescription; and that is when everything changed & I realized how the access to a life-saving medicine is almost anything but accessible.  The cost of suboxone totaled $30 per day, for a total per month of $900. and insurance covered nothing of this cost. 

Add in the office fee that insurance would not reimburse after 2 months, and the grand total every month for my treatment was an astounding $1150.00  Still cheaper than my addiction, yes, but not by a lot.  And seeing as I had burned through so much of our savings and ran up several thousand dollars of credit card cash advances to fund my daily habit, it was not easy to find the extra funds every month.  But my husband did it.  Then I relapsed as is common with our disease, and over the years I went back to a suboxone clinic for 2 more rounds of treatment, all at great expense that was entirely out of pocket. 

Something to note is that most opiate addicts can get by and beat the cravings and stave off withdrawal, with only 1 strip or pill of suboxone.  I was initially started at 3 per day, so later on I got by with 1 per day, which was $9-10. a day instead of $30.  So the out of pocket cost of suboxone though less, was still costing my husband $70 a week plus the $250 office visit fee every month.  This is beyond what one would call "affordable".  Luckily I have a husband who was supportive and somehow found the money to pay for this all out of pocket for 3 full rounds, totaling a time of about 15 months. If you add up the cost of total treatment on suboxone throughout my addiction this last 5 years, it is jaw dropping at the very least. 

Then my husband was laid off from the union and everything changed.  We could not afford this level of treatment and I was still relapsing regularly and needed help.  We couldn't afford the high costs of office fees every month plus the enormous cost of $9-10 per pill, per day for the medicine.  It was out of reach.  I knew I needed the suboxone but could not afford it; so I did what so many people do, and began accessing it illegally on the streets.  We hated having to do it that way but there simply was no other way to afford it, and there are an enormous number of addicts taking suboxone in this same manner.  You don't have to pay any office fee, and the medication averages in the Boston area at $20. per strip/pill. 

After many more years of experience, I learned that with suboxone, one can get by and stave off withdrawal at only 2-4mg per day, therefore one pill or strip can last an addict between 2-4 days.  This is unbelievably cheaper and more affordable than accessing legally.  But there are many risks of obtaining it this way.  One is that you are risking the obvious legal consequences of being in possession of a narcotic which is not prescribed to you.  It is a felony to be in possession of suboxone.  Another risk is that your source of getting this medication, since on the black market, may be available some days and unavailable others, or simply be out of the medication.  Then you are in a vicious cycle of relapse that is never-ending and since you aren't using the suboxone as it is intended, you are not going to get the intended end result, which is sustained, safe, recovery. 

This brings me to insurance versus doctors.  There are almost NO private insurance companies that cover any portion of the cost of a subxone prescription.  And if they do cover it, my case as an example, it is for a very small amount of time, an amount of time which is practically impossible to get clean from using suboxone treatment. 

The interesting yet appalling fact is that there IS another form of buprenorphine, the main ingredient in suboxone, called Subutex.  Subutex does not have the medication addition of Naloxone, which is an opiate blockade. 

One can be on subutex and can still use their opiate drug of choice and get high, while when using suboxone, this is impossible to achieve because the naloxone blocks the effect.  Almost all private insurance companies cover the full cost of subutex prescriptions and the patient only has to pay their regular medication copay.  But try and find a certified doctor to prescribe a patient subutex over suboxone, is literally fruitless.  They do not like giving subutex, even though it was recommended by the FDA some years back that female patients should be on subutex instead of suboxone.  You can cry financial hardship all you want but the doctors do not have sympathy and most will only prescribe suboxone for fear that subutex will be misused.  This is a major problem and this also leaves many people to choose purchasing their treatment on the black market instead of going through a legal, monitored program that gives you a much higher chance at success in recovery.  If a suboxone doctor gave subutex instead of suboxone to those patients with insurance like me, then the treatment would be much more affordable, at the cost of only having to pay the monthly office visit fee plus 1 copay per month.  This would be very affordable but it is almost completely out of reach in most of America.  This is another dead end for the insured middle class. 

Finally, the last straw and the last roadblock came.  I had relapsed on heroin and I was in a very bad place, truly wanting help and I even enlisted my counselor to help me call suboxone clinics, which now years after I first went on suboxone, there were many more in the area.  I was looking for a clinic that accepted regular office visit fees through insurance like a general doctor does.  I had heard of such places but was never able to find one.  I was also hoping to find a doctor that would prescribe subutex, since it was a cost of $15 per month copay through insurance coverage, versus $300 a month that insurance wouldn't cover for suboxone.  Together after 4 days of calling every suboxone clinic around Boston, in New Hampshire, Maine, I was willing to drive anywhere, we called a total of 60 clinics and not 1 took insurance for the office visit.  They demanded large cash payments and only prescribed suboxone.  With my husband still laid off and collecting unemployment, I was truly beside myself and beaten down by all the dead ends of my desperate search. 

I finally drove myself down to a local methadone clinic in Massachusetts, and begged them to help me get in.  I knew methadone was largely an option for people without insurance, and after looking into it, state Medicaid and MassHealth covered 100% of methadone treatment.  I did not qualify for these assistance programs because even laid off, and I not working at all, my husband "made too much money".  I asked through tears of exhaustion how much it would cost for me to start the methadone clinic out of pocket, and it was to be $131. per week and $300 to start.  If you recall that suboxone on the street, cost only $40 for a full week, $131 was just out of the question.  It would be close to the same amount of a regular old suboxone clinic charging cash & insurance not covering the suboxone prescription.  I asked the woman if there was anything I could do to have a reduced fee or any assistance whatsoever. 

Her advice? Drop your private health insurance and apply for MassHealth.  I honestly went home and thought about this option thoroughly.  MassHealth was the 1st state health insurance program, used as a model for the later national health insurance and it is still I believe, the best in the country.  It covers absolutely everything for low-income patients.  It is a reason people move to Massachusetts regularly, knowing that the health coverage is so good.  It is good for addiction services, while my private insurance was not.  However my private insurance by now had already paid almost $200,000 for 7 inpatient hospitalizations I went through in a short period of 5 months, and they were also an amazing insurance for everything besides addiction, so I didn't think it was wise to drop my insurance coverage.  Especially since I did not live in Massachusetts!  To qualify for MassHealth I would have had to lie and chance committing fraud, because I lived 1 mile over the border in New Hampshire.  I had relatives I could have used their addresses to establish residency and risked huge legal implications if I was caught. 

These were my options.  I had NO attainable options that were legal.  It was either risk buying on the black market or risk being caught for healthcare fraud.  Those are pretty bad choices, especially when one is trying so hard to clean up their life.  I was literally at rock bottom and there was no way I could climb back out without huge risks involved.  I needed replacement therapy because I was heavily physically addicted and could not handle withdrawal.  Some people can, many people cannot which is why the number of addicts has exploded and also why methadone & suboxone are used more and more each year. 

Another option was to apply for New Hampshire State Medicaid, which also covered 100% of methadone & suboxone treatment.  I tried, and I was denied based on income.  I did not qualify for any existing assistance whatsoever, and my insurance company paid zero cost of either available treatment. 

This is the dilemma of the middle class.  The low-income population does qualify for Medicaid or MassHealth, they qualify for program reduction fees if they haven't established residency long enough to get this coverage, and the entire cost is covered under these assistance programs. Then you have the patients who are upper middle class or have the needed funds to afford the cost of treatment if their insurance doesn't pay or if they can find a doctor to prescribe subutex in their area.

I worked hard all my adult life until my son was 3 and I was laid off from a school where I worked my way up for 10 years.  My husband and I bought a house when I was only 22 years old.  We then married, and planned to have our son.  We saved, we paid our taxes, we did what we thought was right and wanted to achieve our goals.  Then addiction happened and it happened fast.  The last 5 years of my life has been a roller coaster of spending thousands of dollars on treatment that our insurance would not cover, spending time accessing inpatient treatment over and over, praying I would get out and be well, burning through money and running up debt which caused me to have to declare bankruptcy, and most of all a major decline in my physical and mental health.  I have paid out more money out of pocket than I could count on my treatment. 

But perhaps what is the most difficult part of this all, is the counting I DID do. 

My insurance company has paid to date, a total of $220,000 on my many inpatient hospitalizations, outpatient programs, doctors visits, psychiatric medications, overdose treatment, suicide attempt treatment, ambulance transport, individual counseling sessions and more. They gladly & fully paid for all the expensive treatment I needed once something went horribly & tragically wrong in my addiction, such as overdoses and suicide attempts from the stress of wanting to get help and not being able to.  Yet they would cover no cost of entering recovery or accessing treatment prior to my addiction leading me to near death. 

The cost that would have been incurred if my insurance company would have covered the cost of suboxone treatment for this same time frame, a total of 4 full years would have been only $15,880.  To date, of 8 inpatient hospitalizations, there was not 1 of those hospital stays that cost even close to as little, as 4 years of suboxone treatment would have cost my insurance company.  The difference is astronomical. 

You so often read the words "access to treatment" in articles, on blogs, on the news; people discuss the barriers of accessing treatment or that there needs to be more access to treatment.  Yet nobody truly looks at what the barriers ARE to the people trying to get well.  These are the barriers, that insurance companies deny coverage for the treatment that has the highest success rates for opiate addicts.  Methadone has been used my millions of people for decades, and have remained off of heroin entirely because of methadone.  They lead productive lives, they contribute to society, they are free from the risk of infectious diseases, the risk of overdosing on heroin or laced heroin, they aren't committing illegal crimes to access an illegal drug every day, and they aren't committing other crimes in order to fund their addiction.  These are the differences between replacement therapy and active heroin/opiate addiction.  There are numbers that show the success rate of the replacement therapy treatment option.  But these statistics do not apply to the middle class because eventually they will not be able to afford the ongoing cost and have to drop out of the program, with an almost guaranteed rate of relapse into active addiction.  Suboxone has received a lot of bad press because of the fact that people buy it on the streets and it is now a growing problem criminally, while people who get the medication for free under assistance, are the ones who can get the suboxone at a low enough price to sell that medication and make money from it, off of the people like me who have no other way to afford the access to it. 

It is a major problem and it is not being addressed.  State governments that are acknowledging the growing epidemic of heroin addiction nationwide are focusing on the access to inpatient care.  While inpatient care is a valuable treatment option, when one is released, they are always recommended to continue outpatient treatment.  Statistics document how important outpatient treatment is to the success of recovery, but addicts are met with numerous obstacles and barriers when they begin the process of accessing outpatient care.  The office fees suboxone doctors charge are so far above a regular medical office visit fee, it is completely taking advantage of desperate people who are sick and in need.  It is unaffordable, unattainable and unsustainable.  Even the doctors who accept some insurance find other ways to charge high fees for which they only accept cash payment.  One doctor I came across charged $125 per week for the visit, which is a 1, 5 minute long visit, billed insurance but also charged a cash-only fee of $50 per week for urine testing, even though most all insurance companies cover the cost of these tests.  These doctors could easily have a staff member that bills insurance, but they choose not to, for they make more money charging large cash fees that have no limitations.  There needs to be an outcry for these specially certified doctors to be regulated and monitored as to what they charge patients, because at this rate, people are choosing active addiction over treatment. 

So many people truly believed that when Reckitt Benckiser, the manufacturer of suboxone lost their patent, that the medication would be affordable due to generics.  The truth of what occurred is astonishing, which is that the companies who jumped on the suboxone train and made their own formulations, have all, every single one of them, decided to charge the exact same amount to patients, as the brand name suboxone had cost.  It was devastating that nobody has offered to date, an affordable generic.  But I suppose they figured that people are paying the cost already, so why offer it at a cheaper price?  It is heartbreaking. 

The frustration of having insurance, but it not covering the cost of life-saving treatments is cruel and cries for reform.  People are dying in record numbers from opiate addiction every single day.  When we do accept that we need help and seek it, instead we enter a whole other realm of pure agony and disappointment.  It is then that we realize the very real problem, which IS the Middle-Class dilemma.

 

 

 

 

 

 

 

 

 

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Erika Cormier, author of  the memoir, "As the Smoke Clears", understands first hand that addiction isn't always a "visible" disease.  She has dedicated her life to helping other women suffering from addiction and has drafted a bill to place caps on the high cost of outpatient addiction-related services.



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