Posts Tagged ‘office-based buprenorphine’

Physicians’ Decisions to Start Buprenorphine: The Key Factors

Just a little “If cats were doctors” humor.





Physicians are less likely to prescribe buprenorphine for patients who use illicit benzodiazepines or drink excessive alcohol, who have a spouse with a drug use disorder, or who have Medicaid as their form of payment.

This information comes from an article in the most recent issue of the Journal of Addiction Medicine (Jan/Feb, 2018). Knudsen et al. describe the findings from their investigation about the decision-making process of buprenorphine prescribers.

The authors sent surveys to 3553 physicians, selected at random from all fifty states and the District of Columbia, who were eligible to prescribe buprenorphine and had at least one patient for whom they prescribed buprenorphine. Of this group, 1174 (about a third) of those physicians responded.

These surveys contained twenty patient vignettes describing the various attributes of a prospective patient, then asked about the physicians’ willingness to prescribe buprenorphine for the patient. This study is based on conjoint analysis, which is a way to quantify the contributions of several factors in a decision-making process.

I read all about this method, and following the statistical analysis process was challenging. I wish I could explain it to my readers, but I can’t.

Seven patient attributes were described in the case vignettes, and were the basis upon which the physicians answered whether they would or would not prescribe buprenorphine from their office. The seven attributes were: type of opioid and route of administration, treatment history, risky substance use (benzodiazepine or alcohol use), co-occurring infections (HIV and Hepatitis C), spousal involvement in treatment and whether the spouse was also a drug user, employment status, and method of payment for the office visits.

Of those seven factors, the use of benzodiazepines (or alcohol) had the largest relative importance for the physicians in deciding if they would prescribe buprenorphine or not. In other words, out of all those seven factors, doctors were more influenced not to prescribe buprenorphine if the patient is also using sedative-type drugs.

That makes sense, and I was relieved to see this sample of physicians recognized the risks of this population of patients with opioid use disorders. We know that alcohol and benzodiazepines do increase the risk of mortality and of relapse in patients on medication-assisted treatment with buprenorphine or methadone.

Maybe the physicians felt the risk of treating such patients with buprenorphine is still less than no treatment at all, but that opioid treatment programs are safer settings to start these patients than an office-based setting. At opioid treatment programs, patients can be dosed with buprenorphine, but watched more closely. They can be evaluated for impairment every day when they come to the facility to get that day’s dose. Office-based physicians should be able to refer to local opioid treatment programs easily, and form close working relationships with these facilities.

The next most important factor determining the physicians’ willingness to prescribe buprenorphine was method of payment. Patients with Medicaid were less likely to be started on buprenorphine in the setting of office-based practices.

This did not surprise me.

Medicaid doesn’t pay physicians well for office visits. Medicaid pays much better for surgeries or procedures…that is, “doing” something…. but not well for thinking and patient management in the office setting.

Recently I tried to see how much Medicaid pays for an office visit for a patient being monitored on buprenorphine. It varies by area, but the going rate seems to be $40 to $45. Considering the visit takes about 15-20 minutes, which doesn’t count time spent coordinating care or meeting Medicaid paperwork requirements, that’s not great reimbursement. I don’t know if a practice could break even if they saw only Medicaid patients, unless they saw a high volume, and that’s no fun for patient or doctor.

This study underlines the importance of raising payments to physicians for seeing Medicaid patients, if you want primary care physicians to prescribe buprenorphine from an office setting.

Also, something must be done about eliminating the byzantine Medicaid requirements. It’s altogether too hard to become certified to accept Medicaid, so some doctors don’t bother with it.

The third most important factor was whether a prospective patient’s spouse was going to be involved in the patient’s care, and whether that spouse had an addiction issue too.

I completely get that idea. When I’m admitting a patient and they tell me they live with a significant other who is still using illicit opioids, I worry. Not only could the S.O.’s use of drugs be a trigger for relapse for my new patient, but also that might be at temptation to give some of his dose to the S.O.

We know from research that social contacts influence whether people take drugs or not. Having a stable, non-drug using spouse is a good prognostic sign.

The four other factors didn’t seem to affect whether this group of buprenorphine physicians would start buprenorphine or not.

HIV or Hep C status didn’t matter, and that’s a good thing. Patients with these infections should be able to access treatment.

Surprisingly, the type of opioid used and the route of administration didn’t matter very much. I would have thought that physicians may have considered heroin users higher risk patients than prescription opioid users, but that wasn’t the case. I was surprised that a history of intravenous use didn’t make prescribers hesitate.

In an office-based setting, I think the physician (or physician extender) should ask specifically if the prospective patient has ever injected buprenorphine. If the answer is “yes,” an opioid treatment program, with observed daily dosing until stable, is probably a safer and better choice for these patients. I ask my new patients, and most people who use intravenously have also injected buprenorphine.

Previous treatment episodes didn’t influence physicians’ decisions to prescribe buprenorphine, and neither did employment status.

I would have though physicians would be a little less inclined to start prescribing for a patient who is unemployed, but that wasn’t the case in this study.

I thought this was an interesting article, and showed some insight into how physicians who prescribe buprenorphine decide for whom they will start treatment, and which factors are deterrents to starting a new patient in treatment.