Buprenorphine Treatment Access Limited in States With High Opioid-Related Mortality

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On average, 45% of callers reporting current heroin use were denied an appointment with a buprenorphine provider. More of those paying cash were offered an appointment, compared with those covered by Medicaid.

Access to office-based buprenorphine treatment for opioid use disorder (OUD) was limited in states with high OUD-related mortality rates because of a shortage of buprenorphine prescribers who were taking new patients, but wait times were not long for providers with availability, according to a study published in the Annals of Internal Medicine. However, many prescribers did not offer new appointments or rapid buprenorphine access to callers reporting active heroin use, particularly those with Medicaid coverage.

Tamara Beetham of Harvard TH Chan School of Public Health, Department of Social and Behavioral Sciences, Boston, Massachusetts, and colleagues used an audit survey (secret shopper survey) to determine rates of new appointments, whether buprenorphine prescription was possible at the first visit, and wait times for treatment in 6 US jurisdictions with high opioid-related mortality rates — Massachusetts, Maryland, New Hampshire, West Virginia, Ohio, and the District of Columbia. Trained callers posed as uninsured self-pay or Medicaid-covered patients seeking buprenorphine treatment.

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Among 1092 contacts with 546 clinicians, callers had a 78% response rate. Clinicians offered new appointments to 62% of uninsured self-pay contacts and 54% of Medicaid contacts. Providers offered the potential for receiving a buprenorphine prescription at the first visit to 41% of uninsured self-pay contacts compared with 27% of callers reporting Medicaid coverage. The median wait time to the first appointment was 5 days and 6 days, respectively, while the median wait time from first contact to possible buprenorphine induction was 7 days and 8 days, respectively.1

In a separate editorial, Pooja A Lagisetty, MD, MSc, and Amy Bohnert, PhD, both of the University of Michigan School of Medicine, Veterans Affairs Ann Arbor Healthcare System, and the Institute of Health Policy and Innovation, Ann Arbor, Michigan, noted that the study captured real-time barriers to access that patients may experience when trying to find a buprenorphine provider. They noted that the study found substantial variability among states as to whether Medicaid or cash-only patients had access to more providers. In Ohio, approximately 30% of physicians would make appointments only for self-paying patients, compared with only 10% in Massachusetts. Lagisetty and Bohnert voiced concern that for-profit practices that accept only cash may offer low-quality care with limited monitoring, increasing the likelihood of buprenorphine diversion. Furthermore, cost might be a barrier for cash-only patients, with treatment initiation ranging from $180 to $350, excluding laboratory testing and fees.

Lagisetty and Bohnert also expressed concern that cash-only programs may present a barrier for patients with limited financial resources and deter them from long-term treatment. Another concern was the finding that 50% of clinicians were ineligible for the study, many because of a nonworking phone number or not having a prescriber at the practice. They suggested that a more accurate list of buprenorphine prescribers would improve treatment access and allow acute care clinicians to find outpatient follow-up for patients.2  


1. Beetham R, Saloner B, Wakeman SE, Gaye M, Barnett ML. Access to office-based buprenorphine treatment in areas with high rates of opioid-related mortality: an audit study [published online June 4, 2019]. Ann Intern Med. doi:10.7326/M18-3457

2. Lagisetty PA, Bohnert A. Role of an accurate treatment locator and cash-only practices in access to buprenorphine for opioid use disorders [published online June 4, 2019]. Ann Intern Med. doi:10.7326/M19-1429