Office-based buprenorphine treatment has the potential to significantly expand access to drug treatment for individuals addicted to opioids and has already reached hundreds of thousands of people needing treatment. Despite this success, uptake by U.S. physicians is not yet commensurate with patient need. Factors affecting physician willingness to prescribe buprenorphine must be better understood so that barriers can be effectively addressed. Data from our physician surveys illustrate that most factors that affect willingness to prescribe buprenorphine are less significant for experienced prescribers than they are for physicians new to buprenorphine treatment, suggesting that experience eases—at least in part—a number of concerns. This finding is consistent with the diffusion of innovation theory. Interestingly, however, the similarities in responses between novice and nonprescribers (as compared to those with more experience) for many factors, including availability of clinical guidelines, access to consultation with an expert provider, and induction logistics, suggest that substantial, rather than minimal, experience is required before concerns are significantly reduced. The prolonged need for guidelines and expert support are not surprising given the limited attention paid to drug addiction and treatment in medical school curricula (Fiellin et al., 2002
) and the general discomfort physicians feel when addressing these topics (Friedmann et al., 2001
; Saitz et al., 2002
). Mentorship and education programs, as well as the dissemination of written and web-based materials, may effectively reduce barriers to buprenorphine uptake and should be available to providers prior to their first buprenorphine induction and as they continue to gain experience with the treatment.
However, our data also suggest that some barriers persist even among experienced prescribers. A number of factors, including those related to access to behavioral health services, such as counseling, mental health services, and supportive services were highly relevant even among experienced providers. Given the historic separation between the medical and behavioral health care systems, as well as general shortages in and inadequate reimbursement for behavioral health care, it is not surprising that access to these services was seen by physicians in our sample as affecting their willingness to provide buprenorphine treatment. Indeed, this finding is consistent with prior studies indicating that access to other services affects doctors’ satisfaction with treating opioid dependence (Becker & Fiellin, 2006
). Adequate time for the patient visit and availability of buprenorphine were also seen as relevant factors across physician groups. Concerns around availability may suggest the need for expanded coverage by insurance plans, as well as greater outreach and education for pharmacists.
These findings are similar to those found in the Kissin/ WESTAT study (Kissin et al., 2006
), where providers also reported challenges in payment/reimbursement, availability of buprenorphine, and availability of counseling services. Dissimilarly, providers in this study were less likely to report concern about induction logistics, DEA involvement, and record keeping. The differences may be explained by the fact that the Kissin/WESTAT data were obtained roughly 1 year following buprenorphine approval and so likely represent the opinions of physicians with relatively limited experience.
Adequate reimbursement for drug-abuse-related office visits was the only factor judged more significant for experienced providers than for those with less experience. Furthermore, experienced providers rated it as more relevant (3.5) than any other factor. Although the extent to which reimbursement concerns impact on the number of buprenorphine patients an individual is able to see in his or her practice cannot be determined from this study, this finding does suggest that new prescribers may underestimate the resource needs of buprenorphine visits. In addition, this finding reinforces the call for increased insurance coverage for mental health and substance abuse treatment services.
Our data are subject to several limitations. Although the BHIVES and PCSS samples incorporate variation with regard to geography, practice setting, clinical background, and experience, they are not representative of all physicians trained to prescribe buprenorphine, and therefore, generalizations should be made cautiously. The findings are further limited by the fact that they are drawn from two studies with somewhat different participant pools. Although we used statistical tests to correct for small cell size, the findings about African American and HIV specialists should be interpreted cautiously. In addition, although we did control for certain relevant characteristics (including HIV specialty, race, and gender), we were unable to control for other important intervening variables: We either lacked the data or lacked variation across groups (e.g., HIV physicians were likely to fall into the “novice” group; addiction medication physicians were likely to be in the “experienced” group). There are likely to be other important distinctions between the three groups that affect their perceptions of buprenorphine treatment. For example, the most experienced buprenorphine prescribers, as well as the HIV providers, are likely to be based in well-resourced settings with access to services that may not be available in private practice or smaller community-based clinics. Therefore, the finding that, in comparison to other physicians, the most experienced prescribers rated an adequate referral system and access to mental health and supportive services as less significant may reflect their greater access to ancillary services than would be the case for those working in other settings (Saxon & McCarty, 2005
) rather than an increased level of comfort gained from experience. As mentioned above, the experienced buprenorphine prescribers were more likely to specialize in addiction medicine; they were also more likely to report providing care for patients with opioid dependence for greater than 3 years. Thus, the greater comfort with buprenorphine prescribing found in the most experienced group may reflect, to a large extent, their greater familiarity and comfort with addiction treatment in general.
Despite these limitations, these data do provide important insight into physician concerns with respect to prescribing buprenorphine and have implications for changes in practice, education, policy, and research that may effectively promote and support more widespread adoption of buprenorphine treatment in the United States. Factors like access to counseling and mental health services, reimbursement, and adequate time with patients, although mediated to some extent by physician experience, remain significant obstacles for all physicians. Such barriers must be addressed at the systems and policy level, including increased linkages and information exchange between medical and behavioral health services and new approaches for financing buprenorphine treatment, with all its necessary components, in office-based settings.