Falling through gaps: Albertans with addictions can't always secure 'life-saving' medication

When Calgary resident Michael Brown was 17 years old, he was kicked out of high school for selling OxyContin to one of his football coaches.

It set him down a path to selling drugs to get enough money to feed his addiction. 

In an effort to get sober, Brown tried Suboxone — the brand name for a medication that includes buprenorphine and naloxone, used to treat a dependence on opioid drugs such as fentanyl and heroin. But without drug coverage, he found himself unable to pay for it.

"When I didn't have coverage, it was hard," Brown said. "And lots of times, I'd have to go back to street drugs because I didn't have coverage."

Suboxone suppresses withdrawals and decreases cravings, and blunts the effects of opioids, meaning those drugs will not produce the same effects should users take them while on Suboxone. 

Brown has since secured coverage and credits methadone and Suboxone for his sobriety, allowing him to function without going into withdrawal.

The past few years have been fraught with tragedy as Alberta navigates its way through a serious opioid crisis. Alberta recorded its deadliest year on record for overdoses with more than 1,700 deaths in 2021.

The provincial government has remained focused on recovery-oriented care, rejecting the harm reduction model.

Part of the government's strategy is opioid agonist therapy (OAT), which involves the use of medications like Suboxone and methadone.

Recognizing that additional costs to these treatments can often be a barrier to those individuals accessing the treatment, the Alberta government offers a "gap" program — which was introduced in April 2020 — providing coverage for these medications "for up to 120 days" while those enrolled sign up for supplementary health benefit plans.

Those who sign up for the gap coverage can also receive the medications past the 120 days until benefits come into effect, the government says, should they submit a coverage extension request form.

More than 5,000 Albertans have accessed the program since its implementation.

Some pharmacists and physicians say the program is a big improvement to what was previously in place. Before the program was implemented, those without coverage had no choice but to pay for their medication themselves — something many aren't equipped to do in their lowest moments.

But the coverage isn't perfect, they say, and any cracks are made all the more important when lives hang in the balance.

"This is a good program, but there are gaps in the gap program," said Rich Rego, an addiction medicine pharmacist at the Beacon Pharmacy in downtown Calgary.

Tablets vs. quantity

Justin W. said taking Suboxone made him realize that drugs had destroyed his brain's ability to release dopamine and experience its "reward" system.

CBC News agreed to withhold Justin's last name as he worries about his history with drug use being tied to opportunities for his future employment.

"While I was taking Suboxone, I was able to relearn those reward systems. I was taking my dog for a walk, seeing how happy she was, just looking at nature. I was starting to reground myself," Justin said.

So Justin was surprised to hear from his pharmacist that some patients receiving the drug as part of the provincial government's gap program were being cut off of coverage before the 120-day mark.

"Why are they getting cut off? Who's deciding this?" he said.

Rather than 120 actual days, the program was being calculated based on the quantity of prescription drug dispensed. Program claims are adjudicated against a quantity limit of 1,500 milliltres of methadone, or 360 tablets of buprenorphine/naloxone. 

That represents approximately 120 days of treatment for the average dose patient, according to a Blue Cross bulletin from May 2021. 

However, such an arrangement has caused complex issues for some pharmacists. It comes down to how the medication is parcelled out in doses.

For example, if a person is on 14 milligrams of Suboxone, that might translate into one tablet of eight milligrams and three tablets of two milligrams per day. There are other doses available; but they are not covered under the program.

Compare that to a person getting 24 milligrams, who might get three tablets of eight milligrams per day. That means though a person might be on a lower dose, they would actually be receiving more tablets and would therefore run past the quantity limit prior to someone on a higher dose.

Explaining that to people who are cut off prior to the 120-day mark is complicated for pharmacists and frustrating for patients.

In a statement emailed to CBC News, the press secretary for Mike Ellis, the associate minister of mental health and addictions, said this was the first they were hearing of the issue.

"Thank you for bringing this to our attention. The purpose of the [gap program] is to provide Albertans with four months of uninterrupted coverage while they begin treatment, stabilize and apply for long-term benefits," said Eric Engler in an email.

"I am told that we do have a process in place for pharmacies to contact Alberta Blue Cross on this exact situation. A communication will be going out to all pharmacies in short order on this process, ensuring four months of uninterrupted coverage for Albertans."

Engler said pharmacies need to contact Alberta Blue Cross and additional coverage is usually granted within the same day.

"Coverage will always be approved for program participants if they are prescribed higher dosages than the program provides for," Engler wrote.

Dr. Nathaniel Day, medical director for the Virtual Opioid Dependency Program administered by Alberta Health Services, said the gap program was created for those who don't qualify for typical medication coverage from work, income support or other programs.

"We want to make sure they get care in the moment, then we help them connect with appropriate coverage elsewhere," he said.

He noted that part of the job of officials is to connect those getting coverage with ongoing medication supports.

Day said the future of the program could include an increase to total doses available or a more obvious extension process for pharmacies.

Navigating insurance systems

Buprenorphine is a "life-saving" medication, said Ellie Grossman, a medical director with Cambridge Health Alliance and an instructor in medicine at Harvard Medical School.

It's for that reason that Grossman said she worries about any program that would prescribe a total number of pills over a certain time span, such as the one in place in Alberta.

"The perhaps foolishly optimistic part of me says, 'yeah, OK, [120 days] gives people time to get themselves set up with other payers for this medication,'" she said. 

"But depending on how complex that system is to navigate … I do worry that at a certain period of time, if let's just say that the medication supplies are abruptly cut off, that people will revert to using whatever they were using before."

When it comes to people falling through the "gaps," some feel like the province could do more.

Rego, the pharmacist working out of downtown Calgary, said he would be in favour of the province connecting with a working group of pharmacists to listen to their suggestions as to how gap coverage could be re-evaluated on a regular basis.

"It would be great to see an expansion of the tools that the gap program actually covers," he said.

Brown, who has now been sober for two years, said he empathizes with anyone who is cut off of their coverage, especially those struggling with money or with their mental state.

"[These medications] are made so you don't have to use fentanyl and overdose, right? You can stay on methadone, Suboxone, and you can live your life," Brown said.

"When it comes to coverage … life is worth so much more than trying to figure out, 'How am I going to get covered for this drug that I need?'"