Hannah K. Knudsen, Ph.D.
The increasing rates of opioid use disorder (OUD) and rapid escalation in opioid overdose deaths in the United States (Han et al., 2015; Rudd et al., 2016; Martins et al., 2017) have renewed efforts to expand access to medications for OUD treatment. Buprenorphine is an effective OUD treatment that can be delivered in medical offices and specialty substance use disorder (SUD) programs (Fudula et al., 2003; Fiellin et al., 2008). Because buprenorphine can be delivered in a wider range of settings, more patients are currently being treated with buprenorphine than methadone (Jones et al., 2015).
In general, there was strong endorsement of the benefits of psychosocial supports. Nearly all providers agreed that patients would benefit from counseling during buprenorphine treatment, and most providers agreed that 12-step group involvement would be beneficial for patients.
Clinical practice guidelines recommend that psychosocial supports, such as counseling and case management, be delivered in conjunction with buprenorphine (American Society of Addiction Medicine, 2015; Substance Abuse and Mental Health Services Administration, 2018). However, little is known about the attitudes of buprenorphine providers toward psychosocial interventions, the frequency of their contact with patients, and the percentage of patients who receive counseling. Furthermore, providers working in specialty SUD programs and those in medical settings may vary in their delivery of psychosocial supports. Counseling has long represented the core technology of specialty SUD programs (White, 1998), so buprenorphine providers in such settings may be better able to connect patients to psychosocial supports.
Attitudes and practices related to psychosocial supports were analyzed using data from a national random sample of 1,174 civilian providers currently treating patients with buprenorphine. Mailed surveys were used to collect the data (response rate = 33.0%). A full description of the study methods can be found in Knudsen et al. (2018). One striking aspect of the sample was that the majority of providers (81.7%) delivered buprenorphine in medical settings. Only 18.3% of providers delivered buprenorphine in a specialty SUD program (i.e., licensed opioid treatment program or non-OTP specialty program).
In general, there was strong endorsement of the benefits of psychosocial supports. Nearly all providers agreed that patients would benefit from counseling during buprenorphine treatment, and most providers agreed that 12-step group involvement would be beneficial for patients. The value of group counseling was more strongly endorsed by providers working in specialty SUD treatment settings than those working in medical settings (see Table 1). Providers in specialty SUD treatment settings perceived more sufficient numbers of counselors being available in the local area than those in medical settings.
Table 1: Providers’ attitudes toward psychosocial supports by delivery of buprenorphine in specialty treatment programs
|
|
Providers in Specialty SUD Treatment |
Providers in Medical Settings |
|
Most patients would benefit from group counseling during buprenorphine treatment. |
4.44 (0.76) |
4.29 (0.88) |
|
Most patients would benefit from being involved in 12-step groups during buprenorphine treatment. |
4.13 (0.91) |
4.08 (0.91) |
|
There are sufficient numbers of professional counselors in my area who are well suited to provide counseling to buprenorphine patients.a |
3.02 (1.23) |
2.83 (1.21) |
Notes. Response items for each item were 1=strongly disagree, 2=disagree, 3=neither agree nor disagree, 4=agree, and 5=strongly agree. Specialty treatment providers and non-specialty treatment providers were compared using t-tests.
aSignificant difference by specialty treatment setting, p<.05.
Office visits with the prescribing physician provide the opportunity to assess clinical progress, deliver brief counseling, and reinforce treatment goals. Providers were asked how frequently they saw new buprenorphine patients (i.e., during the first 60 days of treatment), clinically stable patients (i.e., were abstinent from opioids) who had been in treatment for >60 days, and clinically unstable patients who continued to use opioids after >60 days of treatment. For new patients, providers working in specialty SUD treatment settings were more likely to report weekly visits and less likely to report monthly visits than providers working in medical settings (see Table 2). After the first two months of treatment, clinically stable patients were typically seen less frequently, and there was no difference in visit frequency by setting (Table 3). However, for clinically unstable patients who continued to use opioids, providers working in specialty SUD treatment programs were more likely to increase the frequency of visits than providers working in medical settings.
Table 2: Frequency of buprenorphine office visits for new patients with the prescribing physician
|
|
New patients (first 60 days of treatment)a |
|
|
|
Providers in Specialty SUD Treatment |
Providers in Medical Settings |
|
Once a week |
38.1% |
24.0% |
|
Every other week |
37.1% |
35.3% |
|
Once a month |
24.9% |
40.7% |
Notes. The “Once a week” row also includes “More than once a week” responses. The “Once a month” row also includes “Less than once a month” responses. Specialty SUD treatment providers and non-specialty providers were compared using chi-square tests.
aSignificant difference by specialty treatment setting, p<.001.
Table 3: Frequency of buprenorphine office visits after the first 60 days of treatment with the prescribing physician
|
|
Stable patients (after 60 days of treatment) |
Unstable patients (after 60 days of treatment)a |
||
|
|
Providers in Specialty SUD Treatment |
Providers in Medical Settings |
Providers in Specialty SUD Treatment |
Providers in Medical Settings |
|
Every other week (or more frequently) |
19.7% |
14.5% |
50.0% |
36.2% |
|
Monthly |
71.9% |
73.4% |
31.9% |
40.1% |
|
Every two months (or less frequently) |
8.4% |
12.1% |
13.7% |
17.5% |
|
Patient would be discharged and no longer seen |
n/a |
n/a |
4.4% |
6.1% |
Notes. The “Every other week” row also includes “every week” responses. The “every two months” row also includes “Less than every two months” responses. Specialty SUD treatment providers and non-specialty providers were compared using chi-square tests.
aSignificant difference by specialty treatment setting, p=.004.
Buprenorphine providers were asked about the percentage of past-year patients who received counseling from themselves (i.e., the prescribing physician), received counseling from others within the practice/organization where the physician worked, received counseling from external providers, and did not receive any counseling. Delivering buprenorphine treatment in specialty SUD treatment settings was significantly associated with three of the four counseling measures (Table 4). There was no difference by SUD treatment setting in the percentage counseled by the provider. Compared to providers in medical settings, those practicing in specialty SUD treatment settings reported a significantly greater percentage of patients received counseling from other providers within the practice. Conversely, a smaller percentage of patients received counseling from external providers when the provider delivered buprenorphine in a specialty SUD treatment setting. Furthermore, providers in specialty SUD treatment settings reported a significantly small percentage of patients received no counseling, relative to providers in medical settings.
Table 4: Percentages of buprenorphine patients who received counseling in the past year by specialty treatment setting, medical specialty, and payment type
| Percentage of patients who… |
Providers in Specialty SUD Treatment |
Providers in Medical Setting |
|
Received counseling from the prescriber |
51.9 (44.5) |
53.9 (43.8) |
|
Received counseling from providers in the respondent’s practicea |
62.9 (41.0) |
32.1 (38.9) |
|
Received counseling from external providersa |
27.0 (29.8) |
41.8 (32.8) |
|
Did not receive any psychosocial counselinga |
6.7 (14.5) |
13.6 (20.9) |
aSignificant difference between prescribers in specialty treatment and medical treatment settings, p<.001.
These data from a national sample of buprenorphine-prescribing physicians revealed that the majority of providers are supportive of psychosocial interventions and that majority of their patients receive some form of counseling. However, providers working in specialty SUD treatment reported a number of differences with regard to the frequency of office visits and receipt of counseling when compared to providers working in medical settings. Taken together, these data demonstrate that there are varying models of delivering buprenorphine treatment in the US. Future research should consider whether such differences in service delivery are influenced by variation in patients’ needs (e.g., greater severity of OUD and other co-occurring conditions among individuals entering specialty SUD treatment) as well as whether clinical outcomes are impacted by varying models of care.
American Society of Addiction Medicine. The ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioids Chevy Chase, MD: ASAM; 2015.
Fiellin DA, Moore BA, Sullivan LE, et al. Long-term treatment with buprenorphine/naloxone in primary care: Results at 2-5 years. Am J Addict 2008;17:116-120.
Fudula PJ, Bridge TP, Herbert S, et al. Office-based treatment of opiate addiction with a sublingual-tablet formulation of buprenorphine and naloxone. N Engl J Med 2003;349:949-958.
Han B, Compton WM, Jones CM, et al. Nonmedical Prescription Opioid Use and Use Disorders Among Adults Aged 18 Through 64 Years in the United States, 2003-2013. Jama 2015;314:1468-1478.
Jones CM, Campopiano M, Baldwin G, et al. National and state treatment need and capacity for opioid agonist medication-assisted treatment. Am J Public Health 2015;105:e55-e63.
Knudsen HK, Lofwall MR, Walsh SL, et al. Physicians’ decision-making when implementing buprenorphine with new patients: Conjoint analyses in a cohort of current prescribers. J Addict Med2018;12:
Martins SS, Sarvet A, Santaella-Tenorio J, et al. Changes in US lifetime heroin use and heroin use disorder: Prevalence From the 2001-2002 to 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions. JAMA Psychiatry 2017;74:445-455.
Rudd RA, Aleshire N, Zibbell JE, et al. Increases in drug and opioid overdose deaths - United States, 2000-2014. MMWR Morb Mortal Wkly Rep 2016;64:1378-1382.
Substance Abuse and Mental Health Services Administration. Medications for opioid use disorder (Treatment Improvement Protocol (TIP) Series 63). Rockville, MD: SAMHSA; 2018.
White W. Slaying the dragon: The history of addiction treatment and recovery in America. Bloomington, IL: Chestnut Health Systems; 1998.
Hannah K. Knudsen is an Associate Professor in the Department of Behavioral Science and a faculty member of the Center on Drug and Alcohol Research at the University of Kentucky. Drawing upon training in sociology and implementation science, Dr. Knudsen’s research focuses on the diffusion of evidence-based practices in substance use disorder (SUD) treatment settings. She is currently leading a research project funded by the National Institute on Drug Abuse (NIDA) on the availability and quality of buprenorphine treatment for opioid use disorder. Dr. Knudsen’s prior studies, through support from NIDA and the Robert Wood Johnson Foundation, have addressed the implementation of smoking cessation services in addiction treatment organizations, the adoption of pharmacotherapies to treat alcohol and opioid use disorders, and the quality of SUD treatment for adolescents. In addition to her research, she is Editor-in-Chief of the Journal of Substance Abuse Treatment.