The Hawaii agency that polices controlled substances put a scare into the drug treatment community recently when its director said that he planned to start enforcing a state law his agency believed barred the prescribing of Suboxone to treat opioid addiction.

Within a day or so, faced with a backlash from doctors and others, the Narcotics Enforcement Division, part of the Hawaii Department of Public Safety, backed off. The division issued a public statement saying it would ask Attorney General Douglas Chin to review the law to determine whether it allowed the prescribing of Suboxone.

Four days later, Chin said despite ambiguities, the context of the code section made it clear that doctors could continue prescribing the drug.

It's estimated that almost 2 million Americans are addicted to narcotics.

It’s estimated that almost 2 million Americans are addicted to narcotics.

Flickr: Sharyn Morrow

Patients weren’t thrown into withdrawal, as doctors had feared. But the episode worsened a persistent problem, addiction specialists say: Too few physicians are willing and able to prescribe a drug hailed as a lifesaver for many addicts. The legal dustup, though settled for now, could give doctors another reason to believe that Suboxone and related drugs are not worth the trouble.

“It could happen again at any time,” said Dr. Bill Haning, a professor of psychiatry at the University of Hawaii’s John A. Burns School of Medicine. He said he hopes the Narcotics Enforcement Division and the medical community will develop a more cooperative relationship to avoid such misunderstandings.

Recent national studies have documented a gap between the number of people who need drugs such as Suboxone and their availability. Only 2 percent to 3 percent of physicians nationwide have obtained waivers from the federal Drug Enforcement Administration needed to prescribe the drugs — and a substantial number of those doctors don’t actually use them. One group of researchers found that the percentage of doctors in Hawaii with waivers in 2012 was even lower — 1.6 percent.

Despite an increase in the number of prescriptions written for buprenorphine, one of the main addiction medications, the annual growth rate has slowed substantially to about 6.4 percent.

In the meantime, research shows that only one in 10 addicts gets needed treatment. A study published this month by The Journal of the American Medical Association, found that less than a third of the 300,000 Medicare recipients suffering from opioid use disorder are getting the only medicine approved by Medicare for treating it.

Nationally, overdoses deaths from opioids reached a record high in 2014.

Insurers Make It Hard To Prescribe

Some insurers put up unnecessary barriers, addiction specialists say.

Doctors, meanwhile, worry about dealing with a population perceived as difficult, or that the medicine will find its way to street dealers. They may not want to embark on treating a patient’s opioid dependence in the absence of adequate counseling, or without the advice of doctors with more experience in the field.

Some patients resist being diagnosed as opioid addicts, often a prerequisite to getting insurance coverage. And state plans being offered under the Affordable Care Act often fail to offer the full spectrum of medications used to treat addicts.

These drugs can be lifesavers for those who have tried in vain for years to kick opioids.

“I think every person that has some kind of addiction to pain pills should be given this,” said one Suboxone user.

Civil Beat agreed to not use her name because of the stigma attached to opioid dependence.

She told Civil Beat that she started getting opioid prescriptions in 1997 after her neck was injured on the job and required surgery. Over the next 12 years, her addiction turned her into a different person. She would “hibernate” in her bedroom and lash out at her family.

Without Suboxone, she said, “I would be dead by now.”

State’s Suggested Ban Touched Off Firestorm

On Sept. 15, David Thornton, chief of the Hawaii Narcotics Enforcement Division, told a pharmacist  that he would be interpreting Hawaii law to bar the prescribing of Suboxone for opioid addiction. The division believed that the statute only allowed it to be used for pain.

Word apparently got around and addiction specialists mobilized. Haning wrote an email to Virginia Pressler, director of the state Department of Health, after finding out a pharmacist had denied Suboxone to one of his patients.

Haning warned that the move could thrust people into withdrawal and even cause deaths. Some desperate addicts might break the law and end up in jail, he said.

“It is at very least a cruel imposition on a population that can do little to defend itself.” Dr. Bill Haning, UH psychiatry professor

“It is at very least a cruel imposition on a population that can do little to defend itself,” he wrote.

Others contacted legislators and state officials. Within a day, the Narcotics Enforcement Division announced that it would seek the attorney general’s opinion and four days after that Chin assured prescribers they could continue.

But in the eyes of some, including Haning, damage had already been done. Doctors already facing disincentives for prescribing medicines for opioid addiction now had reason to think it might be legally suspect.

Getting A Waiver Not The Only Obstacle

Statistics show that Hawaii does not face the same magnitude of opioid abuse as some other states, particularly those in the Appalachians. Still, the state has its hot spots, and is far from immune to the epidemic.

Doctors must go through eight hours of training before getting a Drug Enforcement Administration waiver to prescribe Suboxone, a brand that includes buprenorphine and naloxone. These drugs offer advantages over methadone, at one time the only choice for treating addiction, because they can be prescribed in a doctor’s office without the patient having to report daily to a clinic and are highly unlikely to cause overdoses.

Getting the waiver is easy compared to persuading insurers to cover the costs, said Dr. Jon Streltzer, a UH psychiatry professor. Private commercial insurers pay for more than half of addiction medicine prescriptions.

Molecular Model of Buprenorphine.

The molecular model of buprenorphine, one of the Suboxone family of anti-addiction drugs. Attorney General Doug Chin has OK’d its use but some addiction specialists are worried doctors will be hesitant to prescribe it.

Many insurers, for instance, require pre-authorization. This involves submitting extensive forms and clinical notes and requiring patients to undergo drug tests.

Some insurers won’t approve the drugs unless the patient is also getting counseling. Others, Streltzer said, want evidence that the patient is tapering off the drug, failing to understand that for many, it’s a long-term need.

“It’s like a hypertension drug,” he said. “There’s a high risk the condition will recur if they don’t stay on it.”

Some companies want a drug test within 30 days both for opioids and for buprenorphine before reauthorizing a prescription. That ensnares doctors in a catch-22, Streltzer said, because no labs in Hawaii screen for buprenorphine. It can take two weeks to 30 days to get the results back from the mainland. In the meantime, the doctor must persuade the insurer to come through with an interim prescription.

Doctors say that if they want to adjust the dose, even downward, they must start the process from scratch. Some insurers require periodic reauthorizations.

Other insurers insist on patients trying another drug first, and only if that fails approve the one the doctor wanted.

“You don’t want to see a treatment failure with these guys,” Haning said.

Likewise, insurers are reluctant to approve a surplus supply if a patient is going on an extended trip or wants to fill a prescription in another state.

Delays Could Cause Deaths

Delays could be harmful or fatal to those in the throes of opioid addiction, experts say. For one thing, patients may be on the verge of withdrawal and need the drug right away to avoid the debilitating symptoms. If they’ve been through detox, they still crave the drug and are very vulnerable to relapse until getting treatment. And for many addicts, there’s a small window when they’re willing to submit to treatment.

“They kind of need their medicine right away,” said Anna Lembke, an assistant professor of psychiatry and behavioral science at the Stanford University School of Medicine. As with diabetes, “you can’t wait around for a couple of days. You might be dead.”

Insurers often require a diagnosis of opioid addiction. But Lembke said there’s a large population that became addicted because they were legally prescribed opioids over many years and are simply having a hard time getting off.

“You can’t wait around for a couple of days. You might be dead.” — Anna Lembke, Stanford University School of Medicine

These patients can benefit from buprenorphine but don’t want to be labeled as addicts – and don’t actually fit that definition, Lembke said. One solution would be for the Food and Drug Administration to expand the use of such drugs for those who are merely dependent.

Lembke and other addiction experts say the larger problem is that substance use disorders and mental illnesses have not reached parity with other kinds of medical conditions, as envisioned in the Affordable Care Act.

One recent study showed that none of the state ACA plans for 2017 cover all the drugs approved by the FDA for opioid addiction. Almost a third may not treat addiction the same as other medical conditions, according to the study, “Uncovering Coverage Gaps: A Review of Addiction Benefits in ACA Plans,” by the National Center on Addiction and Substance Abuse. Most of the plans included such vague coverage descriptions that researchers could not even tell if they met legal standards.

“Your treatment options are very limited,” said Lindsey Vuolo, associate director of health law and policy at the national addiction center. Addiction drugs are not interchangeable, she said, and their effectiveness varies by patient. “To have effective treatment,” she said, “you need to have them all.”

Many doctors are reluctant to prescribe anti-addiction drugs because they’re worried they will be diverted to illicit street use.

In fact, experts say, many addicts buy drugs like Suboxone from dealers to avoid withdrawal rather than to get high. Some resort to buying it illegally because they can’t find a doctor to prescribe it.

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