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.

6 responses to this post.

  1. Posted by Kelli on October 27, 2019 at 6:09 pm

    I feel your frustrations. I also am a provider for MAT specifically buprenorphine and am passionate to help in this opioid epidemic. For insurance companies to do this is crazy and making it more difficult for providers as you said want to spend this time wasted when it could be spent with our patients. We have enough to deal with already and time better spent giving our energy to the patient. I see this as a huge hindrance to the opioid epidemic and discriminating as well.


    • Thank God for people like you, please don’t give up on those of us that are successfully on medication assisted treatment. My life was saved because of this, I posted something below about it. these insurance companies must be held responsible for treatment for addicts. if a person was schizophrenic and completely off their meds, they would be section or at the very least put back on a medication regimen. Insurance would pay for that. I can’t think of any other disorder that is so blatantly pushed away by insurance companies as something they won’t cover. The fact that they don’t cover 30 day programs at times, the fact that they don’t even have halfway houses either built by the federal government, state governments, but we have to rely on wealthy donors at least in Boston to build these places, and now that the AIDS epidemic is, as most people think over, and hepatitis c is curable, a lot of the funding has been cut. The irony is the AIDS epidemic is far from over, and hepatitis c is only curable if you know you have it, that you’re clean enough to take the test and go to your doctor, and then of course there’s the lab test and treatment regimen which no active addict is going to follow properly. Meanwhile, people like my husband died and they don’t even realize they’re dying until it’s too late. The picture on my profile was taken in 2008, about a month before he was told he has end stage liver failure and needed a transplant. I always ask young people if he looks sick. You can imagine the answer.


  2. Posted by bpmurraymd on October 27, 2019 at 9:54 pm

    agree: question is what to do about it ? To some extent you have to put the onus on the patient — it is their insurance — they should speak to their benefits managers. With generics and coupons it is not that expensive compared to the hassle every few months of threats to get thrown off their medications


  3. Posted by John Mark Blowen on October 28, 2019 at 5:39 pm

    So, what do we do ? Call the state insurance commissioner ? Letters to the editor ?
    We need to expose this for what it is – putting people at risk of death – in order to keep money in their accounts earning interest. Perhaps one of the more progressive presidential candidates could take this on….


  4. I am a patient that has been on m80 for 19 years now, 17 of which I have been in full compliance on take-home privileges, and my husband died a couple months ago but I was managing his treatment there as well, because the team trusted me enough to do this. I even dispensed his methadone the hospice finally gave him right before I would go to get my bottles!!
    I’m writing because you all sounds like passionate people that I would like to know. There are so many issues as a patient that I would love to deal with, and I have requested a patient advisory committee four times now, hazard clinic is chronically understaffed, clients that have been on the clinic for 5 or 6 months have yet to meet a single counselor… My son was one of them unfortunately. He went in, got his dose, and left. from what I’ve been told medication-assisted treatment, the medication is really only a small part of the treatment. The treatment is supposed to revolve around a treatment plan, which I believe is mandated by the state or federal government? It is supposed to include long-term goals and short-term goals. I can say that had I not had a counselor in the first two years of my treatment, I’d probably be dead now. It was the counselor that helped me to have little successes, building on those successes came larger tasks that I could complete. I look back now and I’ve achieved so much!!! When my husband died, thankfully I had in place my women’s recovery group, my grief and support group, my psychiatrist and psychologist 17 years from Mass general hospital, and positive people in my family that I reunited with. but what about those clients that are not getting any treatment except liquid methadone? Of course they love it that they have no counselor, they don’t even have a group for people that don’t have counselors!!!
    Is there anything I can do as a patient to change this but not have a Target on my back? I recently lost my take homes after 12 years, and got some back because of a positive opiate urine screen. Everyone assumed that I was abusing morphine, but any addicts could tell you that morphine is not a drug of choice. I’ve been handling all of this for 18 months in hospice, I highly doubt I would relapse after being devoted to my husband for over 10 years right by his side. Because that means going to the clinic every single day, leaving him. I have no reason to lie here, and that’s another problem. I do believe that these urine screens, especially if they are the cheapest, can and do produce false positives. I went to my primary care doctor however, and the urine was positive there too!!! But when they spun it down using the gas chromatography it was negative, just a my new trace of morphine. Perhaps I did something with the liquid thinking it was methadone? at any rate that’s in the past, but the protocol for telling someone they’ve lost their take-homes didn’t exist. No formal paper, nothing to sign, no plans or goals to get them back. Once again, I’ve documented all of this but since you sound like an educated group of people that truly care about those of us on MAT;I LIKE YOUR FEEDBACK AND ANY IDEAS YOU HAVE ON HOW TO HELP BOTH MYSELF AND THE PATIENTS ON THIS CLINIC. MY OWN COUNSELOR IS ADVISING THAT” I DO WHAT I HAVE TO DO”
    I’M SORRY FOR THE POOR TYPING AND ERRORS, I’M SPEAKING INTO A MICROPHONE. God bless you and I’m looking forward to, as I said any feedback or advice.


  5. Posted by Ginger MacKenzie on January 20, 2020 at 11:26 pm

    PA requests like this are commonplace for many drugs, even inexpensive generic drugs, not just buprenrophine. In fact in my area, buprenrophine prescribing has gotten much easier. I cannot remember the last time I had to do a PA for any patient other than Medicaid recipients, and as of December 1st even medicaid has dropped the PA requirement for any formulary buprenorphine including Sublocade.


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