Reproductive Health of Women in North Carolina’s Opioid Treatment Programs

 

 

 

 

 

The November/December issue of the Journal of Addiction Medicine, (Volume 13, Number 6), published a great article based on a 2017 survey of opioid treatment programs in North Carolina. This study was done by the University of Chapel Hill, and the article was titled, “Provision of and Barriers to Integrating Reproductive and Sexual Health Services for Reproductive-age Women in Opioid Treatment Programs.”

Of course, since this data is from my state of North Carolina, I read it with extra interest.

The article reminds us of what we know about women with opioid use disorders: they are more vulnerable to reproductive health issues. These women tend to have more pregnancies, with about 54% having four or more lifetime pregnancies, compared to 14% of women without opioid use disorder having four or more lifetime pregnancies. About 85% of the pregnancies of women with opioid use disorder are unintended, compared to around 45% for women without opioid use disorder. Women with opioid use disorders are less likely to use contraception and about five times more likely to have had an abortion.

Opioid use disorder increases the risk of gender-based violence and increases the risk of infections, for Hepatitis C and B, HIV, and sexually transmitted diseases. Adverse childhood events, termed ACEs, include stressful or traumatic life events, and are associated with reproductive health problems. Women with ACE history are much more likely to develop substance use disorders in general, including opioid use disorder, so a large portion of women enrolled in treatment at OTPs have this additional mental health burden affecting reproductive health.

Since medication is recommended for all patients with opioid use disorder, the authors of the article say pregnant and nonpregnant women with opioid use disorders could get care for reproductive health services within the opioid treatment program. They suggest this would be a way to reduce unwanted pregnancies, opioid-exposed pregnancies, sexually transmitted infections, and improve the overall health of women in these treatment programs.

The article described a survey sent to the medical directors and program directors of all forty-eight opioid treatment programs in the state, in order to assess the extent of reproductive health services offered to reproductive-age women enrolled in NC OTPs, as well as to explore perceived barriers to integrating such services into the care provided at OTPs.

Of the forty-eight OTPs surveyed, thirty-eight completed the survey. Of the programs that responded, 37% were private nonprofit organizations and 63% were private for-profit organizations. Thirty-four percent were in rural counties, 29% located in urban areas and 37% in suburban areas.

Only 21% of the responding OTPs offered female-specific programs.

Most OTPs accepted Medicaid, at 68%, and those programs served more women of reproductive age than did the non-Medicaid programs, which makes sense. The average length of treatment was longer for women in Medicaid program compared to non-Medicaid programs.

Twenty-one percent of OTPs offered non-prescription contraception, while only one program offered prescription contraception.

Only 89% of OTPs did on-site pregnancy tests, meaning 11% are not performing this simple and necessary test for patients.

To summarize this study, the OTPs of NC aren’t doing all they could to address female patient’s reproductive and sexual health issues.

I agree with this finding, and yet, I was a bit offended with the accompanying commentary in this issue of Journal of Addiction Medicine. Dr. Tricia Wright says that OTPs believe it’s outside the scope of their service to provide reproductive and sexual health services, and that this view is “dangerous and wrong.” She says such care is basic care and OTPs can and should do better for their female patients.

Now you’ve stepped on my toes and I’m going to have to step back.

I agree that more services should be provided, including female sexual and reproductive health. After all, as the article’s authors concluded, such efforts have the potential for great good. Increasing reproductive health of our female patients promotes health of children and families, and ultimately, society.

However, as this survey or providers discusses, there are obstacles to providing such services.

First, OTPs care for people with other equally important challenges. Our patients struggle with homelessness, lack of food, serious mental and physical health issues, all of which need addressed. Our resources are limited, both of time and money.

For example, a new patient injecting heroin might be homeless, with no way to afford food, and have serious mental health issues. Such a sick patient needs inpatient care which usually is not available. For example, our state-run program refused to admit a homeless diabetic because her blood sugars weren’t under control. They refused to admit an HIV positive patient because she wasn’t on proper medication for her HIV. Of course, with substance use disorders raging out of control, those goals weren’t realistic.

Our OTP takes care of many such challenging patients as best we can, because usually it’s their only option for care. Ultimately, we do hope to get them care for their other issues, in the form of referrals, because we don’t have the time or personnel to provide those services.

Second, OTPs may not have personnel with the expertise to manage reproductive health needs

I am trained in Internal Medicine. This means I could manage some simple primary care and even some uncomplicated gynecologic and mental health care for OTP patients. But my time is spent providing medication-assisted treatment to those patients. I would have to work additional hours if we provided primary care, probably at least double the hours that I now work. I would need a way to care for those patients for after-hours emergencies. I don’t work for free, and neither do the nurses. The company I work for would have to pay for this expense. They could bill Medicaid, but at least half our patients don’t have any insurance at all. Most uninsured patients get their OTP treatment paid for with grant money, but that doesn’t cover primary care services.

Many OTPs have a psychiatrist as a medical director. They could address mental health needs, but probably wouldn’t be comfortable doing and primary care, and certainly not reproductive health.

In order to meet even some of the reproductive and sexual health needs of just the female patients (ignoring male patients completely for some reason), additional providers would have to be hired. Who pays for that?

It makes more sense to me to have providers come to our OTP to provide essential services under one roof. One day could be for obstetric/gynecologic care. A local OB could come to our facility and see patients all day. Another day could be for a psychiatrist to come and treat patients, and maybe two days for primary care providers to see our OTP patients. It’s an ideal solution, except for finding willing providers, and a way to pay them.

Don’t even get me started on our patients’ dental care needs. We could hire a full-time dentist and keep her busy with only our opioid treatment program patients. But again, who would pay?

I get weary of unfunded mandates and recommendations for opioid treatment programs. I feel like much is expected of providers at opioid treatment programs, mainly because no other providers want to treat these patients.

Our patients often get superficial and substandard treatment from the local emergency department and local providers’ offices due to the stigma against people with substance use disorders in general. Part of this could be because some of our patients offend providers with their desperation and neediness. Patients enrolled at “that methadone clinic” face extra judgment from some providers, making it more difficult for our patients to access appropriate medical treatment.

It’s not feasible for OTPs to provide all the services that patients need, and certainly not fair to expect OTPs to provide this care for free because other providers don’t want to deal with our patients.

OTPs have and will pick up what pieces we can, but maybe it’s not fair to ask OTP providers to fix a broken healthcare system.

STOP Writing Paper Buprenorphine Prescriptions in North Carolina

 

 

 

 

 

The North Carolina STOP Act of June 2017 says that all Schedule 2 or 3 opioid medications must be prescribed electronically as of January 1, 2020. I blogged about this before, on September 8^th of 2019, but I wasn’t sure buprenorphine was included.

Now I’m sure that it is included. I communicated with the NC Attorney General’s office and was assured all buprenorphine products are on the list of opioids which must be electronically prescribed.

Most providers probably already have e-prescribing. But in the OBOT (office-based opioid treatment) world, there are many small practices who may not yet have switched to E-prescribing. It is imperative that you do so by January 1, 2020.

According to the medical board’s website, it doesn’t matter if you only plan to write a few opioid prescriptions per year. The quantity prescribed doesn’t exempt you for the e-prescribing mandate.

I’m a little worried about the opioid treatment programs that also have some office-based patients for whom they prescribe. Most OTPs have electronic medical records, but these aren’t set up to communicate with local pharmacies. I don’t know what kind of solution will be found for these patients and their physicians, but I imagine each facility will need to purchase e-prescribing capabilities…and they will need to do it quickly, given the deadline looming one month away. Hopefully these programs already have provisions to comply with the new law.

What will happen if you ignore the new law and continue to issue paper prescriptions? Per the NC medical board website, it’s initially up to the pharmacy. They can choose to fill a paper prescription, or they may call the prescriber to make sure he/she knows about the new law. With repeated paper prescriptions, pharmacies can report these prescribers to the medical board for investigation. The medical board’s website says it will “…determine an appropriate resolution based on the individual circumstances of each case.”

Like all prescribers, I prefer not to come to the attention of our medical board as a provider who is violating the law. I don’t plan to put myself in the position to find out what “appropriate resolution” means. I encourage other buprenorphine prescribers to comply with the STOP Act, so they won’t have to worry about it either.

E-prescribing is relatively easy to learn. If I was able to use it after a few hours of instruction, anyone can learn it, because I’m naturally slow to grasp technical or electronic learning challenges. The program I purchased for my office doesn’t cost much, only about $30 to $50 per month for a program that meets DEA security standards.

Here’s a link to the DEA’s website with answers to questions about E-prescribing systems in general: https://www.deadiversion.usdoj.gov/ecomm/e_rx/faq/practitioners.htm#transmitting

Here’s a link to the NC medical board’s FAQ page about E-prescribing compliance with the STOP Act: https://www.ncmedboard.org/landing-page/stop-act

I’m happy with my E-prescribing system. It still takes me a minute or two longer to complete than paper prescriptions, but there’s better security, which makes me feel better.

An Evening of Enlightenment

 

 

 

 

I had the great pleasure of going to a training held by Dr. Alan Wartenberg last week, at the Revida Recovery facility in in Johnson City, Tennessee.

His topic was opioid use disorder and its treatment with medication, but the talk was so much more than that. He covered all of that competently and easily, but his talk was funny, poignant, and encouraging. He reminded me of why I love my job.

I loved every minute of his talk, and I felt uplifted and enthusiastic afterward. I went with my long-term fiancé and chatted excitedly for about half of the long drive home. My fiancé, who is an addiction counseling professional specially trained as a Motivational Interviewing Network of Trainers also found the experience to be of great value.

The whole meeting was about four hours, with the first part being educational, then ended with a long question and answer session.

Dr Wartenberg has been around while. He lived through the ridiculous phase of twenty years ago when physicians practically threw opioids at patients for any type of pain. He used intravenous buprenorphine for patients in detox units as far back as 1992, which is kind of amazing.

I particularly absorbed his message about the importance of keeping all patients in treatment, barring specific dangerous situations.

It’s been a very long time, thankfully, since I’ve tapered patients out of treatment because they couldn’t or wouldn’t stop using marijuana. It hasn’t been all that long since I stopped tapering patients out of treatment for continued stimulant use disorder (methamphetamine, cocaine). This year, I’ve become more reticent to taper patients off methadone and buprenorphine because they continue to use benzodiazepine and/or alcohol.

After listening to Dr. Wartenberg, I’m convinced I must go farther in this direction.

In this third wave of the opioid epidemic, fentanyl use changes the decisional balance. Relapse back to heroin/fentanyl use presents such an increased risk of death that it dwarfs the risks of benzodiazepine, alcohol, and other sedative use in methadone patients…in many cases.

There will still be some cases where the risk of remaining on methadone will be too high; for example, if the patient comes to the opioid treatment facility impaired, or if the patient has accidents and continues to drive while on methadone and sedatives. We have a duty to our communities and to other patients to keep the OTP from becoming a negative influence.

But for patients with regular benzodiazepine use without factors that indicate imminent danger, I now feel like I need to work harder at increasing their counseling and contact with treatment staff, without asking them to leave treatment. And I need to push harder for the state ADATC to admit struggling patients to detox and rehab, while continuing their buprenorphine and methadone.

So I had a great evening. Besides what I gained from Dr. Wartenberg, I got to spend a few hours with the love of my life driving through beautiful mountains, I saw some old friends, and I met new friends, other providers working hard to help our patients.

I appreciate Dr. Wartenberg’s experience, passion, and for his ability to re-ignite my enthusiasm for working with our patients. He reminded me of the importance of doing my best for the patient sitting in front of me. And that’s really what’s most important.

 

 

 

Patients with Prior Overdose Still Prescribed Opioids & Benzos

 

 

 

 

I read an interesting article in the latest issue of Journal of Addiction Medicine, titled “Prescribing of Opioids and Benzodiazepines Among Patients With History of Overdose,” by Griggs et al.

This article described a retrospective chart review of patients who had a previous history of opioid or benzodiazepine overdose. They identified patients who were prescribed either an opioid or benzodiazepine in a one-month period, in 2015, then reviewed their charts to see how many of these patients had a previous overdose. Then they studied the patients and prescribing situations to see what they had in common.

This study was done at a large healthcare system based in Charlotte, NC. The system is based at the same hospital where I did my residency in Internal Medicine about a billion years ago. OK, maybe it was only thirty-two years ago, but it feels like another lifetime. This hospital system has a robust Addiction Medicine department now, led by Dr. Stephen Wyatt, an addictionologist of national and perhaps international renown, who co-wrote this study.

The article began by reminding us of the recent increase in morbidity and mortality with opioid use disorder. Then it cited another article that I have written about (see my blog of January 23, 2016) authored by Larochelle et al., 2015, where it was found that in patients who survived an opioid overdose, 91% resumed opioid prescription within the next nine months.

Based on those previous findings, this study proposed to examine the prevalence of prior overdose among patients being prescribed benzodiazepines and/or opioids, and to examine patient and healthcare characteristics in these circumstances.

The study found 543 patients with prior opioid or benzodiazepine overdose history who were prescribed benzodiazepines or opioids during the designated month of the study. All the providers involved in this study use the same electronic medical record (EMR) which contained information about prior overdoses from 2007 forward, though no specific alerts appeared in the EMR.

Interestingly, opioids were involved in just under half of the overdose episodes among these identified patients, and benzodiazepines without opioids were involved in just over half of the overdoses.

Most of the identified patients received opioid or benzodiazepine prescriptions within two years of their documented overdose. Opioids accounted for around 72% of these prescriptions, with benzodiazepines accounting for around 23%, and 5% of the patients got both an opioid and a benzodiazepine, which is a particularly worrisome combination.

Of the patients prescribed opioids and/or benzodiazepines who had a prior overdose, 70% were between the ages of 35 to 64 years old. The leading cause, at 51%, of the prior overdose was unintentional, though 40% were suicide attempts. Many patients had mental health diagnoses: 54% had an anxiety disorder, 55% had depression, and 24% had bipolar disorder. Nearly a third, at 29%, had a diagnosis of substance use disorders.

Around a third of the opioid prescriptions were given for chronic pain issues, despite the prior overdose history. Over 25% of the opioid prescriptions were for more than 50mg daily morphine milligram equivalents. Around half of the patients had a prior drug screen in their record that was positive for marijuana, cocaine, or alcohol.

Most of the post-overdose prescriptions for opioids or benzodiazepines were given in outpatient clinics or emergency departments, but over a fourth of the prescriptions were issued after a medical phone call consultation. Only 5% of opioid or benzodiazepine prescriptions were issued from behavioral health providers, and less than 1% were from cancer care providers.

In the discussion section, the authors of this study voiced surprise that in a fourth of the patients, benzos and/or opioids were prescribed after a telephone consultation. The authors appropriately caution prescribers against this practice.

Having practiced in primary care for ten grueling years, I understand the telephone consult. Heaven help me, but sometimes I was tempted to allow medication to be called in because it would save me time and effort. It would also spare me the unpleasantness of having to see the patient in my office, and the extra time required.

I’m not intentionally being insulting to patients, but I felt patients who repeatedly asked for controlled substances were often miserable people who weren’t fun to take care of. They hurt, both physically and emotionally. I felt hopeless when I saw them, like nothing I could do or say would help them anyway, so where’s the harm in giving them a much-desired controlled substance?

Of course, now that I’m older, wiser, and better educated, I suspect many of these patients had treatable substance use disorder and/or mental health disorders.

The authors of the study concluded that providers for this patient group could have done a better job of identifying higher risk patients. The prescribers could benefit from an electronic tool, which according to the article is presently being developed, to support decision making processes and quantify the risk for a given patient.

I’ve talked in this blog before about the perils of labeling patients as “frequent flyers” or “drug seekers,” pejorative terms that create obstacles between needy patients and their providers. That old kind of labeling fosters the outdated idea that people with substance use disorders are bad, rather than sick. With that old system, patients can receive bad care, because providers stop thinking and start judging.

Instead, this article describes a better idea – one that provides information about the degree of risk for a given patient, before potentially harmful medications are prescribed. It sounds like this sort of tool can help providers mitigate risks for some patients, while not denying them appropriate medical care.

In other words, a high-risk patient with an acute pain situation, like a broken bone, may still need opioids, but fewer pills might be prescribed, with more frequent follow up, than patients at lower risk for overdose.

I don’t know if the tool this healthcare system developed is proprietary; I think I will ask for an example of how it works. I don’t work in primary care any more (addiction medicine is so much more fun), but I like to stay informed about these things.

The Opioid Lawsuits

 

 

 

 

Around twenty-seven hundred plaintiffs, composed of states, counties, and cities, have joined the lawsuit against drug manufacturers, distributors, and some pharmacy chains. Their lawsuit alleges these companies acted illegally and contributed to the opioid epidemic. Last month, some of the organizations being sued offered a common-sense solution that would benefit people with opioid use disorder. [1]

The actual lawsuit is similar to lawsuits against Purdue Pharma, manufacturer of OxyContin. Purdue filed for bankruptcy in September of 2019, offering a settlement to twenty-five hundred or so plaintiffs which included states, cities, counties, and tribes. The proposed settlement, announced in September of 2019, totaled around $12 billion, with $3 billion coming from the Sackler family directly.

Proponents of the Purdue Pharma settlements say it avoids wasting time and money on protracted litigation, which usually provides maximum benefits to the the lawyers on each side, rather than the plaintiffs. A quick settlement also – in theory – makes money available more quickly to people suffering from the opioid epidemic.

On the other side, some lawyers point out this money won’t be enough to cover the damage caused by the opioid epidemic. Some doubt that those who need it will receive much of the $12 billion. They also object to the fraction paid by the Sackler family, owners of Purdue Pharma, made rich by the sales of OxyContin over the years. The settlement, as it stands now, has no provision for admission of guilt by the pharmaceutical company, which does not sit well with some of the plaintiffs.

Both sides make good points. However, I don’t think there’s a settlement large enough to cover all the damages caused by the opioid epidemic, so that’s not a realistic demand. Deciding who benefits from a settlement needs to be determined by representatives of the plaintiffs, not the defendants.

But now last month, a group of pharmaceutical companies, drug distributors, and pharmacy chains proposed a settlement of the lawsuit being brought by states, counties, and cities across the nation. Teva Pharmaceutical, Johnson& Johnson, McKesson, Amerisource Bergen, and Cardinal Health. and announced recently a proposed settlement amounting to $23 billion including some interesting provisions.

Teva, an Israeli company, agreed to provide their part of the settlement of the lawsuit in the form of generic buprenorphine/naloxone tablets to treat opioid use disorder. They would also pay $250 million over ten years. They claim to be capable of providing all the treatment medication needed by patients in the U.S., after a few years to ramp up production.

The drug distributors agreed to distribute this medication for free, which would allow patients access the treatment medication for next to nothing except a small dispensing fee from the pharmacy, which might also be waived by the lawsuit agreement.

The common sense of this settlement is astounding. This settlement would directly benefit the people who need it most. That’s always a challenge in this sort of lawsuit; even when money is won, distribution of the money can be contentious. I’m sure we all could imagine ways the money could be mis-managed and end up in pockets of people who haven’t been extremely affected by the opioid epidemic. But the people who developed opioid use disorder – they deserve help accessing treatment.

Medication-assisted treatment is the gold standard of treatment for opioid use disorder, so this settlement idea is based in good science and supported by tons of literature. Besides the reduction in overdose death seen in treatment with methadone and/or buprenorphine, medication to treat opioid use disorder is also associated with better physical health, lower rates of crime, lower suicide rates, and higher employment rates.

This settlement makes sure an evidence-based treatment gets funded, instead of over-used treatments that are outdated and ineffective, such as detoxification episodes. The relapse rates for patients with opioid use disorder are greater than 90% with detoxification, yet we see patients cycle in and out of detox, over and over. Detox alone also increases the risk of death. After patients leave detox, tolerance for opioids is reduced, creating a dangerous risk for overdose death when the relapse does happen. Can you think of any other treatment in the field of medicine that increases the risk of death, yet remains standard practice in many communities? If you did a procedure or prescribed a medication that increased the risk of death to people with diabetes, malpractice lawsuits would sprout all over the place.

Not so with the treatment of opioid use disorder.

Teva has made a common sense offer that allows them to do what they do best – make pharmaceuticals – in order to help people with opioid use disorder. The distributors would do what they do best – distribute – in order to help people with opioid use disorder.

Rarely in civil litigation do we see such meaningful settlements with the potential to help the people who suffer most from corporate wrongdoing. This could be a great example of corporate amends…when you break something, do your best to fix it.

Also, this solution would allow Teva and other pharmaceutical companies and distributors to stay in business. Demanding an unreasonable payday might push these big companies to declare bankruptcy and go out of business. These companies provide employment for people and provide services to our nation. We need them to stay in business, while still acknowledging the harm they did and taking financial responsibility for helping clean up the mess

Only the combination product would be donated. This means patients who are prescribed the monoproduct purely for economic reasons could be switched to the less-divertible combination product. That would be wonderful for facilities like the opioid treatment program where I work. Right now, our OTP buys monoproduct because it’s the cheapest form of buprenorphine on the market. Since we do directly observed dosing, diversion is less of an issue, though still an issue. With this sort of agreement, we would switch to the combination product, since not only would the combo product be less expensive, but it would be free.

What would this mean for opioid treatment programs? I’m not sure, but if OTPs could obtain buprenorphine/naloxone treatment medication for free, there should be a corresponding drop in treatment fees. Perhaps instead of a patient having to pay $15 per day for buprenorphine 16mg, they might pay less than $8 per day. I don’t know how much our OTPs pay per pill now, so I’m estimating. I do know that a bigger chunk of what OTP patients pay each day goes to medication costs with buprenorphine, compared to patients on methadone.

For patients who dose at OTPs who are now covered by the recent SORs and CURES grants, that’s money that could be saved, and spread farther to cover more patients. It’s a direct benefit to the taxpayers.

Some patients now on methadone for the treatment of opioid use disorder would switch to buprenorphine/naloxone if it were cheaper. At the opioid treatment program, some patients start methadone because it costs about three dollars per day less than buprenorphine. Again, it doesn’t sound like much of a cost savings, but $3 per day adds up over time. With this proposal, choosing buprenorphine/naloxone would be the cheapest (and often safest) option for treatment.

Of course, there are nay-sayers regarding the settlement. Already, I found online articles complaining that the $23 billion was based on Teva’s retail price for the medication and not their cost of producing the medication.

I suspect lawyers representing plaintiffs won’t be happy about the settlement. If they take cases like this on contingency fees, they would be happier with a big settlement where they take their percentage off the top. This solution wouldn’t benefit lawyers as much as the people who have opioid use disorder, and their families.

I’m proud that my home state of North Carolina is one of four states supporting this innovative settlement proposition along with Tennessee, Pennsylvania, and Texas. The other states, not to mention numerous counties and cities, have not – yet – agreed to the proposed settlement.

There are sure to be talks about pros and cons of the settlement, but I’m hoping this proposed settlement moves forward, because I love a common-sense solution.

1. https://www.biopharmadive.com/news/teva-opioid-settlement-offer-23-billion-suboxone/565493/

I’m Back

 

 

 

 

 

 

I’m back to blogging, after a short break, during which I took my Addiction Medicine board re-certification exam. I think I did well on it, but with those sorts of exam one never knows for sure. If any of my readers are planning to take the exam soon, I have a bit of advice: it’s great to go to the annual Review Course hosted by the American Society of Addiction Medicine, but you should also read the textbook, “Principles of Addiction Medicine.”

I listened to both the 2018 and 2019 Review Courses online. Those courses are great if you want to know all the essentials of the field. However, many of the questions on the test went a layer deeper than the review courses covered.

For example, rather than just asking which receptor type a drug of abuse activates, the test would ask what subtype of that receptor was involved. I don’t find that sort of question to be clinically relevant, but then I’m not a researcher, just a worker on the front lines of the opioid epidemic.

So now I’m happy to back into my routine, seeing patients and doing the work I love.

However, this month I’ve had to confront issues that I thought were resolved months ago. For example, I’m vexed by new prior authorization forms. It seems that large insurance companies like Cigna might be asking smaller companies to do their management of prescription costs, a service euphemistically called “pharmacy benefit management.”

This is an example of a form I got last week:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

As you can see, it asks for chart notes, drug screen results, documentation that the patient isn’t on any other opioids, per the state prescription monitoring program, and a plan and evaluation/assessment for potential to taper.

This happens to be a patient of mine who has been in successful, relapse-free recovery for over nine years. She is extremely high functioning at her job, and a delightful patient. I provided all the information they needed to approve her generic buprenorphine/naloxone medication, but I don’t think that should be required for coverage. They approved it for only six months, so we’ll have to repeat this process twice per year.

I think it’s discriminatory to demand this of a patient in treatment for opioid use disorder, but not for diabetes. It also discourages providers from wanting to treat patients with buprenorphine products, since it requires considerable time and energy to respond to these prior authorization demands.

Another company, called Southern Scripts, working for a larger health insurance company, asked for this form to be completed on a patient prior to paying for his buprenorphine/naloxone tablets:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

After completing the form and asking for an expedited review, I got this letter:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

There’s no way I’m sending notes regarding a patient’s substance use disorder treatment to an insurer, so instead I wrote a summary letter, in which I described the progress this patient has made & how well he is doing, and that delay in coverage for his medications could have catastrophic medical consequences to his health.

In response to my letter, Southern scripts issued a six-month approval for coverage of his medication. So, in six months, we’ll do this whole thing over again, I guess.

We are now twenty years into this opioid epidemic. I thought we were all at the point where we realized that it’s not good public policy to have insurance companies erect barriers to treatment with buprenorphine products to treat patients with opioid use disorder.

I’ve saved the best for last.

I’ve dealt with my share of frustrations with pharmacists and pharmacies.

Readers know I went to electronic prescribing a month or so ago. Last week one of my patients, stable for years, went to get his refill from his pharmacy. I submitted it electronically, and put one refill on it, since I see him only every two months at this point.

When the Walgreen’s pharmacy refused to give my patient his refill, he called my Health Services Manager, who called the pharmacy. They said my patient’s refill had been cancelled, and that I would need to submit a new electronic prescription. Worried I’d made an error, I went to my E-prescribing program and found I did write for a refill. Confused, I asked my Health Services Manager to call the pharmacy back, to discover why they wouldn’t honor the refill.

They told him that Schedule 3, 4, and 5 opioids could not be refilled, and that a new prescription had to be submitted.

This is not accurate, of course.

I wasn’t in a mood to argue. I just re-submitted the prescription and my patient filled it. Of course, now on my e-prescribing software it looks like I issued two prescriptions for the same month, which I did. I’ll have to document in his chart about the problem with the pharmacy.

I had hoped e-prescribing was going to remove some of the difficulties I’ve encountered with the pharmacies filling buprenorphine products. Now, I’ve lowered my expectations.