Patients and Psychiatrists Alike Face Hurdles in Buprenorphine Prescribing

Patients who have opioid use disorder (OUD) face myriad barriers to obtaining medication for addiction treatment, from stigma and shame that keep them from seeking help to racial and socioeconomic disparities in access and prescribing. Yet perhaps most challenging are the barriers inherent in the health care system, particularly when it comes to buprenorphine. There may be no qualified prescriber nearby, and when there is, patients may have to wait first for an appointment, then for approval from an insurance company for the prescription.

Physicians, nurse practitioners, certified registered nurse anesthetists, clinical nurse specialists, certified nurse midwives, and physician assistants face their own challenges in obtaining the waiver to their Drug Enforcement Administration license to prescribe buprenorphine for OUD, as they must take an approved eight-hour training course and then apply for the waiver. Prescribers start at 30 patients and must wait a year until they can apply to treat 100 patients. Physicians may apply to increase the number to 275 patients after another year, but they must have certain additional credentialing, such as board certification in addiction or practice in a qualified practice setting that meets certain criteria, such as providing case management services.

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“It’s not a good state that we’re in,” said Elie Aoun, M.D., a general addictions and forensic psychiatrist at Columbia University and vice chair of APA’s Council on Addiction Psychiatry. “Everyone talks about how severe the opioid crisis is, but it’s a problem that affects the whole health care system. When you look at the solutions and what’s being done in our communities, you quickly become aware of how limited the resources are.”

Indeed, a study in the November Drug and Alcohol Dependence found that although the number of waivered buprenorphine prescribers in the United States had increased 175% between 2016 and 2018, 35% of counties still have none. Furthermore, waivered prescribers are concentrated in urban and suburban areas, and nearly 57% of rural counties do not have one.

Wavering on Training

One potential speedbump on the road to increasing access is the training course prescribers must take before they can qualify for the waiver. While some see it as necessary, others see it as a barrier to overcome, said Petros Levounis, M.D., M.A., a professor and chair of the Department of Psychiatry at Rutgers New Jersey Medical School and an addiction psychiatrist. He is also a member of the Psychiatric News Editorial Advisory Board.

“One camp says we should not have the waiver course at all because it stigmatizes buprenorphine and makes it look like something dangerous and outside the normal practice of medicine, while it’s a very safe and effective medication,” Levounis said. “The other camp sees it as an opportunity to teach people about addiction. It’s an opportunity we don’t get very often, so we shouldn’t kick the course out of the mix. Instead we should make it more accessible and more specific to different practices.

“The solution to the issue is not to fight against each other,” he continued, “but to embed the course in the medical school curriculum or nurse practitioner or physician assistant school so that students will have already taken the federally approved course before they graduate.”

Some physicians, such as Amesika Nyaku, M.D., M.S., an assistant professor in the Division of Infectious Diseases at Rutgers New Jersey Medical School, feel the waiver itself is a barrier to providing care. Nyaku is co-director of the Northern New Jersey Medication-Assisted Treatment Center of Excellence.

“I don’t need a waiver to prescribe narcotics, but to provide treatment for opioid use disorder requires special training. There is a disconnect here,” Nyaku said. Nyaku added that she has encountered addiction specialists who believe prescribing should be limited to their specialty. “They feel that specialty training is required to manage OUD appropriately. I think that given the shortage of providers and the enormity of the crisis, we have to do something different. We can’t just have a small group of people trying to manage this.

Waivers Are No Guarantee of Access

Living in proximity to waivered prescribers does not necessarily guarantee patients access to buprenorphine treatment. According to a study of 558 waivered and nonwaivered physicians in the July 2017 Journal of Substance Abuse Treatment (JSAT), 56% of waivered physicians are not prescribing for the full number of patients their waivers allow. The most common reason they cited was not having time to care for more patients.

“When providing buprenorphine for those who clinically need it, physicians have to come up with a clinical model that works for them, but it won’t be perfect. Something has to give,” said Aoun. “My practice is designed for maintaining a small number of patients so I can provide individualized care and handle [urgent] issues when they come up, but that comes at the cost of not being able to treat a lot of patients. Seeing more patients improves access to care, but that compromises the amount of time you can spend with them. No matter what model you use, you will lose something.”

Even when waivered prescribers have room on their rosters, patients may face a delay in scheduling and buprenorphine induction, according to a “secret shopper” study in the July 2 Annals of Internal Medicine. Callers to physicians, nurse practitioners, and physician assistants listed on the Buprenorphine Practitioner Locator website posed as a patient with either Medicaid coverage or no insurance in five states and the District of Columbia.

Only 54% of the Medicaid callers and 62% of the self-pay callers were offered an appointment. The median wait time to the first appointment was six days for Medicaid callers and five days for self-pay callers. Only 27% of Medicaid callers and 41% of self-pay callers were offered an appointment with the possibility of a buprenorphine prescription at the first visit. The median wait time from first contact to possible induction was eight days for Medicaid callers and seven days for self-pay callers.

In the best of scenarios—nearby access to a waivered prescriber with immediate availability—patients with OUD may face another hurdle: prior authorization. A research letter in the February 12 JAMA found that 65% of Medicare Part D insurance plans required prior authorization for buprenorphine products in 2018, up from just 11% in 2007.

Although private insurers are slowly starting to do away with prior authorization of buprenorphine, and several states have either banned or have introduced legislation to ban prior authorization in Medicaid plans, that the restriction exists at all vexes APA President Bruce Schwartz, M.D., deputy chair and professor of psychiatry in the Department of Psychiatry and Behavioral Sciences at Montefiore Medical Center and the Albert Einstein College of Medicine. The Montefiore Department of Psychiatry operates one of the largest substance use treatment programs in the United States “Many insurance policies place impediments to starting medication so you lose the window of opportunity for treatment. You have a patient who comes in and you can’t get approval for the medication, so you tell the patient you’ll work with their insurance company to authorize it, but by the time you get authorization, that person may be in another cycle of use,” Schwartz said.

For Want of Medical Education

In the JSAT study, 13.3% of the 558 physicians surveyed did not have the waiver. Among their top reasons was that they felt they did not have enough education about OUD. Physicians in a small study in the April 2018 International Journal of Drug Policy echoed this sentiment. When asked what barriers they faced to prescribing buprenorphine and extended-release naltrexone in office-based practices, they cited a lack of addiction education in medical school and residency first and foremost.

“The reality is that physicians from all specialties are fighting for time in medical education curricula and trying to expose students to their specialties. Teaching hours are a precious and limited resource,” said Aoun.

Aoun said that the Milestones the Accreditation Council for Graduate Medical Education (ACGME) sets for psychiatry residents should put more emphasis on substance use disorders (SUDs) as an area of special interest in residency training requirements.

“The Milestones barely include anything about SUDs, yet psychiatrists see a disproportionate number of patients with addictions. We’re not teaching residents one of the most common [conditions] they will deal with in their practice,” said Aoun, who is a member of the ACGME’s Psychiatry Milestones 2.0 Work Group.

Aoun said that a change in perspective among psychiatrists as a group may be necessary because some do not see OUD and other SUDs as psychiatric problems. “Psychiatrists, even nonaddiction specialists, are still the best-trained physicians to treat SUDs because of our unique training and expertise in delivering behavioral and other psychotherapeutic interventions and social support,” Aoun said. ■