Effects of Limiting Physician Capacity to Rx Buprenorphine for Opioid Use Disorder

In an analysis of the 7 states with the highest number of physicians who have received a waiver to prescribe buprenorphine, researchers noted that very few patients are actually being prescribed buprenorphine compared with the limit of patients that each physician is allowed to treat. The findings are published in JAMA.

“Policymakers have prioritized increasing capacity [of physicians] to provide buprenorphine to fight the opioid epidemic but lack adequate information about how to do so effectively,” wrote Bradley D. Stein, MD, PhD, from the RAND Corporation and the University of Pittsburgh School of Medicine in Pittsburgh, Pennsylvania.

Currently, physicians or addiction specialists who complete an 8 hour course and who obtain a US Drug Enforcement Administration waiver can prescribe buprenorphine, enabling them to concurrently treat up to 30 patients with opioid use disorder. After 1 year, they can request that the number be raised to 100 patients.

To see if limiting the number of patients who can be treated with buprenorphine presents a barrier to treating opioid use disorder, the researchers analyzed patient censuses of buprenorphine prescribers using the Symphony Health Solutions’ Integrated Dataverse. The Dataverse contains information from more than 80% of pharmacies in the US, resulting in information on about 90% of prescriptions filled in the United States.

Data from the 7 states with the most buprenorphine-waivered physicians (California, Florida, Massachusetts, Michigan, New York, Pennsylvania, and Texas) were analyzed from January 2010 to December 2013.

The researchers identified 3234 buprenorphine prescribers and 245 016 patients who received a new buprenorphine prescription. They found that:

• Prescribers’ median monthly patient census was 13 patients (interquartile range [IQR], 5-36), and the median episode duration was 53 days (IQR, 20-120)

• 22% of prescribers had monthly censuses of only 1 to 3 patients

• 49% of prescribers had monthly censuses of 4 to 30 patients

• 20% of prescribers had monthly censuses of 31 to 75 patients

• Only 9% of prescribers had monthly censuses of over 75 patients

“The monthly patient censuses for buprenorphine-prescribing physicians were substantially below patient limits at the time; more than 20% treated 3 or fewer patients, and fewer than 10% treated more than 75 patients,” the authors wrote.

They also noted that the median treatment duration of 53 days was lower than expected, given that current clinical recommendations for observation of maintenance treatment are for up to 12 months,² and given that evidence has linked longer treatment to better outcomes.

The researchers found that novice prescribers cited insufficient access to substance abuse counseling for patients, as well as insufficient access to more experienced prescribers, as reasons for not treating more patients.³ “Such barriers might be addressed by web-based or tele-counseling for patients and by programs providing mentoring and telephone consultation from more experienced prescribers,” the authors noted. “Strategies to help current prescribers treat more patients safely and effectively could complement policy initiatives designed to increase access to treatment by increasing patient limits and number of waivered prescribers.”

Limitations & Disclosures

• Prescriber waiver status was unknown

• Patient clinical status was unknown

• The researchers can’t exclude the possibility that buprenorphine was prescribed off-label for indication of pain

Bradley D. Stein, MD, PhD has served on an advisory board for Otsuka Pharmaceuticals. Adam J. Gordon, MD, MPH, has received royalties from Cambridge University Press and UptoDate. Rosalie Liccardo Pacula, PhD, has received royalties from Cambridge University Press.

References

1. Stein BD, Sorbero M, Dick AW, Pacula RL, Burns RM, Gordon AJ. Physician Capacity to Treat Opioid Use Disorder With Buprenorphine-Assisted Treatment. JAMA. 2016;316(11):1211-1212. doi:10.1001/jama.2016.10542.

2. Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine Treatment of Opioid Addiction. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2004.

3. Netherland J, Botsko M, Egan JE, et al; BHIVES Collaborative. Factors affecting willingness to provide buprenorphine treatment. J Subst Abuse Treat. 2009;36(3):244-251.