Few PCPs Have Waivers to Prescribe Buprenorphine

Diana Phillips

January 08, 2020

Although the number of clinicians who have waivers to prescribe buprenorphine in the United States has increased by more than 350% during the past decade, fewer than 10% of the nation's primary care clinicians have such waivers, a study has shown.

Further, the growth has been slower in regions that have been disproportionately affected by the opioid crisis, suggesting a need for targeted efforts to increase access to this potentially lifesaving medication, Ryan K. McBain, PhD, of the Rand Corporation in Boston, Massachusetts, and colleagues write. The researchers discuss their findings in a report published online January 7 in the Annals of Internal Medicine.

The findings are consistent with previous research indicating that buprenorphine is underused in primary care.

To examine the county-level growth in the number of buprenorphine-waivered prescribers and regional demographic differences, the researchers analyzed information obtained from the Substance Abuse and Mental Health Services Administration, the Drug Enforcement Administration, the Pew Foundation, and Deerfield Management. Using county population estimates from the 2010 US census and total physicians per capita, they calculated the total number of waivered prescribers per 100,000 persons from 2007 to 2017, overall and by per-physician patient limit. The also used Census Bureau data to estimate per-capita sociodemographic characteristics.

During the 10-year period, the number of waivered prescribers increased from 3.80 to 17.29 per 100,000 persons. The majority of wavered providers in 2017 were physicians (94.6%), followed by nurse practitioners (4.2%) and physician assistants (1.2%). With respect to patient limits, 71.9% had waivers for 30 patients, 21.9% for 100 patients, and 6.2% for 275 patients, the authors report.

In regression analyses, the growth in waivered prescribers per 100,000 persons was faster in counties where rates of opioid-related overdose deaths in the preceding year were higher (β = 0.44) and were faster in metropolitan and large nonmetropolitan counties compared with small nonmetropolitan counties (β = 4.25) and medium nonmetropolitan counties (β = 2.29).

In contrast, the authors write, "we found that waivered prescriber growth was markedly slower in small nonmetropolitan counties than urban counties, as well as slower in communities with lower levels of education, even after adjusting for the severity of the crisis." This finding raises concerns, given evidence indicating that rural, socioeconomically disadvantaged counties have been disproportionately affected by the opioid crisis, they explain.

Despite certain methodologic limitations, including the lack of information on patient use of the medication, whether waivered providers were actively prescribing buprenorphine, and how many patients they treated, "[t]his study sheds light on the evolution of the distribution of buprenorphine-waivered prescribers over the past decade," the authors write.

"Given the importance of access to effective medication treatment in responding to the opioid crisis, that growth has been most rapid in communities substantially affected by the crisis is reassuring." The fact that growth is slower in rural communities and in areas where educational levels are lower, however, "suggests the need for ongoing efforts to enhance medication treatment availability in such communities."

Coauthor Bradley D. Stein, MD, PhD, reports receiving grants from NIDA of the NIH during the conduct of the study. The remaining authors have disclosed no relevant financial relationships.

Ann Intern Med. Published online January 7, 2020. Abstract

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