Insurance company red tape: a potentially deadly barrier to opioid addiction treatment

America is in the midst of an opioid epidemic, with more than 40,000 people dying from overdose each of the past two years and millions more at risk. News outlets have been covering the story from seemingly every angle. 

And yet, there are still angles to be explored. In this story, NPR took on the burdens of addiction to families — not only personal loss when a family member dies, but economic impact.

One line in the story stood out to some readers:

Her parents say Katy had been trying to fill a prescription for medication to blunt the drug cravings, but insurance required a waiting period. 

Listen to this & rage. Daughter struggles with OUD. Family loses life savings on costly, likely non-evidence based “rehab” & then loses daughter to OD. Just prior to death, daughter unable to fill Bupe Rx due to insurance barriers. THAT is the story @npr https://t.co/5eRbpd0Tug

— Jonathan Giftos, MD (@jonathan_giftos) April 19, 2018

Jonathan Giftos, MD, is a physician at Albert Einstein College of Medicine and he’s clinical director of substance abuse treatment at Rikers Island, the New York City jail.

Here’s the shorthand: OUD is opioid use disorder and OD is overdose. “Bupe” is short for buprenorphine (brand name Suboxone), a medication Katy’s doctor prescribed (that’s the “Rx”) to help with opioid withdrawal.

But what are these insurance barriers?

The NPR story and Giftos are referring to “prior authorization,” when an insurance company requires “an extra step and more information before they approve a medication,” says Sarah Wakeman, MD, via email. Wakeman is an addiction specialist at Massachusetts General Hospital. In practical terms that means a physician writes a prescription, but the pharmacist cannot fill it. The doctor has to fill out a form with more information, submit it to the insurance company, and wait for a reply — which can take up to 72 hours. They may be required by the company to provide specifics of the case over the phone. “Meanwhile the patient is waiting without medication,” Wakeman says.

Insurance companies impose prior authorization for certain medications, sometimes for cost reasons or sometimes because they think another treatment is preferable. These restrictions vary by company and by state.

“In the setting of opioid use disorder this can mean 72 hours where a person is at imminent risk of death from overdose,” Wakeman says. 

Barriers to treatment

Buprenorphine works by reducing cravings and staving off withdrawal, which allows people to break the dangerous cycle of addiction — the risky behaviors or the inability to have a functional daily life. It also reduces the risk of death from overdose. It’s one of three so-called medication-assisted treatments for opioid addiction. (The other two are methadone and naltrexone.)

Medications for addiction come with their own stigma. Some people, including former Department of Health and Human Services Secretary Tom Price, say they substitute one addictive drug for another. Such objections essentially ignore the evidence basis for buprenorphine and methadone in reducing overdose mortality (and other health risks). More than half of all drug addiction treatment facilities don’t even offer medication-assisted treatment as an option for recovery.

“I think a combination of stigma and misinformation has guided a lot of the barriers to effective treatment with medications for opioid use disorder,” Wakeman says.

Other barriers include restrictions on who can prescribe buprenorphine and caps on how many patients they can prescribe to. These restrictions were reasonable when the medicine was first approved in 2002, says Michael Bierer, MD, a HealthNewsReview.org contributor and an addiction specialist at Massachusetts General Hospital. People were worried about diversion and misuse, putting another abusable drug out on the street. “That’s why the rollout was very cautious.”

Bierer says there’s some justification for prescriber training and limiting patients, as well. “Patients with opioid use disorder have complicated lives in general,” he says. “A few people only need their prescription — they’re fine, they’re working, they have a family — but many more have co-morbid psychiatric and social problems.”

But the prior authorization? “It’s standard operating procedure in a messed-up medical system,” Bierer says. A doctor-written opinion piece in the Washington Post attests to the grave impact that this barrier has on patients who need access.

A few points of change

Buprenorphine has risks, as all medications do, but the benefits are profound — it can save lives. One could make the case that easier access to the drug could stem the death toll. France is a good case study; the country dropped prescribing restrictions on buprenorphine in 1995 and dramatically reduced the rates of opioid overdose deaths.

Wakeman says: “Many insurance companies are coming around on this issue and are aware of the evidence showing that medication treatment is more clinically and cost effective, which is a long time coming.” Indeed insurance giant Aetna dropped its prior authorization requirement for buprenorphine last year. 

Massachusetts recently passed legislation removing prior authorization for buprenorphine up to a certain dosage. Bierer says that he and his colleagues spend noticeably less time on the phone with his patients’ insurance companies.

Giftos’s tweet generated several replies from doctors and journalists.

Marc Larochelle MD, a Boston University internist, tweeted: 

I'll rage. Prior auth for bupe needs to end – there is no rational defense of it. Life saving, first-line med with a single indication. Only serves to further stigmatize individuals, their illness and furthers challenges to expanding access. https://t.co/fVSLweVrp2

— Marc Larochelle (@LarochelleMarc) April 20, 2018

Maia Szalavitz, a journalist and author whose beat is addiction, tweeted: 

exactly, how do you cover this without highlighting that she died because she wasn't allowed to access medication *proven* to cut death risk by half or more??? this isn't some random tragedy: it's malpractice. https://t.co/Kekq3bXxqJ

— Maia Szalavitz (@maiasz) April 19, 2018

As the US continues to grapple with the opioid crisis, we’ve only found a few news outlets reporting on this part of the story, including an earlier story by NPR. Despite the few bright spots of change by some insurers and some states, the practice continues. I’d like to see more health care journalists take it on.