With millions of Americans suffering from opioid use disorder, many tools are needed to tackle the opioid epidemic.
But these tools can only help if they are actually being used.
A new study published last month in the Journal of Substance Abuse Treatment concluded that physicians are underprescribing buprenorphine/naloxone (Suboxone), a medication for treating opioid use disorder.
Buprenorphine activates the same receptors in the body as prescription opioids, morphine, and other opioids.
Its effect, though, is less intense and longer lasting, which advocates say can suppress withdrawal symptoms with less risk of being abused.
Treatment below capacity
Last year, researchers from Johns Hopkins School of Medicine surveyed 558 physicians by email.
They said only 44 percent of doctors who had secured a waiver to prescribe buprenorphine were doing so at full capacity — 30 patients in the first year after receiving a waiver, and up to 275 patients per year afterward.
The most common reasons physicians gave for not prescribing at capacity were they lacked time to see more patients with opioid addictions, and they were not being reimbursed adequately by insurance companies for these visits.
Researchers also found that 54 percent of doctors with waivers who were not prescribing to capacity said “nothing would increase their willingness” to do so.
Doctors who responded were also concerned that patients would give or sell the Suboxone to other people and that they would be “inundated” with patient requests for Suboxone.
Physicians in certain fields were more likely to prescribe to capacity — the highest rates were among addiction medicine specialists (40 percent) and psychiatrists (23 percent). Only 17 percent of family medicine physicians prescribed Suboxone to capacity.
“Though it was widely believed that allowing physicians to prescribe this drug in a primary care setting would increase the number of patients receiving treatment, the number of physicians adopting this therapy has not kept pace with the magnitude of the opioid epidemic,” Andrew Huhn, PhD, a study author and post-doctoral fellow at the Johns Hopkins University School of Medicine, said in a press release.
Among the 74 doctors without a waiver, the most common reasons for not applying for one were not wanting to be inundated with requests for Suboxone, and concerns about patients selling the drug.
About a third of nonwaivered doctors said nothing would increase their willingness to obtain one.
More addiction education needed
The study shows that just convincing physicians to obtain a waiver to prescribe buprenorphine may not be enough to increase patient access to this potentially life-saving medication.
Dr. Ako Jacintho, director of addiction medicine at HealthRIGHT 360, a community health provider in San Francisco, identified many of the barriers to increasing the prescribing of buprenorphine by doctors in primary care clinics.
A key one is education.
Many primary care doctors currently practicing in the United States never learned about addiction in medical school or during their residencies.
“You’re talking about a generation of physicians and other medical providers today that were never educated and trained to treat addiction,” Jacintho told Healthline.
If a patient came to them with diabetes or high cholesterol, primary care doctors wouldn’t hesitate to help them with medication or other treatments.
But traditionally, if someone with an opioid use disorder walked into their office, a doctor might instead refer the patient to a psychiatrist or a program like Narcotics Anonymous.
A law enacted in 2000 was supposed to change that by allowing doctors to prescribe buprenorphine in their practice after receiving a waiver from the federal government. That waiver includes completing eight hours of required training.
Eight hours may not be enough to encourage them to actually prescribe buprenorphine. However, doctors can always receive more training in addiction medicine.
“To inject a certification into the current population of clinicians and say, ‘Here, now you have the ability to do it, so go do it,’ is not going to work,” said Jacintho. “They don’t feel comfortable doing it.”
One reason is that treating addiction with buprenorphine is not always straightforward.
“There are too many nuances to it,” said Jacintho.
A person who has been off opioids for two months and is having cravings might need a different treatment plan and a different starting dose of buprenorphine than someone who is currently using heroin or nonprescription opioid pain medications.
Some of this can be addressed by adding addiction training to medical school and residency programs, or requiring it as part of doctors’ continuing medical education.
But doctors will also need to work alongside others with more experience in treating addiction.
“Clinicians need a mentorship,” said Jacintho. “They need at least five patients. They need someone to hold their hand with five to 10 patients.”
Reimbursing for addiction treatment
In the new study, physicians who responded to the survey also were concerned about low reimbursement by insurance companies for treating patients with opioid addictions.
With good reason.
“Induction with Suboxone or buprenorphine is a more complex office visit than a standard office visit — it takes longer, patients have to be watched and monitored, etc.,” Dr. Doug Nemecek, chief medical officer for behavioral health at the Cigna health insurance company, told Healthline.
Starting someone on Suboxone also requires many more visits to the doctor in the beginning the treatment, compared with other illnesses.
Jacintho said that after an initial visit, a patient might come back in two or three days so the doctor can make sure the dose is correct. Then there’s another visit five days later to “tweak the dose.”
Patients would then have several more visits over the next two months as the doctor checks in with them and gets patients into a behavioral health program like individual or group counseling.
On top of that, there is the cost of routine urine drug screens and counseling referrals for patients with an opioid addiction.
Some insurers have been reluctant to cover all these costs.
“Who is going to reimburse for seven visits or eight visits within the course of eight weeks?” said Jacintho. “That’s huge.”
One insurer stepping up is Cigna.
Cigna has been “actively engaged with primary care physicians — as well as addiction physicians and psychiatrists — in promoting evidence-based treatment for opioid use disorders,” said Nemecek.
This includes medication-assisted treatment with Suboxone.
The company also offers physicians in its network “increased reimbursement for what we know is a more complex office visit,” said Nemecek. “This allows them to feel comfortable taking on patients that they want to treat.”
The company’s efforts have paid off.
“We saw great uptake by physicians who were interested in participating in our network and providing buprenorphine at that time,” said Nemecek.
This approach is part of the company’s overall efforts to address the opioid epidemic.
Over the past year, the company has already seen a 12 percent drop in use of prescription opioids by its insurance customers — halfway to its goal of a 25 percent reduction by 2019.
Finding addiction treatment champions
Even if a primary care physician would like to treat more patients with opioid addiction, it may not work within their practice.
With seven or eight visits within the first two months for a person with an opioid addiction, a doctor with a full practice may not be able to fit in more than a few patients with addiction.
HealthRight 360 has found a way that works for its community health centers.
“Within our primary care clinic, we’ve created an addiction champion who sees more of our patients who come in with addiction, gets them stable, and then transfers them to general primary care once they’re stable,” said Jacintho.
With board certifications in family medicine and addiction medicine, Jacintho is one of those addiction champions. He treats people with addiction to alcohol, opiates, stimulants, and other drugs.
The other members of the primary care team take care of patients’ other needs, such as treating diabetes or high blood pressure.
By focusing mainly on treating addiction, Jacintho is able to keep HealthRight 360’s doors open to people needing help.
“I have more space for other patients who are coming in with their addiction disorders,” said Jacintho. “Traditionally these people have been pushed away.”