Research Article
Opioid Use DisorderBuprenorphine Treatment By Primary Care Providers, Psychiatrists, Addiction Specialists, And Others
- Mark Olfson ([email protected]) is the Elizabeth K. Dollard Professor of Psychiatry, Medicine, and Law in the Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University; a professor of epidemiology in the Mailman School of Public Health, Columbia University; and a research psychiatrist at the New York State Psychiatric Institute, all in New York City.
- Victoria Zhang is a postdoctoral research associate at the School of Management, Yale University, in New Haven, Connecticut.
- Michael Schoenbaum is a senior adviser for mental health services at the National Institute of Mental Health, in Bethesda, Maryland,
- Marissa King is a professor of management and sociology at the School of Management and Department of Sociology, Yale University.
Abstract
Substantial increases in opioid-related morbidity and mortality have motivated the implementation of federal policies to expand the buprenorphine prescribing capacity of primary care providers and other clinicians. Using a national prescription database that covered 72–92 percent of the US population during 2010–18, we analyzed trends in buprenorphine treatment by prescriber specialty. Buprenorphine treatment rates by primary care providers increased from 12.9 people per 10,000 population in 2010 to 27.4 in 2018. The numbers for psychiatrists and addiction medicine specialists increased from 8.7 to 12.0 per 10,000 and those for other prescribers from 5.8 to 16.3 per 10,000. However, treatment of people ages 15–24 by primary care providers and by psychiatrists and addiction medicine specialists declined significantly. Across all patient age and provider groups, most patients were not retained on buprenorphine for the benchmark period of at least 180 days. Despite a recent national increase in buprenorphine treatment fueled primarily by nonspecialists, challenges persist with buprenorphine access—especially for younger people—and with retaining patients in long-term treatment.
The striking increase in US drug overdose deaths involving opioids1,2 has motivated policy makers to enhance the nation’s capacity to treat patients with opioid use disorder. Despite evidence that supports the efficacy of pharmacological treatments including buprenorphine,3 methadone,4 and naltrexone,5 substantial gaps exist between treatment need and treatment supply, access, and quality.6 As a result, most of the estimated 2.1 million Americans living with opioid use disorder do not receive any treatment for their disorder.7,8
Among the three treatments approved by the Food and Drug Administration (FDA) for opioid use disorder, buprenorphine presents the greatest opportunities for expanding access.9 In contrast to naltrexone, which requires opioid abstinence prior to treatment initiation, buprenorphine can be initiated in outpatient settings while patients are in mild-to-moderate opioid withdrawal. Unlike methadone, which is restricted to federally certified specialty Opioid Treatment Programs, buprenorphine can be prescribed outside of specialized settings by prescribers following eight hours of training for physicians and twenty-four-hours of training for nurse practitioners and physician assistants, along with certification by the Drug Enforcement Agency. A federal prescription waiver program for buprenorphine was enacted in 2000 under the Drug Addiction Treatment Act. This legislation was subsequently amended in 2006 and again in 2016 to increase the buprenorphine patient treatment limit for individual prescribing physicians from 30 (in 2000) to 100 (in 2006) and 275 (in 2016).10 The Comprehensive Addiction and Recovery Act of 2016 extended the ability to obtain waivers to physician assistants and nurse practitioners.
In this clinical and policy context, there has been an increase in the number of people who were prescribed buprenorphine in the US.11 US visits to office-based medical practices that involved buprenorphine prescriptions increased from 1.9 million in 2009–11 to 4.3 million in 2012–14, with increases in buprenorphine prescribed during visits to primary care physicians and to other nonpsychiatrist physicians.12 The number of buprenorphine prescriptions per 1,000 Medicaid beneficiaries also increased, from 48 in 2013 to 102 in 2017.13
Beyond concerns about access, there are also concerns about buprenorphine treatment retention and dosing. Although extended buprenorphine treatment is associated with improved outcomes,14,15 and a National Quality Forum measure recommends at least 180 days of treatment,16 many patients discontinue buprenorphine treatment within the first few months, before reaching this benchmark.17 Higher daily doses of buprenorphine have also been found to predict better treatment retention,18,19 and guidelines set targets of sixteen milligrams per day.20 However, buprenorphine dosing is variable in community practice.11,21,22 Finally, while policy makers have expressed interest in hub-and-spoke care models that have the capacity for specialists to initiate and stabilize patients on buprenorphine before transferring them to nonspecialists, it is unknown how buprenorphine prescribing patterns across providers have shifted in recent years.23
We derived national estimates of the annual rate of buprenorphine treatment in the United States provided by primary care providers, psychiatrists and addiction medicine specialists, and other prescribers in the period 2010–18. Among people who initiated buprenorphine treatment, we compared the percentages among those whose treatment was initiated by each prescriber group who received at least 180 days of buprenorphine treatment and who achieved a prescribed dose of at least sixteen milligrams per day. Because of concerns over the limited availability of substance use services for young people,24 we assessed trends by age group. Our overall goal was to evaluate the broad effects of policy initiatives aimed at increasing buprenorphine treatment, with a focus on nonspecialists.
Study Data And Methods
Data Source
The analysis was based on all buprenorphine prescriptions for opioid use disorder in the IQVIA Real World Longitudinal Prescription Data (IQVIA LRx) for the period January 2010–December 2018. The IQVIA LRx is a longitudinal database of prescriptions from retail and nonretail pharmacies for individuals followed across years, pharmacies, and payment sources. The estimated proportion of the US population covered in the data set increased from 72.0 percent in 2010 to 92.0 percent in 2018.
All data were deidentified and exempted from consent by the Institutional Review Board of Yale University.
Buprenorphine And Prescriber Groups
Prescriptions that included buprenorphine were identified in the IQVIA LRx. Buprenorphine formulations not approved for opioid use disorder, such as Buprenex injectable or Butrans transdermal patch, were excluded from the analysis.
We categorized buprenorphine prescribers into three groups: psychiatrists and addiction medicine specialists; primary care providers, which included physicians specializing in general practice, family practice, internal medicine, or general obstetrics and gynecology, as well as nurse practitioners and physician assistants; and other prescribers. The latter included all other physician specialties and subspecialties as well as nurse anesthetists, pharmacists, and dentists.
Analysis
The analysis was conducted in three stages. In the first stage, we calculated buprenorphine treatment rates per 10,000 population in the United States using population data obtained from the Census Bureau25 and accounting for changes over time in IQVIA LRx national coverage. We then calculated trends in annual rates of buprenorphine treatment in 2010–18 for people ages 15–80 separately for the three prescriber groups. People were defined as receiving buprenorphine treatment if they filled at least one prescription for buprenorphine during a calendar year.
In the second stage of the analysis, we calculated annual rates of buprenorphine treatment by prescriber type, patient age group (ages 15–24, 25–34, 35–44, 45–54, and 55–80), and year. To estimate trends in buprenorphine treatment over the study period, negative binomial regression models were fit with the number of people treated with buprenorphine in each year as the dependent variable, the year as the independent variable, and population counts as the exposure. From this estimation, we derived incidence rate ratios for the change in the rate per year and their associated 95% confidence intervals. We report the ratios for the 2010–18 period by exponentiating the one-year ratios and confidence intervals by a factor of 8. Annual percentage changes in buprenorphine treatment were estimated by subtracting 1 from the one-year ratio and multiplying the result by 100.
Because some people received prescriptions from more than one prescriber group, the sum of rates for the three treated groups exceeds the total rates.
In the third stage of the analysis, we evaluated trends in new buprenorphine treatment episodes. New episodes started on the date of a buprenorphine prescription fill when there was no fill in at least the previous 180 days and ended after more than thirty days without a buprenorphine supply.22 Based on which prescriber group was the source of the initial prescription, new episodes were assigned to psychiatrists and addiction medicine specialists, primary care providers, or other prescribers. Some analyses of new episodes involved following patients forward to determine duration, dose, and shared prescriber groups. Because the IQVIA data were available through 2018, these analyses of new buprenorphine episodes were reported only for episodes that started before the end of 2017.
Trends in new buprenorphine treatment episodes were examined with respect to the percentage that were at least 180 days in duration and that included at least one buprenorphine prescription with a dose of at least sixteen milligrams per day. Among new episodes initiated by psychiatrists or addiction medicine specialists, trends were also examined in the percentage that included at least one buprenorphine prescription from a primary care provider or other prescriber. Each of these trends was examined by patient age group.
Limitations
This analysis had several limitations. First, there is uncertainty in the accuracy of population coverage estimates from IQVIA.
Second, durations of new buprenorphine treatment episodes were estimated by the prescription record. Actual durations were not known.
Third, we were unable to exclude patients who were treated with buprenorphine off label for chronic pain. In prior research, this group accounted for approximately 11 percent of buprenorphine prescriptions.26
Fourth, IQVIA LRx does not capture buprenorphine prescriptions filled within opioid treatment programs certified by the Substance Abuse and Mental Health Services Administration.
Fifth, although we treated a dosage of at least sixteen milligrams per day as the standard of care for all age groups, there is uncertainty over the dose-response curve in younger patients.27
Finally, the IQVIA LRx data measured buprenorphine purchases rather than buprenorphine consumption, and the data do not permit any assessment of the extent to which illicit diversion occurred.28
Study Results
Trends In Any Buprenorphine Treatment
Among people ages 15–80, the annual rate per 10,000 population of any buprenorphine treatment increased from 23.6 in 2010 to 44.3 in 2018. During this period, the rate of buprenorphine treatment prescribed by primary care providers increased from 12.9 people per 10,000 population to 27.4, by psychiatrists and addiction medicine specialists from 8.7 to 12.0, and by other prescribers from 5.8 to 16.3. In the same period, the estimated national annual number of people prescribed buprenorphine by primary care providers increased from 219,000 to 641,000, by psychiatrists and addiction medicine specialists from 148,000 to 282,000, and by other prescribers from 99,000 to 382,000 (exhibit 1).
Across the three prescriber groups, trends in rates of buprenorphine treatment varied by patient age. The largest estimated annual increase in buprenorphine treatment occurred among adults ages 35–44 and was related to increased prescribing by all three prescriber groups (exhibit 2). Significant increases in buprenorphine treatment also occurred among people ages 25–34, 45–54, and 55–80 years. By contrast, there was an overall decline in the rate of buprenorphine treatment among people ages 15–24. This decrease was related to a steep decline in the buprenorphine treatment rates among psychiatrists and addiction medicine specialists, a smaller decline among primary care providers, and no significant change by other prescribers.
Per 10,000 population | |||||
Age/prescriber group | 2010 | 2018 | IRR | 95% CI | Estimated annual change |
All | 20.4 | 14.0 | 0.61 | 0.51, 0.72 | −5.74% |
Primary care provider | 10.9 | 8.5 | 0.72 | 0.61, 0.85 | −4.04 |
Psychiatrist or addiction medicine specialist | 8.1 | 4.0 | 0.47 | 0.33, 0.61 | −9.24 |
Other prescriber | 4.6 | 5.3 | 0.92 | 0.78, 1.08 | −0.62 |
All | 51.4 | 87.0 | 1.59 | 1.48, 1.72 | 6.25% |
Primary care provider | 29.1 | 54.7 | 1.85 | 1.72, 1.99 | 7.80 |
Psychiatrist or addiction medicine specialist | 18.2 | 23.2 | 1.27 | 1.08, 1.48 | 3.14 |
Other prescriber | 12.5 | 32.7 | 2.30 | 1.99, 2.66 | 11.14 |
All | 29.7 | 83.4 | 2.79 | 2.68, 2.91 | 13.69% |
Primary care provider | 16.2 | 52.2 | 3.21 | 3.08, 3.35 | 15.74 |
Psychiatrist or addiction medicine specialist | 10.9 | 22.7 | 2.14 | 1.99, 2.30 | 10.02 |
Other prescriber | 7.3 | 30.3 | 3.76 | 3.28, 4.59 | 18.43 |
All | 20.1 | 43.0 | 2.14 | 1.85, 2.30 | 9.62% |
Primary care provider | 10.6 | 26.3 | 2.48 | 2.14, 2.66 | 11.78 |
Psychiatrist or addiction medicine specialist | 7.4 | 11.8 | 1.62 | 1.53, 1.69 | 6.15 |
Other prescriber | 5.1 | 15.5 | 2.66 | 2.14, 3.51 | 13.44 |
All | 7.0 | 18.0 | 2.48 | 2.30, 2.66 | 11.74% |
Primary care provider | 3.5 | 10.5 | 2.85 | 2.66, 3.06 | 13.99 |
Psychiatrist or addiction medicine specialist | 2.6 | 4.9 | 1.89 | 1.81, 1.98 | 8.27 |
Other prescriber | 1.9 | 6.5 | 3.06 | 2.30, 3.76 | 14.55 |
Trends In The Rate Of New Treatment Episodes
The annual rate of new buprenorphine treatment episodes increased from 13.7 per 10,000 population in 2010 to 22.1 in 2018 (incidence rate ratio: 1.48; 95% confidence interval: 1.37, 1.59) (data not shown). This increase was related to increases in new episodes initiated by primary care providers from 6.7 per 10,000 population to 11.3 (IRR: 1.59; 95% CI: 1.48, 1.72) and initiated by the other prescriber group from 2.7 per 10,000 population to 6.4 (IRR: 1.99; 95% CI: 1.59, 2.48). During the study period, the rate of new buprenorphine treatment episodes initiated by psychiatrists and addiction medicine specialists remained stable, increasing only from 4.4 per 10,000 population to 4.5 (IRR: 1.00; 95% CI: 0.92, 1.17).
Trends In The Duration Of New Treatment Episodes
The percentage of new buprenorphine treatment episodes that reached the 180-day benchmark in duration increased from 23.7 percent in 2010 to 29.3 percent in 2017 (IRR: 1.21; 95% CI: 1.14, 1.30). This included a significant increase in the percentages reaching the benchmark among people whose treatment was initiated by primary care providers (from 23.7 percent to 30.3 percent; IRR: 1.25; 95% CI: 1.17, 1.33) and among people whose treatment was initiated by the other prescriber group (from 22.4 percent to 26.7 percent; IRR: 1.34; 95% CI: 1.25, 1.45). There was no significant increase among people whose treatment was initiated by psychiatrists and addiction medicine specialists (from 24.5 percent to 26.7 percent; IRR: 1.07; 95% CI: 1.00, 1.15).
Significant increases in the overall percentage of new treatment episodes of at least 180 days in duration were observed among people ages 25–34, 35–44, 45–54, and 55–80, while a decline in the overall percentage was observed among people ages 15–24 (exhibit 3). This decline was related to a decrease in the percentage of new episodes initiated by psychiatrists and addiction medicine specialists that reached the 180-day benchmark. Among people ages 25–34, there were increases in the percentages of new treatment episodes initiated by primary care providers and by the other prescriber group that were at least 180 days in duration.
Age/prescriber group | 2010 | 2017 | IRR | 95% CI | Estimated annual change |
All | 20.5% | 19.3% | 0.90 | 0.82, 0.99 | −1.50% |
Primary care provider | 20.4 | 20.8 | 0.97 | 0.87, 1.06 | −0.55 |
Psychiatrist or addiction medicine specialist | 20.8 | 16.3 | 0.73 | 0.65, 0.82 | −4.38 |
Other prescriber | 20.2 | 20.0 | 1.01 | 0.93, 1.09 | 0.11 |
All | 24.5% | 27.8% | 1.11 | 1.03, 1.20 | 1.50% |
Primary care provider | 24.4 | 29.0 | 1.16 | 1.07, 1.25 | 2.09 |
Psychiatrist or addiction medicine specialist | 25.2 | 24.9 | 0.97 | 0.89, 1.05 | −0.54 |
Other prescriber | 23.6 | 28.3 | 1.20 | 1.09, 1.30 | 2.55 |
All | 25.0% | 31.6% | 1.26 | 1.16, 1.35 | 3.27% |
Primary care provider | 25.1 | 32.3 | 1.27 | 1.18, 1.37 | 3.51 |
Psychiatrist or addiction medicine specialist | 26.0 | 29.5 | 1.11 | 1.01, 1.21 | 1.52 |
Other prescriber | 23.2 | 32.4 | 1.40 | 1.27, 1.53 | 4.87 |
All | 24.8% | 32.3% | 1.32 | 1.24, 1.42 | 4.11% |
Primary care provider | 25.0 | 33.1 | 1.33 | 1.26, 1.43 | 4.25 |
Psychiatrist or addiction medicine specialist | 26.0 | 30.8 | 1.19 | 1.10, 1.29 | 2.55 |
Other prescriber | 22.6 | 32.0 | 1.48 | 1.36, 1.61 | 5.76 |
All | 22.3% | 33.8% | 1.52 | 1.44, 1.62 | 6.19% |
Primary care provider | 22.2 | 35.0 | 1.52 | 1.44, 1.63 | 6.24 |
Psychiatrist or addiction medicine specialist | 24.4 | 32.4 | 1.34 | 1.26, 1.43 | 4.32 |
Other prescriber | 19.6 | 32.7 | 1.88 | 1.60, 1.94 | 8.36 |
The percentage of new episodes that included at least one prescription of at least sixteen milligrams of buprenorphine per day declined significantly, from 68.9 percent in 2010 to 62.9 percent in 2017 (IRR: 0.91; 95% CI: 0.89, 0.93) (data not shown). This included declines among episodes initiated by primary care providers (from 71.8 percent to 65.0 percent; IRR: 0.89; 95% CI: 0.88, 0.91), the other prescriber group (from 70.0 percent to 65.8 percent; IRR: 0.96; 95% CI: 0.93, 0.99), and psychiatrists and addiction medicine specialists (from 63.7 percent to 55.9 percent; IRR: 0.86; 95% CI: 0.81, 0.89).
Adults ages 55–80 were the only age group that did not experience an overall significant decline in the percentage of new episodes with at least one prescription for at least sixteen milligrams of buprenorphine per day (exhibit 4). For this age group, however, there was a significant decline in the proportion of new episodes initiated by primary care providers that met the dosing threshold.
Age/prescriber group | 2010 | 2017 | IRR | 95% CI | Estimated annual change |
All | 65.1% | 51.5% | 0.77 | 0.75, 0.80 | −3.66% |
Primary care provider | 68.2 | 54.9 | 0.78 | 0.76, 0.81 | −3.43 |
Psychiatrist or addiction medicine specialist | 59.3 | 42.0 | 0.67 | 0.63, 0.71 | −5.57 |
Other prescriber | 68.4 | 55.8 | 0.85 | 0.80, 0.90 | −2.32 |
All | 71.4% | 62.9% | 0.87 | 0.85, 0.90 | −1.92% |
Primary care provider | 73.7 | 64.9 | 0.87 | 0.86, 0.89 | −1.95 |
Psychiatrist or addiction medicine specialist | 66.4 | 55.4 | 0.81 | 0.77, 0.86 | −2.90 |
Other prescriber | 73.4 | 66.4 | 0.93 | 0.89, 0.97 | −1.08 |
All | 71.0% | 66.6% | 0.93 | 0.91, 0.96 | −1.00% |
Primary care provider | 73.7 | 68.1 | 0.92 | 0.90, 0.94 | −1.23 |
Psychiatrist or addiction medicine specialist | 66.1 | 60.3 | 0.89 | 0.83, 0.94 | −1.60 |
Other prescriber | 72.2 | 69.8 | 0.98 | 0.95, 1.02 | −0.28 |
All | 68.4% | 65.2% | 0.95 | 0.93, 0.97 | −0.75% |
Primary care provider | 71.6 | 67.0 | 0.93 | 0.92, 0.95 | −1.01 |
Psychiatrist or addiction medicine specialist | 64.0 | 59.9 | 0.91 | 0.88, 0.95 | −1.29 |
Other prescriber | 67.8 | 67.0 | 1.00 | 0.97, 1.03 | −0.03 |
All | 60.9% | 59.9% | 0.99 | 0.96, 1.00 | −0.23% |
Primary care provider | 65.6 | 62.4 | 0.95 | 0.93, 0.97 | −0.70 |
Psychiatrist or addiction medicine specialist | 56.1 | 55.0 | 0.90 | 0.92, 1.01 | −0.53 |
Other prescriber | 58.4 | 59.9 | 1.03 | 0.99, 1.06 | 0.40 |
Trends In Shared Specialist And Generalist Treatment
There was an overall decline from 2010 to 2017 in the percentage of new treatment episodes initiated by psychiatrists and addiction medicine specialists (from 31.8 percent to 25.0 percent; IRR: 0.80; 95% CI: 0.74, 0.87) (data not shown). However, there were increases in the percentages whose treatment was initiated by this group that included buprenorphine prescriptions from primary care providers (from 6.6 percent to 11.2 percent; IRR: 1.71; 95% CI: 1.61, 1.83) and those whose treatment was initiated by the other prescriber group (from 6.1 percent to 9.3 percent; IRR: 1.38; 95%: 1.13, 1.68) (online appendix exhibit).29 A similar set of trends was observed for the primary care provider and other prescriber groups in each of the five age groups.
However, among people ages 15–24, the percentage of treatment episodes initiated by psychiatrists or addiction medicine specialists that included buprenorphine prescriptions from the other prescriber group did not increase significantly (from 5.6 percent to 6.7 percent; IRR: 1.03; 95% CI: 0.82, 1.29).
Discussion
In the period 2010–18 the increase in the number of people treated with buprenorphine in the US was primarily attributable to increased prescribing by primary care providers and other non–behavioral health specialists rather than by psychiatrists and addiction medicine specialists. Although an increasing share of people who initiated treatment continued to receive buprenorphine prescriptions for at least 180 days, most patients did not reach this benchmark.
At least four factors may have contributed to the increase in buprenorphine treatment. First, there has been an increase in the public health and clinical burden of opioid use disorder. According to the National Survey on Drug Use and Health, past-year opioid use disorder for adults was estimated to have increased from 0.5 percent in 2010 to 0.8 percent in 2018.30,31 There was also a nearly threefold increase between 2006–10 and 2011–15 in the percentage of outpatient visits in which opioid use disorder was diagnosed.32 Second, practice guidelines and clinical research have supported buprenorphine as an evidence-based treatment for opioid use disorder.33 Third, successful models have been developed34 and implemented35 that engage nursing care managers and primary care physicians in integrated buprenorphine treatment within primary care settings. Fourth, federal policies increased waiver limits and extended eligibility for waivers to new health care groups. At the state level, the volume of buprenorphine dispensed has been correlated with the number of buprenorphine-waivered providers—especially waivered physicians able to treat up to a hundred patients with buprenorphine.35 In addition to the Drug Addiction Treatment Act and the Comprehensive Addiction and Recovery Act, changes in public and private health care coverage and benefit design may have helped increase buprenorphine treatment. All state Medicaid programs include at least some coverage for buprenorphine,36 and the expansion of eligibility for Medicaid under the Affordable Care Act has been associated with increased access to buprenorphine.37 In addition, 86 percent of Marketplace plans provided at least some coverage of buprenorphine in 2017.38
People ages 15–24 were the only age group with declining buprenorphine treatment during the study period. This finding is consistent both with a commercial insurance claims analysis that reported a decline from 2009 to 2014 in the percentage of youths who were prescribed buprenorphine following a clinical opioid use disorder diagnosis39 and with a prior prescription data analysis.11 Young people, who are likely early in the course of their addictions, may face particular challenges accessing substance use treatment:40 Only around one-third of US drug treatment programs offer treatment to adolescents,24 and pediatricians account for only about 1 percent of physicians waivered to prescribe buprenorphine.41 Strategies to increase buprenorphine access for young people include expanding the training of pediatricians in addiction medicine, encouraging more pediatricians to receive federal waivers, and increasing clinical research to investigate the safety and effectiveness of buprenorphine in younger age groups that could support lowering FDA approval of buprenorphine prescribing below age sixteen.
Consistent with prior research, we found that primary care providers accounted for the largest share of42 and fastest growth in12 buprenorphine treatment. The increase in buprenorphine treatment by primary care providers may be a response to both federal policies that promote substance use treatment in general health care settings43 and clinical initiatives to increase primary care physician prescribing of buprenorphine to their opioid-dependent patients.44 The fact that primary care providers have a broader geographic distribution than psychiatrists do offers opportunities to further extend access to buprenorphine treatment.
Most patients who initiated buprenorphine treatment discontinued it within the first few months: The percentage retained for at least 180 days increased during the study period from 23.7 percent to 29.3 percent. These percentages resemble results from those of studies of a large Medicaid-insured population (35.4 percent)22 and of a primary care sample (35.7 percent), which was based on appointments rather than the prescription record.45 Because relapse is the most common reason for disengagement from treatment for opioid use disorder,46 the low percentage of patients who continued filling buprenorphine prescriptions for at least 180 days suggests widespread clinical problems associated with treatment retention.
In line with an analysis of a commercially insured population,47 we found that the duration of treatment episodes from primary care providers, psychiatrists or addiction medicine specialists, and other providers did not vary markedly. Prior authorization and reauthorization requirements, which remain common even for generic buprenorphine,48 may increase provider administrative burden and lead to buprenorphine discontinuation. More detailed research is needed to determine the extent to which treatment episode length is related to pharmacy benefit factors, such as limits on quantity, dose, or duration and other benefit design elements;36 patient characteristics; or clinical aspects of care.
Most patients treated with buprenorphine by each of the three provider groups received a dosage of at least sixteen milligrams per day during their treatment episode. The percentage that met this dosing threshold was lower among the youngest patients. In prior research, higher average daily doses have tended to be associated with improved retention in treatment18 and improved outcomes.19
Compared with more experienced buprenorphine prescribers, less experienced prescribers tend to find the logistics of initiating patients on buprenorphine more difficult.49 One benefit of integrated systems of care, such as the hub-and-spoke system developed in Vermont,24 is that opportunities exist for specialists to transfer patients to office-based opioid treatment following acute stabilization. A small but increasing percentage of treatment episodes were initiated by psychiatrists or addiction medicine specialists and subsequently included prescriptions from nonspecialists.
Conclusion
Growth in buprenorphine treatment in the United States from 2010 to 2018 coincided with primary care providers’ and other nonspecialists’ assuming a more prominent role in opioid addiction treatment. These trends represent important historic developments in the availability of buprenorphine treatment for people with opioid use disorder in the US. Federal policies that promote buprenorphine prescription authority for nonspecialists as well as other factors likely played critical roles. Although buprenorphine treatment has increased in recent years, low treatment retention and persisting unmet need for treatment7 underscore the need for maintaining a policy and clinical focus aimed at promoting greater access to buprenorphine and treatment retention. Only approximately 5 percent of physicians are waivered to prescribe buprenorphine,50 and most US rural counties do not have a single buprenorphine-waivered physician.51 However, between passage of the Comprehensive Addiction and Recovery Act in December 2016 and March 2019, 286 rural counties without buprenorphine-waivered clinicians acquired at least one nurse practitioner or physician assistant with a waiver.52
Promising clinical interventions (such as emergency department initiation of buprenorphine treatment for opioid dependent patients followed by referral to primary care)53 and innovative policies (for example, New Jersey’s recent authorization54 that permits paramedics to initiate buprenorphine treatment shortly after naloxone reversal of overdoses) offer opportunities to expand treatment access. Yet restrictions on buprenorphine coverage in private and public health plans remain common, as do requirements for preauthorization.36,39 Identifying and implementing promising policies and clinical practices to promote improved buprenorphine access and retention remain public health goals as part of a broader strategy to combat the opioid crisis.
ACKNOWLEDGMENTS
This work was supported by the National Institute on Drug Abuse (Grant No. R01 DA044981 to Marissa King). The opinions expressed in this article are the authors’ own and do not reflect the views of the National Institutes of Health, the Department of Health and Human Services, or the United States government.
NOTES
- 1 . Drug and opioid-involved overdose deaths: United States, 2013–2017. MMWR Morb Mortal Wkly Rep. 2018;67(5152):1419– 27. Crossref, Medline, Google Scholar
- 2 Centers for Disease Control and Prevention. Annual surveillance report of drug-related risks and outcomes—United States, 2019 [Internet]. Atlanta (GA): CDC; 2019 Nov 1 [cited
2020 Mar 19 ]. Available from: https://www.cdc.gov/drugoverdose/pdf/pubs/2019-cdc-drug-surveillance-report.pdf Google Scholar - 3 . Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014;(2):CD002207. Google Scholar
- 4 Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ. 2017;357:j1550. Crossref, Medline, Google Scholar
- 5 Effectiveness of injectable extended-release naltrexone vs daily buprenorphine-naloxone for opioid dependence: a randomized clinical noninferiority trial. JAMA Psychiatry. 2017;74(12):1197– 205. Crossref, Medline, Google Scholar
- 6 . National and state treatment need and capacity for opioid agonist medication-assisted treatment. Am J Public Health. 2015;105(8):e55– 63. Crossref, Medline, Google Scholar
- 7 Substance Abuse and Mental Health Services Administration. Results from the 2017 National Survey on Drug Use and Health: detailed tables [Internet]. Rockville (MD): SAMHSA. Table 6.43A, Opioid use disorder status in past year among persons aged 12 or older, by age group and past year opioid misuse characteristics: numbers in thousands, 2016 and 2017; [cited
2020 Mar 19 ]. Available from: https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHDetailedTabs2017/NSDUHDetailedTabs2017.htm#tab6-43A Google Scholar - 8 Trends in insurance coverage and treatment among persons with opioid use disorders following the Affordable Care Act. Drug Alcohol Depend. 2017;179:271– 4. Crossref, Medline, Google Scholar
- 9 . Moving addiction care to the mainstream—improving the quality of buprenorphine treatment. N Engl J Med. 2018;379(1):4– 6. Crossref, Medline, Google Scholar
- 10 . Policy pathways to address provider workforce barriers to buprenorphine treatment. Am J Prev Med. 2018;54(6 Suppl 3):S230– 42. Google Scholar
- 11 . Trends in buprenorphine treatment in the United States, 2009–2018. JAMA. 2020;323(3):276– 7. Crossref, Medline, Google Scholar
- 12 . Trends in buprenorphine prescribing by physician specialty. Health Aff (Millwood). 2019;38(1):24– 8. Go to the article, Google Scholar
- 13 . Rapid growth in Medicaid spending and prescriptions to treat opioid use disorder and opioid overdose from 2010 to 2017 [Internet]. Washington (DC): Urban Institute; [updated 2019 Mar; cited
2020 Mar 19 ]. Available from: https://www.urban.org/sites/default/files/publication/99798/rapid_growth_in_medicaid_spending_and_prescriptions_to_treat_opioid_use_disorder_and_opioid_overdose_from_2010_to_2017_2.pdf Google Scholar - 14 Association between trajectories of buprenorphine treatment and emergency department and in-patient utilization. Addiction. 2016;111(5):892– 902. Crossref, Medline, Google Scholar
- 15 Long-term outcomes of office-based buprenorphine/naloxone maintenance therapy. Drug Alcohol Depend. 2010;106(1):56– 60. Crossref, Medline, Google Scholar
- 16 National Quality Forum. Behavioral health 2016–2017: technical report [Internet]. Washington (DC): NQF; 2017 Aug 28 [cited
2020 Mar 19 ]. Available for download from: https://www.qualityforum.org/Publications/2017/08/Behavioral_Health_2016-2017_Final_Report.aspx Google Scholar - 17 . Retention in medication-assisted treatment for opiate dependence: a systematic review. J Addict Dis. 2016;35(1):22– 35. Crossref, Medline, Google Scholar
- 18 . Analysis of buprenorphine/naloxone dosing impact on treatment duration, resource use, and costs in the treatment of opioid-dependent adults: a retrospective study of US public and private health care claims. Postgrad Med. 2014;126(5):113– 20. Crossref, Medline, Google Scholar
- 19 Treatment retention among patients randomized to buprenorphine/naloxone compared to methadone in a multi-site trial. Addiction. 2014;109(1):79– 87. Crossref, Medline, Google Scholar
- 20 Center for Substance Abuse Treatment. Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction: a Treatment Improvement Protocol. Rockville (MD): Substance Abuse and Mental Health Services Administration; 2004. Treatment Improvement Protocol (TIP) Series, No. 40, Publication No. (SMA) 04-3939. Google Scholar
- 21 Patterns and quality of buprenorphine opioid agonist treatment in a large Medicaid program. J Addict Med. 2015;9(6):470– 7. Crossref, Medline, Google Scholar
- 22 . Risk factors for discontinuation of buprenorphine treatment for opioid use disorders in a multi-state sample of Medicaid enrollees. J Subst Abuse Treat. 2018;95:9– 17. Crossref, Medline, Google Scholar
- 23 . Vermont hub-and-spoke model of care for opioid use disorder: development, implementation, and impact. J Addict Med. 2017;11(4):286– 92. Crossref, Medline, Google Scholar
- 24 . National trends in adolescent substance use disorders and treatment availability: 2003–2010. J Child Adolesc Subst Abuse. 2015;24(5):255– 63. Crossref, Medline, Google Scholar
- 25 Census Bureau. 2018 population estimates by age, sex, race, and Hispanic origin [Internet]. Washington (DC): Census Bureau; 2019 Jun 20 [cited
2020 Mar 20 ]. Available from: https://www.census.gov/newsroom/press-kits/2019/detailed-estimates.html Google Scholar - 26 . Trends in the use of buprenorphine by office-based physicians in the United States, 2003–2013. Am J Addict. 2015;24(1):24– 9. Crossref, Medline, Google Scholar
- 27 Predictors of abstinence: National Institute of Drug Abuse multisite buprenorphine/naloxone treatment trial in opioid-dependent youth. J Am Acad Child Adolesc Psychiatry. 2011;50(11):1120– 8. Crossref, Medline, Google Scholar
- 28 . Diversion of buprenorphine/naloxone coformulated tablets in a region with high prescribing prevalence. J Addict Dis. 2009;28(3):226– 31. Crossref, Medline, Google Scholar
- 29 To access the appendix, click on the Details tab of the article online.
- 30 Substance Abuse and Mental Health Services Administration. Results from the 2018 National Survey on Drug Use and Health: detailed tables [Internet]. Rockville (MD): SAMHSA; 2019 Aug [cited
2020 Mar 20 ]. Available from: https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHDetailedTabs2018R2/NSDUHDetailedTabs2018.pdf Google Scholar - 31 Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health: detailed tables [Internet]. Rockville (MD): SAMHSA; 2014 Sep 4 [cited
2020 Apr 29 ]. Available from: https://www.samhsa.gov/data/report/results-2010-national-survey-drug-use-and-health-detailed-tables Google Scholar - 32 . Buprenorphine prescribing for opioid use disorder in medical practices: can office-based out-patient care address the opiate crisis in the United States? Addiction. 2019;114(11):1992– 9. Crossref, Medline, Google Scholar
- 33 . Treatment of opioid-use disorders. N Engl J Med. 2016;375(4):357– 68. Crossref, Medline, Google Scholar
- 34 Collaborative care of opioid-addicted patients in primary care using buprenorphine: five-year experience. Arch Intern Med. 2011;171(5):425– 31. Crossref, Medline, Google Scholar
- 35 . Office-based opioid treatment with buprenorphine (OBOT-B): statewide implementation of the Massachusetts Collaborative Care Model in community health centers. J Subst Abuse Treat. 2016;60:6– 13. Crossref, Medline, Google Scholar
- 36 Survey highlights differences in Medicaid coverage for substance use treatment and opioid use disorder medications. Health Aff (Millwood). 2016;35(12):2289– 96. Go to the article, Google Scholar
- 37 . Medication treatment for opioid use disorders in substance use treatment facilities. Health Aff (Millwood). 2019;38(1):14– 23. Go to the article, Google Scholar
- 38 . Coverage of medications that treat opioid use disorder and opioids for pain management in Marketplace plans, 2017. Med Care. 2018;56(6):505– 9. Crossref, Medline, Google Scholar
- 39 . Trends in receipt of buprenorphine and naltrexone for opioid use disorder among adolescents and young adults, 2001–2014. JAMA Pediatr. 2017;171(8):747– 55. Crossref, Medline, Google Scholar
- 40 Committee on Substance Use and Prevention. Medication-assisted treatment of adolescents with opioid use disorders. Pediatrics. 2016;138(3):e20161893. Crossref, Medline, Google Scholar
- 41 . How the paediatric workforce can address the opioid crisis. Lancet. 2016;388(10051):1260– 1. Crossref, Medline, Google Scholar
- 42 . Patterns of buprenorphine-naloxone treatment for opioid use disorder in a multistate population. Med Care. 2017;55(7):669– 76. Crossref, Medline, Google Scholar
- 43 . The looming expansion and transformation of public substance abuse treatment under the Affordable Care Act. Health Aff (Millwood). 2011;30(8):1402– 10. Go to the article, Google Scholar
- 44 . Buprenorphine prescribing availability in a sample of Ohio specialty treatment organizations. J Addict Behav Ther Rehabil. 2015;4(2):1000140. Medline, Google Scholar
- 45 . Primary care patient characteristics associated with completion of 6-month buprenorphine treatment. Addict Behav. 2013;38(11):2724– 8. Crossref, Medline, Google Scholar
- 46 Long-term retention in office based opioid treatment with buprenorphine. J Subst Abuse Treat. 2017;74:65– 70. Crossref, Medline, Google Scholar
- 47 . Injectable naltrexone, oral naltrexone, and buprenorphine utilization and discontinuation among individuals treated for opioid use disorder in a United States commercially insured population. J Subst Abuse Treat. 2018;85:90– 6. Crossref, Medline, Google Scholar
- 48 . Buprenorphine coverage in the Medicare Part D program for 2007 to 2018. JAMA. 2019;321(6):607– 9. Crossref, Medline, Google Scholar
- 49 Factors affecting willingness to provide buprenorphine treatment. J Subst Abuse Treat. 2009;36(3):244– 51. Crossref, Medline, Google Scholar
- 50 Substance Abuse and Mental Health Services Administration. Medication-assisted treatment—Practitioner and program data [Internet]. Rockville (MD): SAMHSA; [cited
2020 Apr 29 ]. Available from: https://www.samhsa.gov/medication-assisted-treatment/training-materials-resources/practitioner-program-data Google Scholar - 51 . Geographic distribution of providers with a DEA waiver to prescribe buprenorphine for the treatment of opioid use disorder: a 5-year update. J Rural Health. 2019;35(1):108– 12. Crossref, Medline, Google Scholar
- 52 . In rural areas, buprenorphine waiver adoption since 2017 driven by nurse practitioners and physician assistants. Health Aff (Millwood). 2019;38(12):2048– 56. Go to the article, Google Scholar
- 53 Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636– 44. Crossref, Medline, Google Scholar
- 54 State of New Jersey, Department of Health [Internet]. Trenton (NJ): The Department. Press release, Commissioner authorizes paramedics to carry buprenorphine; 2019 Jun 24 [cited
2020 Apr 29 ]. Available from: https://www.nj.gov/health/news/2019/approved/20190624a.shtml Google Scholar