Buprenorphine use remains hit or miss

There are increasing numbers of physicians who are credentialed to prescribe buprenorphine. However, according to a study conducted by RAND Corporation, presented in the Journal of Substance Abuse Treatment in October, while the providers were available in more places in 2011 compared with 2008, the number of physicians varied greatly by county—from a high of 20 or more in 7% of counties, to zero in 43% of counties.

Researchers aimed to discover the factors that contributed to the variation.

“The sources of reimbursement really tend to be critical,” Bradley Stein, MD, PhD, lead study author, and senior scientist for RAND Corporation, tells Behavioral Healthcare. “Being in a state where Medicaid was reimbursing for buprenorphine [made a positive difference], and also some states devoted some of their block grant funding to support the use of buprenorphine, so the counties in those states were associated with having substantially more doctors.”

Stein, who is a practicing psychiatrist, says it’s no surprise that reimbursement plays a key role in the treatment’s use, but lack of reimbursement also translates into fewer waivered physicians in a community. For example, an area with high rates of uninsured individuals was unlikely to have many credentialed physicians able to prescribe buprenorphine.

“It reinforces the importance of robust public sector funding in making sure there is sufficient provider capacity for providing this effective treatment,” he says.

Practical implications

But there are also non-financial actions that states can take to increase the number of waivered doctors, such as creating specific clinical guidelines for buprenorphine use and disseminating them to potential providers. Stein says issuing guidelines could sway some physicians who were previously ambivalent and make them more comfortable with buprenorphine use. In the study, guidelines that had an effect were those that provided patient-care tools and were more than just awareness programs about the availability of buprenorphine.

Community influence might be a factor although it was hard to quantify, according to Stein. For example, the total number of opioid-related overdose deaths per capita was positively and significantly associated with the number of physicians able to prescribe the treatment.

However, the study also found that encouraging methadone programs to take on the role to promote buprenorphine use had no significant impact on the number of waivered doctors. Stein says communities with methadone clinics could be fundamentally different than those without, so it’s difficult to pinpoint the underlying factors. The authors note that it’s concerning because the counties without methadone clinics could potentially benefit the most from improved access to opioid-addiction treatments.

“If I’m a state administrator and have limited resources, it’s important to know what works but also what doesn’t work so I know where to devote my time and energy,” Stein says.

State policies—both financial and through other actions—to increase the number of waivered doctors might be key to managing the growing demand for treatment. Stein says additional study is underway to find out why only a small percentage of those who could benefit from buprenorphine receive it.