Barriers and Facilitators to Primary Care or Human Immunodeficiency Virus Clinics Providing Methadone or Buprenorphine for the Management of Opioid Dependence

Abstract

These clinics serving Medicaid enrollees were more receptive to buprenorphine than methadone treatment. Willingness to provide this care was greater in clinics offering human immunodeficiency virus services, treating more chronic pain, or affiliated with methadone programs. Accessible addiction experts and continuing medical education for training may facilitate adoption of this care.

Barriers to Obtaining Waivers to Prescribe Buprenorphine for Opioid Addiction Treatment Among HIV Physicians

“…18,26,27 Previous studies have shown that knowledge deficits have posed significant barriers to physicians offering opioid addiction treatment. 16,20,28 Inadequate substance abuse education has been documented both at the undergraduate and graduate medical education levels. [29][30][31][32] For example, in 1991-92 only eight U.S. medical schools had required courses in substance abuse treatment.…”

“…Systems-level barriers to substance abuse treatment such as inadequate access to substance abuse expert consultation have similarly been reported in other studies. 16,20 To address this need for physician consultation about buprenorphine, the Substance Abuse and Mental Health Services Administration (SAMHSA) established a web site for clinical questions (the SAMHSA Buprenorphine Clinical Discussion WebBoard at http://bup-webboard.samhsa.gov/login.asp). In addition, the SAMHSA-sponsored Physician Clinical Support System (at http://www.pcssmentor.org/) provides a national network of expert physician mentors who provide consultation to new buprenorphine prescribers.…”

“…15,16,24 Unlike the questions used in previous studies, we modified our questions to specifically addressed buprenorphine. We included the following key variables:…”

“…In addition to obtaining a waiver and DEA X number, other system-level issues that have been reported as barriers to treating substance abuse disorders include inadequate financial reimbursement, limited access to mental health physicians and addiction specialists, medicolegal risks, perceived lack of responsibility for management of addiction disorders, and perceived lack of efficacy of addiction treatment. [15][16][17][18][19] Previous studies have identified important provider-level barriers to prescribing buprenorphine, including lack of education, training, experience, time, support, and patient compliance; high level of patient complexity; and concern about buprenorphine abuse. 14,16,[20][21][22][23] Of the studies that have examined barriers to prescribing buprenorphine, only one has examined barriers experienced specifically by HIV physicians, 21 who may be particularly well positioned to treat opioid dependence in the course of routine medical care.…”

“…[15][16][17][18][19] Previous studies have identified important provider-level barriers to prescribing buprenorphine, including lack of education, training, experience, time, support, and patient compliance; high level of patient complexity; and concern about buprenorphine abuse. 14,16,[20][21][22][23] Of the studies that have examined barriers to prescribing buprenorphine, only one has examined barriers experienced specifically by HIV physicians, 21 who may be particularly well positioned to treat opioid dependence in the course of routine medical care. Sites providing HIV care frequently offer multidisciplinary care, and have supportive services such as social workers, mental health providers, and even substance abuse counselors available.…”