In the Journals

Some eligible physicians avoid prescribing buprenorphine

Cynthia Coulthard
Cynthia Coulthard

Fewer than one in three rural physicians who have a waiver to prescribe buprenorphine for opioid use disorder currently do so, according to research that recently appeared in Annals of Family Medicine.

Compounding the problem of opioid misuse in rural areas is that 60.1% of nonurban counties lack physicians that have these waivers, hindering treatment in these locations, noted researchers.

“A few studies, limited to one or only a few states, have looked at the barriers physicians face providing buprenorphine maintenance treatment, but none has examined nationally the differences between physician groups who are and are not actively using their waivers or accepting new patients,” C. Holly A. Andrilla, MS, department of family medicine, University of Washington School of Medicine, and colleagues wrote. “This study’s purpose was to understand the barriers physicians with waivers face in providing buprenorphine maintenance treatment.”

Andrilla and colleagues mailed surveys to the 2,577 rural physicians on the Drug Enforcement Agency’s list who had waivers to prescribe buprenorphine. Of the 1,124 physicians who returned surveys that were eligible for analysis, 321 indicated they don’t currently prescribe buprenorphine or have never done so.

Concerns about diversion or medication misuse, time constraints and lack of available mental health or psychosocial support services were common barriers identified among responders. Never and former prescribers reported the following barriers significantly more often than current prescribers: concerns about Drug Enforcement Agency intrusions on their practice (P = .028); time constraints (P = .003); lack of specialty backup for complex problems (P < .002); lack of patient need (P = .002); resistance from practice partners (P < .001); lack of confidence in their ability to manage opioid use disorders (P < .001), and attraction of drug users to their practice (P < .001).

In addition, a subset of these doctors (n = 205) noted other concerns such as administrative or infrastructure issues, such as being told they cannot do it or not having the space or staff (17.6%), facing regulatory hurdles such as prior authorization and paperwork (16.6%), having difficult patients (11.7%) and having concerns about stigma (9.3%).

One of the study’s researchers, Cynthia Coulthard, MPH, department of family medicine, University of Washington School of Medicine, said that there is no one-size-fits-all solution to these obstacles.

“...We suggest tailored strategies and multi-pronged approaches [to overcoming these barriers] because ... the overall mix of barriers is quite varied. It will be important to tailor strategies to each physician or region’s needs,” Coulthard told Healio Family Medicine. “However, many of the physicians we spoke to described a lack of mental health providers as barriers to prescribing buprenorphine. Another barrier I heard often was a lack of backup, or other waivered providers in their region; many physicians are the only buprenorphine provider in their county so finding ways to provide backup for these physicians will be essential to encouraging other physicians to ‘pick up the mantle.’’’

She suggested expanding waiver eligibility to nurse practitioners and physician assistants as one possible way to alleviate some of that burden.

The lack of uptake of buprenorphine is particularly discouraging given a study published this week showing the agent to have a strong protective effect against mortality. The medical community continues to struggle with how to address the U.S.’ opioid epidemic, which is linked to 91 deaths a day, according to the CDC. This epidemic has been particularly hard-hitting in many rural communities, where some have suggested that increasing access to care, providing the tools for care in the form of education, training, and assistance in meeting the regulatory requirements of caring for patients with opioid use disorder would be beneficial.

This call for more training was echoed in proposals announced this week by FDA Commissioner Scott Gottlieb. – by Janel Miller

Disclosure: The researchers report no relevant financial disclosures.

Cynthia Coulthard
Cynthia Coulthard

Fewer than one in three rural physicians who have a waiver to prescribe buprenorphine for opioid use disorder currently do so, according to research that recently appeared in Annals of Family Medicine.

Compounding the problem of opioid misuse in rural areas is that 60.1% of nonurban counties lack physicians that have these waivers, hindering treatment in these locations, noted researchers.

“A few studies, limited to one or only a few states, have looked at the barriers physicians face providing buprenorphine maintenance treatment, but none has examined nationally the differences between physician groups who are and are not actively using their waivers or accepting new patients,” C. Holly A. Andrilla, MS, department of family medicine, University of Washington School of Medicine, and colleagues wrote. “This study’s purpose was to understand the barriers physicians with waivers face in providing buprenorphine maintenance treatment.”

Andrilla and colleagues mailed surveys to the 2,577 rural physicians on the Drug Enforcement Agency’s list who had waivers to prescribe buprenorphine. Of the 1,124 physicians who returned surveys that were eligible for analysis, 321 indicated they don’t currently prescribe buprenorphine or have never done so.

Concerns about diversion or medication misuse, time constraints and lack of available mental health or psychosocial support services were common barriers identified among responders. Never and former prescribers reported the following barriers significantly more often than current prescribers: concerns about Drug Enforcement Agency intrusions on their practice (P = .028); time constraints (P = .003); lack of specialty backup for complex problems (P < .002); lack of patient need (P = .002); resistance from practice partners (P < .001); lack of confidence in their ability to manage opioid use disorders (P < .001), and attraction of drug users to their practice (P < .001).

In addition, a subset of these doctors (n = 205) noted other concerns such as administrative or infrastructure issues, such as being told they cannot do it or not having the space or staff (17.6%), facing regulatory hurdles such as prior authorization and paperwork (16.6%), having difficult patients (11.7%) and having concerns about stigma (9.3%).

One of the study’s researchers, Cynthia Coulthard, MPH, department of family medicine, University of Washington School of Medicine, said that there is no one-size-fits-all solution to these obstacles.

“...We suggest tailored strategies and multi-pronged approaches [to overcoming these barriers] because ... the overall mix of barriers is quite varied. It will be important to tailor strategies to each physician or region’s needs,” Coulthard told Healio Family Medicine. “However, many of the physicians we spoke to described a lack of mental health providers as barriers to prescribing buprenorphine. Another barrier I heard often was a lack of backup, or other waivered providers in their region; many physicians are the only buprenorphine provider in their county so finding ways to provide backup for these physicians will be essential to encouraging other physicians to ‘pick up the mantle.’’’

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She suggested expanding waiver eligibility to nurse practitioners and physician assistants as one possible way to alleviate some of that burden.

The lack of uptake of buprenorphine is particularly discouraging given a study published this week showing the agent to have a strong protective effect against mortality. The medical community continues to struggle with how to address the U.S.’ opioid epidemic, which is linked to 91 deaths a day, according to the CDC. This epidemic has been particularly hard-hitting in many rural communities, where some have suggested that increasing access to care, providing the tools for care in the form of education, training, and assistance in meeting the regulatory requirements of caring for patients with opioid use disorder would be beneficial.

This call for more training was echoed in proposals announced this week by FDA Commissioner Scott Gottlieb. – by Janel Miller

Disclosure: The researchers report no relevant financial disclosures.