Despite all the attention focused on the opioid addiction epidemic, the delay in prescribing buprenorphine because of insurance company rules has created a significant obstacle to treatment. There is no evidence that the requirement for prior authorization improves the quality of care or reduces medical costs; In fact, the opposite is true. This seemingly minor and little known administrative process has endangered patients, in addition to diverting medical staff from their clinical work by necessitating hours of waiting on a telephone line.
With buprenorphine, patients must be in withdrawal before they begin to take it. Otherwise, buprenorphine will cause “precipitated withdrawal,” severe withdrawal symptoms instead of relief from them. Patients are therefore instructed to stop using opioids the day before their treatment appointment so they will begin to experience withdrawal symptoms that will be quickly relieved by the buprenorphine they receive when they arrive.
If patients follow the instructions but the insurance company takes a few hours to state that the patient only needs to wait for another 24 to 48 hours for a decision, the discomfort of intensifying symptoms will often drive patients back to the addictive substance for relief. The irony is that of the 5,000 requests that we have made in over 14 years, none has been denied. This unreasonable and dangerous requirement has been so frustrating that several years ago I, along with several colleagues, began trying to eliminate it. We are about to celebrate achieving that goal.
On March 2nd, I testified before the Heath and Government Operations Committee of the Maryland Legislature in support of House Bill 887, submitted by Delegate Joseline Pena-Melnyk. It bans in Maryland the prior authorization process for any medication approved for the treatment of opioid addiction. A team led by Ellen Weber, a University of Maryland Law Professor and Ann Ciekot, an addiction advocate, convinced the insurance industry to drop its opposition and join us in supporting the bill.
On April 11, the Maryland Legislature passed the bill, and the Governor is expected to sign it shortly. When I announced this impending event to several hundred addiction specialists at the Annual Meeting of the American Society of Addiction Medicine, the room packed with clinicians who shared my frustrations erupted in applause. Many of them came up to me afterward and asked how they could replicate this in their own states. I plan to help them start a movement so that prior authorization for buprenorphine will be abandoned by the insurance industry and a barrier to addressing the opioid epidemic will be removed.