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Insurance Rules Curtail Use Of Drug To Fight Opioid Addiction, Study Says

February 17, 2019

A two-decade surge in opioid overdose deaths has prompted health officials, addiction specialists and the federal government to declare opioid addiction a public health emergency.

But researchers at Oregon Health & Science University recently found that a potentially life-saving drug shown to block the effects of opioids has gotten harder to access for a large portion of patients over much of that time.

In a newly published research letter in the Journal of the American Medical Association, an OHSU team found a sharp rise in insurer reluctance to cover prescriptions of buprenorphine, an opioid derivative regarded by many addiction specialists as a safe and effective treatment for opioid use disorder.

The rate of insurance plans offering buprenorphine coverage through Medicare Part D without restrictions plummeted from 89 percent in 2007 to just 35 percent last year. While coverage of the drug remained high throughout that period, prior authorization – the requirement that physicians gain insurance approval before prescribing the drug – increased.

“We were very startled by what we saw,” said Dan Hartung, an associate professor in the joint OHSU-Oregon State University College of Pharmacy program, and a co-author of the research letter. “But in a way it kind of jibed with what we’d been hearing, just in clinicians who treat patients with these disorders, that dealing with insurance company hassles is one of the top issues that they have to navigate in making sure patients have the treatments they need.”

Taken in several generic forms, buprenorphine can prevent opioid withdrawal symptoms while providing many of the same pain-dulling properties. But unlike other opioids, where painkilling effects are heightened along with the dosage, buprenorphine’s effects level off at a moderate dose, which pharmacologists say lowers its dependency and overdose risks. And unlike methadone treatment, which historically hasn’t been covered by insurance, buprenorphine can be prescribed by a primary care physician, provided they’ve undergone eight hours of training to qualify for a waiver from the U.S. Drug Enforcement Agency.

But the research letter cited insurance cost-control measures as a major factor in why its authors consider buprenorphine underused. The Oregon Legislature is currently looking at loosening prior authorization restrictions.  

Some of the workers on the front lines of Oregon’s opioid addiction battle say insurer reluctance to prescribe buprenorphine can put lives at risk by making sufferers of opioid use disorder wait days, weeks or even longer before receiving critical treatment.

“Prior authorization is a huge hurdle, and it’s totally short-sighted for a health system,” said Dwight Holton, CEO of Lines for Life, an Oregon substance abuse and suicide prevention nonprofit. “People who are dependent on opioids are a much more expensive burden on the health care system than people who aren’t.”

For insurers, prior authorization is meant to control the cost of prescription drugs. With the cost of buprenorphine in an opioid treatment program estimated at $115 per week, according to the National Institute on Drug Abuse, ensuring the drug is only prescribed to patients who truly need it keeps the price from rising even higher, said Cathryn Donaldson, spokeswoman for America’s Health Insurance plans, a Washington, D.C.-based health insurance company advocacy group.

Medication-assisted treatment “including buprenorphine is a critical part of a comprehensive, evidence-based treatment and recovery strategy for (opioid use disorder),” Donaldson said in an email. “But we also know (medication-assisted treatment) alone doesn’t guarantee a successful recovery from opioid use disorder. Patients need personalized treatment plans for ongoing recovery including counseling, other psychosocial supports, as well as coordinated care for related physical and mental health needs.”

Some health insurers are lifting prior authorization requirements for lower dosages of medications like buprenorphine, Donaldson said. But over-prescription risks further spiking opioid treatment costs.

“These price increases impact both patients managing pain and those suffering from substance use disorder,” she said.

Still, the OHSU study found prior authorization rates rose sharply even for the cheapest generic version of buprenorphine.

The issue has Oregon lawmakers’ attention. A state report on opioid addiction mandated by the state Legislature last year found most insurance carriers placed buprenorphine in one of their two highest-cost tiers. It concluded that preferred drug lists and prior authorization requirements “restricts the use of buprenorphine products to the management of opioid use disorder.”

Several bills in the current legislative session seek to address those restrictions. Proposals that could be voted on in the coming months include two-day time limits for insurers to make prior authorization determinations, guarantees of a minimum supply of a medication once it’s approved and prohibition of its use for treatments that a physician deems medically necessary for a patient, as long as it falls within insurer limits.

Even with more focus on the issue, the high cost of buprenorphine and the lack of prescribing physicians in rural parts of Oregon make the drug difficult to access for many of the patients who would most benefit from it, said Dr. Jim Shames, medical director of Jackson County Health and Human Services and a physician certified in addiction medicine.

“If buprenorphine were cheap, would we really be having all these prior authorizations and scrutiny of a drug that is clearly safer than any other opioid, and is a useful tool?” Shames said. “I think it’s helpful to remember that part of what we’re dealing with is the fact that we have a drug-pricing system in this country that is based on the pharmaceutical companies’ whimsy. We’re left to deal with that.”

You can reach Elon Glucklich at [email protected].