A DRUG-WAR SETBACK

Red Tape, Doctors Say, Cuts Buprenorphine Prescriptions

Faced with Medicaid's low payments and bureaucratic red tape, some
Maryland doctors are reluctant to prescribe buprenorphine for heroin
addicts, even though the drug has been promoted as a potential magic
bullet in the war against addiction, according to a survey set for
release today.

The survey, commissioned by the Center for a Healthy Maryland Inc.,
found that doctors were not always sufficiently reimbursed for their
time and services and that there were other "hassles," including
medication preauthorization, a process that in some cases can take 48
hours, and varying and confusing protocols among Medicaid providers.

The report comes as state officials are deciding how to spend an extra
$3 million earmarked for buprenorphine treatment in the budget year
that starts July 1.

Medicaid is a state-run program that uses federal and state money to
pay medical bills for the poor and disabled. In Maryland, the program
is run through seven managed-care organizations that contract with a
network of health care providers.

Buprenorphine advocates want Medicaid officials to quickly fix the red
tape and payment problems so the $3 million can be used to help
uninsured addicts and others who want treatment but do not qualify for
Medicaid.

"One of the biggest barriers to prescribing buprenorphine is dealing
with the insurance companies," said Dr. Christopher Welsh, a
psychiatrist and assistant professor at the University of Maryland
School of Medicine in Baltimore. Welsh uses the drug to treat patients
at the university's hospital. Some come from hundreds of miles away to
get a prescription, only to have their treatment thwarted by red tape.

"A few hours later, you'll get a call, and the patient will tell you
that the pharmacy said the prescription wasn't authorized," said
Welsh, who participated in the survey.

He added that a physician who intervenes to help the patient is often
"passed from voice mail to voice mail" by the health care provider,
and the experience "can be very time- and labor-intensive."

Of the 17 doctors from across the state who participated in the
survey, some said they have been so frustrated by the system that they
have paid for the drug themselves.

Only 25 percent of those surveyed said they were willing to prescribe
buprenorphine for a variety of reasons. Some of the reasons given for
not prescribing the drug included negative attitudes about drug
addiction and a lack of experience regarding care of addicted
patients. Some managed-care organizations don't view drug addiction as
a long-term disease, according to doctors.

"It is a disorganized and chaotic system according to physicians,"
said Dr. Robert Schwartz, director of drug addiction treatment
programs at the Open Society Institute - Baltimore, which provided
grant money to pay for the survey.

As a result of the study, doctors and representatives of managed-care
organizations have agreed to work together to improve addiction
treatment opportunities for residents, including those in rural parts
of the state where few doctors have the necessary certification to
prescribe buprenorphine. State officials, who only recently received
the survey, have also said they will cooperate.

"We have a real chance here to work together to deal with the concerns
doctors have and the barriers they have told us about," said Dr. Meena
R. Abraham, executive director of the Center for a Healthy Maryland,
an affiliate of the Maryland State Medical Society.

Susan Tucker, executive director of the Office of Health Services for
the Maryland Medicaid Program, said she plans to discuss the survey's
findings tonight at a forum scheduled by the medical society. She said
some doctors are hampered by federal rules regulating the use of
buprenorphine and a lack of education about drug treatment.

"It is clear that it is more than insurance," said Tucker. "Some
doctors don't feel comfortable providing counseling for patients; some
don't feel they have the background."

The pill form of buprenorphine was approved by the Federal Drug
Administration for use in the treatment of opioid addictions in 2002.
Before that, it was used in a liquid form in the operating room to
help with pain. Doctors must go through a certification program to
prescribe the drug and initially are allowed to give it to only 30
patients. After a year, they can treat up to 100 patients.

Recently, Baltimore health officials have advocated the use of
buprenorphine, which helps relieve withdrawal symptoms, as an
alternative to methadone, a synthetic opiate that is addictive and
requires close supervision.

Doctors must take a short class to receive a certificate to prescribe
buprenorphine, and the city has launched a program recently to help
cover the costs of such coursework. Ninety-one doctors have signed up
for the training, and nearly 50 have completed it, according to Dr.
Joshua M. Sharfstein, the city health commissioner.

Sharfstein said that he has not heard complaints from doctors who work
with the city to treat drug addicts, in large part because the city
runs interference between physicians and managed-care organizations.
Sharfstein said it also helps that most buprenorphine patients start
off in buprenorphine-oriented treatment programs. By the time they
phase out to care with a private doctor, their treatment has been
approved by Medicaid providers.

"We are not expecting doctors to go out on their own," said
Sharfstein, who added, however, that the system should work for every
doctor, not just those dealing with patients in the public health
sector. "It is not an either/or situation. It needs to work for everyone."