These data from privately funded treatment programs represent a snapshot of a segment of the specialty care system that has previously been shown to have higher rates of medication adoption than public-sector programs.3, 4
While not directly comparable to the NSSATS and not representative of the entire US addiction treatment system, these data revealed three important findings related to the adoption and implementation of medications. First, programs with access to physicians differed from those programs without physician access on a variety of organizational and client characteristics. These differences are suggestive of disparities in access to medications for different types of patients based on where they receive care, since access to physicians has previously been shown to substantially increase the likelihood of adoption.4,17
Second, the lack of adoption of FDA-approved medications by addiction treatment programs documented in prior studies continues to persist, even in programs with access to physicians. Third, while psychiatric medications are routinely used within adopting programs, the extent to which addiction treatment medications have been implemented is modest.
Consistent with prior studies, this research continued to show the importance of access to physicians in facilitating adoption of pharmacotherapies. Access to physicians via employment or contracts was the norm rather than the exception in this sample of privately funded programs, and rates of pharmacotherapy adoption were indeed higher when the sample was restricted to such programs. However, comparing rates of adoption of addiction treatment medications to psychiatric medications revealed a disparity in adoption even within programs with access to physicians.
The disparity between psychiatric and addiction medications continued when implementation was considered. Within adopting programs, clients with co-occurring psychiatric diagnoses were highly likely to receive medications. Implementation of maintenance medications for opioid addiction and pharmacotherapies for alcohol dependence was much lower than the implementation of psychiatric medications. To some extent, this difference may be reflective of the far larger range of pharmacotherapies that have been FDA-approved for psychiatric conditions than the relatively limited number of medications that are available to treat opioid and alcohol dependent patients.
Additional research is needed on the adoption and implementation of medications in specialty addiction treatment settings. Lack of access to physicians is a clear barrier to adoption. This barrier is likely to be even more salient in publicly funded treatment programs, which are less likely to have access to physicians. Research is needed to identify the barriers to creating linkages between physicians and treatment programs. Potential barriers may include limited financial resources due to tight budgets, purchasing constraints (e.g. contracts that do not allow for reimbursement of physician services), and shortages of physicians with expertise in addiction treatment.
While lack of access to physicians is a barrier to adoption, it does not explain the low rates of implementation of addiction treatment medications within adopting programs. Key questions that need to be addressed in future research include: What are the barriers that prevent adopters from using addiction treatment medications more frequently? How can those barriers be addressed? Possible barriers may occur at the levels of systems, patients, and physicians. System barriers may include the lack of inclusion of medications on Medicaid formularies24
and high co-payments when private insurance offers coverage for these medications.25
Given the recent passage of the federal parity law, it will be important to measure whether this policy change promotes implementation of medication-assisted treatment.
Client characteristics may also be factors in explaining suboptimal rates of implementation. For example, there may be a lack of patient demand for certain medications.19
Some patients may have clinical contraindications that may reduce the appropriateness of medication-assisted treatment. For example, buprenorphine may less clinically appropriate for opioid dependent individuals who are also alcohol or benzodiazepine dependent.26
Earlier studies have strongly suggested that unsupportive attitudes among counseling staff may be a barrier to implementing medication-assisted treatment.27-30
Much less attention has been given to physicians working within treatment programs, resulting in a variety of possible topics for future research. More research is needed on the extent to which physicians' perceptions about the clinical effectiveness of these medications influences prescribing decisions.31, 32
Perceptions about the challenges of patient adherence may also explain some of the variation in medication implementation. Differences in implementation may also reflect the specialty training areas of physicians. For example, it may be that training in addiction medicine is associated with greater implementation of pharmacotherapies for addiction, but that addiction specialists are under-represented relative to general psychiatrists within treatment programs. Comparing physicians' perceptions about psychiatric and addiction treatment medications in terms of clinical effectiveness and patient adherence may yield important information about the implementation process.
There are several limitations in the current study that must be noted. First, the data are limited to privately funded specialty treatment programs and do not include office-based physician practices in primary care or psychiatric specialties. However, recent data about buprenorphine suggest that about one-quarter of addiction physicians who completed the required training have not written any prescriptions for buprenorphine,19
suggesting that implementation problems may extend to other sectors of care.
Second, the NTCS data are based on the reports of administrators or clinical directors. Responses were not validated with client chart reviews. Given the variability of implementation between psychiatric medications and addiction treatment medications, it seems that substantial over-reporting is unlikely. Nonetheless, a study using chart review data would be of great value, especially in identifying the diagnostic profiles and other characteristics of clients who are and are not prescribed medications.
Third, the private-sector programs in this sample are a relatively small proportion of those represented in NSSATS. Eligibility criteria for the NTCS sample do not directly map onto the organizational characteristics measured in NSSATS, so direct comparisons of these data to NSSATS is inadvisable. Moreover, these private-sector programs are known to be more likely than their public sector counterparts to have adopted medications for the treatment of addiction and related conditions. Thus, these data on implementation likely represent a “best case” scenario. We make no claims that these data generalize to the universe of specialty treatment programs; indeed, our conclusions are quite the contrary. However, the modest implementation in programs where both physicians and insurance coverage are more widely available does not portend well for implementation in the rest of the treatment system.
In our analysis of adoption, we focused exclusively on the presence of physicians and did not examine the role of non-physician prescribers, such as physician assistants and nurse practitioners. For the adoption of methadone and buprenorphine, an exclusive focus on physicians is appropriate since non-physicians are prohibited from prescribing these medications. However, non-physician prescribers may have a role in the adoption and implementation of less tightly regulated medications, such as naltrexone. Future research on medication implementation should explore the involvement of the full range of medical professionals.
It is important to also note that this descriptive analysis of medication implementation does not address the factors that may be associated with levels of implementation. For example, future research might consider whether implementation varies by the available levels of care within treatment programs. Some addiction treatment facilities exclusively offer outpatient treatment while others provide outpatient and more intensive levels of care, such as inpatient or residential treatment. Programs also vary in the availability of detoxification services. Our prior work on adoption suggests that levels of care are associated with the availability of medications.3,4
It would be interesting to test whether implementation is also associated with the types of care that treatment organizations offer.