Volume 4, Issue 3

Access to Buprenorphine Treatment: Complexities across the National Landscape
Hannah Knudsen, PhD
University of Kentucky

I read with great interest the interview between Dr. Paul Roman from the University of Georgia and Dr. Jeffrey Junig, who is a psychiatrist in private practice in Wisconsin. As I read the transcript, there were many points of intersection with research that our team at the University of Kentucky is conducting on the impact of the Affordable Care Act on buprenorphine treatment in the US through a grant supported by the National Institute on Drug Abuse (R33DA035641).

Our mixed methods study collected qualitative interview data in 2013 from 21 buprenorphine-prescribing physicians who have served as expert mentors to support the implementation of buprenorphine by other physicians. Currently, we are recruiting a large nationally representative sample of prescribers for a survey, and we are also examining state-level measures of treatment availability and utilization.

A striking finding of our research is how variable the availability of buprenorphine treatment is across the country. Shortages of prescribers and challenges with treatment access were noted by many of our interview participants. Several participants noted the many physicians, themselves included, are usually at the 100 patient limit. These multiple challenges were described by one participant: “You can’t get into treatment in a lot of places. That’s number one. I guess I’ll sum it up in one word; it’s access. Okay, there’s not enough Suboxone doctors to go around; if there are Suboxone doctors, they won’t accept Medicaid; they only want cash. Once you are in a Suboxone program and then the person is having trouble and you want to refer them to an IOP [intensive outpatient program], you often can’t get them into a local IOP for again, same access reasons, long waiting lists, those kind of things.” This participant notes intersecting challenges—an insufficient number of prescribers coupled with limits to treatment access that may occur when some physicians will not accept insurance for payment.

The issue of the number of waivered physicians is a key facet of our current study. We are monitoring the number of physicians who hold the X-license to prescribe buprenorphine at the state-level. One interesting finding thus far is that there has been significant growth in the number of waivered physicians since we began our study. Over a 13-month period, the total number of waivered physicians in the US has increased by more than 2,200 physicians, which represents about a 10% increase. This rate of increase outpaces the growth in the overall number of physicians in the US over the same period. At the state-level, the average number of waivered physicians has grown from about 442 to 487 physicians, which is a statistically significant increase; even when the numbers are adjusted for population (i.e., the number of waivered physicians per 100,000 residents in the state), the difference is still significant.

We have also begun to look at the distribution of waivered physicians across the country. At the end of 2013, the average state had 8 waivered physicians for every 100,000 residents. However, the range was quite large for this measure, with Nebraska having just 2 physicians per 100,000 residents and Vermont having almost 28 waivered physicians per 100,000 residents. Dr. Junig’s home state of Wisconsin had only 5.7 waivered physicians per 100,000 residents. A large portion of the state-level variation in the numbers of waivered physicians can be attributed to significantly greater numbers of waivered physicians in Northeastern states, relative to the rest of the country.

But the number and distribution of waivered physicians is only one aspect of the challenges of treatment access and availability. Dr. Junig notes that the 100 patient limit is a substantial barrier for patients, and that perspective was echoed by some of the participants in our qualitative interviews. As described by one qualitative participant: “The numbers of individuals that are seeking help versus the people that can provide them help—there’s a disconnect between the two…I don’t know of one of them that’s practicing …and that doesn’t have a waiting list.…I’m in the process of tapering people and some of them finally, they may, they have their last visit. But until one of those things happens, you know you can’t bring another patient in without jeopardizing the possibility of sanction from the licensure board or the Drug Enforcement Administration or other entities…I’m on about a 30-35 day wait list. I’ve got colleagues that have a 90 day wait list.”

However, other participants noted that waiting lists were not an issue in their area. One participant said, “But most providers are not overly swamped. I mean, there’s some people who are at their limits, right--you know their 100 patient limits pretty consistently--but most aren’t.” The unequal distribution of waivered physician across different parts of the country may be one influence on physicians’ perspectives about how much the 100 patient limit is a barrier to care.

It may also be useful to note that only a minority of waivered physicians actually hold a waiver to treat 100 patients. In December 2013, just 6,851 physicians were waivered for 100 patients, representing about 29% of all physicians who hold the buprenorphine waiver. This statistic does not diminish the challenges faced by physicians who are allowed to treat 100 patients and yet still have waiting lists, but does suggest that part of the conversation about increasing treatment access may need to address the limited number of physicians who seek the 100 patient waiver.

From my perspective, buprenorphine is a lifesaving medication and as such, I share Dr. Junig’s concerns about patients being able to access this treatment. I hope that our research can inform some of discussion about treatment access, particularly the data regarding the unevenness of the distribution of waivered physicians across different parts of the country and the relatively few physicians who can actually treat 100 patients. The methods of payment that prescribers will accept from patients further complicates these questions about access.

The extent to which prescribers will not accept Medicaid or private insurance poses an additional barrier for patients. From a policy perspective, the prevalence of cash-only practices where insurance is not accepted may limit the extent to which health reform can actually improve patients’ access to care. Our large national survey of current prescribers will help to elucidate the relationships between states’ implementation of the Affordable Care Act, how physicians structure the payment aspects of buprenorphine services, and the numbers of patients receiving this lifesaving treatment. We are excited that our research can be part of this ongoing dialogue about how to increase buprenorphine treatment access and treatment quality.

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