Buprenorphine Prescribers Treat Far Below Legal Patient Limits

Megan Brooks

September 22, 2016

Many physicians who prescribe buprenorphine (multiple brands) for opioid addiction treat far fewer patients than allowed under the law, a new study from the RAND Corporation shows.

Clinicians who complete an 8-hour course and obtain a waiver from the US Drug Enforcement Administration can prescribe buprenorphine to treat individuals with opioid addiction. Under initial rules, which were in place when the RAND study was conducted, waivered prescribers were restricted to treating a maximum to 30 patients diagnosed with an opioid use disorder concurrently; after 1 year, physicians can request that the limit be increased to 100 patients.

Concern has been raised that these limits prevent patients from receiving treatment. But the RAND study, published online September 20 in JAMA, suggests that prescribers are treating fewer patients than these limits allow.

Patients Undertreated

Bradley Stein, MD, PhD, and colleagues looked at pharmacy records from seven states that had the most physicians cleared to prescribe buprenorphine. Those states are California, Florida, Massachusetts, Michigan, New York, Pennsylvania, and Texas. They identified 3234 buprenorphine prescribers with 245,015 patients who received a new prescription of buprenorphine between January 2010 and December 2013.

They found that 22% of prescribers treated two or fewer patients per month, 49% treated four to 30 patients monthly, 20% treated 31 to 75 patients per month, and only 9% had 75 or more patients.

In addition to finding that many physicians treat relatively few patients, the researchers found that the median duration of treatment was just 53 days.

"Given that we were looking at physicians who were prescribing buprenorphine over an extended period, and therefore we assume more experienced with using it, we were surprised that the median duration of a treatment episode was less than 2 months, particularly since studies are increasingly suggesting that longer treatment episodes are associated with better outcomes for individuals being treated for opioid use disorders," Dr Stein, senior physician scientist at RAND and associate professor of psychiatry at the University of Pittsburgh School of Medicine in Pennsylvania, told Medscape Medical News. Current recommendations call for maintenance treatment to continue for up to 12 months.

"We were also surprised at how many of these doctors who were prescribing were treating relatively few patients each month with buprenorphine," Dr Stein said.

The findings, he added, suggest that for many physicians who are actively prescribing buprenorphine, there remain "important barriers that we need to better understand and address."

Support for Prescribers

Brendan Saloner, PhD, of the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, is not surprised by the RAND study findings.

"The low monthly census of buprenorphine patients among waivered physicians is very consistent with some other data points from surveys of physician practices and select samples from Medicaid or private insurance," he told Medscape Medical News.

Under new rules put in place in July, clinicians with an active waiver can treat up to 100 patients for 1 year, and that can be increased to 275 patients with additional credentialing.

Dr Saloner believes this is "unlikely to have an impact on the broad majority of practices where buprenorphine is prescribed, since we are seeing that most physicians are nowhere near their cap. That said, it could be beneficial in helping the small percentage of practices where physicians are bumping up against their cap. This could allow some physicians to become true buprenorphine specialists, but we want to make sure that they have capacity and knowledge to prescribe this medication," he noted.

"Another area for policy is helping those physicians who have dipped a toe in the water ― committed a little bit, but not much ― to really feel supported in helping patients with opioid use disorder," said Dr Saloner.

Dr Stein and colleagues agree.

"Novice prescribers cite insufficient access to more experienced prescribers and insufficient access to substance abuse counseling for patients as barriers to treating more patients," they write. "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."

Room for Improvement

In an interview with Medscape Medical News, Wilson Compton, MD, deputy director, National Institute on Drug Abuse (NIDA), said the fact that "so few physicians are at the patient limit for buprenorphine prescribing tells us that we have some room for improvement in helping patients access the care that they need and that some of that is a matter of helping physicians see more patients."

He also noted that although the new patient limits "may be useful for certain providers who are really quite prolific, there are other approaches that we need to consider as well. As the authors suggest, newly trained providers need mentors and others to help guide them in their practice. That's very typical of all medical practice. When you first start a new procedure or any new intervention, you want somebody to talk to and make sure that you're doing it correctly and providing the service that they need," Dr Compton said.

He also cautioned that the observation that treatment duration (53 days) was far shorter than recommended probably has more to do with the patient's dropping out of treatment than with the provider.

"Inadherence is a notorious problem, [which] is why we are excited about the buprenorphine implant as an alternative, which will provide treatment for 6 months at a time, or the extended-release naltrexone, which is a very different medication but provides at least 1 month of coverage with each injection," said Dr. Compton.

The study was funded by the NIDA. Dr Stein has served on an advisory board for Otsuka Pharmaceuticals. Dr Saloner has disclosed no relevant financial relationships.

JAMA. Published online September 20, 2016. Abstract

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