The barriers to obtaining a buprenorphine (Suboxone) waiver in the U.S. are small, but loom large in many physicians' minds.
Only -- about 5% of the nation's doctors -- have waivers to prescribe buprenorphine, a medication used to treat opioid addiction. While that number has grown in recent years, it includes psychiatrists and addiction specialists, many of whom don't practice in rural areas.
But even including those specialties, it's not enough. "The current number of waivered physicians is not sufficient to ensure access to buprenorphine treatment for all individuals with opioid use disorder, even if every physician were prescribing at the maximum of their waivers," said Hannah Knudsen, PhD, of the University of Kentucky College of Medicine in Lexington. Knudsen has studied the between the supply of buprenorphine-waivered physicians and prescription opioid mortality.
Pamela Pentin, MD, JD, a family medicine doctor at the University of Washington Medical Center in Seattle, obtained her buprenorphine waiver in 2004. "I saw patients walking into a doctor's office with chronic pain, being prescribed opioids without regard for any true functional improvement, and then coming in again with opioid addiction as their primary problem," she recalled.
To Pentin, addiction treatment is part of family care. "We deal with addiction every minute in our practices," she said. "My obese patients who have diabetes and heart disease are addicted to food. My alcoholic patients with cirrhosis are addicted to alcohol. Why should it be any different for me to treat opioid addiction than it is to treat all the other addictions that family doctors and internists deal with all the time?"
Early in her medical education, Alicia Agnoli, MD, MPH, a family practice doctor at the University of California Davis, did elective training with a buprenorphine-waivered physician. "I saw a whole range of individuals struggling with their drug use," she said. "And I saw this treatment was really effective. It was not only helping their addiction, but it was engaging them with their primary care doctor and their overall health in a way that was profound."
Still, many physicians, especially in primary care, are reluctant to get buprenorphine waivers. Agnoli cited a couple of reasons. "There are a few extra hoops to jump through in order to prescribe buprenorphine, and extra [] oversight that a lot of physicians don't want to bother with," she said.
And there's the primary care office culture to contend with. "If no one else in their practice is providing this care, a physician might not want to take on the role of champion, of being the sole person taking care of all opioid dependent patients," she added. "They may not want to deal with fighting with the clinic management. And they probably don't want to be the first pioneer to figure out how to do drug testing, what's our relationship with the pharmacy, and who deals with the prior authorizations."
Despite the growing opioid problem in the U.S., many doctors do not understand addiction treatment. "This is the number one public health problem, yet we continue to approach it as a separate quasi-professional field with no required coursework in the curriculum for medical schools, psychology or social work, despite these professions being the primary point of contact for people with substance use disorders," said Dessa Bergen-Cico, PhD, of Syracuse University in New York.
Even among doctors who have buprenorphine waivers, utilization is low. In a 2017 , Kelly Dunn, MS, PhD, of Johns Hopkins University in Baltimore saw physicians were concerned about not having enough time or resources to help patients with opioid addiction.
"The research suggested that physicians either don't feel informed enough, or aren't comfortable with, the idea of prescribing," she said. "They also said they don't have the infrastructure to take on many new patients, and have concerns about patients needing additional access to counseling that isn't generally available in primary care settings. They may not know best way to refer patients or what local resources they have."
But that may need to change. "Addiction medicine is the newest medical specialty to be recognized, but there are not enough specialists now to combat the opioid epidemic, so primary care providers will be on the front lines whether they want to or not," said Michael Weaver, MD, of the University of Texas Health Science Center in Houston.
To obtain a buprenorphine waiver, clinicians need to apply to the Substance Abuse and Mental Health Services Administration (). "Physicians need 8 hours of online training which covers pharmacology, the induction process for the drug, and information about best practices," Pentin explained. Training is free through the Provider's Clinical Support System for Medication-Assisted Treatment () and qualifies for CME, she added.
Demystifying addiction treatment goes a long way, Agnoli observed.
"We are in a culture shift; addiction treatment has not historically been part of primary care practice," she said. "Like with any culture change, we see greater gains in newer generations of physicians. Normalizing this in the training phase stands to produce more willing and capable primary care doctors."