This study is, to our knowledge, the first to assess methods of training physicians about the use of buprenorphine for treatment of opioid dependence. Physicians were surveyed after participation in a CSAT-sponsored curriculum that fulfilled the eight-hour educational requirement specified by DATA 2000 for qualification to prescribe buprenorphine for treatment of opioid dependence. The curriculum combined four hours each of online and in person instruction with content standardized to national APA requirements. Although the combined approach was well received overall, survey respondents preferred in person instruction. In particular, they rated highest the session in which they met with and interviewed two patients on buprenorphine maintenance. During this session, they learned first hand about the patients’ experience transitioning onto buprenorphine and became familiar with strategies to monitor and prevent relapse.
Survey respondents were divided into two groups for analysis: those who intended or were hesitant to prescribe buprenorphine after the training. Two thirds stated that they intended to prescribe buprenorphine after the training while a third expressed reluctance. Surprisingly, intention to prescribe buprenorphine did not vary by physician background characteristics such as specialty or prior experience managing opioid dependence. However, those who intended to prescribe buprenorphine were significantly more likely to feel that the curriculum provided enough information. They also were more likely to agree that telephone access to experienced providers would improve their confidence. This later finding is potentially important as physician confidence has been associated with more favorable practices regarding substance use disorders (9
). Among physicians hesitant to begin prescribing buprenorphine, the primary barrier reported by 41% was a lack of experience.
Since eight hours of instruction fulfills only the minimal training requirement under DATA 2000, it previously has been expected that physicians would benefit from additional training, including experience with opioid-dependent patients on buprenorphine (10
). While incorporating a greater degree of experiential training into an 8-hour course may not be feasible, the potential benefit of additional experiential training and access to experienced buprenorphine treatment providers served as the impetus to the development of the Physician Clinical Support System (PCSS). The PCSS is a national mentoring network established by SAMHSA in collaboration with ASAM and other specialty addiction medical societies to assist physicians with the appropriate use of buprenorphine (available at http://www.pcssmentor.org
, accessed March 20, 2006). Mentors experienced with buprenorphine treatment provide assistance by telephone, email, and at their place of clinical practice enabling interested physicians to gain experience with buprenorphine treatment through direct observation of in-office patient care. Thus, the mentoring can be tailored to the needs of the mentee. Based on our findings, one might expect that phone consultation would suffice for physicians who intend to prescribe after training completion, while in-office experiential training with a mentor might be necessary for those reluctant to prescribe. In addition, as nearly a quarter of hesitant physicians cited concern about induction difficulty as a barrier to prescribing, in-office mentoring provides an opportunity for the mentee to observe an induction first hand, potentially allaying concerns about the induction process.
Although the online course rated lower than most aspects of the in person training, the presence of an online component did not seem to diminish the overall opinion of the curriculum, given that the overall course rated similarly to the in person training components. The potential benefit of incorporating an online component into physician training is convenience; the online course can be completed any time of day and be stopped and resumed by participants. In addition, the pace of learning during online instruction may be adapted to suit the individual learner’s needs, a benefit of potential importance with wide variation in clinical specialization of course participants. Nearly 90% completed the online training prior to the in-person component, and all attended a 30-minute review lecture at the start of the in-person training. With this introduction to the basics of buprenorphine treatment, participants anecdotally seemed to achieve a similar level of preparedness prior to the small-group discussions, thus enabling more sophisticated clinical discussion.
There are several limitations to the study. With a response rate of 76%, it is unknown whether program ratings or physician willingness to prescribe are under- or overestimated. Assessing the extent to which responders differ from total course participants is limited as little is known about the non-responders or the whole population of 70 trainees eligible for the study. The percentage of all trainees and survey respondents who completed the online course prior to the in-person training was similar, perhaps indicating a similar interest in and enthusiasm for providing office-based buprenorphine treatment. Although 67% reported intent to prescribe, we are unable to assess the percent who actually initiated treatment of opioid dependent patients with buprenorphine. Future studies should attempt to correlate physician background, curricular assessment measures, and perceived barriers with actual prescribing.
The current evaluation adds to and expands the literature on physician training in Australia (11
) and the United States (12
) on the use of buprenorphine. Hopefully, with ongoing evaluation of methods used to train physicians on the use of buprenorphine, we will be able to optimize physician preparation to provide this medication for office-based treatment of opioid dependence.