Buprenorphine Provision by Early Career Family Physicians

Introduction
The aims of the study were to identify how many primary care physicians are treating opioid addiction with buprenorphine and what their characteristics are. The authors also sought to find out what proportion of providers felt prepared to use a buprenorphine regimen and what proportion of providers is actively utilizing a buprenorphine regimen in their practice.

Methods and Results
In a cross-sectional study design, the authors administered surveys to all 3,051 family medicine residency graduates in 2013. The survey addressed whether their residency program left them feeling prepared to utilize a buprenorphine regimen in the management of opioid addiction in their practice and whether they were actively doing so. The authors achieved an impressive response rate of 67.8%, as 2,069 family medicine physicians responded to the survey.

The authors used a bivariate comparison between outcome and each characteristic listed in Table 1 of their paper. In their multivariate analysis, they found a statistically significant association (p = 0.02) between the preparedness to provide buprenorphine treatment and whether the physician was engaged in research or practice-based research network activities. The group discussed this finding and hypothesized that if some causal relationship does in fact exist between these two variables that it is likely because physicians who participate in research activities are likely to stay on the cutting edge of what research currently suggests to best improve patient outcomes.

The group was surprised to see that physicians who attended residency programs with a federally qualified health center location did not report feeling prepared to utilize buprenorphine in the management of opioid addiction (p = 0.25). Several studies have shown the opioid epidemic to be especially prevalent in rural areas and areas of lower socioeconomic status. Federally qualified health centers (FQHCs) serve these regions and populations that would otherwise not have access to healthcare. As such the group was not surprised to find that there was a strong association (p = 0.01) between whether the physicians' current locations of practice were FQHCs and whether buprenorphine management was a part of their current practice. The group hypothesized that because FQHCs are located in underserved regions, such as rural areas, that have been hit the hardest by the opioid epidemic, the physicians practicing in these regions are more familiar with the management of opioid addiction and consequently more comfortable with using buprenorphine to treat it.

The authors additionally found a strong association (p = 0.01) between the geographic region--Northeast, South, Midwest, and West--of residency training and preparedness and practice implementation of buprenorphine management. Family physicians who trained in the Northeast or the West were more likely to report feeling prepared to use buprenorphine. Additionally, physicians currently practicing in the Northeast and West were more likely to report actively using buprenorphine as a treatment modality (p < 0.01). The group hypothesized that it may be possible these two regions are most affected by the national opioid epidemic, increasing the opioid-dependent patient load physicians must manage in these regions.

Limitations and Group Thoughts
The group was concerned to find a discrepancy between how many family physicians reported feeling prepared to use buprenorphine and how many more were actively prescribing it in the management of opioid addiction. This implies that there are physicians who are using this medication to help their patients when they are not necessarily comfortable in doing so. Additionally, it is possible that buprenorphine is not the most efficacious option on the market. This paper does not address the efficacy of this medication.

There was no data presented on the number or proportion of patients with an opioid addiction problem each physician surveyed was actively treating. It may be possible that only a few physicians are managing most of the opioid-dependent patients in a given area. If only a few physicians in a given area happen to be well trained in utilizing a buprenorphine regimen to treat opioid addiction, then they may absorb a large proportion of the available opioid-dependent patients in their area. This would leave fewer treatable patients for other physicians in that area to manage.

A clear limitation of this study is how subjective the definition of "preparedness" is in this context. What one physician may consider "prepared" may be what another physician considers to be "unprepared." The group does not believe this variable should have been collected in such a binary manner. It would have been more appropriate of the authors to split this variable into several subcategories that may define preparedness to utilize buprenorphine (i.e. dosing details, scheduling regimens, how many opioid-dependent patients they see, etc).

Another limitation of the study was the limited data on what comprised the addiction curricula of these residency programs. Additionally, the group suggested that it may be invalid to draw many conclusions from this study, as the landscape surrounding opioid management has changed significantly since these family medicine physicians completed their residency in 2013. As the opioid crisis has in more recent years reached the forefront of the minds of physicians and the general public, it is likely that addiction management has become a much more prominent feature of family medicine residency curricula across the country.

Competing interests: None declared