This survey of waivered physicians in Massachusetts revealed several important findings about who is prescribing buprenorphine and how they are doing it. Given the median number of active patients among prescribers (i.e., ten), substantial treatment capacity among current prescribers remains. Thus, efforts to increase OBOT treatment could be directed to both waivered physicians who already prescribe but have further capacity by regulations as well as those who do not prescribe. The lack of office and nursing support noted as common barriers by both prescribers and non-prescribers is evidence that for many providers adding OBOT with buprenorphine to one’s practice requires increased administrative and clinical resources. An example of a successful collaborative care model was recently described.3
As prescribers commonly identified payment and pharmacy issues as barriers, it is likely that increasing insurance coverage for buprenorphine and making it more available in pharmacies would help prescribers treat more patients. Increasing prescribing among non-prescribers will likely require improved top-down institutional support and improved systems that match patients seeking treatment to waivered physicians.
Determining why psychiatrists were less likely to prescribe than physicians in primary care specialties warrants further investigation. This reluctance of psychiatrists to prescribe buprenorpine was noted previously in a national survey of 1,203 psychiatrists conducted before buprenorphine was released for OBOT, where four-fifths of all respondents, including 43% of those certified in addiction psychiatry, reported they would not be comfortable providing OBOT.19
The increased likelihood of prescribing we found among primary care physicians compared to psychiatrists may be evidence that the DATA 2000 legislation has encouraged office-based treatment beyond specialty practices and into primary care. According to the CSAT guidelines, DATA 2000 “promises to bring opioid addiction care into the mainstream of medical practice.”14
We found that being in solo practice versus being in a group practice was also associated with prescribing buprenorphine. Wolinsky and Friedson have described a trade off between greater resources and greater autonomy for physicians who choose to work in group or solo practices, respectively.20
We expected that group practices could provide more administrative support to waivered physicians who would therefore be more likely to prescribe. However, it is likely that while group practices are better resourced, they present more bureaucratic or administrative barriers to instituting a new treatment such as OBOT. Furthermore, early regulations restricted not only each individual physician to 30 patients, but each group practice to 30 total patients, which likely reduced the incentive for group practices to support providing buprenorphine treatment over competing priorities.
Clinical practices of prescribers were largely consistent with the substance and spirit of buprenorphine training and the CSAT guidelines in that they conform to the 30-patient limit that was in effect at the time of this survey, substance abuse counseling was available and being offered, and monitoring of adherence and relapse through drug screens and pill counts occured widely among prescribers.
Although these OBOT practices were CSAT guideline-driven, others were not. Substantial numbers of physicians use unobserved home induction where patients start buprenorphine at home, usually with telephone support from a nurse or physician. A successful home induction protocol has been described,3
but is not part of the CSAT guidelines. Some physicians prescribe the mono tablet for “patient preference.” This is not an appropriate indication because the mono tablet is more likely to be abused by crushing it and injecting it. Thus, it is more likely to be diverted and has a higher risk of contributing to overdoses.21
Only one third of prescribers store their notes separately from other medical information, which is a practice not specifically required, but may facilitate compliance with federal confidentiality requirements.
Because this study targeted all physicians eligible to provide OBOT with buprenorphine in a single state almost 3 years after buprenorphine was available, it adds to and supports previous examinations of treatment practices and barriers.22
We found that two thirds of waivered physicians provided OBOT with buprenorphine, confirming preliminary national estimates.1,16,17
As in our study, Kissin et al. found that factors associated with not prescribing buprenorphine included being a psychiatrist and working in a setting other than a solo practice. Common barriers noted in this study included concern around the induction logistics, availability of the medication, and the 30-patient limit per physician and per practice that was in force at that time.
A survey of 375 physicians attending HIV educational conferences in 2006 found 25% had obtained a waiver to prescribe buprenorphine, but only 6% had ever prescribed.23
As in our study, the provider specialty was significantly associated with likelihood of prescribing buprenorphine. Among the HIV providers, general internists were more likely to prescribe than family medicine or infectious disease physicians. Common barriers to providing care noted by waivered respondents included deficits in knowledge about opioid treatment, lack of immediate telephone access to an addiction expert, inability to refer to a substance abuse treatment program, concern about resistance from staff or colleagues, and fear of taking on increased medicolegal risks, overly complicated patients, and issues of medication diversion. Similar knowledge deficits were not commonly reported in our study, though lack of nursing, office, and institutional support were.
The issue of lack of institutional support as a barrier deserves further study. Our survey did not clearly define lack of institutional support, whether it is a barrier from group practice, insurance carrier, hospital or clinic administration. Our findings do suggest that the impact of lack of institutional support is independent of whether a waivered physician is in a solo or group practice. Potential improvements in institutional support are suggested by a 2003 survey of primary care and HIV clinic directors in New York examining the barriers to providing OBOT with buprenorphine.24
This study found 60% would be likely to provide OBOT with buprenorphine if training was offered. Clinic characteristics associated with increased likelihood of prescribing included providing HIV specialty care, having a secure site to store narcotics, having immediate telephone access to an addiction expert, and receiving continuing medical education credits for training.
Our study has some limitations. First, the number of patients physicians are permitted to treat has evolved, and thus our results may not fully reflect current conditions. We conducted the survey 1 month after the 30-patient limit on each group practice was lifted. Thus, some group practices may have been unwilling to commit physician time or resources to so few patients at the time of the survey, which may explain why physicians in group practices were less likely to be prescribers. Furthermore, in January of 2007, the 30-patient limit per physician was increased to 100 patients for approved physicians prescribing for greater than 1 year. As this Massachusetts sample shows that most prescribers are not close to the 30-patient limit, the impact of increasing the limit to 100 is unlikely to be immediate. Another limitation is that the survey instrument provided nine barriers for respondents to endorse, yet important barriers may not have been included on the list, such as the 30-patient limit. A third of the non-prescribers reported none of the barriers listed, and thus some barriers to prescribing were not identified in this study.
Addictive disorders, such as opioid dependence, are chronic relapsing brain diseases. Like methadone maintenance, OBOT with buprenorphine is probably most effective as a chronic therapy for opioid dependence.2
Fully integrating this treatment for a chronic disease into mainstream medical practice is occurring among generalist physicians and will likely be enhanced with substantial systematic, multidisciplinary support. Prescribing practices are largely consistent with guidelines, though more education about home induction and the indications for the mono buprenorphine-only formulation should be incorporated into training. Our study provides evidence that utilizing the exisitng treatment capacity among physicians waivered to provide OBOT awaits the improvement of nursing, office, and institutional support and the resolution of payment and pharmacy issues.