Financing Buprenorphine Treatment in Primary Care: A Microsimulation Model

As a student who has taken the waiver training for medication assisted treatment and awaits the ability to use it in practice, I am delighted to see this interesting work presented in the journal, and I want to take the opportunity to remind readers of the humanistic concerns interwoven into the financial ones.[1] As the opioid epidemic continues, access to buprenorphine is a significant unmet community need, and family physicians are well-positioned to fill the gap.[2] It also makes sense that many family physicians within a fragmented healthcare landscape may be uncertain whether or how to incorporate MAT in their practices. As the authors admit, more work must be done, but for now, modeling practice costs and revenues and identifying practice targets for profitability seems to be an excellent step to demonstrate feasibility of MAT implementation across practice styles. I am hopeful that the authors’ work should encourage more family physicians to begin providing MAT.

It is also essential to address attitudes about acceptability as we address barriers to MAT in training, clinician support, or financial solvency. Alongside more tangible hurdles, stigma is a significant workforce barrier to buprenorphine treatment and one that is likely underreported.[3] Stigma against people who use drugs and against MAT continues to block progress in efforts to control the opioid epidemic, and in the AMA Journal of Ethics, the Surgeon General and the Director of the National Institute on Drug Abuse recently outlined an ethical obligation to “recognize addiction not as a moral failing but as a treatable disease.”[4]

Not only providing buprenorphine – but addressing stigma that stands between communities and evidence-based treatment – sounds like a job for which family physicians should be uniquely suited given connections built with patients, their families, and communities. With this in mind, some have recognized that “doing ethics” in family medicine looks different from other fields because of the physician’s relationship with patients.[5] So as studies like this pave the way for the average family physician to implement evidence-based treatment for her community, it seems essential to include a reminder of the ethical significance of taking steps toward MAT implementation. In providing buprenorphine in their clinics, physicians can acknowledge addiction as a disease and model this compassion for patients and fellow physicians. Those already doing this work in family medicine can help us reimagine medicine’s role in the opioid epidemic, and their stories can invite compassion in the place of stigma.[6]

1. Fried JE, Basu S, Phillips RS, Landon BE. Financing buprenorphine treatment in primary care: A microsimulation model. Ann Fam Med 2020;18(6):535-544
2. Middleton JL. How family physicians can combat the opioid epidemic. Am Fam Physician 2017;96(6):357-358.
3. Haffajee RL, Bohnert ASB, Lagisetty PA. Policy pathways to address provider workforce barriers to buprenorphine treatment. Am J Prev Med. 2018;54(6 Suppl 3):S230-S242.
4. Adams JM, Volkow ND. Ethical imperatives to overcome stigma against people with substance use disorders. AMA J Ethics 2020;22(8):E702-708.
5. Tunzi M, Ventres W. Family medicine ethics: An integrative approach. Fam Med 2018;50(8):583-588.
6. See Gastala N. Denial: The greatest barrier to the opioid epidemic. Ann Fam Med 2017;15(4):372-374.