Buprenorphine Prescribing Availability in a Sample of Ohio Specialty Treatment Organizations

"It's more than Just a Job to Them": A Qualitative Examination of Patient and Provider Perspectives on Medication-Assisted Treatment for Opioid Use Disorder

The expansion of access to medication-assisted treatment by states and the federal government serves as one important tool for tackling the opioid crisis. Achieving this goal requires increasing the number of medical professionals who hold DATA Waiver 2000 waived status, which allows providers to prescribe the medication utilized by treatment programs. Waived providers are scarce throughout rural America, placing a potentially large burden on those who do hold a waiver. This paper uses data gathered through qualitative interviews with healthcare workers and patients at MAT clinics in Montana to understand how the relationship between rural healthcare workers and MAT patients contributes to burnout and potential staff turnover in a rural setting. Patients defined quality care via the patient-staff relationship, including expectations of personal support and viewing staff availability as a requirement for their recovery. Healthcare workers, in contrast, refer to their availability to patients as overwhelming and necessary both during and after business hours. These findings illuminate the need to continue expanding MAT access in rural communities, especially in non-specialty care settings including primary care offices and Federally Qualified Health Centers.

Pharmacotherapy, Resource Needs, and Physician Recruitment Practices in Substance Use Disorder Treatment Programs

OBJECTIVES

Effective pharmacological treatments for opioid use disorder (OUD) continue to be underutilized, particularly within specialty substance use disorder (SUD) treatment organizations. Few studies have examined whether specific practices to recruit prescribers, financial needs, and human resource needs facilitate or impede the implementation of pharmacotherapy.

METHODS

Surveys were completed by administrators from 160 treatment programs in Florida, Ohio, and Wisconsin. Respondents described availability of five pharmacotherapies for treating OUD, organizational resource needs, current use of physician recruitment practices, and buprenorphine treatment slots.

RESULTS

The mostly commonly available medications were injectable naltrexone (65.4%; n = 102), buprenorphine-naloxone (55.7%; n = 88), and tablet naltrexone (50.0%; n = 78). Adopters of each of the 5 pharmacotherapies reported significantly greater physician outreach than organizations that did not provide these medications. The mean number of buprenorphine slots was 94.1 (SD 205.9). There were unique correlates of adoption (ie, any slots) and availability (number of slots) of buprenorphine. Physician outreach activities were correlated with the likelihood of nonadoption, whereas medical resource needs (ie, needing more physicians to prescribe pharmacotherapy) and dedicated resources for physician recruitment were associated with the number of slots.

CONCLUSIONS

Physician recruitment activities differentiated those organizations that had existing pharmacotherapy treatment capacity (ie, any slots) from those that had no capacity. Efforts to address the medical resource needs of treatment organizations, and also strategies that encourage organizations to devote resources to recruiting prescribers may hold promise for increasing access to these lifesaving treatments.

Payer Policy Behavior Towards Opioid Pharmacotherapy Treatment in Ohio

Objective:

Few studies examine how payers address the need for improved access to pharmacotherapy for opioid use disorders and the influence of environmental variables on access to opioid agonist and antagonist medications.

Method:

The 52 Ohio Addiction Drug Abuse and Mental Health Services (ADAMHS) Boards that disburse funds for treatment services for the uninsured and underinsured were surveyed to assess coverage for opioid agonist and antagonist treatment medications. Analyses examined public health data on regional opioid addiction patterns, characteristics of the local health insurance market, and their associations with coverage for opioid addiction pharmacotherapy.

Results:

Most (70%) of the 44 participating ADAMHS Boards paid for opioid treatment medications. For payment policy, all Boards required behavioral therapy to be provided in conjunction with opioid agonist or opioid antagonist therapy, and 27% of the Boards limited length of a buprenorphine therapy regimen. Higher local opioid treatment admission rates were associated with higher rates of Board funding for opioid treatment pharmacotherapy. Environmental variables (eg, overdose fatality rates or the behaviors of private insurance payers) were not associated with ADAMHS support for opioid agonist or antagonist medication.

Conclusions:

The analysis highlights the policy preferences of these payers. Follow-up studies should examine the payer decision-making processes, preferences, and attitudes that affect support for pharmacotherapy for opioid dependence.

Barriers to Buprenorphine Expansion in Ohio: A Time-Elapsed Qualitative Study

Buprenorphine partial opioid agonist pharmacotherapy, a key treatment for opioid use disorders (OUDs), is underutilized in the United States. Qualitative interviews, conducted in 2012/2013 and repeated in 2015, identified systemic barriers to providing buprenorphine treatment in Ohio. A representative sample of Ohio's Alcohol, Drug Abuse and Mental Health Services (ADAMHS) county boards (n = 18) was selected based on percentage of OUD admissions, density of buprenorphine prescribers, and county board area population. Boards reported that the barriers to the use of buprenorphine in 2012/2013 included (1) negative attitudes toward the use of buprenorphine among substance use disorder treatment providers; (2) a lack of prescribers; and (3) lack of funding. The 2015 interviews suggested that the lack of prescribers surpassed lack of funding as the main impediment to buprenorphine expansion. Negative provider attitudes were no longer problematic. Concerns about buprenorphine diversion, however, had emerged as a new barrier. This article offers recommendations for future policy efforts to overcome these barriers and expand the use of evidence-based opioid treatments. It highlights the need for payers and policymakers to increase the number of buprenorphine prescribers to make best use of funding available to fight the opioid epidemic.

Test of a workforce development intervention to expand opioid use disorder treatment pharmacotherapy prescribers: protocol for a cluster randomized trial

BACKGROUND

Overdoses due to non-medical use of prescription opioids and other opiates have become the leading cause of accidental deaths in the USA. Buprenorphine and extended-release naltrexone are key evidence-based pharmacotherapies available to addiction treatment providers to address opioid use disorder (OUD) and prevent overdose deaths. Treatment organizations' efforts to provide these pharmacotherapies have, however, been stymied by limited success in recruiting providers (physicians, nurse practitioners, and physician assistants) to prescribe these medications. Historically, the addiction treatment field has not attracted physicians, and many barriers to implementing OUD pharmacotherapy exist, ranging from lack of confidence in treating OUD patients to concerns regarding reimbursement. Throughout the USA, the prevalence of OUD far exceeds the capacity of the OUD pharmacotherapy treatment system. Poor access to OUD pharmacotherapy prescribers has become a workforce development need for the addiction treatment field and a significant health issue.

METHODS

This cluster randomized controlled trial (RCT) is designed to increase buprenorphine and extended-release naltrexone treatment capacity for OUD. The implementation intervention to be tested is a bundle of OUD pharmacotherapy capacity building practices called the Prescriber Recruitment Bundle (PRB), which was developed and piloted in a previous statewide buprenorphine implementation study. For this cluster RCT, organizational sites will be recruited and then randomized into one of two arms: (1) control, with treatment as usual and access to a website with PRB resources, or (2) intervention, with organizations implementing the PRB using the Network for the Improvement of Addiction Treatment organizational change model over a 24-month intervention period and a 10-month sustainability period. The primary treatment outcomes for each organizational site are self-reported monthly counts of buprenorphine slots, extended-release naltrexone capacity, number of buprenorphine patients, and number of extended-release naltrexone patients. This trial will be conducted in Florida, Ohio, and Wisconsin, resulting in 35 sites in each arm, for a total sample size of 70 organizations.

DISCUSSION

This study addresses three issues of substantial public health significance: (1) the pressing opioid misuse epidemic, (2) the low uptake of OUD treatment pharmacotherapies, and (3) the need to increase prescriber participation in the addiction treatment workforce.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02926482.

Why aren't physicians prescribing more buprenorphine?

BACKGROUND & OBJECTIVE

Buprenorphine is an underutilized pharmacotherapy that can play a key role in combating the opioid epidemic. Individuals with opioid use disorder (OUD) often struggle to find physicians that prescribe buprenorphine. Many physicians do not have the waiver to prescribe buprenorphine, and a large proportion of physicians that are waivered do not prescribe to capacity. This study aimed to quantitatively understand why physicians do not utilize buprenorphine for the treatment of OUD more frequently.

METHODS

Physicians (n=558) with and without the waiver to prescribe buprenorphine were surveyed about perceived drawbacks associated with prescribing buprenorphine. Furthermore, resources were identified that would encourage those without the waiver to obtain it, and those with the waiver to accept more new patients. The survey was distributed online to physicians in the spring/summer of 2016 via the American Society for Addiction Medicine and American Medical Association listservs.

RESULTS AND CONCLUSIONS

A logistic regression analysis was used to identify reasons that respondents indicated no willingness to increase prescribing (χ²(4)=73.18, p<0.001); main reasons were lack of belief in agonist treatment (OR 3.98, 95% CI, 1.43 to 11.1, p=0.008), lack of time for additional patients (OR 5.54, 95% CI, 3.5 to 8.7, p<0.001), and belief that reimbursement rates are insufficient (OR 2.50, 95% CI, 1.3 to 4.8, p=0.006). Differences between non-waivered and waivered physicians concerning attitudes toward buprenorphine treatment as well as resources that would increase willingness to prescribe are also discussed. Identifying barriers to buprenorphine utilization is crucial in expanding treatment options for individuals with OUD.

Buprenorphine physician supply: Relationship with state-level prescription opioid mortality

BACKGROUND

Buprenorphine is an effective treatment for opioid use disorder but the supply of buprenorphine physicians is currently inadequate to address the nation's prescription opioid crisis. Perception of need due to rising opioid overdose rates is one possible reason for physicians to adopt buprenorphine. This study examined associations between rates of growth in buprenorphine physicians and prescription opioid overdose mortality rates in US states.

METHODS

The total buprenorphine physician supply and number of physicians approved to treat 100 patients (per 100,000 population) were measured from June 2013 to January 2016. States were divided into two groups: those with rates of prescription opioid overdose mortality in 2013 at or above the median (>5.5 deaths per 100,000 population) and those with rates below the median. State-level growth curves were estimated using mixed-effects regression to compare rates of growth between high and low overdose states.

RESULTS

The total supply and the supply of 100-patient buprenorphine physicians grew significantly (total supply from 7.7 to 9.9 per 100,000 population, p<0.001; 100-patient supply from 2.2 to 3.4 per 100,000 population, p<0.001). Rates of growth were significantly greater in high overdose states when compared to low overdose states (total supply b=0.033, p<0.01; 100-patient b=0.022, p<0.01).

CONCLUSIONS

The magnitude of the US prescription opioid crisis, as measured by the rate of prescription opioid overdose mortality, is associated with growth in the number of buprenorphine physicians. Because this observational design cannot establish causality, further research is needed to elucidate the factors influencing physicians' decisions to begin prescribing buprenorphine.