Attitudes of Patients and Primary Care Physicians Toward Office-Based Buprenorphine Treatment

The current opioid epidemic is a public health emergency recognized at the highest levels of the U. S. government.(1) Despite this attention, the rural overdose death rate continues to increase at an alarming rate, with more than 40,000 Americans dying from opioid overdoses in 2016 alone.(2,3) Efforts are underway to further educate primary care physicians on management of pain and on safer uses of opiates.(4)

For patients suffering from opioid abuse disorders, especially in rural communities, treatment often is difficult to access. The Drug Addiction Treatment Act of 2000 allows primary care physicians with a specific waiver to prescribe buprenorphine as medication-assisted therapy (MAT) for opiate addiction disorders and was intended to facilitate primary care treatment of opiate addiction.(5) Despite the potential for a primary care response, currently too few physicians have applied for prescribing waivers, and physicians with waivers are treating limited numbers of patients due to factors including personal reluctance, stigma, legal restrictions, the other medical demands of their communities, and lack of institutional support.(6,7) Given our current healthcare workforce, the most feasible way to address the worsening epidemic is a concerted effort by primary care physicians to provide evidence-based MAT.(8) Published research on factors contributing to success in primary care MAT with buprenorphine is scarce. Lack of evidence may contribute, therefore, to physicians’ reluctance to obtain a waiver or to prescribe once they have a waiver.(6) To address these issues, we interviewed patients and physicians in a well-established, successful primary care MAT practice to allow their ideas to be shared and to explore factors supporting successful MAT.

Methods

After receiving local institutional review board approval, we interviewed patients prescribed buprenorphine by our Family Medicine residency in a small Western Pennsylvania city in the heart of the opioid epidemic. The office has been prescribing buprenorphine for about 10 years in partnership with an offsite drug and alcohol counseling facility. Our research team consisted of a family physician, a psychologist, a psychology intern, and student interns who worked directly and indirectly with our patients using buprenorphine. Participant interviews were conducted by interviewers independent of the patient’s treatment team, and all patient information was anonymously analyzed. All patients in the program are required to attend counseling, and study participants were selected from patients treated for at least four months. A convenience sample of patients was selected for inclusion based on patient consent and interviewer availability concurrent with medical care management appointments. Patients were assured that their responses would remain anonymous and that interview participation would not affect their treatment. In-depth semi-structured interviews were conducted by researchers using a standard interview guide. Ten-dollar gift cards were provided after interview completion. Thirty-six of the 48 patients agreed to be interviewed; the other 12 patients could not be reached by the researchers. Twenty-one of those who agreed were interviewed, based on their ability to be scheduled. All interviews were recorded, transcribed, and thematically analyzed by two researchers who did not conduct the interview. After patient data collection, a survey was provided to attending and resident physicians working at the clinic. Out of those, 12 of 19 resident and 4 of 7 attending physicians responded. Following that survey, a round-table discussion was held where 2 attending and 13 resident physicians shared their perceptions of outpatient MAT. This discussion also was transcribed.

Results

Of the 21 patient participants, 9 identified as male and 12 identified as female. Twenty participants identified as Caucasian and one as Hispanic. The average participant age was 39 years (range, 22–63 years). At study completion, all participants remained engaged in MAT.

All participants noted the importance of their relationship with their physician.

Patient responses to the research question, “What factors support successful MAT?” predominantly focused on relationships. All participants (100%) noted the importance of their relationship with their physician: “I think the doctor has been a big help and I don’t mean for writing out the script. I mean they actually listen.” Nearly all perceived counseling as valuable (90%). Although family factors often were observed to be motivational for patients, responses were highly variable. “Triggers from the past” were identified by many participants (52%) as a significant obstacle to successful MAT:

Even after I was on the Suboxone ‘cause it’s like, you know, ok you don’t want to put yourself in that same place or that mindset and it only takes one bad day to make you relapse. I mean honestly . . . you know you’re just one step away for it, I think. But if you go to therapy and learn the tools and stuff, in addition to taking the medicine as prescribed, then I would definitely say it helps.”

Beyond those factors, participants overwhelmingly noted that supportive and nonjudgmental physicians were essential to recovery:

One of the first things on the page said—I don’t know the exact words, but it was like, “We will treat you like a human being.” And, you know, that just meant so much to me because I’ve been to other places and people just—some people treat you like, you know, you’re lesser-than because you’re a drug addict.

Due to these relationships, many patients described the MAT program as a “safe place” where they could openly discuss their history and challenges and continue to strive for recovery in spite of setbacks.

For patients, decreasing the barriers to MAT is essential.

Similarly to patient responses, 12 of 13 physicians in the study (92%) described their relationships with MAT as very positive. More detailed investigation of the physician perspective on relationships in MAT revealed that this work is seen as challenging but particularly rewarding. In terms of relationships, physicians relayed a range of experiences including frustration: “some abuse the system and waste your time” or even fulfillment: “It gives me fulfillment that I’m part of the Suboxone program and I’m part of the process of that big change in their lives.” Between those extremes, physicians noted that successful MAT patients become routine patients: “but you also have just routine patients, many patients become routine. You just write their script and make sure they aren’t doing anything bad and that’s it.” Perhaps due to the range of patient experiences and after-graduation career planning, 50% of residents who took the survey indicated they planned to provide MAT after graduation. Factors supporting the desire to provide MAT included: “Decreased chance of overdoses, trying to do something [regarding ongoing epidemic]”, “there’s a sense of obligation”, “working in a primary care setting”, and “[MAT] is an important and valuable tool.” Noted barriers to providing MAT included: concern over available staff or community resources, fear of legal entanglements, perception of patient population as difficult and inexperience. Additionally, entering geriatric or hospitalist medicine was considered to be incompatible with MAT. Despite the variable degree of interest in providing MAT after residency graduation, 14 of 15 physicians (93%) involved in the survey believed MAT should be a component of primary care practice.

Discussion

To the best of our knowledge, the importance of physician–patient relationships in supporting MAT success and physician fulfillment has not been reported previously. In our study, these relationships were highly valued by nearly all participants, including both patients and physicians.Notably, this idea has been reported in a previous study as a minor theme in an evaluation of retention in buprenorphine treatment.(9) If our findings are replicated, providing MAT may be portrayed as a satisfying and rewarding aspect of primary care practice, not merely an ethical burden. We believe emphasizing the positive experiences is particularly important within the context of the U. S. healthcare system, where primary care physicians are the most plausible group of physicians who can respond to the epidemic.(8)

For patients, decreasing the barriers to MAT is essential. Current practice in the United States includes high barriers to entrance and low tolerance of relapse. Often these processes increase the stigma associated with opiate abuse and addiction.( 10) If the goal is to increase the number of patients entering lasting recovery, the process needs to be changed. A primary care–based process could accomplish this.

Our work has several limitations. The interviews were conducted at a single site, so this is an initial pilot study. Because all interviewees continued in our program for at least four months, and the program requires counseling, we likely have failed to include patients who do not see counseling as beneficial. It also is possible that patients who are less satisfied with our model of care or staff were less likely to participate in our study. Similarly, the response rate from our physicians was less than ideal. The study was conducted in a residency clinic, so although patients are assigned to a continuity physician, they at times see other physicians. The noted benefits of doctor–patient relationships would likely be even stronger in settings with greater continuity. Our program uses primarily off-site drug and alcohol counselors. This is likely the model that would be used in most primary care offices, especially the smaller ones. In addition, in recent years we have added an on-site drug and alcohol counselor. Many of the physicians see the counselor as instrumental to the success of the program. That counselor is able to streamline the physician encounters and limit the administrative burden on physicians. Some residents felt that a lack of such support would deter them from adding buprenorphine prescribing to their future practice, so our results may not be applicable to primary care practices without this support. In our setting, insurance coverage for office visits has been the norm. Given the enhanced efficiency the counselor affords it is likely financially beneficial to add at least a part-time counselor or train an office assistant dedicated to this work.

Future research is needed to elucidate the fiscal implications of incorporating MAT in a primary care practice. Our experience has been that no-shows are reduced in this population compared with the remainder of our practice and that these patients are more likely to be fully insured, but it would be helpful to quantitate this.

Conclusion

In conclusion, despite the political attention and devastation of the opiate epidemic, corresponding research is in its early stages. We hope this project encourages primary care physicians to add MAT to their practices. This inclusion need not be an onerous ethical obligation but, rather, can be an opportunity to provide highly effective, personally fulfilling, financially sustainable treatment. Providing MAT can be extremely rewarding for both patients and physicians, as expressed by the following from a patient:

“This is success right here (laughs). Yeah, I um, I’ve never been able to hold a job, and I’ve had the same job for 8 and a half years and I wouldn’t of been able to do it without the Suboxone. I know it. Like it has led me to live a normal life. I’ve never had this before and it’s the most— it’s the most like comforting feeling. You know? I have a home to go to, you know, ‘cause I was homeless when I was using at the end there. And um so yeah I’m what they call a productive member of society.”

One physician summed it up this way: “Most of my patients are doing very well, probably 80% to 90% are doing very well. It makes me so happy, because I’ve seen before when they were just starting and now 2 to 3 years after, they have jobs and are taking care of their family.”

Acknowledgements. The authors thank John Luczik, Daphne Moot, and counselors at New Visions Chemical Dependency Unit for their support with our buprenorphine program. Additionally we would like to acknowledge the support of Marc Khouzami and Jessica Scott for their assistance in conducting this research.

References

1. U. S. Department of Health and Human Services (HHS), Office of the Surgeon General. Facing Addiction in America: “The Surgeon General’s Spotlight on Opioids. Washington, DC: HHS, September 2018.

2. Buchanich JM, Balmert LC, Pringle JL, et al. Patterns and trends in accidental poisoning death rates in the US, 1979–2014. Prev Med. 2016;89:317-323.

3. Centers for Disease Control. Opioid Overdose. January 17, 2018. www.cdc.gov/drugoverdose/index.html .

4. Dowell D, Haegerich TM, Chou R.CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315:1624-645.

5. The Drug Addiction Treatment Act of 2000 (DATA 2000). 2000. www.deadiversion.usdoj.gov/pubs/docs/dwp_buprenorphine.htm. Accessed December 27, 2017.

6. Andrilla CHA, Coulthard C, Larson EH, et al. Barriers rural physicians face prescribing buprenorphine for opioid use disorder. Ann Fam Med. 2017;15:359-362.

7. Chou R, Korthuis PT, et al. Medication-assisted treatment models of care for opioid use disorder in primary care settings. Technical Brief No. 28. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2015-00009-I.) AHRQ Publication No. 16(17)-EHC039- EF..December 2016. Rockville, MD: Agency for Healthcare Research and Quality.

8. Wakeman SE, Barnett ML. Primary care and the opioid-overdose crisis - buprenorphine myths and realities. N Engl J Med. 2018;5;379:1-4.

9. Teruya C, Schwartz RP, Mitchell SG, et al. Patient perspectives on buprenorphine/naloxone: a qualitative study of retention during the Starting Treatment with Agonist Replacement Therapies (START) study. J Psychoactive Drugs. 2014;46:412–426.

10. McElrath K. Medication-assisted treatment for opioid addiction in the United States: critique and commentary. Subst Use Misuse. 2018;53:334-343.