Abstract
BACKGROUND
Despite the availability and demonstrated effectiveness of office-based buprenorphine maintenance treatment (BMT), the systematic examination of physicians’ attitudes towards this new medical practice has been largely neglected.
OBJECTIVE
To identify facilitators and barriers to the potential or actual implementation of BMT by office-based medical providers.
DESIGN
Qualitative study using individual and group semi-structured interviews.
PARTICIPANTS
Twenty-three practicing office-based physicians in New England.
APPROACH
Interviews were audiotaped, transcribed, and entered into a qualitative software program. The transcripts were thematically coded using the constant comparative method by a multidisciplinary team.
RESULTS
Eighty percent of the physicians were white; 55% were women. The mean number of years since graduating medical school was 14 (SD = 10). The primary areas of clinical specialization were internal medicine (50%), infectious disease (20%), and addiction medicine (15%). Physicians identified physician, patient, and logistical factors that would either facilitate or serve as a barrier to their integration of BMT into clinical practice. Physician facilitators included promoting continuity of patient care, positive perceptions of BMT, and viewing BMT as a positive alternative to methadone maintenance. Physician barriers included competing activities, lack of interest, and lack of expertise in addiction treatment. Physicians’ perceptions of patient-related barriers included concerns about confidentiality and cost, and low motivation for treatment. Perceived logistical barriers included lack of remuneration for BMT, limited ancillary support for physicians, not enough time, and a perceived low prevalence of opioid dependence in physicians’ practices.
CONCLUSIONS
Addressing physicians’ perceptions of facilitators and barriers to BMT is crucial to supporting the further expansion of BMT into primary care and office-based practices.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (text revision). 4th edn. Washington, DC: Author; 2000.
Sullivan LE, Chawarski M, O’Connor PG, Schottenfeld RS, Fiellin DA. The practice of office-based buprenorphine treatment of opioid dependence: is it associated with new patients entering into treatment? Drug Alcohol Depend. 2005;79(1):113–6.
Becker WC, Sullivan LE, Tetrault JM, Desai RA, Fiellin DA. Non-medical use, abuse and dependence on prescription opioids among US adults: psychiatric, medical and substance use correlates. Drug Alcohol Depend. 2007; 94(1):38–47.
Martell BA, O’Connor PG, Kerns RD, Becker WC, Morales KH, Kosten TR, Fiellin DA. Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med. 2007;146(2):116.
Fiellin DA, O’Connor PG. Office-based treatment of opioid-dependent patients. N Engl J Med. 2002;347(11):817–23.
Sullivan LE, Moore BA, Chawarski MC, Pantalon MV, Barry D, O’Connor PG, Schottenfeld RS, Fiellin DA. Buprenorphine/naloxone treatment in primary care is associated with decreased human immunodeficiency virus risk behaviors. J Subst Abuse Treat. 2008;35(1)87–92.
O’Connor PG, Fiellin DA. Pharmacologic treatment of heroin-dependent patients. Ann Intern Med. 2000;133(1):40–54.
Sullivan LE, Metzger DS, Fudala PJ, Fiellin DA. Decreasing international HIV transmission: the role of expanding access to opioid agonist therapies for injection drug users. Addiction. 2005;100(2):150–8.
NIH Consensus Panel. Effective medical treatment of opiate addiction. National Consensus Development Panel of Effective Medical Treatment of Opiate Addiction. 1998;280:1936–43.
Office of National Drug Control Policy. Policy Paper –Opioid Agonist Treatment. Washington, D.C.: Executive Office of the President, Office of National Drug Control Policy; March, 1999.
Rettig RA, Yarmolinsky A, eds. Federal Regulation of Methadone Treatment. Washington, DC: Institute of Medicine, National Academy Press; 1995.
Brady KT. Medical treatment of opiate dependence: expanding treatment options. Am J Psych. 2007;164(5):702–4.
Fiellin DA. The first 3 years of buprenorphine in the United States: experience to date and future directions. J Addict Medicine. 2007;1(2):62–7.
Fiellin D, Pantalon MV, Chawarski M. Buprenorphine maintenance in primary care: a randomized controlled trial of counseling conditions and medication dispensing. N Engl J Med. 2006;355:365–74.
Fiellin DA, O’Connor PG, Chawarski M, Pakes JP, Pantalon MV, Schottenfeld RS. Methadone maintenance in primary care a randomized controlled trial. JAMA. 2001;286(14):1724–31.
Fiellin DA, Pantalon MV, Pakes JP, O’Connor PG, Chawarksi M, Schottenfeld RS. Treatment of heroin dependence with buprenorphine in primary care. Am J Drug Alcohol Abuse. 2002;28(2):231–42.
O’Connor PG, Oliveto AH, Shi JM, Triffleman EG, Carroll KM, Kosten TR, Rounsaville BJ, Pakes JA, Schottenfeld RS. A randomized trial of buprenorphine maintenance for heroin dependence in a primary care clinic for substance users versus a methadone clinic. Am J Med. 1998;105(2):100–05.
Glaser BG, Strauss AL. The Discovery of Grounded Theory: Strategies for Qualitative Research. New York: Aldine Publishing Company; 1967.
Duszynski KR, Nieto F, Valente CM. Reported practices, attitudes, and confidence levels of primary care physicians regarding patients who abuse alcohol and other drugs. Md Med J. 1995;44:439–46.
McMurphy S, Shea J, Switzer J, Turner BJ. Clinic-based treatment for opioid dependence: a qualitative inquiry. Am J Health Behav. 2006;30(5):544–54.
Miller NS, Sheppard LM, Colenda CC, Magen J. Why physicians are unprepared to treat patients who have alcohol-and drug-related disorders. Acad Med. 2001;7:410–8.
Karam-Hage M, Nerenberg L, Brower KJ. Modifying residents’ professional attitudes about substance abuse treatment and training. Am J Addict. 2001;10(1):40–7.
Parish SJ, Ramaswamy M, Stein MR, Kachur EK, Arnsten JH. Teaching about substance abuse with objective structured clinical exams. J Gen Intern Med. 2006;21(5):453–9.
Cunningham CO, Kunins HV, Roose RJ, Elam RT, Sohler NL. Barriers to obtaining waivers to prescribe buprenorphine for opioid addiction treatment among HIV physicians. J Gen Intern Med. 2007;22(9):1325–29.
Egan J, Netherland J, Finkelstein R, Fiellin D. Facilitating buprenorphine implementation: The physician Clinical Support System. College on Problems of Drug Dependence Annual Meeting, June 18, 2006, Scottsdale, Arizona.
Netherland J, Botsko M, Egan J, Saxon A, Cunningham CO, Finkelstein R, Gourevitch MN, Renner J, Sohler NL, Sullivan LE, Weiss L, Fiellin D, (in press). Factors affecting willingness to provide buprenorphine treatment. J Subst Abuse Treat.
McCance-Katz EF. Office-based buprenorphine treatment for opioid-dependent patients. Harv Rev Psychiatry. 2004;12(6):321–38.
Barry DT, Moore BA, Pantalon MV, Chawarski MC, Sullivan LE, O’Connor PG, Schottenfeld RS, Fiellin DA. Patient satisfaction with primary care office-based buprenorphine/naloxone treatment. J Gen Intern Med. 2007;22(2):242–5.
Becker WC, Fiellin DA. Provider satisfaction with office-based treatment of opioid dependence: a systematic review. Subst Abuse. 2006;26(1):15–22.
Chou WC, Tinetti ME, King MB, Irwin K, Fortinsky RH. Perceptions of physicians on the barriers and facilitators to integrating fall risk evaluation and management into practice. J Gen Intern Med. 2006;212117–122.
Yarnall KSH, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am Public Health Assoc; 2003;93(4):635–641.
McPherson TL, Hersch RK. Brief substance use screening instruments for primary care settings a review. J Subst Abuse Treat. 2000;18(2):193–202.
Acknowledgments
The primary support for this project was a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar Award to Dr. Fiellin. Dr. Sullivan was supported by the National Institute on Drug Abuse (NIDA) Physician Scientist Award (K12 DA00167). Dr. Sullivan is currently a Robert Wood Johnson Foundation Physician Faculty Scholar. This work was also supported by grants from NIDA to Dr. Barry (K23 DA024050-01), Dr. Schottenfeld (K24 DA000445-03 and R01 DA009803-07), and Dr. Fiellin (RO1 DA020576-01, RO1 DA019511-03).
Conflict of Interest
None disclosed.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Barry, D.T., Irwin, K.S., Jones, E.S. et al. Integrating Buprenorphine Treatment into Office-based Practice: a Qualitative Study. J GEN INTERN MED 24, 218–225 (2009). https://doi.org/10.1007/s11606-008-0881-9
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11606-008-0881-9