Barriers to Primary Care Physicians Prescribing Buprenorphine

In the movie Invictus, the characters of South African president Nelson Mandela and rugby team captain Francois Pienaar meet for the first time. Following years of isolation under Apartheid, the rugby team is a shambles, a demoralized group of mostly white players in a black nation still racially divided. The meeting is awkward yet transformative. Afterwards, Pienaar's fiance asks him what Mandela wanted. Haltingly, he answers, "I think...I think he wants us to win the World Cup."

This moment from cinema was inspired by the true events culminating in South Africa's 1995 Rugby World Cup win, and it comes to me almost every time I witness a patient leaving behind opioid addiction to start buprenorphine.

Before decrying that comparison as ludicrous--certainly any mention of an icon of Mandela's stature all but guarantees hyperbole--consider: patients addicted to heroin or hydrocodone often come to us with their lives in shambles. They have lost their families and friends and spent down their savings. They certainly no longer believe in themselves, much less their ability to take control of their destinies. As physicians, we ask them to take a leap of faith, to trust that a tab that dissolves under their tongue will transform their lives, allowing them to do the impossible. Somehow, most of the time, it does.

When I read "Barriers to Primary Care Physicians Prescribing Buprenorphine," especially when I look at Figure 1, it makes me think that perhaps two of the eight hours of buprenorphine training should be spent watching Invictus. After "Lack of Institutional Support", the biggest divider between prescribers and non-prescribers is "Lack of Confidence". Almost every other concern identified by those physicians who don't prescribe is cited, in equal or higher numbers, by those who do. And I suspect that confidence, and gaining administrative support, go hand-in-hand.

I am one of the lucky ones: my Mandela came in the form of a doctor at my clinic who had already paved the way by becoming the solo buprenorphine provider for a radius of about 150 miles. This physician had enough conviction to carry the institution, without a back-up and pre-telemedicine, and by the time I arrived all I had to do was start seeing patients. How do we inspire others to do better than their best? "Sometimes, I think, it is by using the work of others."

Seeing what I've seen, now, I would now feel confident enough to start a program anywhere. It doesn't take much. A single patient who goes from street addict, to full participation in the roles of breadwinner, spouse and parent, and then maintains that for three years running, is pretty inspiring.

South Africa's 1995 World Cup victory did not erase its history of racial disparities, of course. Neither does taking buprenorphine relieve a patient of the stresses of daily living in the United States. We have the highest income disparity in the developed world and the health problems to match, of which drug addiction is only one. As physicians we must help our patients grapple with these other problems, not to mention that addiction can always resurface. But when prescribing buprenorphine, uniquely in the world of drugs active at the opioid receptor, at least it feels like we're on the same team.

Competing interests: None declared

I totally support Dr. Gianutsos' comments, and thank him for providing more data on the the results of the mandatory buprenorphine training that all his residents receive. As we learn more about the widespread personal and institutional reticence to use this effective evidence-based modality to treat addiction and reduce the epidemic of preventable deaths, it is clear that we need a much broader effort to make physicians - and the insitutions for which many of them work - feel more comfortable about preventing, detecting, and treating addiction in the ambulatory office-based setting.

Opioid addiction is to a large extent an iatrogenic chronic disease. Clinicans have caused a large part of the problem by failing to learn enough about how to treat chronic pain without opioids, which are suitable for long-term use only in special situations such as palliative and end-of-life care. Now that we have caused the problem, we need to address it just as we address other chronic diseases, such as diabetes. First, reduce the onset of new cases by becoming masters at treating chronic pain without causing addiction. And secondly, using buprenorphine - an incredibly effective harm-reduction therapy - as a tool in the primary care mileu.

Competing interests: None declared

Australia, too, has trouble getting family physicians to become Opioid Substitution Therapy prescribers (OSTPs). Less than 2% of medical practitioners in total are registered OSTPs and most of those who train then prescribe to few or no patients (1, 2). To try and develop strategies to provide access to Opioid Substitution Therapy, we identified previously documented barriers to, and facilitating factors for, prescribing this, such as those in Hutchinson et al (3). We then looked at the prevalence and demographic associations of these. We found very high rates of most barriers amongst the 404 respondent family physicians. OSTPs and practitioners who had done relevant training reported lower rates of most barriers (2). The same survey also looked at the use of guideline-endorsed strategies for managing patients on opioid analgesia for chronic non-cancer pain (4). We found these same two groups were more likely to report implementing such strategies. This strengthens those calls for prescribers of opioids for chronic pain to do training in both pain management and addictions (5).

1. Longman C, Lintzeris N, Temple-Smith M, Gilchrist G. Methadone and buprenorphine prescribing patterns of Victorian general practitioners: Their first 5 years after authorisation. Drug and Alcohol Review. July 2011; 30(4):355-9.
2. Holliday S, Magin P, Oldmeadow C, Dunbabin J, Henry J, Attia J, et al. An examination of the influences on New South Wales general practitioners regarding the provision of Opioid Substitution Therapy. Drug and Alcohol review. 2013;32(5):495-503.
3. Hutchinson E, Catlin M, Andrilla CHA, Baldwin L-M, Rosenblatt RA. Barriers to Primary Care Physicians Prescribing Buprenorphine. Annals of Family Medicine. 2014; 12(2):128-33.
4. Holliday S, Magin P, Dunbabin J, Oldmeadow C, Attia J, Henry J, et al. An evaluation of the prescription of opioids for chronic non malignant pain by Australian General Practitioners Pain Medicine. 2013; 14(1):62-74.
5. Lembke A. Why Doctors Prescribe Opioids to Known Opioid Abusers. New England Journal of Medicine. 2012; 367(17):1580-1.

Competing interests: None declared

The article by Hutchinson, et al, (1) helps highlight additional barriers to prescribing buprenorphine. Overall, these are disappointing results considering only 64% of program completers went on to obtain a waiver to prescribe and, of those, only 44% actually prescribed. Ultimately then less than one third (28%) of program completers ever wrote a prescription for buprenorphine.

Our Family Medicine Residency Program trains residents in the use of buprenorphine. For the past four years, our program with 36 residents has required as a condition of graduation that residents obtain a buprenorphine waiver. Despite this we continued to see only one or two residents actually prescribe after graduation. For the past two years we have required that senior residents at the largest of our four clinic sites maintain a panel of patients on buprenorphine. Our residency program is configured as a 6-6-6 at the main site where residents are prescribing, with three additional sites located in independent Community Health Centers, each a 2-2-2 satellite. Senior residents in the 2-2-2 sites are not prescribing due to restrictions by administrators at those clinics that reflect concerns cited in the article. After graduating one cohort of residents using this model we have found that 4 of the 6 residents who had experience prescribing buprenorphine continue to prescribe after graduation. None of the graduates who did not prescribe as a resident are currently prescribing. These are small numbers and we are in the early stages of understanding what it takes to convince physicians that the benefits of prescribing are worth the challenges but we think these are encouraging results.

We are facing an epidemic of opioid misuse (2) and mortality with over 16,000 deaths for the last full year reported. (3) Prescription opioid prescribing has had the most significant impact on the increased mortality rate (4) and family medicine physicians have been responsible for a significant portion of that prescribing.(5) As educators we have a responsibility to society to train physicians who practice evidence-based, safe and effective care. Buprenorphine is unquestionably the best therapy available for the treatment of opiate dependence in primary care. It is incumbent upon us to find effective methods of training physicians to treat opiate dependence (and other substance use disorders). To not provide this training is a disservice to those we train and to society.

Louis Paul Gianutsos, MD, MPH. Program Director, Swedish Family Medicine Residency Cherry Hill. Clinical Associate Professor of Family Medicine, University of Washington. 550 16th Ave, Suite 100, Seattle, WA 98122

1. Hutchinson, et al. Barriers to primary care physicians prescribing buprenorphine Ann Fam Med. 2014 Mar-Apr; 12(2):128-33.
2. Therapeutic use, abuse, and nonmedical use of opioids: a ten-year perspective. Manchikanti L, Fellows B, Ailinani H, Pampati V. Pain Physician. 2010 Sep-Oct; 13(5):401-35.
3. MMWR. Vital Signs: Overdoses of Prescription Opioid Pain Relievers, United States, 1999-2008. November 4, 2011; 60(43):1487-1492.
4. CDC. Vital Signs: Overdoses of Prescription Opioid Pain Relievers--United States, 1999-2008. MMWR 2011; 60:1-6.
5. Volkow ND, McLellan TA, Cotto JH, Karithanom M, Weiss SRB. Characteristics of opioid prescriptions in 2009. JAMA 2011; 305(13):1299-1301.

Competing interests: None declared

Dr. Yu suggests a very interesting way for doctors interested in prescribing buprenorphine for opioid addiction to build experience and confidence: spend a day a week working in a local clinic that offers this service. We have certainly seen this work in our region, and given the tremendous shortage of waivered buprenorphine providers in many areas of the country, I suspect that many such opportunities exist.

And I would emphasize what Dr. Wu eloquently said. These patients are not only like your other patients, they may BE your other patients. Most patients who have become dependent on opioids did so not because they were seeking the dubious thrill of becoming addicted to a substance that came to control their lives, but because some misguided clinician prescribed too many opioids for too long a period. Treating opioid addiction should be just as much a part of the repertoire of the average primary care as treating diabetes. It is certainly easier and more rewarding.

Roger Rosenblatt

Competing interests: None declared

This program provided the much needed training in a very acceptable format, easy to understand, in a short course. For me, receiving this training took one barrier down. Getting started with your own program may be met with other barriers.

As discussed in the article, doctors in solo practice may not have the support staff to do an adequate job of monitoring patients on Buprenorphine. Doctors may not have support from their business partners to start prescribing Buprenorphine in their clinics. There is always the fear of turning your practice into an "addiction clinic." We also have different learning styles. Knowing and understanding the science may not always translate into knowing how to implement the training.

There are opiate replacement therapy (ORT) clinics in many urban areas that already employ counsellors, mental health profesisonals and other support staff. They have policies, standard operating procedures, clinical space and patients waiting to receive treatment.

For doctors who hesitate because they do not have the experience or do not want to "bring in" addicts into their practice, working in an established ORT clinical setting on your "day off" may be a good option, if available. As you become more familiar and comfortable working with patients with addiction, then prescribing in your own practice will follow. You soon realize that opiate addicted patients are just like any of your other patients, many are your patients.

The training takes down one barrier, but actually implementing the training in a private clinic setting can be daunting. Actually working in a well established ORT clinic, with supportive mentoring, may give us the confidence to begin incorporating Buprenorphine use in our own practice.

Competing interests: None declared

Dr. Lessenger presents a graphic example of the role he played in stepping into a personal and family crisis, and prescribing buprenorphine as a stepping-stone to recovery for a homeless heroin addict. On paper, there were other addiction treatment facilities in his community, but the reality was that none of them were available during the relatively brief window when the patient was ready to make the first step towards leaving heroin and its destructive life-style behind.

I liken opioid addiction - whether from prescription drugs or illicit street substances - as a severe, potentially fatal chronic disease like diabetes. When someone with diabetes goes into diabetic coma, he or she needs to be treated with insulin. And, as we know from our own clinical experience, most patients with diabetes will need drug treatment of some sort for the rest of their lives. Opioid addicition is very similar. The rare patient manages to become totally abstinent without the ???crutch??? - or we could call it the harm-reduction therapy - of buprenorphine. But most patients with severe chronic diseases need life-long treatment, and opioid addiction is no different. Physicians can use this medication to save not only individuals, but the families to which they belong. Very few other medications that we use are so effective, or so rewarding for both the physician and the patient.

Competing interests: ?? None declared