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Opioid abuse and dependence are reaching epidemic proportions in the United States, resulting in a staggering number of overdose deaths1 and economic costs that exceed $56 billion annually.2 Medication-assisted therapies, such as buprenorphine (Suboxone) and methadone, represent the most efficacious treatments for opioid dependence. Office-based buprenorphine treatment is especially well positioned to provide a rapid response to the opioid crisis, particularly in rural areas where efforts to expand methadone clinics often face sizeable barriers and opioid-dependent patients are widely dispersed throughout a large geographic area.3 However, there has been increasing concern that these life-saving medications are severely underused.4
We analyzed billed buprenorphine pharmacy claims data from Vermont Medicaid beneficiaries for each of 3 consecutive months (February-April 2014). An average was calculated for the number of buprenorphine patients treated by each physician buprenorphine provider during this 3-month period. The University of Vermont determined that this study did not require institutional review board approval and patient consent was not obtained because patient data were deidentified and only aggregate patient totals were used.
During the evaluation period, 1964 Vermont residents received at least 1 buprenorphine prescription. Their prescribers consisted of 133 physicians (of the approximately 190 currently waivered physicians in Vermont), translating to an average of 14.8 patients per physician buprenorphine provider (range, 1-76). However, closer inspection of the data revealed that most physician buprenorphine providers were only treating a small handful of patients (Figure), with 29.3% of physician providers having only a single buprenorphine patient and 48.1% treating 5 or fewer patients.
The data points represent the number of physician buprenorphine providers (y-axis) who are treating the number of buprenorphine patients depicted along the x-axis. For example, 39 physician providers were treating a single buprenorphine patient whereas 7 physician providers had 2 buprenorphine patients.
Vermont has long been at the forefront of buprenorphine treatment. Our university was the site of National Institutes of Health–funded clinical trials demonstrating buprenorphine’s efficacy prior to its Food and Drug Administration approval. In recent years, Vermont has been identified as a model for other states to follow in their efforts to develop and expand office-based buprenorphine treatment, with a per capita rate of buprenorphine prescriptions that is more than 10 times the national average.5
However, despite Vermont’s early and aggressive adoption of office-based buprenorphine for opioid dependence, pharmacy claims data suggest that we are far from realizing the potential of this important treatment modality. Indeed, our current use translates to approximately 10% of the maximum capacity possible with 190 waivered physician buprenorphine providers, which is significant underutilization in a rural state that desperately needs more treatment slots. These data also contrast sharply with an earlier national survey in which physician providers typically treated 25 to 40 buprenorphine patients.6
Whether the Vermont experience is representative of other states is unclear. However, what is certain is that we cannot afford a backslide in our efforts to develop a robust office-based buprenorphine system. An improved understanding is needed of the factors limiting buprenorphine’s widespread use including physicians’ concerns about induction logistics, reimbursement challenges, and the potential for medication abuse or diversion. Efforts to address these barriers may include greater initial and ongoing support for physician buprenorphine providers, improved methods for screening and identifying the patients most appropriate for office-based buprenorphine, and improved methods for monitoring patient progress and medication adherence. Taken together, we must think hard about how to better support our physician buprenorphine providers, as this treatment modality plays a vital role in our ability to respond appropriately to the country’s opioid abuse epidemic.
Corresponding Author: Stacey C. Sigmon, PhD, University Health Center–Substance Abuse Treatment Center, 1 S Prospect St, Room 1415, Burlington, VT 05401 (email@example.com).
Published Online: February 11, 2015. doi:10.1001/jamapsychiatry.2014.2421.
Conflict of Interest Disclosures: Dr Sigmon has received research grants from the National Institute on Drug Abuse, consulting payments from Alkermes, and research support from Titan Pharmaceuticals through her university. No pharmaceutical or industry support was used in this manuscript.
Funding/Support: Preparation of this manuscript was supported in part by National Institutes of Health research grant R34DA037385 and Center of Biomedical Research Excellence award P20GM103644 from the National Institute of General Medical Sciences.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Sigmon SC. The Untapped Potential of Office-Based Buprenorphine Treatment. JAMA Psychiatry. 2015;72(4):395-396. doi:10.1001/jamapsychiatry.2014.2421