How to Help Those Helping the Underserved

Suboxone prescribing has not kept up with the growing need for opioid use disorder treatment. Understanding the hurdles faced by those prescribing in the most under-resourced areas, could help increase access to treatment.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

In the face of the opioid use and overdose epidemic, the demand for medications has ballooned and the availability of Suboxone (buprenorphine/naloxone) prescribers has not kept pace, particularly in high-opioid use urban settings. This is due in part to the reality that many physicians chose to not pursue the licensing required to prescribe Suboxone. In New York State, for example, the Suboxone treatment rates are the lowest in the most impoverished neighborhoods despite being adequately covered by New York’s Medicaid program. This study examines the attitudes of, and the barriers faced by, Suboxone prescribers (predominantly in the primary care setting) serving Medicaid and uninsured patients in the New York City area.

HOW WAS THIS STUDY CONDUCTED?

A 25-question Web-based questionnaire was administered to 72 public sector Suboxone prescribers (out of 132 contacted; 55% response rate) in the New York City area in 2016. The questions asked about provider and practice demographics, Suboxone induction protocols, and attitudes regarding a number of perceived barriers (Suboxone diversion, patient limits, insurance issues, etc).

WHAT DID THIS STUDY FIND?

Most of the prescribers worked in non-psychiatric specialties: 72% of the respondents were in non-psychiatric specialties although the majority of the respondents were certified by addiction specialty organizations (e.g., the American Academy of Health Care Providers Addiction Specialist Certification). Only 36% worked in hospital-based or affiliated clinics.

In this public sector population, the majority of patients were heroin users: (51%) including 45% that mixed heroin and prescription opioids.

Unobserved home inductions for new patients was a common practice: (65% of the providers) – Office based inductions are a common barrier for Suboxone treatment as it involves keeping a patient in an office and monitored for hours on the day of the first induction. By doing home inductions, a barrier to care is bypassed.

Adjunctive therapy or psychosocial counseling was routinely recommended but not required: Although 62% of prescribers ranked therapy or counseling to be of essential or high importance, only 37% of the providers mandated it as part of the treatment contract.

Most prescribers’ practices were not Suboxone-focused: The majority of practices surveyed were small (a mean of 31 patients receiving Suboxone per prescriber) and represented on average less than 25% of the patients treated by that provider.

Barriers to prescribing Suboxone: The need for prior authorizations was the leading barrier to prescribing Suboxone: (relevant to the Medicaid but not the uninsured population) The lack of psychiatric services for those with dual diagnoses was also an important barrier ranked by these providers, as was inadequate reimbursement rates. Concerns about Suboxone diversion was not ranked highly. Interestingly, some of the barriers previously identified by providers in an array of studies from 2006-2009 were no longer ranked highly (inadequate space for doing in-office inductions, inadequate prescriber training, poor insurance coverage, the limits on the number of Suboxone-prescribing licenses per institution) suggesting that many of these previously-identified barriers had been addressed.

Gaps between prescribing practices described by this group and the National practice guidelines: The National practice guidelines continue to emphasize having the patient observed in the medical office for 3-4 hours following the administration of the first Suboxone dose which poses an important barrier as all of the clinics surveyed were limited in terms of clinical space. These national guidelines also continue to emphasize the importance of additional psychosocial treatments outside of the Suboxone prescriber relationship, despite a lack of evidence for the superiority of resource-intensive care over care focused simply on the medication and brief visits with their medical team.

WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

Suboxone prescribing seems to be handled effectively in non-psychiatric settings, including primary care practices, although prescribers may benefit from additional certification by addiction specialty organizations. The maximum number of patients that can be treated by a single licensed provider was increased from 100 to 275 patients in a nation-wide attempt to increase access to Suboxone treatment. Unfortunately, increasing that cap will not result in increased access if providers are electing to see a small volume of Suboxone-treated patients, as suggested by this study. Most prescribers are not treating large numbers of patients, which may be due to the remaining barriers to care (need for prior authorizations, low reimbursements rates, inadequate counseling and psychiatric care to complement Suboxone treatment). One barrier to care, in-office inductions, which is resource-intensive, is bypassed in a majority of cases by using home inductions.

LIMITATIONS

This is a small (72 respondents) questionnaire-based study and only slightly more than half of those approached to complete the survey completed it so the representative these findings are of all prescribers is unknown. This study also focused on public-sector prescribers only.
The population of prescribers was obtained primarily by targeting prescribers known to the authors and then their referrals in turn – thus increasing the chances that this is not a representative sample of the different prescribing practices used.
The questionnaire only included closed-answer Likert scale questions (strong disagree to strongly agree range). Thus in the case of barriers to care, the analysis was limited to the authors’ own ideas about significant barriers to care.
The authors did not survey similar providers not electing to provide Suboxone treatment, and thus did not explore a different range of barriers to Suboxone prescribing in underserved areas.

BOTTOM LINE

For policy makers: The 2016 Federal effort to increase the number of patients that can be treated by a single licensed provider will not result in increased access to Suboxone unless providers are motivated to increase their panel of Suboxone-treated patients. Understanding the reluctance to have larger practices involves understanding and targeting the barriers to this process. The need for obtaining prior authorizations for both Medicaid and private insurance is listed as the primary barrier to increased prescribing by this group of providers. Removing this barrier should be included in the list of priorities for the numerous task forces focused on tackling the opioid epidemic. Also, further outreach and education to those electing not to prescribe Suboxone could greatly enhance the accessibility of this treatment with demonstrated efficacy.

For individuals & families seeking recovery: Given the availability of Suboxone in non-psychiatric settings, those affected by opioid use disorder should explore whether Suboxone prescribing is available through the primary care provider’s office or through local medical clinics.
For scientists: There is an opportunity to study outcomes of home inductions vs office-based inductions to determine if there is sufficient evidence to shift the National practice guidelines and thus limit a barrier to care. In addition, one might compare the outcomes of Suboxone provided by non-psychiatric providers. Lastly, although there is some research on the added benefit of therapy, counseling and group support to the efficacy of Suboxone prescribing, the majority of data suggest that psychosocial treatments, mostly consisting of cognitive-behavioral therapy and/or contingency management, don’t improve opioid outcomes over and above Suboxone and medication management. Thus, there is great need for research that identifies approaches to enhance Suboxone outcomes, psychosocial and otherwise (see Weiss POATS 2012 study).
For treatment professionals and treatment systems: The addiction specialty organizations that provide training and certification for opioid use disorder might coordinate with large primary care organizations to increase the number of primary care clinics comfortable with prescribing Suboxone. Given the much larger number of primary care providers (approximately 250,000) vs the smaller number of psychiatrists (28,000) this might dramatically increase access to medications and help alleviate the crisis in opioid use and opioid-associated deaths.

CITATIONS

Kermack, A., Flannery, M., Tofighi, B., McNeely, J., & Lee, J. D. (2017). Buprenorphine prescribing practice trends and attitudes among New York providers. Journal of substance abuse treatment, 74, 1-6.