Suboxone crackdown by WI Medicaid

Wisconsin has been very generous in regard to covering prescriptions for buprenorphine.  The State’s main Medicaid program, BadgerCare, generally covers buprenorphine indefinitely;  while that probably  rubs some people the wrong way, the simple fact is that opioid dependence is a life-long condition marked by repeated relapse, even after expensive residential treatment.  We know that stopping buprenorphine after short-term treatment– less than 6-12 months of maintenance– virtually guarantees a return to using opioids.  There are likely some people who, after staying away from addictive behavior and having their minds freed from obsession for some period fo time, can go off buprenorphine and remain clean.  But there are many who will need buprenorphine as a long-term maintenance agent, or as I like to say, a ‘remission’ agent.  I believe that ‘remission’ best captures the essence of what buprenorphine does for opioid addicts.
I’ll add, for those who still object to the concept of requiring long-term buprenorphine, that we don’t think twice about ‘remission’ treatment of many other diseases;  we don’t object to treating hypertension, diabetes, or asthma throughout a person’s life, for example.  Where did this idea start that addicts only deserve temporary treatment for their disease?
Michigan is a state with a different approach than that of Wisconsin.  Michigan will cover buprenorphine in general after a prior authorization, but after six months authorization must be sought again.  Up until recently it was difficult to obtain coverage beyond one year.  I have a few patients who have managed to remain covered beyond a year, but doing so requires jumping through several hoops;  the state of Michigan wants to see the results of urine tests and wants to see a ‘plan for discontinuation of buprenorphine,’ for example, before reauthorizing buprenorphine coverage.
Wisconsin has recently made some changes to their generous policies regarding buprenorphine.  While I agree with the philosophy behind the policy changes, the enactment of the policies can work against an addict’s sobriety in some cases.   One of my patients had been filling her script a day or two early each month for about six months.  She received notice that a count of her scripts shows that she should have about 14 extra tablets of Suboxone, because of those early fills.  Ideally the state would be correct;  if she took the exact dose each day (as she should) she would have the extra tablets in a bottle somewhere.  But like some other people, she occasionally takes an extra tablet of buprenorphine.  She may forget whether she took her day’s dose, and take another ‘just to be safe.’  Or she may occasionally succumb to the forces of addiction that create psychological cravings, and on a stressful day imagine that an extra tablet of buprenorphine will make things less stressful.  Of course, taking that extra tablet does almost nothing, as her blood level of buprenorphine is already above the threshold of the ‘ceiling effect.’  But many people succumb to those cravings all the same.  My job as their physician is to help them see what that extra use truly represents– i.e. their addiction– and to help them get their use under control and on schedule.
Wisconsin Medicaid deals with the situation by telling patients that they can have no buprenorphine for the number of extra days that they have accumulated– if they have accumulated 7 day’s worth of early refills, the State makes them do wihout buprenorphine for 7 days before allowing a refill.  You might think ‘that’s OK— I’ll pay cash for a few days.’  But the pharmacy involved would not allow the patient to do even that, saying that ‘if you have the money to buy your own, you shouldn’t be on Medicaid in the first place.’    Wisconsin has taken similar steps in related situations;  a patient (I carry 100 patients) who was struggling received pain pills from the ER for a visit for headaches, and when the State of WI got the bill, they sent a letter to the patient telling her that they would no longer cover buprenorphine for her– ever.  Again, I understand the need for limits and rules, but such a decision literally has life or death ramifications.  Keeping with the disease approach, I see the struggle of this particular patient as I would view a diabetic who eats sweets and needs extra insulin or even hospital admission, or similar to the person with hypertension who struggles with dietary changes or exercise.  All of the diseases mentioned, including addiction, are manifest by occasional relapses or compliance problems by patients.  Onlywith the disease of addiction are compliance problems handled by cutting off access to treatment!
I do understand the need to tighten the control of prescriptions for opioids including buprenorphine, although I question why there are greater efforts to control buprenorphine than there are for opioid agonists like oxycodone.  I have not, for example, heard of prescriptions for oxycodone cut off because a patient used other controlled substances.  Instead, such situations result in a letter to all of the patient’s prescribers notifying  them that the patient is seeing multiple doctors.  The patient is NOT cut off from further coverage for medication, as is the case for buprenorphine.
The bottom line:  if you are taking buprenorphine, every tablet should be guarded closely, kept safe, and fully accounted for.  While I don’t agree with the double standard used by the State or with cutting off coverage for patients who are not yet completely stable, we are in the midst of a serious public health problem with opioid dependence, and the magnitude of the problem raises the bar for everyone to reduce complacency and prevent diversion.