Are Insurers Restricting Expensive & Less Addictive Painkillers?

By Paul Fuhr 09/22/17

The Times/ProPublica investigated the role that insurance companies play in the current opioid epidemic. 

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According to a recent New York Times article, written in collaboration with ProPublica, the Pulitzer Prize winning investigative newsroom, insurance companies are reportedly restricting access to generic opioid medications with low risk for dependency because they are too expensive. 

“Opioid drugs are generally cheap while safer alternatives are often more expensive,” experts told the Times.

The New York state attorney general’s office is questioning the three largest pharmacy benefit managers in the nation about their plans to address the opioid crisis. Letters have been sent to Express Scripts, OptumRX, and CVS Caremark. On Thursday, CVS announced its decision to institute a seven-day supply limit on opioid prescriptions, meaning that patients with specific conditions will only receive a week's supply of opioids at a time from the chain. 

ProPublica and the Times examined the Medicare prescription drug plans of more than 35 million people from the second quarter of 2017.

Their findings? “Only one-third of the people covered, for example, had any access to Butrans, a painkilling skin patch that contains a less-risky opioid, buprenorphine,” the article reported. “And every drug plan that covered lidocaine patches, which are not addictive but cost more than other generic pain drugs, required that patients get prior approval for them.” 

Butrans is a long-acting, extended-release patch that treats addiction, though it’s not highly addictive itself. One patient featured in the Times story noted that she benefited from Butrans, as it was the only drug that made life “with stabbing pain in her abdomen” tolerable.

Without warning, her insurer, UnitedHealthcare, reportedly stopped covering the drug, which had cost the company $342 per month's supply. After unsuccessfully appealing, the patient switched to a low-dose, longer-acting regime of morphine which carried a more pocket-friendly price tag of $29 per month. While Butrans was just as effective at a much higher price, it carries far less risk for abuse and dependency than morphine.

Companies like UnitedHealthcare claim that they exhaustively work with patients’ physicians to find non-opioid treatment options for chronic pain patients.

A spokesman for UnitedHealthcare issued a statement to the Times saying, “All opioids are addictive, which is why we work with care providers and members to promote non-opioid treatment options for people suffering from chronic pain.”

But Dr. Thomas R. Frieden, the ex-leader of the Centers for Disease Control and Prevention (CDC) for the Obama Administration, thinks it’s all window dressing. He feels that insurance companies, aside from a few exceptions, had “not done what they need to do to address” the opioid epidemic that’s ravaging the country. Rather, he says it’s created the perfect conditions for “most patients to get opioids [instead of] treatment for addiction.”

Leo Beletsky, a Northeastern University professor of law and health sciences, agrees with Frieden. Beletsky called the nation’s insurance system “one of the major causes of the crisis”—placing blame squarely at the feet of doctors who are given incentives to use far less expensive treatments that provide fast relief.

Now, the Department of Health and Human Services is conducting a deep investigation into whether insurance companies are, in fact, making opioids more available than other pain treatments. 

Insurers argue that they’re attacking the issue on many different levels, including monitoring opioid prescriptions and doctors’ prescription patterns. The chief medical officer of Aetna Behavioral Health told the Times that they’re able to identify “in advance who might be getting into trouble, and who may be on that trajectory toward becoming dependent on opioids.”

Aetna and other insurers claim that they’ve seen “marked declines in monthly opioid prescriptions in the past year or so,” the story said. They’re also piloting the prescription of pain pills in seven- to 10-day supplies. 

With all the behind-the-scenes changes in drug laws and prescription patterns, are insurers singlehandedly driving pain sufferers out into the streets to find relief, despite all the warning signs and red flags? 

According to the Times, yes...with addiction experts noting that the main change is “rooted more in the illicit trade of heroin and fentanyl,” certainly a byproduct of an industry caught unaware and unprepared by the epidemic. “But the potential for addiction to prescribed opioids is real: 20% of patients who receive an initial 10-day prescription for opioids will still be using the drugs after a year,” the article says, citing research out of the University of Arkansas.

Some Medicaid programs, “which pay for a large share of addiction treatments,” require advance approval before Suboxone can be prescribed—or worse, place time limits on when it can be used, which could certainly interfere with much-needed treatment. Suboxone accounts for 33.6 million drug plans covered by Medicare, the article said, though two-thirds of them require prior authorization. Unfortunately, the out-of-pocket costs for the drugs aren’t just astronomical—they all but drive people with addiction to easier (albeit deadlier) alternatives, serving to feed other grim statistics about the epidemic.

According to the Times, some opioid abuse experts believe there’s even more trouble ahead.

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Paul Fuhr lives in Columbus, Ohio with his family and two cats, Vesper and Dr. No. He's written for AfterParty MagazineThe Literary Review and The Live Oak Review, among others. He's also the host of "Drop the Needle," a podcast about music and addiction recovery. More at paulfuhr.com. You can also find Paul on Linkedin and Twitter.

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