In this study of 375 physicians who provide HIV care in six different metropolitan areas across the United States, one quarter reported that they had a waiver to prescribe buprenorphine, but less than 6% reported that they had ever prescribed buprenorphine. Physicians reported a variety of barriers to prescribing buprenorphine, with more barriers reported by those who did not have a waiver to prescribe buprenorphine compared to those who did have a waiver. Physicians with waivers were significantly more likely to be confident in their ability to address drug problems, and less likely to be concerned about the lack of immediate access to consult with an addiction specialist.
Similar to other investigations, our study revealed that confidence in one’s ability to address drug problems is associated with substance abuse treatment.18,26,27
Previous studies have shown that knowledge deficits have posed significant barriers to physicians offering opioid addiction treatment.16,20,28
Inadequate substance abuse education has been documented both at the undergraduate and graduate medical education levels.29–32
For example, in 1991–92 only eight U.S. medical schools had required courses in substance abuse treatment.33
Furthermore, education and training interventions focusing on management of opioid addiction have been associated with improved ratings of confidence in opioid addiction treatment, and increased likelihood of treating opioid addiction with pharmacologic therapy.28
Strengthening physician training in substance abuse may therefore ultimately serve to improve access for patients with opioid dependence.
Systems-level barriers to substance abuse treatment such as inadequate access to substance abuse expert consultation have similarly been reported in other studies.16,20
To address this need for physician consultation about buprenorphine, the Substance Abuse and Mental Health Services Administration (SAMHSA) established a web site for clinical questions (the SAMHSA Buprenorphine Clinical Discussion WebBoard at http://bup-webboard.samhsa.gov/login.asp
). In addition, the SAMHSA-sponsored Physician Clinical Support System (at http://www.pcssmentor.org/
) provides a national network of expert physician mentors who provide consultation to new buprenorphine prescribers. Both of these resources were available before this study, yet our findings reveal access to consultation remains a barrier. Thus, informing potential providers about existing support systems may promote physician willingness to obtain a waiver and to prescribe buprenorphine.
We are aware of only one other study that examined HIV physicians’ perceptions of barriers to prescribing buprenorphine.21
In that study, HIV and non-HIV physicians were surveyed to assess their preparedness for prescribing buprenorphine after attending an 8-hour buprenorphine course. Both groups reported lack of experience as the biggest barrier to prescribing buprenorphine, and most felt they would be more comfortable prescribing buprenorphine if they had access to an expert mentor. In addition, the majority of HIV physicians reported concern about prescribing buprenorphine to HIV-infected patients, with many citing concerns about drug interactions. Unlike our study participants, HIV physicians in that study were attending buprenorphine training courses; thus, they were a select group of providers already interested in opioid addiction treatment with buprenorphine. Despite this difference, both studies demonstrate the important issue of having access to an addiction expert.
In this study we chose to examine barriers to obtaining a waiver to prescribe buprenorphine, rather than barriers to having a DEA X number, or barriers to prescribing buprenorphine. Our rationale is that we believe that having a waiver is the appropriate “starting point” for demonstrating interest in prescribing buprenorphine. Because the vast majority of physicians in the United States do not even have waivers,34
it is important to evaluate barriers at this first step.
We acknowledge that the low response rate in our study (44%) may have influenced our results in ways that would be difficult to predict. In addition, it is impossible to draw inferences about directionality from this cross-sectional study. It is equally likely that confidence addressing drug problems led physicians to obtain a waiver, or that once providers had a waiver, their confidence in addressing drug problems improved. Finally, the ability to generalize our findings to other HIV and non-HIV physicians is uncertain.
In conclusion, in this study of physicians attending HIV educational conferences, 25% obtained a waiver to prescribe buprenorphine for opioid addiction treatment, but only 6% reported ever prescribing buprenorphine. Confidence in addressing drug problems was positively associated with having a waiver to prescribe buprenorphine, and concern about lack of access to consult with an addiction expert was negatively associated with it. HIV physicians are uniquely positioned to address opioid addiction treatment in the primary care setting. In addition, HIV physicians are likely to be caring for individuals who use or abuse opioids, and they frequently practice in multidisciplinary environments. Understanding and remediating the barriers HIV physicians face may lead to new opportunities to improve health care and health outcomes for opioid-dependent HIV-infected patients.