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Expanding Buprenorphine Treatment: An Underutilized, Evidence-Based Practice for Treating Opioid Dependence

Friday, October 19, 2018

With the help of our partners at the talent development firm Maher & Maher, IMPAQ International’s policy researchers have been studying the plight of communities and identifying some of the most effective solutions to combat the opioid crisis. This is the third of a four-part blog series.

Introduction

Previous posts in this blog series emphasized the effectiveness of employment services at supporting sobriety in those with substance abuse issues. However, individuals with opioid use disorder (OUD) typically need access to treatment before they can fully benefit from recovery services, such as the Career Building Initiative in Massachusetts. Treatment services are expanding in response to the opioid crisis—for example, 54.9 percent of people with heroin-use disorders received treatment in 2017 compared to 37.5 percent in 2016.1

Typical approaches to OUD treatment include cognitive-behavioral therapy, counseling, residential programs, 12-step sobriety programs, and peer supports,2 as well as medication-assisted treatment (MAT) with methadone, buprenorphine (including a combination with naloxone), and naltrexone.3 MAT has become recognized by the medical community as “an evidence-based best practice for treating opioid dependence,”4 with endorsements from organizations like the World Health Organization, the National Institute on Drug Abuse, the Substance Abuse and Mental Health Service Administration, and the American Medical Association.4,5

Yet amidst the growing opioid crisis in the United States, this proven method is being severely underutilized. The Blue Cross Blue Shield Association reported that, while from 2011 to 2016 there was a 493 percent increase in opioid-use disorder diagnoses, the use of MAT only increased by 65 percent.6 Treatment plans that incorporate the use of medications are clearly not being applied enough to support prolonged recovery for people with OUD.   

Best Practices to Support Recovery

In a person with OUD, MAT acts on brain receptors to reduce opioid cravings and withdrawal symptoms without producing euphoria.2,7

As of 2016, buprenorphine is prescribed at significantly higher rates than all other MAT options combined.8 Whereas methadone requires daily visits to special clinics to obtain dosages, buprenorphine can be prescribed by any certified healthcare provider and taken by the patient at home. To deter potential abuse, naloxone can be merged with buprenorphine to create the combination product Suboxone, which can bring on withdrawal if injected rather than taken in pill form.9

To prescribe buprenorphine to treat OUD, physicians must take an eight-hour training course and are initially limited to treating a maximum of 30 patients at a time, though this can be increased to 275 patients if the physician meets additional requirements. The Comprehensive Addiction and Recovery Act (CARA) of 2016 expanded buprenorphine prescribing capabilities to nurse practitioners and physician assistants if they complete 24-hours of training.8

Overwhelming evidence shows that, in addition to supporting participation in recovery programs, 10 MAT reduces illicit opioid use, HIV and Hepatitis C transmission rates, overdoses, and relapses.5 Patients treated with either methadone or buprenorphine are half as likely to relapse compared to those treated with only behavioral therapies.11 The Stanley Street Treatment and Resource Center in Massachusetts reported a relapse rate of only about 10 percent in 2014 while using Suboxone to treat its patients.12 Another recent study from 2015 found that people who received only mental health support were more at risk for an overdose than those who had MAT, both with and without mental health support.13

Access to Treatment Below Optimal Levels

Even with encouragement from Congress to expand access to buprenorphine, the White House Opioid Commission found that 47 percent of counties and 72 percent of rural counties had no waivered (certified) physician in 2016.14

As of June 2018, only 5 percent of the nation’s physicians were waivered,15 with further evidence revealing that many are not prescribing anywhere near their waiver limit.16,17 One survey from 2015 found that only 43.8 percent of certified physicians were prescribing at full capacity.17 Another recent survey of rural physicians found that only 56.2 percent of physicians with waivers were accepting new patients. Those with the 30-patient waiver were treating 8.8 patients on average and 53 percent were treating none.18

Barriers to Prescribing Buprenorphine at Full Capacity

One of the most commonly cited reasons for not having a waiver or not accepting new buprenorphine patients is that the physicians do not have enough time.19 Those not treating at full capacity respond that receiving information about local counseling services would increase their willingness to treat additional patients.19 Among rural physicians, 44.4 percent cited a lack of available mental health or psychological services as being a barrier to prescribing buprenorphine at their practice.20

Physicians also comment on the perceived difficulties associated with addiction treatment.21,22 Physicians without a waiver are concerned with being inundated with buprenorphine requests, the complexity of supporting recovery, and diversion of the medication.19 Additionally, stigma against addiction is still present, with 27.8 percent of rural physicians in 2016 not wanting to attract “drug users" to their office.20

One study found that 48.4 percent of rural physicians worried about misuse of the buprenorphine prescription, despite the availability of abuse-deterrent formulations such as Suboxone.20 However, only 1 percent of injection users indicate buprenorphine as their drug of choice.23 The majority of illicit buprenorphine use is to attempt sobriety and/or to suppress withdrawal,9 with 64 percent doing so because they could not afford treatment services.24 In fact, attempting but failing to access buprenorphine treatment was found to be the strongest predictor of diversion.25

Physicians have also mentioned frustration with the prior authorization requirement from health insurance companies to start a patient with MAT.26 Initiating treatment can be delayed by up to 72 hours due to the requirement, which is not typically feasible for someone experiencing withdrawal. In response, many major insurers are eliminating prior authorizations for MAT27 and some states are also requiring insurers to discontinue prior authorization.28

Promising Advances

Across the US, states and communities are developing interventions to expand treatment services as part of broader efforts to support the needs of people with OUD. The hub-and-spoke system in Vermont has been very successful in advancing the state’s opioid treatment capacity and has contributed to a 64 percent increase in waivered physicians.29 The model created a specialized clinic to initiate buprenorphine treatment before transferring patients to outside certified providers to continue treatment, addressing the intensive time concerns of physicians. It also provides consultation resources to physicians and connects patients to behavioral health services and counselors to reduce physician apprehensions about expertise.

Project ECHO in New Mexico uses teleconference sessions to connect specialists with local providers to discuss patient cases and share lessons learned from their own experiences.21 Telehealth can be leveraged to support waivered physicians with unfamiliar cases and help bring mental health resources to rural communities.

Innovations like the ones mentioned above, in addition to the trend to eliminate prior authorization for MAT, are promising ways to expand access to buprenorphine for OUD. Given that a multitude of research demonstrates that employment reinforces sobriety, evidence-based outpatient treatment options should be prioritized as they allow individuals with OUD to continue to work. Additionally, outpatient services are traditionally more scalable than inpatient services, which are limited by bed availability.

IMPAQ International recognizes the importance of removing barriers to prescribing buprenorphine MAT to help end the opioid crisis and is looking forward to assisting efforts to achieve this goal. 

Read Part Four Here

References
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