You did a fabulous job in covering so many of the nuances and ongoing aspects of local and national insurance company contributions to this access to treatment fiasco!
Edwin C Chapman, MD
There’s medicine to quiet his opioid cravings. Getting it can be hard.
It had been four days since Kevin Hargrove last took the medication that stilled his dangerous cravings. He awoke with a queasy stomach and achy muscles, then vomited on the sidewalk as he set off from his encampment under a D.C. bridge this month.
Hargrove recently changed his Medicare-funded insurance company and was unable to fill his prescription for buprenorphine, the medication he has taken for years to treat his opioid addiction. The withdrawals proved too much. The 66-year-old found a dealer on the street, paid $6 for two pills he believed were codeine painkillers and washed them down with a can of Olde English 800 malt liquor.
Less than an hour later, Hargrove passed out inside his sister’s Columbia Heights apartment, overdosing on what was suspected to be fentanyl. “Don’t tell me!” his sister cried. “You’ve been doing so well!”
Hargrove’s story illustrates the challenges often faced by those struggling with opioid addiction — especially people of color — in receiving buprenorphine, a medication that public health experts believe should play a critical role in curbing an addiction-and-overdose crisis fueled by fentanyl. His overdose happened this month as a newly published national study from the Harvard T.H. Chan School of Public Health showed that White patients are up to 80 percent more likely to receive buprenorphine than Black patients, and that Black patients receive a more limited supply.
“There are lots of totally counterproductive insurance restrictions on this drug, particularly for populations in which the need is the greatest,” said the study’s lead author, Michael L. Barnett, an associate professor of health policy and management at Harvard’s School of Public Health.
The study published in the New England Journal of Medicine reviewed medical records for more than 23,300 disabled Medicare beneficiaries whose encounters with opioids led to nonfatal overdoses, injection-related infections, or inpatient or rehabilitation treatment between 2016 and 2019. In the six months after the event that led to treatment, more than 23 percent of White patients filled prescriptions for buprenorphine, compared with fewer than 13 percent of Black patients. Nearly 19 percent of Hispanics received medication. The study did not measure whether prescriptions were written and went unfilled.
The large-scale study adds to a growing body of research reflecting racial disparities in medication-assisted treatment for opioid addiction. Last fall, an analysis of 15 years’ worth of prescription data published in JAMA Psychiatry revealed that Black and Hispanic patients receive shorter treatment periods with buprenorphine than White patients.
More than 100,000 Americans are dying each year from drug overdoses — mostly from opioids — and that includes a spike in the rate of deaths among African Americans.
“The system has the capacity to treat chronic health problems aggressively. They just don’t do it when it comes to substance-use disorder, especially for African Americans,” said Ricky Bluthenthal, a professor of population and public health sciences at the University of Southern California’s Keck School of Medicine who was not involved in the recently published study.
In the Harvard study, researchers reviewed a random sample of Medicare beneficiaries diagnosed with disabilities, a group greatly affected by opioid addiction. The study also found that Black and Hispanic patients were less likely to receive prescriptions for naloxone, a medication used to reverse opioid overdoses.
Another alarming conclusion: Patients in all three racial or ethnic groups were prescribed opioid painkillers or benzodiazepines, which are commonly used to treat anxiety, at a higher rate than they received buprenorphine. Those painkillers and benzodiazepines can greatly increase the risk of overdose for someone already addicted to opioids.
Experts say there are many reasons for the disparities in buprenorphine access, including a lack of providers willing to prescribe the medication, bias in prescribing, distrust of medical institutions and racism long ingrained in the U.S. health system.
The expansion of medication-assisted treatment for opioid addiction is a plank of the Biden administration’s strategy to combat the overdose crisis. First approved to treat opioid addiction in 2002, buprenorphine helps fight craving and withdrawal from heroin and, increasingly, illicit fentanyl. Last year, the federal government made it easier for more doctors to prescribe the drug, and the Drug Enforcement Administration has extended the pandemic-era rule allowing doctors to prescribe buprenorphine through telemedicine.
Still, doctors who lack experience with buprenorphine are sometimes disinclined to prescribe it. Oluwole Jegede, a Yale University professor of psychiatry, said stereotyping and implicit racial bias may also keep doctors from prescribing buprenorphine to Black and Hispanic patients, especially if those physicians harbor fears that patients may abuse or sell the drug, or not succeed in treatment. Instead, patients of color may be directed to methadone, a more powerful but highly restricted addiction-treatment drug that for five decades has been allowed to be dispensed only from specialized clinics, he said.
Jegede called it a “two-class system” underpinned by false notions. “We do know from the data that the fear of patients selling their buprenorphine is not warranted,” he said.
That contention was underscored by a Department of Health and Human Services inspector general report this month that concluded that the risk of patients selling or giving away their buprenorphine is extremely low.
Mario, a 26-year-old Mexican American and former U.S. Army soldier, had never heard of buprenorphine. His addiction started with painkillers prescribed for a shoulder injury after a tank accident, then progressed to fentanyl after he couldn’t get pills following discharge.
He sought help at a Veterans Affairs hospital in Orange County, Calif. No one mentioned buprenorphine, Mario recalled, although he was offered care at a methadone clinic. But he worried methadone was too strong. Plus, he would have to wait in daily lines at a clinic in a tough part of his hometown of Santa Ana.
“I didn’t want to do that,” said Mario, who spoke on the condition that his full name not be used because of fear of stigma. “What if someone I knew saw me there?”
He later learned about buprenorphine from other users. When he called two clinics for a prescription, Mario said, he was denied without explanation, despite having VA and California state-subsidized insurance. Mario said he was baffled when a White friend, also a veteran but with a job and stable housing, got a prescription through one of the same clinics.
“At the time, I was living out of my car,” said Mario, who is on disability and suffers from post-traumatic stress syndrome.
Mario eventually secured a buprenorphine prescription through a telehealth provider. He credits the drug with helping him kick fentanyl. After months of use, he has since quit buprenorphine, too, fearful he was still using an addictive drug.
His perceptions are not unusual. Negative views of buprenorphine from patients may also play a role in disparities, addiction experts say.
The Harvard study found that across racial groups, patients made a similar number of visits to health-care providers, which means disparities aren’t always explained by fewer contacts with the medical system. Last year, researchers in a separate study detailed interviews with 41 Boston patients who were not using buprenorphine, and found Black and Hispanic patients “expressed a stronger distrust” of medication treatments, some preferring to quit cold turkey and join group or residential programs.
Jawad Husain, an addiction psychiatry fellow at Mass General Brigham in Boston and the study’s lead author, said researchers found Black and Hispanic patients tended to view methadone or buprenorphine as substitutes for illicit opioids.
“That’s not the case,” he said. “When they get on those medications, they’re not getting high. They have a tolerance built up where it just makes them feel normal again.”
Husain, like other addiction specialists, believes educating a wider array of doctors, community groups and patients about medication-assisted treatment is key to breaking down barriers.
Even with doctors and patients such as Hargrove who embrace buprenorphine, the insurance system can impose obstacles.
An affable former martial arts instructor, Hargrove suffers from mental illness and has lived on D.C. streets for most of the past two decades. He said he became dependent on codeine painkillers decades ago to deal with fighting injuries.
About a decade ago, he turned to Edwin Chapman, 77, a doctor who specializes in addiction medicine and treats mostly Black patients on the outskirts of Capitol Hill. He’s known as a fierce advocate for his patients, sending frequent emails to public officials to warn about the dangers of D.C.’s toxic drug supply while pushing to expand access to buprenorphine.
“He’s the reason I’m alive today,” Hargrove said.
Chapman said Hargrove’s case illustrates a persistent problem for addiction-treatment doctors: that insurers’ “prior authorization” policies hinder treatment. Hargrove receives disability benefits, D.C. Medicaid and Medicare Advantage, in which an insurance company contracts with Medicare. Hargrove’s previous insurance covered a month’s supply of four daily eight-milligram doses of buprenorphine, with him checking in monthly to Chapman’s office for a prescription renewal.
Hargrove recently switched to UnitedHealthcare. In March, Chapman and Hargrove said, the company would agree to only three doses a day, meaning he had to stretch out his supply for the month. “That first month was hell,” Hargrove said.
UnitedHealthcare said in a statement that Hargrove’s prescription was “filled according to his plan benefits,” which are in line with Food and Drug Administration guidelines for the drug. “We did not have documentation or other support from his provider to support a larger dosage requirement,” the company said.
Chapman said his prescription recommendation was overruled by United’s pharmacy. “How is it that a pharmacist gets to overrule the treating physician?” Chapman said.
Hargrove overdosed on the suspected fentanyl pills May 11, before he was authorized to pick up his new prescription of three daily doses. Inside his sister’s apartment, he plopped down on a chair in her bedroom and passed out. The whites of his eyes turned gray. His sister, Claudette Inge, called 911, frantically poured a glass of cold water on his face and began chest compressions.
Paramedics used Narcan to revive him. “I died on that chair,” Hargrove said the next day, recounting the scene while inside his sister’s apartment.
Said Chapman: “This was really scary, and you hate to see a stable patient become unstable for no reason at all just because of the bureaucracy.”
The day after the overdose, Hargrove could finally pick up his buprenorphine. “I’ll just have to stretch it out like I’d been doing,” he told Chapman on speaker phone.
That afternoon, Hargrove walked into an Anacostia pharmacy, picked up his medication, pulled out a brown tab of buprenorphine and popped it in his mouth. “I’ll feel better in about three minutes,” he said before walking to a bus stop.
He would later learn that the insurer, responding to an urgent appeal from Chapman, approved an extra daily dose — only after his near-fatal overdose.