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 Since 2000, physicians have been able to seek waivers from the
federal government to prescribe buprenorphine, seen as an
alternative to methadone dispensed at federally approved clinics,
said study co-author Ryan McBain of the RAND Corporation in Boston.
More recently, nurse practitioners and physician assistants have
been allowed to seek waivers, too, helping to drive a four-fold
increase in the number of clinicians nationwide able to prescribe
buprenorphine.
From 2007 to 2017, the number of providers with waivers to prescribe
buprenorphine climbed from 3.8 for every 100,000 people in the
population to 17.3 per 100,000, researchers report in Annals of
Internal medicine. Still, less than 10% of primary care providers
could prescribe the drug by the end of the study period.
"Over the same period, opioid deaths skyrocketed from about 16,500
per year to 46,000 per year," McBain said by email. "So we see that
need for treatment also ballooned."
As of 2017, almost 95% of clinicians with waivers to prescribe
buprenorphine were physicians. About 4% were nurse practitioners and
about 1% were physician assistants, the analysis of government data
found.
Among those with waivers, 72% were approved to treat up to 30
patients, while 22% could treat up to 100 patients and 6% could
treat a maximum of 275 patients.
The number of clinicians who could prescribe buprenorphine climbed
fastest in communities with the most opioid overdose deaths per
capita, the study found. The proportion of waivered providers
climbed about five-fold in communities with the most overdose
deaths, compared to about a three-fold increase in places with the
fewest overdose deaths.
However, even after researchers accounted for need based on overdose
death rates, they still found rural counties didn't gain as many
providers able to prescribe the drug.
Counties with more college graduates gained more providers able to
prescribe buprenorphine than communities with fewer college
graduates, the study also found.
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The researchers lacked data on how many prescriptions clinicians
with waivers actually wrote, or how many patients they treated.
Still, the results suggest gains in access to buprenorphine aren't
keeping pace with needs, said Dr. Stefan Kertesz of the University
of Alabama at Birmingham School of Medicine.
"The kind of doctor most people actually get to see is legally
prohibited from offering the most accessible and effective form of
treatment for opioid addiction," Kertesz, who wasn't involved in the
study, said by email. "The fact that most of our health care
workforce is not ready to treat a devastating and treatable disease
is a tragedy that we need to fix."
Other medication options include methadone, which can only be
obtained through licensed clinics, and naltrexone, which any doctor
can prescribe but many don't know how to use, Kertesz said.
These hurdles for people with opioid use disorder aren't encountered
by patients with other chronic health problems, said Dr. Pooja
Lagisetty of the University of Michigan Medical School and the VA
Ann Arbor Healthcare System.
"With other diseases, we meet patients where they are at, and tailor
treatment to their preferences and needs," Lagisetty, who wasn't
involved in the study, said by email.
For many chronic diseases, there are a dozen medication treatment
options, she added.
"But with opioid use disorder, we have three," Lagisetty said. "With
so few options, we have to make all of them readily available for
all patients, not just those living in certain communities."
SOURCE: https://bit.ly/2sRKAX6 Annals of Internal Medicine, online
January 6, 2019.
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