Office-based opioid treatment centers that accept only cash to prescribe recovery medications such as Suboxone are hindering treatment and diverting dangerous medications to the street in Clark County and across Ohio, experts said.
But the clinics provide a necessary service for some patients who don’t have time for more extensive counseling, proponents said.
Suboxone is used to help people stop using heroin or other illicit drugs such as fentanyl without going through withdrawal.
A recent study of opioid treatment providers in Ohio by Dr. Ted Parran of St. Vincent Charity Medical Center in Cleveland showed about 48 percent of the clinics accepting new patients took only cash for services instead of insurance.
Some cash clinics charge about $500 for an initial office visit and $200 to $300 a week for follow-ups, Parran’s study found. Those appointments would typically be reimbursed $20 by Medicaid and $50 to $60 by Medicare, he said.
“If you saw a patient every week and asked for $200 for the month, that would be more in line with the typical $50 per outpatient visit that would be reimbursed by insurance,” Parran said.
Some doctor’s offices or clinics typically charge cash for recovery services, including providing prescriptions that can be filled at a pharmacy using Medicaid or Medicare, said Wendy Doolittle, CEO of the Springfield-based nonprofit drug treatment center McKinley Hall.
Those clinics typically won’t provide counseling treatment more than once a month, she said. Some clients have told Doolittle a portion of the prescription can be sold on the streets.
However, one local treatment center told the Springfield News-Sun that recovery medications can be used for people who work full-time jobs and cannot attend treatment three to five days per week.
Brenda Griffith is the director of the nonprofit Reasonable Choices Inc., a certified alcohol and drug treatment provider on Urbana Road in Moorefield Twp. The organization charges $150 per month for cash clients but also accepts Medicaid and private insurance.
“Our niche is a working class clientele,” Griffith said. “You can’t have one size fits all.”
Some people with good insurance will choose to pay cash for Suboxone or similar medications because of the stigma that comes with it, said Jeanette Limoli, a recovering addict and director of Choices Inc., a new outpatient treatment facility that opened in December on South Burnett Road. The facility accepts only Medicaid and private insurance payments, she said.
“Cash clinics sometimes give people a chance to go on with their busy lives but also get some help,” Limoli said. “Sometimes it can also be a place that breeds addiction because there’s not a lot of accountability. It all depends on what the clients going for … There’s got to be more than one way to get clean.”
More providers are needed in the community, especially those looking to collaborate with certified treatment centers on a full slate of services, not just prescribing medications, Doolittle said. The local substance abuse coalition hopes to educate doctors about prescribing recovery drugs in hopes of collaborating in the future.
“That medication is just that — it’s medication-assisted treatment,” Doolittle said. “Treatment is important. We need them to get on board with us and to work together with certified treatment centers so that people can get better … We need to make sure we’re not adding to the problem but correcting it.”
On the streets
Parran also is studying whether cash clinics prescribe more Suboxone to patients than needed.
“Law enforcement has that impression and the state pharmacy board has that impression but nobody really has the data to prove the point,” he said.
Initial data indicates clinics that accept insurance prescribe 16 mg per day of buprenorphine, a recovery medication, while those that require cash are more likely to prescribe 16 or more mg per day, Parran said.
“That then really becomes a moral and ethical issue for prescribers if requiring large amounts of cash for visits is associated with prescribing higher doses of an opiate that has a street value and can be diverted in order to generate money perhaps for office visits,” he said.
Most of the recovery medications sold on the streets is used by people as their own sort of outpatient detox, Parran said.
An 8 mg strip of Suboxone sells for about $20 on the street, according to the Ohio Substance Abuse Monitoring Network. If a patient needs 12 mg per day but receives 24 mg as part of a prescription, Parran said they can take what they need and sell the rest.
It also puts some addicts back in an environment with people who might be selling or abusing drugs, he said.
“It’s a very safe medicine from an overdose standpoint but it’s still a medicine of use and abuse and a medicine of addiction if used in the wrong way,” Parran said.
A drug raid at a Springfield home earlier this month netted 20 grams of drugs, as well as a pill bottle containing buprenorphine, according to court records.
Suboxone is moderately available in the Dayton region but is highly available in Columbus, which saw an increase in illegal use of Suboxone on the streets the first six months of 2017, according to the substance monitoring network.
Springfield and Clark County haven’t seen a lot of illegal Suboxone recently like in other areas, Springfield Police Division Opioid Diversion Officer Meredith Freeman said. The city has had an influx of methamphetamine and cocaine, she said.
“I’m not hearing (about Suboxone) like I used to,” she said. “I don’t know if that follows the trend that they’re going to different things now or different drugs.”
Making it harder
Reasonable Choices Inc. began as a free store and food pantry 13 years ago, said Griffith, a recovering alcoholic.
It later morphed into a counseling center and decided to offer treatment services to residents who were driving to Columbus for office-based treatment, she said.
In July of 2016, the Ohio Attorney General’s Office and the Drug Enforcement Agency raided the treatment facility’s office on North Limestone Street near Madison Avenue.
The search ultimately led to one of its doctors voluntarily retiring his license in lieu of further investigation in April 2017, according to the State Medical Board of Ohio.
Reasonable Choices hasn’t been charged criminally as of Feb. 21 but the investigation remains open and ongoing, Attorney General’s Office spokeswoman Jill Del Greco said.
Griffith told the News-Sun she hasn’t spoken with AG’s office since the raid.
Since that time, the nonprofit received accreditation from the federal Commission on Accreditation for Rehabilitation Facilities in December, Griffith said. It’s also in the process of opening both a peer support building at its old facility on North Limestone Street.
The organization accepts private insurance, Medicaid and cash payments, Griffith said. It typically charges about $150 per month, or $37.50 per week for its cash protocol, Griffith said. The majority of the people who pay cash continue to work professional jobs in multiple fields, including manufacturing, while using recovery medications, she said.
Some people can’t work full-time jobs and go to a clinic five days per week, Griffith said.
“You can’t have a cookie cutter, one-size-fits-all approach,” she said.
Griffith has never raised rates, she said, but other cash centers are charging hundreds of dollars per visit.
The center also cannot prescribe more than 16 mg of Suboxone per day because it doesn’t have an addictionologist on staff, she said.
The organization also offers Vivitrol — an injectable drug that blocks opioids from interacting with the receptors in the brain and eliminates the experience of feeling high. However, it requires clients to stay clean for 10 days before they take the injection, which has been difficult for some patients, Griffith said.
Next month Reasonable Choices will begin offering injectable Suboxone that will keep addicts from selling leftover strips, she said.
“These things are being addressed,” Griffith said. “It’s going to make it a lot harder.”
Later this year, the Substance Abuse Prevention and Treatment Coalition will sponsor a medical providers training about addiction, said Greta Mayer, CEO of the Mental Health and Recovery Board of Clark, Greene and Madison Counties.
They hope to host a dinner for physician, physicians’ assistants and nurses, Mayer said, that will include a discussion with an addiction specialist. The dinner will likely also include a panel discussion with local experts.
“They’ll understand the disease of addiction and they’ll understand the full continuum of treatment and recovery supports that are needed long-term so the medication is just one piece and how they can be a part of that one piece,” Mayer said.
After the training, the board will then host a training to help doctors get a waiver to prescribe buprenorphine, Mayer said. The Drug Enforcement Agency can then assign the physician a special identification number, which is required to be included on all buprenorphine prescriptions to allow for better record keeping.
“We’re hoping that general training will feed some interested folks to learn about how to do this type of treatment so we have more responsible, ethical, quality providers in the community,” Mayer said.
Some doctors may look at Suboxone as harm reduction because it’s not heroin or fentanyl, Doolittle said.
At McKinley Hall, treatment includes nine hours per week of counseling, including educating patients about addiction and triggers, as well as group therapy, Doolittle said.
“If more doctors can see just how effective this is, it may change their minds,” she said.
Most people use services for about a year, including recovery housing, transportation, peer support specialists and case management, she said.
“All of these things are required for people to get well,” Doolittle said. “You can’t just do a 15-minute session and give someone 24 mg of Suboxone per day and think they’re going to get well.”
SPRINGFIELD’S OPIOID WAR