The SUPPORT for Patients and Communities Act—the massive piece of legislation signed into law on October 24, 2018—is not going to take care of the prior authorization problem. That means countless patients with opioid use disorders (OUDs) will still be unable to access treatment when they need it. Some will relapse; some will die.
That’s the opinion of Barbara Andraka-Christou, JD, PhD, assistant professor in the department of health management and informatics at the University of Central Florida.
The Act, known formally as the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (the SUPPORT for Patients and Communities Act), is a massive piece of legislation that has some positive features. But it falls far short in dealing with the opioid crisis, especially in helping patients with OUDs who need buprenorphine.
Where the SUPPORT Act Falls Short
In an accompanying article in this issue of AT Forum, Dr. Andraka-Christou, who has published extensively in the field, and is an attorney as well, discusses three problems related to prior authorizations for OUD medications: they are time-consuming; they are dangerous (when causing treatment delays); and they are inequitable—possibly violating federal parity laws.
In sharing with AT Forum her thoughts on the last point—the parity laws—she went into some detail. “Insurance requirements for prior authorizations are inequitable. In my opinion, such insurance requirements sometimes violate federal parity laws if applied to medications for OUD, but not to opioids for chronic pain management.”
She also stressed the difference between the two types of medications. “Ironically, medications for OUD, especially methadone and buprenorphine, are the most effective treatment for OUD, in combination with psychosocial support, while opioids for chronic pain management have questionable efficacy. Yet the OUD medications are more likely to be subject to prior authorization requirements.
“Furthermore, buprenorphine is a schedule III controlled substance, according to the Controlled Substances Act, meaning the government has already recognized in another law that it should have lower regulatory barriers than do schedule II controlled substances, like oxycodone or hydrocodone.”
The Answer: Federal Legislation
Dr. Andraka-Christou wants to see federal legislation banning prior authorization requirements for typical dosages of evidence-based and cost-effective medication for OUD. She acknowledges that insurance companies should continue to require prior authorizations for atypical dosages of evidence-based medication, for medication with a smaller or emerging evidence base, or for OUD medications that have not yet been demonstrated to be cost-effective. But, as she points out, typical dosages of methadone, oral buprenorphine, and extended-release naltrexone do not meet these criteria.
The discrepancy between treatment access for OUD and chronic pain management is the focus of Dr. Andraka-Christou’s academic research, and the topic of her forthcoming book, Opioid Naïve: America’s Addiction to Failing Treatment, Johns Hopkins University Press. Publication is scheduled for 2019.
