Use of Buprenorphine for Addiction Treatment: Perspectives of Addiction Specialists and General Psychiatrists

In 2005 an estimated 1.2 million persons were dependent on opiates ( 8 ). The burden of opiate dependence is heavy, both for the addicted individual and for society. Substitution therapy is effective for detoxification and maintenance, but methadone can be administered only in highly regulated environments that may discourage treatment entry ( 9 ). Only 20% of opiate-dependent patients received treatment in 2005 ( 10 ). The unmet need for treatment makes office-based approaches attractive because they expand the base of providers and venues at which opiate-dependent persons can receive substitution therapies, and they provide a setting for maintenance treatment that does not have the inconvenience or stigma of daily dispensing as does methadone.

The Drug Addiction Treatment Act (DATA) of 2000 established a system that allows for office-based prescribing of medications approved by the FDA to treat opiate addiction. Physicians obtain waivers by receiving eight hours of training, acquiring addiction specialty certification, conducting research on approved drugs, or meeting state regulations ( 1 ). In 2002 FDA approved buprenorphine for the treatment of opiate dependence, making it the first drug available via the DATA waiver program ( 11 ). In clinical trials buprenorphine has been shown to reduce craving, the percentage of opioid-positive urine samples, and self-reported addiction severity compared with placebo ( 12, 13 ). In a study of 1,203 psychiatrists conducted on the eve of buprenorphine's FDA approval, West and colleagues ( 6 ) found that 81% were not comfortable prescribing office-based opiate agonist treatment. The size of a psychiatrist's substance abuse caseload was found to be associated with the level of comfort with office-based treatment, but only 57% of the 41 certified addiction psychiatrists reported comfort with such an approach. Similarly, Koch and colleagues ( 7 ) found that among substance abuse treatment facilities, certified opioid treatment programs were more than twice as likely as noncertified programs to offer buprenorphine. This suggests that prescribing of buprenorphine may be related to the treatment philosophy of these facilities—a medical approach—as well as to program type.

Physicians and facilities interdependently influence one another in the decision to incorporate new treatments. Previous research has found that organizational support of adoption of naltrexone was strongly associated with its adoption by physicians, but the mechanisms by which organizations supported prescribing, and the interrelationships between physicians and their organizations, was less clear ( 2 ). This article extends earlier research on adoption of substance abuse treatment pharmacotherapy and follows a framework that recognizes the importance of physicians, their work environment and treatment organizations, and the public policy environment in contributing to adoption ( 2, 14 ).

The following research questions were addressed: What are the personal, practice, treatment organization, and market characteristics that are associated with receipt of training, receipt of a waiver, and prescription of buprenorphine in office-based settings? How well has buprenorphine been accepted outside the realm of addiction treatment specialists by general psychiatrists and why? What are the barriers to and facilitators of prescribing buprenorphine?

As shown in Table 1, among both addiction specialists and non-addiction specialist psychiatrists, respondents were mostly male and nearly all were board certified, with an average of 14 or 15 years of experience treating addictions. Addiction specialists reported treating an average of 56 patients for opiate dependence in the past month, and other psychiatrists reported an average of 2.4 (not shown). Addiction specialists reported that more than 20% of their patients were dependent on heroin, alcohol, or prescription opiates. Non-addiction specialist psychiatrists had many fewer patients with opioid addictions, but nearly 20% of their patients were alcohol dependent.

This survey, conducted three years after buprenorphine was approved and marketed for office-based treatment, is the first to include both physicians who have received waivers to prescribe buprenorphine and those who have not. The goal of the survey was to understand barriers to prescribing this new addiction treatment. However, the study was a preliminary examination of use of a new treatment and is limited to particular markets and not necessarily generalizable to all physicians who treat opiate-dependent patients, such as general practitioners. Results indicate that most addiction specialists have adopted it, but beyond addiction specialists, few other clinicians have incorporated it into practice.

These findings also reveal the importance of organizational influence and patient satisfaction, which probably also reflects patient demand, in adopting buprenorphine. The study also identified differences in behavior and characteristics of organizations that support use of buprenorphine and those that do not. The differences in the models predicting certification and predicting prescribing showed important factors that facilitate prescribing: organizational support appears to be more important in obtaining certification than in prescribing, and being in a group practice setting and strong patient demand are strong predictors of prescribing but not of receipt of training. Thus, in comparing predictors of training to those of prescribing, it appears that physicians may train or seek certification with less commitment to the role of medications in treatment, but they need to really believe in the effectiveness of buprenorphine if they are to prescribe.

Low prescribing rates beyond the core group of addiction specialists are consistent with other addiction pharmacotherapies ( 2, 3 ) and reflect challenges predicted by others ( 6 ). The Center for Substance Abuse Treatment has endeavored to provide information and training to physicians to encourage use of buprenorphine in office-based practice. However, the fact that psychiatrists other than AAAP or ASAM members rarely prescribe it raises the concern of how well the message about buprenorphine and its advantages has been communicated. The survey also found that among addiction specialists, having spent more time in general psychiatry decreased the likelihood of prescribing buprenorphine. Although research indicates that pharmacological treatments are commonly prescribed by psychiatrists for patients with and without substance use disorders ( 17, 18 ), there may be several reasons that buprenorphine has not been more widely prescribed by non-addiction specialist psychiatrists. Unlike many other medications prescribed by the psychiatric community, addiction treatment medications such as buprenorphine are most effective when used in a comprehensive recovery program. In particular, initial dosing of buprenorphine requires its on-site storage and availability and resources for extended monitoring of patients' response. Psychiatrists with limited clinical staff or those not affiliated with addiction treatment programs or recovery support systems may thus be reluctant to prescribe buprenorphine. In addition, psychiatrists unfamiliar with the safety features of the combined buprenorphine-naloxone preparation may be worried about the potential for abuse. Of critical importance is the fact that non-addiction specialist psychiatrists treat fewer patients with addictions than do addiction specialists, which may make it not worth their while to seek training and certification to prescribe buprenorphine.

Both addiction specialists and other psychiatrists ranked "does not fit with my practice" and "would change my patient mix" as important barriers and cost as less important, although the current cost of buprenorphine is $160 per month. It may merely be that some psychiatrists specialize in conditions unrelated to the use of medication-assisted treatments or, of greater concern, that certain psychiatrists do not want to treat opiate-addicted patients. Beyond the issues of medication-assisted treatment, stigma and stereotypes must be addressed to overcome these barriers.

Although knowledge about buprenorphine and a positive attitude toward the role of medications in addictions treatment are both necessary for prescribing, the treatment organization plays a critical role that cannot be ignored. As was found in studies mentioned earlier, the support of an organization is an important factor in adopting new addiction treatment medications. According to physicians, organizations that encourage prescribing of buprenorphine are more likely to be collaborative, reward new treatments, and value professional development.

The goal of office-based treatment of opiate dependence is to improve access and reduce unmet demand by bringing more people into treatment. Our study strongly suggests that more work must be done to familiarize physicians with buprenorphine, destigmatize opiate addiction, and bring additional providers into the treatment of addictions. Fulfilling the promise of office-based treatment may be difficult for two reasons. First, given the importance of organizational influences in prescribing, it is not clear how psychiatrists who are not affiliated with addiction treatment programs will have incentives to obtain training and prescribe buprenorphine. Second, it may be difficult for psychiatrists in solo or small group practice to provide both buprenorphine-based maintenance services and the more complex detoxification without the added resources provided by treatment programs and other facilities. However, as time passes, if more patients with addiction seek treatment in office-based settings, more providers may be willing to change practices to accommodate such patients.

Finally, to the extent that buprenorphine gains broader acceptance among providers, additional surveys are needed to address issues related to cost and access, because a large proportion of patients are not insured. These include determining whether insurers cover buprenorphine and under what restrictions and examining the cost of treatment, drug diversion in the community, and nonadherence to treatment. Thus, although office-based treatment offers a promising path to improved access, expanding addiction treatment through office-based practitioners promises to be a continuing challenge, warranting continued monitoring.

This research was funded by grant R01-DA-014578 from the National Institute on Drug Abuse.

The authors report no competing interests.

The authors are affiliated with the Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University, 415 South St., MS035, Waltham, MA 02454-9110 (e-mail: [email protected]).