Practice Predictors of Buprenorphine Prescribing by Family Physicians

Lars E. Peterson, MD, PhD; Zachary J. Morgan, MS; Tyrone F. Borders, PhD

Disclosures

J Am Board Fam Med. 2020;33(1):118-123. 

In This Article

Abstract and Introduction

Abstract

Introduction: Both opioid use disorder and mortality for opioid overdoses are increasing. Family physicians (FPs) can treat opioid use disorder if they are waivered to prescribe buprenorphine. Our objective was to determine personal, practice, and community characteristics associated with FPs prescribing buprenorphine.

Methods: We used data from the 2017 and 2018 American Board of Family Medicine examination registration questionnaire. The questionnaire asked about current prescribing of buprenorphine, as well as about practice size, organization, and location. Logistic regression was used to determine associations between buprenorphine treatment and individual, practice, and county characteristics.

Results: The questionnaire had a 100% response rate. After excluding FPs in noncontinuity practices and those who could not be linked to a US county, our final sample was 2726. Only 161 (5.9%) prescribed buprenorphine. Practice in a Federal Qualified Health Center (adjusted Odds Ratio [aOR] = 1.98 (95% CI, 1.08, 3.63)), in solo practice (aOR = 2.60 (1.38, 4.92)), or with a mental health professional (aOR = 2.70 (1.73, 4.22)) were positively associated with prescribing buprenorphine. Practice in a rural county or in a whole county mental health professional shortage area were not associated with buprenorphine prescribing.

Discussion: Few FPs prescribed buprenorphine, but those in practice settings with supporting mental health services were more likely to prescribe. With their training in the biopsychosocial model and a more even distribution across the rural continuum, FPs are perfectly situated to meet the increasing need for medication-assisted treatment. However, ensuring they have supporting mental health services will be central to having more FPs provide medication-assisted treatment.

Introduction

In 2017 there were 70,237 drug overdose deaths in the US, with two thirds of these attributed to opioids.[1] Medication-assisted treatment (MAT) with either methadone or buprenorphine is effective in reducing illicit substance use,[2] but access to treatment can be challenging. Buprenorphine can be prescribed by clinicians who have completed additional training as part of their usual practice, but methadone can only be accessed at an outpatient treatment facility that patients visit daily. Analyses of the 2012 waivered clinician registry found that nationally there were 5.8 waivered physicians per 10,000 county residents and that family physicians (FPs) were the second most common physician specialty waivered at 3.6%, behind psychiatry.[3] An update using the 2017 registry found that the availability of any clinician (nurse practitioners and physician assistants gained the ability to become waivered since 2012) with a waiver increased to 10.3 per 10,000 county residents but rural disparities remained.[4] Unfortunately, this updated analysis did not provide a breakdown by specialty, so the rate of growth in buprenorphine waivered FPs is unknown. Evidence of an increase in availability of MAT is corroborated by an analysis of ambulatory care visits from 2006–2008 and 2012–2014, that found the number of primary care visits where buprenorphine was prescribed increased 6.7-fold.[5]

Obtaining a waiver to prescribe buprenorphine is not sufficient for patient access as many physicians with a waiver report not using it.[6] A significant barrier is access to mental health services, as counseling is a critical part of treatment, particularly during initiation. A survey of buprenorphine prescribers found that rural physicians were more likely to have patients use nonintegrated counseling services while physicians in urban areas were more likely to have integrated resources.[7,8] Access to mental health resources is particularly problematic in rural areas due to lower clinician availability.[9,10]

While past research has documented disparities in location and logistic barriers to prescribing buprenorphine, it remains unknown if practice features are associated with prescribing buprenorphine. Our objective was to examine whether rurality of practice location, individual physician and practice characteristics, and county-level mental health services are associated with FPs' prescribing of buprenorphine.

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