High Wire is Maia Szalavitz's reported opinion column on drugs and drug policy.

Update 1/2/20: In part, Governor Cuomo did the right thing and banned prior authorization for opioid use disorder medication by private insurers. Unfortunately, he then vetoed the bill to prohibit this practice in government-funded Medicaid coverage for low-income people, claiming that this would just provide an "unfair competitive advantage to one pharmaceutical manufacturer in particular" (referring to the maker of Suboxone) and that there are "no clinical differences" between formulations of buprenorphine. This is contrary to the experiences reported by both doctors and patients—and clearly discriminates against Medicaid patients.

Ironically, because the benefits of medication for opioid use disorder are so large, even with the greater expense for the brand-name drugs, this will cost the state more money than it could possibly save.

Luke Grandis, 30, was in the giddy delight of new love, having proposed to Francis Talbot in Minnewaska State Park in upstate New York on October 10th. Grandis, who is nonbinary, was also two years free of heroin addiction, supported by the medication Suboxone.

The couple wanted time to plan their wedding—but because Grandis got a new job and new insurance, they wound up getting married just weeks later with only five people in attendance. It was the only way they could ensure uninterrupted access to the lifesaving medication: The new employer's insurance required “prior authorization,” which could take days or weeks after the old prescription ended. During that time, Grandis would suffer withdrawal—or worse, a potentially fatal relapse. Grandis needed to get on Talbot's insurance as soon as possible.

“We are in love and we wanted to get married, no matter what,” Grandis said. “But no one really wanted it to be that rushed.” The wedding was so small that Grandis spent weeks afterwards having to explain to relatives and friends why they hadn’t been invited.

Bipartisan legislation banning prior authorization for medication that treats addiction overwhelmingly passed the New York state legislature this year (the vote was 55 to 7 in the state senate and 141 to 5 in the house for the bill banning the practice in Medicaid; there was a similarly lopsided margin for banning it in private insurance).

But Governor Andrew Cuomo has so far indicated that he may not sign these laws, citing cost concerns. If he doesn’t sign within 10 days of the bills being called up, the clock starts running on a “pocket veto” and the laws would go back to the legislature. That clock starts for the Medicaid bill on December 20; it started on the 19th for the private insurance bill. Although vetoes can be overridden, this has rarely ever happened in New York state.

In light of an ongoing overdose crisis, however, permitting any roadblocks to accessing medications proven to cut the death rate by 50 percent or more makes little sense. And it shows how little value the governor places on the lives of people with addiction, many of whom don’t have the resources that allowed Grandis to avoid a dangerous lapse in medication.

Making Cuomo’s reluctance even more puzzling is the fact that eliminating prior authorization is far more likely to save money than increase costs. Indeed, a recent study conducted for the Legal Action Center by the research group RTI International shows just some of the potential for savings.

“The bottom line is that removing prior authorization will reduce mortality and healthcare costs,” said Christine Khaikin, health policy attorney at the Legal Action Center.

That’s because untreated addiction is expensive. Hospitalizations for overdose and injection-related infections alone cost the state millions each year. The study estimated that eliminating prior authorization policies in Medicaid alone could save the state nearly $52 million annually and lead to a 42 percent reduction in emergency room visits.

And that doesn’t even take into account the value associated with lives saved, such as their own ongoing productivity and reduced distress or less of a need for foster care among families and children. Nor does it take into account the effect of banning prior authorization requirements in private insurance, like Grandis has, which would cost the state nothing.

Earlier research from other states shows that banning prior authorization is associated with a 20 percent increase in the number of people starting buprenorphine (the active ingredient in Suboxone). The RTI researchers estimated that, in New York, the new law would save nearly 600 lives each year.

The main rationale for prior authorization is that it allows insurance companies to make sure that doctors prescribe the least expensive treatment that’s still effective. In the case of addiction medications, this means sticking to certain formulations, although the preferred drug will vary depending on negotiations between specific pharmaceutical companies and insurers. In some instances, brand name medications will be preferred; in most, a generic made by one company will be selected.

When it comes to treating a life-threatening condition like opioid use disorder, however, even slight changes in access to medication and the specific formulation of the drug used matter.

Justine Waldman is medical director of a program in Ithaca, New York called REACH, which treats around 900 patients with various forms of buprenorphine. Her experience with prior authorization has been “scary” and “difficult,” she said, explaining that she has to deal with dozens of different insurance companies, nearly all of which have different policies about which medications are covered.

Most of her patients, she said, have done well on the brand name drug, Suboxone. However, when they have been forced to switch to certain generics, some experience severe nausea or actual vomiting. “This happens really often,” she said, explaining that after about three months, some do manage to adjust to the change, but others just drop out of the program and she doesn’t know what happens to them.

Waldman estimated that between 10 and 30 percent of her patients struggle with distressing side effects from being made to switch meds. And time spent waiting for authorization of different formulas can lead to gaps in care.

Since interruption in buprenorphine treatment can lead to withdrawal, this makes relapse, which is already common, far more likely. And with the prevalence of highly potent fentanyls in New York’s heroin supply rising, even one slip is extremely risky.

Before 2012, fentanyls were associated with only 2 percent of opioid overdose deaths in New York City—but by 2017, the drug was found in more than two-thirds of these cases. Outside of the city, deaths related to fentanyls rose 124 percent between 2015 and 2016 alone, with Suffolk County on Long Island being hardest hit.

The best known way to reduce the risk of overdose is staying on a steady dose of buprenorphine, or another drug, methadone. When people continue to take these medications at appropriate doses, they have a risk of death that is cut at least in half compared to other treatment or no treatment. And even if they relapse during treatment, which occurs at least once in most cases, their death risk remains lower on medication than if they quit care altogether.

However, even brief gaps in medication treatment are extremely dangerous because tolerance to opioids falls quickly: Research shows that risk of death is roughly four times higher for those who discontinue buprenorphine.

“I’m sure that it has caused people to lapse,” Waldman said of medication interruptions, “Obviously, that puts them at risk of overdose.” Waldman also noted that she could hire more medical staff and see more patients if she didn’t have to pay for the time spent dealing with these insurance issues.

“We have all pleaded with the Governor, shown him research on how this bill will save lives and dollars, and have brought our personal stories of loss to his doorstep," said Jasmine Budnella, drug policy coordinator for VOCAL-NY, an activist group that has demonstrated outside of Governor Cuomo’s office to protest this policy, in a statement. "Sadly, our fiscally conservative Governor has shown no indication that he will sign this bill. Although his office has repeatedly stated that cost is the main barrier to this bill, they have given us no information as to how they are determining their fiscal analysis, what the cost of the bill is, nor have they responded to the recent study proving this bill will save nearly 600 lives and $51.9 million a year."

Asked about the study’s findings and whether the governor will sign the bill, Cuomo’s press secretary Caitlin Girouard said in an email that “There were more than 900 bills that passed both houses at the end of session and over 150 bills remain under review by Counsel’s Office and the Division of the Budget. It is our responsibility to ensure that the bills, as written, are responsible, enforceable and accomplish their intended purpose.”

It’s hard to imagine how this legislation wouldn’t meet those criteria. A bipartisan bill to ban prior authorization for opioid addiction medications nationally was introduced in Congress in November—but it’s nowhere near passage yet, so it's on states to take action. And Cuomo himself proudly supported 2016 state legislation that banned prior authorization requirements for inpatient addiction treatment and emergency supplies of addiction medications.

For the first time since 2009, overdose deaths in the state (outside New York City) have fallen—by nearly 16 percent between 2017 and 2018. During that time, the state has made significant efforts to ramp up access to buprenorphine, nearly doubling the number of patients receiving the medication between 2012 and 2018. This was achieved through measures like increasing the number of prescribers, expanding prescribing in emergency rooms and other non-traditional settings, educating the public about the importance of medication and, yes, banning prior authorization for initial supplies. Why impede further progress?

If Governor Cuomo doesn’t sign this law, he is literally condemning hundreds of people to die for the sake of insurance company greed. Not to mention needlessly disrupting the lives of thousands of people whose recovery depends on access to these essential medications.