Facilitators and barriers in implementing buprenorphine in the Veterans Health Administration.

Abstract

Opioid dependence is a chronic, relapsing disorder that deleteriously influences the health of those afflicted. Sublingual buprenorphine opioid agonist treatment (OAT) has been shown to be safe, effective, and cost-effective for the treatment of opioid dependence in nonspecialized, office-based settings, including the Veterans Health Administration (VHA). We sought to examine and describe provider-, facility-, and system-level barriers and facilitators to implementing buprenorphine therapy within the VHA. From June 2006 to October 2007, we conducted semistructured telephone interviews of key personnel at a national sample of VHA facilities with high prevalence of opioid dependence and without methadone OAT programs. Sites were categorized based on the number of veterans receiving buprenorphine prescriptions: More Buprenorphine (MB, >40 prescriptions, 5 sites), Some Buprenorphine (SB, 5-40 prescriptions, 3 sites), and No Buprenorphine (NB, 0-5 prescriptions, 9 sites). Interviews were taped, transcribed, and coded; consensus of coding themes was reached; and data were evaluated using grounded theory. Sixty-two staff members were interviewed. For NB sites, perceived patient barriers included lack of need and attitudes/stigma associated with opioid dependence. Provider barriers included lack of interest, stigma toward the population, and lack of education about buprenorphine-OAT. Prominent facilitators at MB sites included having established need, provider interest, and resources/time available for buprenorphine-OAT. The presence of a champion/role-model for buprenorphine care greatly facilitated its implementation. We conclude that factors that enable or impede buprenorphine-OAT vary by facility. Strategies and policies to encourage implementation of buprenorphine should be adaptable and target needs of each facility.

Barriers to Primary Care Physicians Prescribing Buprenorphine

“…The need for behavioral health services is commonly cited as a barrier to prescribing buprenorphine, 6,8,11,18 and in our study this need was cited most frequently by both physicians who do and do not prescribe buprenorphine. In Washington State, Medicaid pays for buprenorphine treatment only if clients receive chemical dependency counseling despite the lack of data that additional counseling improves outcomes.…”

“…Buprenorphinenaloxone, hereafter referred to as buprenorphine, is the only treatment available to office-based physicians that has high rates of prolonged success for the treatment of opioid addiction. 1,2 Although physicians have reported a wide range of barriers that have dissuaded them from prescribing buprenorphine, [3][4][5][6][7][8][9][10][11][12][13][14][15][16] few studies specifically addressed the barriers family practice physicians encounter. McCarty et al 10 found that 6 of 17 Oregonian family physicians trained to use buprenorphine prescribe it, whereas those who do not prescribe buprenorphine cited concerns of being overwhelmed by needy patients, the cost of medication, reimbursement, being the only physician prescribing buprenorphine in the practice, and lack of administrative support.…”

Methadone, buprenorphine and preferences for opioid agonist treatment: A qualitative analysis

“…In 2011, nearly 10 years after buprenorphine first became available, 43% of US counties had no buprenorphine-waivered physicians (Murphy et al, 2014). Organizational- and practitioner-level barriers also prevented diffusion (Gordon et al, 2011; Green et al, 2014; Hutchinson et al, 2014; Roman et al, 2011; Savage et al, 2012). …”

Characteristics of veterans receiving buprenorphine vs. methadone for opioid use disorder nationally in the Veterans Health Administration

“…By 2009, VHA had created a nationwide mandate to make buprenorphine and methadone for OUD available to every veteran who might benefit from them. Although implementation has been uneven across VHA facilities, overall access to buprenorphine has substantially increased with these efforts (Gordon et al, 2009, 2011). Paralleling national non-VHA trends (Jones et al, 2015a; Stanton, 2006), the number of buprenorphine prescriptions, number of physicians prescribing buprenorphine and number of facilities providing buprenorphine all increased substantially between 2004 and 2010, while methadone maintenance utilization increased only slightly (Oliva et al, 2013).…”