Obstacles for PCPs Prescribing Buprenorphine for Opioid Addiction

Although buprenorphine is the only available drug for office-based physicians for the treatment of opioid addiction that reports high rates of prolonged success, a recent study found 11 of 17 Oregon primary care physicians (PCPs) trained to use buprenorphine do not prescribe it [J Subst Abuse Treat. 2004;26(3):203-208]. This statistic may be attributed to a number of barriers PCPs face when prescribing buprenorphine.

To increase the number of physicians treating opioid addiction, the Rural Opioid Addiction Management Project (ROAM) offered training to physicians who were interested in becoming qualified (ie, waiver holding) to prescribe buprenorphine. Some physicians were trained, but not all followed through to obtain the Drug Enforcement Administration (DEA) waiver that legally allows physicians to prescribe buprenorphine. Note, the Rural Opioid Addiction Management Project is located in Washington state, so statistics are true to Washington state, not necessarily the United States as a whole.

A total of 78 physicians who were trained through the Rural Opioid Addiction Management Project were surveyed. The survey found that, of these trained physicians, 50 obtained the DEA waiver to prescribe buprenorphine. From there, the survey categorized physicians as those who have prescribed buprenorphine (n=22) and those who have not (n=56).

Of the 22 physicians who had prescribed buprenorphine, 21 of them identified themselves as PCPs. Overall, PCPs were >5 times more likely to prescribe buprenorphine than physicians in other specialties (33% vs 7%; P=.05). Of the 22 physicians who prescribed buprenorphine, 15 had practice partners who also held the DEA waiver needed to prescribe buprenorphine (68%).

Among the 78 physicians surveyed, 69 physicians offered their clinical opinion on buprenorphine’s effectiveness. The average rating issued for the effectiveness of buprenorphine was 4.3 (1=very unfavorable, 5=very favorable).         

The primary barrier cited in prescribing buprenorphine was lack of psychosocial support (64%; n=50). Other barriers included:

• Time constraints (54%; n=42)

• Lack of specialty backup (45%; n=35)

• Lack of confidence in their abilities to manage opioid addiction (41%; n=33)

• Resistance from practice partners (42%; n=33)

• Lack of institutional support (36%; n=28)

• Financial issues (28%; n=22)

These barriers to prescribing buprenorphine show that there is a need for behavioral health services. When asked directly what could facilitate prescribing buprenorphine, 10 physicians mentioned that a follow-up course or site visits after training would assist in implementing the use of buprenorphine. Also, 9 physicians stated that local telemedicine access to specialists that did not conflict with practice hours would facilitate prescribing buprenorphine.

In terms of limitations, the results only apply to Washington state physicians newly trained to prescribe buprenorphine in 1 of the first 5 courses provided by Project ROAM.

The results suggest that more than a training course is needed to get physicians and primary care offices to prescribe buprenorphine in regions that do not have access to the drug. Prior to training, it may be beneficial to obtain an administrative commitment to provide treatment for addiction.

It should be noted that new barriers may emerge and/or old barriers may desist, contingent on any substance abuse treatments that may be funded under healthcare reforms.