Initiation rates and six-month retention rates for buprenorphine haven’t budged despite relaxed telehealth rules and prescriber training requirements
Treating opioid addiction should be much easier now than it was a few years ago, thanks to pandemic-era rule changes that aim to improve access to buprenorphine, a medicine proven to help in recovery.
But a new study shows the rate of people starting on buprenorphine remained flat from 2019 through 2022, while the percentage of patients who stayed on buprenorphine for at least six months hovered at just over 20% from 2016 through 2022.
Until more health care providers start offering buprenorphine treatment -- and to take advantage of opportunities like emergency visits and hospitalizations for opioid overdose to start the medication -- the picture isn’t likely to change, the researchers say in a new research letter published in JAMA.
The new study, by a team from the University of Michigan and Boston University, used national prescription dispensing data to examine trends in the rate of starting buprenorphine treatment, and the percentage of patients starting treatment who stayed on it for at least six months, from 2016 to 2022.
The rate of people starting a new course of buprenorphine treatment rose from January 2016 to September 2018, but then flattened out, with a bit of a dip in the first months of the pandemic.
And only 22% of those who started a course of buprenorphine kept refilling their prescriptions for at least six months from 2016 through 2022. Longer periods of buprenorphine treatment are associated with reduced risk of opioid overdose death.
The study timeframe includes two major changes to the rules around buprenorphine prescribing. In spring of 2020, as part of sweeping relaxation of rules around telehealth-based care at the start of the pandemic, prescribers no longer had to see a patient in person before prescribing buprenorphine. Then, starting in spring 2021, prescribers no longer had to meet an eight-hour federal education requirement to prescribe buprenorphine.
“The fact that buprenorphine initiation and retention did not rise after these efforts were implemented suggests that these policy changes were insufficient to address the barriers to prescribing enough to meet the rising need for this medication,” says Kao-Ping Chua, M.D., Ph.D., the lead author of the new study and an assistant professor of pediatrics in the Susan B. Meister Child Health and Evaluation Research Center at the U-M Medical School.
As of this year, the federal government lifted another hurdle for prescribers. Now, any physician, nurse practitioner or other clinician who can prescribe other controlled substances can prescribe buprenorphine without needing special approval from the federal government.
“It remains to be seen whether the elimination of the waiver requirement will move the needle on buprenorphine initiation and retention,” says Chua. “Based on our study, it seems likely that this intervention will be insufficient to overcome the many other barriers to buprenorphine initiation and retention, such as stigma about the drug among clinicians, patients and pharmacists.”
At the same time, the federal government may soon impose new hurdles for prescribers. A new proposed rule from the U.S. Drug Enforcement Agency would partially reverse the pandemic policy of not requiring in-person visits before buprenorphine can be prescribed via telehealth. Chua worries that these new restrictions may further impede efforts to improve buprenorphine initiation and retention.
The federal government is now also requiring all clinicians to complete eight hours of training in addiction treatment upon renewal of their controlled substance license.
“I worry that this requirement, which hasn’t been well publicized, could result in some prescribers no longer having a controlled substance license entirely, decreasing the number of eligible prescribers”, says Amy Bohnert, Ph.D., the senior author of the new paper and a professor in the U-M Department of Anesthesiology.
The new study builds on previous work by Chua and colleagues, in which they showed that only 1 in 12 patients who visited an emergency department for an opioid overdose were prescribed buprenorphine within 30 days of that crisis. By comparison, half of patients who went to an ED for a severe allergic reaction called anaphylaxis received a prescription for an epinephrine injection device. “My hope is that our new study will further underscore how much the health care system is underusing a critical tool to prevent opioid overdose deaths,” says Chua.
Because it is based on retail pharmacy data, the new study has a few limitations. It does not include buprenorphine administration during health care visits, including office visits and visits to opioid treatment programs among people with opioid addiction.
Free resources, training and consultation services for prospective, new and existing buprenorphine prescribers are available via the Michigan Opioid Collaborative, led by Bohnert, who is also co-director of the new U-M Opioid Research Institute.
In addition to Chua, who is part of the Department of Pediatrics, and Bohnert, the study’s authors include Pooja Lagisetty, M.D. of the Department of Internal Medicine, who heads the Addiction Consultation Team at Michigan Medicine, as well as Jason Zhang, M.S. of Pediatrics, Thuy Nguyen, Ph.D. of the U-M School of Public Health, and Rena Conti, Ph.D. of the Boston University Questrom School of Business. All the U-M authors except Zhang are member of the Institute for Healthcare Policy and Innovation; Chua and Zhang are part of the Susan B. Meister Child Health and Evaluation Research Center.
The study was funded by the Benter Foundation, the Michigan Department of Health and Human Services, the Susan B. Meister Child Health Evaluation Research Center, and the National Institute on Drug Abuse (DA056438, DA057284, DA048110).
Trends in Buprenorphine Initiation and Retention in the United States, 2016-2022, JAMA, doi:10.1001/jama.2023.1207