Minnesota's Medicaid program will make it easier for doctors to prescribe treatment medications for opioid addiction, removing one of the biggest obstacles that has faced people seeking drug therapy.
Physicians will no longer need to obtain prior approval from the state agency that runs the health insurance program for the poor — a process that often caused dangerous delays in treatment and sent some patients back to using heroin or prescription painkillers as a way to cope with intense withdrawal symptoms.
"We realized it was a problem," state Human Services Commissioner Emily Piper said at a treatment event Friday morning. "It became clear to me that [prior approval] is not necessary."
Piper said the change will broaden access to treatment at a time when Minnesota is grappling with an opioid abuse epidemic. The state recorded 401 opioid-related deaths in 2017, a sixfold increase since 2000. Last year, more than 11,000 Minnesotans sought treatment for opioid addiction, counting Medicaid and non-Medicaid patients.
Prior approval for the treatment medications has already been dropped by Medicaid programs in some other states and by most of the private insurers in Minnesota that administer managed-care benefits for Medicaid enrollees.
The change comes after the Star Tribune reported last month that doctors across the state had seen patients relapse because they could not get medication approval from state officials, sometimes even after several days. Some physicians reported that patients had later died because of the lag in receiving medications.
The paperwork burden on many clinics has been so great that they dedicate one employee to submit, track and sometimes plead with the state to approve treatment drugs, which go by the names buprenorphine, Suboxone as well as others.
"Prior authorization for opioid treatment is killing people and there is no excuse," said Sen. John Marty, DFL-Roseville, who said he urged the department to make a change after reading the Star Tribune article.
"I am really troubled by the idea that somebody who may not have any medical training and certainly has not seen a patient is making a decision that should be made by doctors," Marty said.
Minnesota's Medicaid program, known as Medical Assistance, covers about 1.1 million people, mostly poor families, the elderly poor and people with disabilities.
Cold sweats, goose bumps
Last month, Deputy Human Services Commissioner Chuck Johnson said the department retained the prior approval requirement partly as a cost control measure but also as a safeguard that the treatment drugs, which themselves contain a form of an opioid that is less prone to abuse, were not getting into the wrong hands.
Clinics, however, told the Star Tribune that nearly all prior authorizations submitted to the state eventually got approved and that the whole process created unnecessary delays.
"This will make a huge difference," said Dr. Mike Aylward, an internal medicine specialist at the Community-University Health Care Center in Minneapolis. "This will dramatically increase the access to treatment."
Federal law requires doctors to obtain special permission from the U.S. Drug Enforcement Administration and complete special training before they can prescribe the treatment drugs — requirements not imposed on other medications, including opioids.
"There is no evidence that eliminating prior authorizations will lead to changes in safety or diversion," Aylward said. "It is safer than many medications that are already being prescribed and certainly safer than opioids."
The drugs help patients cope with withdrawal symptoms and are typically used as part of a wider treatment program that addresses underlying issues such as anxiety or depression, as well as challenges such as homelessness and unemployment.
"It is medication-assisted treatment, not medication as treatment," said Dr. Emily Brunner, an addiction medicine specialist at St. Joseph's Hospital in St. Paul. "It is not a stand-alone cure but certainly has incredibly good data supporting it."
But timing, physicians say, is critical in the use of the treatment drugs.
"If you take it too early, it makes people go into worse withdrawal," said Dr. Ryan Kelly, an internal medicine specialist at the Community-University clinic in Minneapolis.
Delays caused by prior authorizations can upset the timing and leave the patient without a way to handle powerful withdrawal symptoms.
Ryan said patients have told him that withdrawal creates cold sweats, feelings of foreboding, goose bumps, jumpiness and a sense "that you are not human." One of his patients described it this way: "It is as if the bone marrow started to expand against your muscles but your skin didn't stretch."
Blue Cross and Blue Shield of Minnesota, HealthPartners and UCare had already eliminated prior authorization for treatment medications in response to the growing need for treatment to address the opioid abuse crisis.