Overcoming Barriers to Prescribing Buprenorphine for the Treatment of Opioid Use Disorder: Recommendations from Rural Physicians C. HOLLY A. ANDRILLA, TESSA E. MOORE, DAVIS G. PATTERSON WWAMI Rural Health Research Center AcademyHealth Annual Research Meeting June 4, 2019
Acknowledgements and Disclaimer This research was supported by the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS) under cooperative agreement #U1CRH03712 . The information, conclusions and opinions expressed in this presentation are those of the authors and no endorsement by FORHP, HRSA, or HHS is intended or should be inferred.
Contributors C. Holly A. Andrilla, MS Research Scientist & Program Manager WWAMI Rural Health Research Center Tessa E. Moore Former Research Coordinator, WWAMI Rural Health Research Center, Current Medical Student, UW School of Medicine Davis G. Patterson, PhD Deputy Director of the WWAMI Rural Health Research Center
Background The United States is in the midst of a severe opioid abuse epidemic. In 2015, an estimated 2.0 million people, 12 and older, had a pain reliever use disorder, and 591,000 people had heroin use disorder. In 2017, an estimated 47,600 people died of opioid overdose.
To Expand Treatment Options The U.S. Congress passed the Drug Addiction Treatment Act (DATA 2000) • Allows physicians who complete 8 hours of required training to obtain a Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine. The U.S. Congress passed the Comprehensive Addiction and Recovery Act of 2016 (CARA 2016) • Extends ability to nurse practitioners (NPs) and physician assistants (PAs) who complete 24 hours of required training to obtain a DEA waiver to prescribe buprenorphine.
Study Goals Many physicians report experiencing a variety of barriers to providing medication-assisted treatment (MAT). However, a significant number of providers have successfully overcome these barriers and are actively using their waiver. These results are from 43 interviews with rurally located physicians who have identified strategies to overcome barriers to prescribing buprenorphine for the treatment of opioid use disorder (OUD).
Waivered Physician Recommendations
Methods Physicians who were prescribing to an above average number of patients were identified using the 2016 WWAMI RHRC national survey of waivered physicians. Selected physicians (n=75) with the 30 patient waiver, and (n= 211) with the 100 patient waiver were randomly ordered, contacted and interviews scheduled. Each interview was recorded and lasted approximately 20 minutes. Census Division was tracked and a targeted number of responses from each Census Division was sought.
Barriers We asked physicians about the following previously identified barriers: ▪ Time constraints ▪ Financial /reimbursement concerns ▪ Resistance from practice partners ▪ Lack of specialty backup for complex problems ▪ Lack of confidence in your ability to manage opioid use disorder ▪ Lack of available mental health or psychosocial support services ▪ Attraction of drug users ▪ DEA intrusion on your practice ▪ Concerns about diversion or misuse of medication
Barriers Physicians identified an additional barrier Stigma from pharmacies in filling prescriptions for buprenorphine “These patients are discriminated at the pharmacies. It takes tremendous courage to even admit they need help, then when they get the help if they go to a pharmacy to fill the medication they are treated, some pharmacies, pharmacists, staff workers, they’re not nice to these patients.”
Pharmacy Stigma Barrier “And [patients] said you know it would be a lot easier, I’d be treated a lot nicer if I was getting pain medication maybe.’’
Physician Recommendations ▪ Getting Started ▪ Maintaining medication-assisted treatment service ▪ Complying with DEA requirements ▪ Ensuring financial viability ▪ Combatting diversion and misuse ▪ Ensuring access to mental health services ▪ Overcoming stigma ▪ Doing rewarding work ▪ Other advice
Getting Started • Find a mentor (can apply for one through PCSS.org). • Start with just a few patients while you get accustomed to it. • Dedicate a discrete amount of time to this part of your practice.
Get a mentor “I would recommend to spend 1 hour talking to someone who has already been doing this for a while somewhere else. Because it would seem daunting, and would be probably discouraging to try to sort of reinvent the wheel on your own, and sort of figure out how to have really firm boundaries in certain areas and how to have an efficient way of doing this . . . You wouldn’t have the frustrations that we’ve had as we were developing our program. “
Start with just a few patients while you get accustomed to it. “If you can get several people in the office to do it, you are sharing the burden. It is going to overwhelm your practice if you take on too many patients”
Maintaining medication-assisted treatment service • Use a contract • Establish boundaries • Terminate treatment when necessary • Implement the “Hub and Spoke” model
Have patients sign a contract/agreement and stick to it “Laying down the ground rules in the beginning, what’s going to be allowed and not allowed, and being really strict on it in the beginning, that’s probably the most important thing.”
Establish boundaries “If you’re not going to hold people accountable, then don’t do this work.” “Because of our reputation, people won’t show up if they want to play games —they will go elsewhere.”
Terminate treatment when necessary “I don’t discharge a patient for, by any means, a single relapsed urine specimen or relapse by history. But eventually if patients over and over and over again are indicating relapse, then we’ll have to disengage them, and that doesn’t happen too often.”
Complying with DEA requirements • Follow the rules and keep detailed records
Keep detailed records “We try to keep as good of records as possible. When they made their first visit, the fellows that came over from the Boise area were very nice and made several suggestions, otherwise they kind of left me alone.”
Ensuring financial viability • Accept all insurance types • Become a cash-only practice
Accept all insurance types “I think the reimbursement for Medicaid in our area has been at least adequate to do the job. I do not feel like we are loosing a lot of money on seeing those Suboxone patients.”
Combatting diversion and misuse • Require pill counts and urine drug screens • Check prescription drug monitoring programs • Create relationships with pharmacies
Ensuring access to mental health services • Provide office-based group sessions • Utilize free resources such as Narcotics Anonymous (NA) • Allow patients to graduate from counseling requirements
Allow patients to graduate from counseling requirements “Require counseling, but not indefinitely. If they complete a course of AOD counseling and the counselor and I mutually decide that there is no benefit to more counseling, then I don’t require it at that point .”
Overcoming Stigma • Have open honest dialogue with colleagues and staff • Most felt stigmas was a problem that still needed to be better addressed.
Stigma “My medical staff (not other doctors) think addicts are bad people and do not think we should be treating them at all. Some say we will treat the ones who are trying hard and doing well, which usually is the moms and not the scary types. They give me grief, it’s hard to deal with that on the day to day basis. We have tried to work through these issues. Without a supportive staff it is hard to do.”
Doing rewarding work “The addicted patient who gets better, it just has ripple effects through the community; it keeps families together, moms and children and grandparents are all much happier, so it’s much more rewarding in a lot of ways than routine family practice.”
Rewarding work “It has made such a change in the community and in individual people’s lives, it’s pretty cool.” “It’s the most satisfying, personally nourishing medical activity I’ve done in my practice lifetime”
Other advice ▪ At the minimum, getting the waiver so you can treat your own patients, you do not have to take on new ones.
Treat your own patients “If everybody would take 30 people or 15 and 20, we could solve this opiate problem.” “I tell them you must, you must. You did it, I did it, we all did it, we are all in this together, and now we need to help fix it.”
Summary and Future Implications ▪ Access to MAT for OUD must be improved for all U.S. patients, especially those located in rural areas with limited access to treatment options. ▪ In order to increase the number of physicians, NPs, and PAs that obtain and actively use their waiver, it is important that practice support is provided and solutions are found and incorporated that combat the barriers associated with providing buprenorphine treatment.
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