Higher caps may not increase buprenorphine utilization

In July, the U.S. Department of Health and Human Services and the Office of National Drug Control Policy announced that the maximum number of patients an individual physician can treat with buprenorphine would increase from 100 to 275.

Officials estimate that the cap increase could allow between 10,000 to 70,000 more patients to receive the medication in the course of the first year. However, research from the RAND Corporation indicates that the effect might not be quite that dramatic, as few physicians currently prescribing the medication have even approached the lower cap, and many of those that are prescribing might be underutilizing the drug.

The study, published in the September 20 issue of the Journal of the American Medical Association, found that more than 20% of actively prescribing waivered physicians treated three or fewer patients, and fewer than 10% treated more than 75 patients.

RAND also discovered that the median treatment duration among the survey population was just 53 days, which is shorter than is considered likely to produce a successful outcome.

Underlying reasons

Exactly why physicians are treating so few patients was not illuminated in the study, but there could be a number of contributing factors. Some cited insufficient access to more experienced prescribers and to substance abuse counseling for patients as barriers to treating more patients.

“First, it’s important to have a financial incentive to prescribe,” Bradley Stein, senior author of the study and senior physician scientist at RAND. “This is a very complicated patient population. It’s not a matter of whether the medication is going to be paid for, but also if the physician will be paid enough to manage that population.”

Second, most physicians lack the training to be completely comfortable treating substance use disorder patients. Most are waivered after taking only the standard eight-hour course.

“Physicians really want to have more consultation and more mentorship,” Stein says.

He says there should be more investment in mentorship and training programs. There are a number of existing programs available such as those through PCSS-MAT, the American Society of Addiction Medicine, Project ECHO, and others.

Patients may also lack access to the type of quality counseling and therapy that are required for them to truly benefit from the use of medication assisted therapy, so access can be an issue, Stein says.

Finally, physicians may not be interested in treating large numbers of patients with buprenorphine because other factors are limiting the population in their practice.

“It may be they became waivered to take better care of particular patients in their practice,” Stein says. “They view it in the same way that a doctor may have a patient with diabetes that requires insulin. Increasingly doctors are saying ‘these are my patients, and I want to learn how to manage their treatment.’ The idea that everyone with a waiver may care for lots of patients [with substance use disorders] may not be the way that we should be thinking about this.”

RAND recommends developing strategies to help current prescribers treat more patients effectively which could help improve the success of the new cap levels, as well as including more training/mentoring and resolving counseling access issues.

Whether the waiver expansion will increase the level of patients treated with buprenorphine remains to be seen.

“Clearly opioid use disorders are a crisis, so anything that potentially expands access has the potential to be a good thing,” Stein says. “That said, if you look at our findings, they suggest the impact of just increasing the patient limit may be far more modest than people hope it might be.”

The researchers used prescribing data from approximately 90% of prescriptions filled at retail pharmacies from January 2010 through December 2013 from the seven states with the most buprenorphine-waivered physicians—California, Florida, Massachusetts, Michigan, New York, Pennsylvania and Texas.

The study only looked at physicians who consistently prescribed buprenorphine over several years.

Brian Albright is a freelance writer based in Ohio.