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May 24, 2021
State Health Policy Leadership Mental Health
Bradley D. Stein
Back to The Milbank Blog
Copublished with The Pew Charitable Trusts and Deerfield Management
Despite overwhelming research showing that three approved medications to treat opioid use disorder (OUD) are effective, too few of the estimated 1.6 million US residents with the disease can access these medications. In particular, buprenorphine has been shown to reduce mortality and illicit opioid use and increase treatment retention. Yet in 2019, only 18.1% of people with OUD received buprenorphine or one of the other approved drugs. One important reason for the low rate of buprenorphine use is that too few medical professionals prescribe this clinically effective treatment.
The Drug Addiction Treatment Act of 2000 (DATA 2000) established a pathway for doctors to prescribe medications to treat OUD in office settings, albeit one with a number of hoops that clinicians must jump through. Under this law, clinicians must complete training and receive a Drug Enforcement Administration (DEA) license, or “waiver,” before they can prescribe buprenorphine to treat OUD. DATA 2000 also limited the number of patients a clinician can treat concurrently to 30 in the first year and 100 after that. In the last five years, changes to federal law have expanded the waiver to allow advanced practice providers, like nurse practitioners and physician assistants, to prescribe buprenorphine. Changes to the law also allowed more clinicians to concurrently treat 100 patients and increased the maximum patient limit to 275, depending on the treatment setting and the clinician’s credentials.
DEA data show that only about 6% of active physicians in the United States hold this DEA waiver, known as an X-waiver. In far too many parts of the country — especially rural areas — there are few buprenorphine prescribers; 40% of US counties did not have a single waivered prescriber in 2018. Yet having a waiver doesn’t necessarily mean a clinician will prescribe buprenorphine. A recent study by The Pew Charitable Trusts and Deerfield Management Company, based on data provided by Symphony Health and other sources, shows that across the country, only half of buprenorphine-waivered prescribers actually treat patients for OUD.
Using these data, we examined prescribing in three states with high overdose death rates — Kentucky, Ohio, and West Virginia — and three with low overdose death rates — Nebraska, North Dakota, and South Dakota — to determine if there were differences in the numbers of active prescribers and treated patients in places with vastly different overdose fatality rates ( See Table 1). While the three hard-hit states had more buprenorphine-waivered prescribers than the other three states, many waivered prescribers across all six states, particularly those with a 30-patient limit, did not treat any patients with buprenorphine. Surprisingly, despite high death rates that reflect the need for treatment in Kentucky, Ohio, and West Virginia, the median number of patients treated by active prescribers was far below the prescribers’ limits in each state examined and did not vary drastically between the two groups of states.
While this study does not explore specific reasons for the low prescribing rates, evidence suggests they are likely related to lack of adequate clinician training in treating substance use disorders, stigma toward individuals with substance use disorders, insufficient reimbursement and other structural factors, as well as complex rules surrounding buprenorphine prescribing, all of which may have an impact on clinicians’ decision to prescribe buprenorphine.
Studies of buprenorphine prescribers around the country show a number of barriers that contribute to buprenorphine under-prescribing even by clinicians authorized to do so. Insufficient nursing and administrative support for payment and pharmacy issues, state requirements for counseling to receive buprenorphine, and, for more experienced prescribers, inadequate reimbursement particularly by Medicaid were cited as barriers to treating more patients.
Regulatory oversight has also influenced willingness to prescribe among clinicians with waivers. Some clinicians were deterred from treating buprenorphine patients for fear of being targeted by the DEA. Waivered prescribers also cited the required training — eight hours for physicians and 24 hours for advance practice providers — as a barrier to recruiting more buprenorphine prescribers.
Requiring providers to obtain a DEA waiver for buprenorphine is unnecessarily burdensome; there is no similar national mandatory training requirement to prescribe opioid pain medications or to prescribe buprenorphine to treat pain. The Biden administration recently took an important step by expanding the pool of providers eligible to prescribe buprenorphine by removing waiver training requirements for clinicians treating 30 or fewer patients. Nevertheless, Congress should pass the Mainstreaming Addiction Treatment (MAT) Act, which has bipartisan support and would eliminate the waiver, allowing any provider with a controlled substance license to prescribe the medication. Eliminating the waiver could encourage clinicians who haven’t previously prescribed buprenorphine to begin doing so without concern for patient limits — and could help destigmatize buprenorphine.
Eliminating the waiver will immediately increase the number of clinicians eligible to prescribe buprenorphine. But states will need to support prescribers, such as by adopting supportive treatment models, raising reimbursement rates, and easing sometimes prohibitive behavioral counseling requirements. (Though some studies show counseling is beneficial for buprenorphine patients, not all patients are willing or able to participate in counseling — and buprenorphine may have a clinical benefit even without counseling.) Research shows that with clinical and policy support, the number of buprenorphine prescribers increases and more patients receive buprenorphine.
Despite the increasing number of waivered prescribers, recent research shows that gaps between presumed treatment need and capacity warrant increased efforts to connect patients with willing prescribers. State policymakers should work to address barriers and increase buprenorphine prescribing to meet treatment needs in states with high opioid overdose death rates. Improving outdated federal and state policies and implementing innovative new strategies are keys to expanding access to a lifesaving medication for OUD.
Authors’ Note: The authors acknowledge Alaina McBournie and Beth Connolly for their comments.
Note: Population data are based on 2018 US Census Bureau estimates. Numbers of patients treated are based on the clinician’s monthly patient census.
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