Real-world access to buprenorphine treatment in Philadelphia: A secret shopper study

Abstract

Purpose:

To assess real-world access to buprenorphine treatment in Philadelphia and measure adoption of policies and practices that facilitate buprenorphine access.

Methods:

We used an audit (“secret shopper”) design to survey all programs providing longitudinal, outpatient buprenorphine in Philadelphia from 9/2022–1/2023 (n = 130). After validating eligibility, a research coordinator posing as a case manager called eligible programs to inquire about appointment availability and treatment policies. We used descriptive statistics to analyze the data and compared practices between primary and subspecialty treatment providers.

Results:

We reached 107 programs with audit calls (82 % response rate). 56 (52 %) were primary care offices and 51 (48 %) were specialty addiction providers. 96 (90 %) accepted new patients for buprenorphine treatment, and 83 (78 %) accepted insurance. Median time-to-appointment was 3 business days (range 0–120), and 42 % of visits were offered with a single call. Only 42 % of programs could confirm the possibility of a buprenorphine prescription at an initial visit. 48 % of programs could not provide information about requirements for counseling or behavioral health, and few could provide information about policies for patients with ongoing substance use. Specialty models were more likely than primary care programs to provide information about medication availability at the first visit but also were more likely to require counseling and abstinence.

Conclusions:

Our study provides a simulation of real-world experiences accessing buprenorphine, revealing significant variability in treatment access and persistence of practice-level barriers to treatment. These findings can inform efforts to increase engagement and retention in treatment and better align care with evidence.

1. Introduction

Overdose deaths continue to increase in the US, and fatal overdoses are growing among certain marginalized populations, including racial and ethnic minorites, (Khatri et al., 2021; Friedman et al., 2021) people experiencing homelessness, (Austin et al., 2021) and people with criminal-legal involvement (Binswanger et al., 2016; Green et al., 2018). Medications for opioid use disorder (MOUDs) such as methadone and buprenorphine are key pillars in reducing OUD-related morbidity and mortality, (Sordo et al., 2017) but a minority of affected individuals receive treatment (Krawczyk et al., 2022). Barriers to MOUDs exist at multiple levels. Methadone treatment is strictly regulated and can only be dispensed in Opioid Treatment Programs (OTP), often with daily observed dosing and counseling requirements (Substance Abuse and Mental Health Services Administration, 2021). Buprenorphine can be prescribed in general medical settings, allowing for greater flexibility, but barriers to treatment access and retention remain. Some of these barriers include mandates for intensive counseling, strict abstinence, dose limits, or other requirements as a precondition for buprenorphine treatment (Pew Charitable Trusts, 2021; Aronowitz et al., 2022; Andraka-Christou et al., 2023; Nguemeni Tiako et al., 2023; Gertner et al., 2022; Hill et al., 2022).

Clinical justifications for such requirements are limited. Multiple high-quality studies show no added benefit of counseling to routine office-based buprenorphine maintenance treatment, (Weiss et al., 2011; Fiellin et al., 2006, 2013; Carroll and Weiss, 2017) concurrent substance use does not reduce treatment retention in multiple contexts, (Weinstein et al., 2020; Cunningham et al., 2013) and higher buprenorphine doses are associated with improved treatment retention (Hser et al., 2014). There is strong evidence that initiating buprenorphine as soon as possible is associated with better retention in treatment in ED and outpatient settings (Roy et al., 2021; D’Onofrio et al., 2015). Yet, “high-barrier” care models incorporating many of these requirements persist, and prior work has suggested that high-barrier practices can reduce treatment retention (Gertner et al., 2022; Gryczynski et al., 2014; Lowenstein et al., 2023; Dickson-Gomez et al., 2024). Among patients self-treating with non-prescribed buprenorphine, burdensome requirements are frequently cited as a major motivation for opting out of formal treatment and serve as a deterrent to patients seeking care (Hayes et al., 2021).

While prior work has explored the prevalence and impact of requirements imposed by payors and pharmacies, there is less evidence about the prevalence or impact of prescriber or clinic-level policies and practices on treatment access and retention (Pew Charitable Trusts, 2021; Aronowitz et al., 2022; Andraka-Christou et al., 2023; Nguemeni Tiako et al., 2023; Gertner et al., 2022; Hill et al., 2022). A previous audit study by Beetham et al., completed in 2018, included audit calls to publicly listed buprenorphine prescribers in six US states with high opioid-related mortality (Beetham et al., 2019). That study found that many prescribers did not offer new buprenorphine appointments or rapid access to treatment to callers reporting OUD, especially those with Medicaid. Among prescribers who would schedule an appointment, median wait times were 6 days for a new appointment and 8 days for an appointment with buprenorphine induction.

Since the Beetham study, few studies have explored the status of real-world buprenorphine access from the perspective of individuals seeking treatment. Also since that time, major national, state, and local initiatives have been implemented that could promote buprenorphine prescribing. Further, we have limited understanding about provider or clinic-level adoption of low-barrier prescribing practices that may influence engagement and retention in real-world settings.

In this study, we sought to describe the landscape of buprenorphine treatment among programs providing longitudinal OUD buprenorphine treatment in Philadelphia. Our goal was to understand the experiences of individuals seeking timely, evidence-based buprenorphine treatment from providers or programs in a city highly impacted by OUD and overdose. Our aims were: 1) to assess real-world access to buprenorphine treatment in Philadelphia, 2) to measure adoption of policies and practices that facilitate access to medication.

2. Materials methods

2.1. Study design

We conducted an audit survey study to assess appointment availability and care practices among buprenorphine treatment programs in Philadelphia. A research staff member posed as a case manager helping a patient with OUD seeking buprenorphine treatment following non-fatal overdose to simulate a common, urgent presentation. Audit surveys, also known as “secret shopper” studies, are designed to simulate real-world interactions and help overcome challenges common to other survey methodologies including social desirability bias and low response rates (Rhodes, 2011). Audit methods have been used to study treatment access, including for OUD, as this is most reflective of real-life experiences of patients seeking care (Beetham et al., 2019; Meyerson et al., 2024). The University of Pennsylvania Institutional Review Board approved this research.

2.2. Study population and sample selection

Our study was set in Philadelphia, which is impacted by substance use and overdose and has one of the highest overdose death rates among the large U.S. cities (Pew Charitable Trusts, 2022). Philadelphia County behavioral health Medicaid also has an MOUD mandate that requires all its in-network licensed specialty substance use treatment providers to offer MOUDs, either on-site or via referral, (Stewart et al., 2021, 2024) and there are citywide initiatives to promote treatment and harm reduction services, (City of Philadelphia. Substance Use Prevention and Harm Reduction n.d.) although these have been in jeopardy in the current local political climate (Orso, 2024).

To identify our study sample, we assembled a database of longitudinal buprenorphine treatment providers across Philadelphia, including those in large health systems, safety net clinics, harm reduction organizations, and other community-based programs, both in specialty substance use treatment settings and general medical settings like primary care. We chose to conduct the study at the program level since this is the access point for patients calling and seeking treatment and because this would allow us to assess the first available appointment within any given treatment setting regardless of individual provider availability. Programs could include specialty behavioral health outpatient facilities (e.g. an intensive outpatient treatment program), clinic-based treatment in general medical settings (e.g. a primary care clinic with one or more buprenorphine prescribers), a harm reduction treatment program (e.g. prescribers based in a syringe service program), and solo or small group prescribers in private practice.

Programs were identified by triangulating a variety of publicly available data sources for potential buprenorphine prescribers. First, we identified all buprenorphine prescribers publicly listed in the Substance Abuse and Mental Health Services Administration (SAMHSA) database of X-waivered clinicians in Philadelphia and included all associated program or practice locations. Because the publicly available database only included providers who opted to have their information listed, we also included all Medicaid behavioral health programs in Philadelphia County and primary care and behavioral health programs within large local large health systems and primary care networks. Finally, we cross-referenced our list with sources assembled by outside entities, including a provider database created by an area foundation, a Philadelphia organization that supports primary care-based MOUD providers, and local professional networks to create our final list of 265 potential programs.

Programs were eligible to be included in the final sample if they 1) were an outpatient treatment clinic or program (standalone or part of another clinic or agency such as primary care, a behavioral health treatment program, or harm reduction agency); 2) have one or more providers prescribing buprenorphine for OUD treatment; 3) provide longitudinal care (i.e. more than a single visit or transitional services). We verified eligibility of all 265 potentially eligible programs via an initial phone screen completed in July and August 2022, in which a research coordinator called each program up to three times to verify that they met study inclusion criteria. The research coordinator inquired about each of the inclusion criteria but did not indicate that programs were part of a research study. After verifying eligibility via the phone screen, we created a final sample of programs for inclusion in the audit calls.

2.3. Instrument development and testing

All audit (secret shopper) calls were made using a standardized script developed by our team and adapted from content in prior secret shopper studies assessing MOUD access (Appendix) (Beetham et al., 2019). The caller self-identified as a case manager seeking treatment with buprenorphine for a client who recently experienced a non-fatal overdose. The script stated that the case manager wanted to inquire about appointment availability and other practice information for the client under their care. We made the decision to use the scenario of a case manager rather than the patient seeking treatment because we thought programs would be more likely to disclose treatment requirements and policies to a case manager than a patient. We also thought a conversation with a case manager might reduce the emotional toll for the people who answered the phone, rather than speaking with someone who had just experienced an overdose seeking care.

The instrument first included a question about appointment availability to ensure that this metric was captured as well as other questions about program policies (such as insurance acceptance, requirements for state identification) and practices (such as requirements for counseling). If a program could not answer the question, the caller would move on to the next query. Calls could also be transferred to another clinic staff member if that was offered by the practice staff, and we allowed callbacks if a staff member was not available at the time

Prior to study launch, the script was pilot tested through calls to programs or clinics outside Philadelphia County that were not included in our sample. Based on these initial pilot calls, the research team refined the script.

2.4. Data collection

Once the final sample was identified through the screening calls, one trained research coordinator called all eligible programs between September 2022 and January 2023, a minimum of one month after the screening call. The research coordinator placing the calls had prior experience working in MOUD treatment environments and was trained to use the standardized script by the research team as well as by conducting the pilot calls to clinics outside the study sample.

Programs were called in random order during business hours up to three times, with deliberate efforts made to vary the days and times of the call. The caller used the standard script to first ascertain appointment availability and wait time until the first available appointment and then ask a series of additional questions about program requirements and policies for treatment. The caller would start with a call to a scheduler or front desk staff member but could be transferred to a different staff person if offered, and they were able to leave a voicemail or a message with a staff member. If a program was unable to schedule without detailed patient information, the caller would continue to ask the additional questions and would move on to additional questions if the individual on the call could not provide a response.

No appointments were scheduled. No information was collected that would identify individual staff members and no information about individual clinics or locations was disclosed. Following the completion of the call, participating programs were mailed a debriefing letter, notifying them about their inclusion in the study, the use of secret shopper methods, our study aims, aggregate findings, the security of collected information, and offering contact information for any questions they may have.

2.5. Study outcomes

The primary outcome for our study was wait time to new patient appointment. We also assessed program policies such as provision of buprenorphine on the first visit, requirements for treatment, such as counseling or group therapy, attitudes towards ongoing substance use and questions about insurance acceptance, requirements for state or other identification, and availability of telehealth. Finally, we recorded measures of administrative friction associated with the attempts to assess appointment availability. This included a measure of first call resolution rate – a measure borrowed from the business literature and previously used in health care telephone service assessment (Rim et al., 2018) – meaning that an appointment was offered within a single call attempt. We also measured whether multiple calls were required, voicemails were left, and whether the caller was transferred or placed on hold. Programs were classified as unreachable during the audit call if a staff member could not be reached within three contact attempts.

2.6. Data analysis

We assessed response rates to the audit calls at the program level. We also used descriptive statistics to characterize practices, appointment availability, measures of administrative friction, and program policies. We also used chi-square, t-tests, and Mann-Whitney tests for comparisons of program characteristics between primary and subspecialty buprenorphine treatment providers. Analyses were conducted using STATA 17 (StataCorp, College Station, TX).

3. Results

Through screening calls to our initial sample of 265 programs, we were able to confirm study eligibility of 130 programs (Fig. 1). The remaining 135 programs were either unreachable on three attempts or did not meet study criteria. Of those deemed ineligible, 84 could not be reached, 28 could not verify inclusion criteria, and 23 were ineligible practice types (residential, pain management, or non-clinical programs).

Fig. 1.

Cohort flow diagram.

Among ineligible programs that were unreachable or could not verify inclusion criteria, 47 (42 %) were primarily SUD treatment programs and 65 (58 %) were non-specialty programs or clinics. This distribution was not significantly different than eligible programs in the final sample.

Of those 130 programs included in the initial sample, we reached 107 programs with our audit call (response rate=82 %). Non-responding programs included those that confirmed initial eligibility buprenorphine prescribing but then could not be reached after three attempts during the audit call stage.

Program characteristics for the 107 programs in the final sample are shown in Table 1. Approximately half the programs were primarily SUD treatment providers (48 %), and half were primary care-based programs (52 %). Most programs were able to confirm insurance acceptance (78 %); 7 % were self-pay only with the remaining not providing this information to the caller. 68 % accepted Medicaid insurance, 52 % accepted Medicare, and 34 % accepted commercial insurance. Patients were required to have a form of identification such as state ID for 47 (44 %) of programs; no ID was required for 37 (35 %) of programs and 23 (21 %) were unsure. In comparing primary care to specialty care programs, the only significant difference was higher acceptance of commercial insurance by primary care practices (45 % vs 22 %, p = 0.012), with no differences across other insurance types or self-pay.

Table 1.

Program characteristics of practices reached by audit call.

Program Characteristics	Total (n = 107)	Primary Care (n = 56)	Specialty Care (n = 51)	p-value
Accepting new patients for bupe, n (%)
Yes	96 (90 %)	52 (93 %)	44 (86 %)	p = 0.219
No	10 (9 %)	1 (2 %)	0 (0 %)
Unsure	1 1(%)	3 (5 %)	7 (14 %)
Accepts Insurance, n (%)
Yes	76 (71 %)	39 (70 %)	37 (73 %)	p = 0.494
No - self-pay only	8 (7 %)	3 (5 %)	5 (10 %)
Unsure/Missing	23 (22 %)	14 (25 %)	9 (18 %)
Types of Insurance is accepted, n (%)
Commercial	36 (34 %)	25 (45 %)	11 (22 %)	p = 0.012
Medicare	56 (52 %)	33 (59 %)	23 (45 %)	p = 0.153
Medicaid	73 (68 %)	39 (70 %)	34 (67 %)	p = 0.741
Self-pay options	18 (17 %)	6 (11 %)	12 (24 %)	p = 0.077
Self-pay only	8 (7 %)	3 (5 %)	5 (10 %)	p = 0.382
Unsure/Missing	23 (21 %)	14 (25 %)	9 (18 %)	p = 0.355
ID Required
Yes	50 (47 %)	22 (39 %)	28 (55 %)	p = 0.237
No	37 (35 %)	23 (41 %)	14 (27 %)
Unsure	20 (19 %)	11 (20 %)	9 (18 %)

Of the 107 programs reached in the audit call stage, 96 programs (90 %) were accepting new patients for buprenorphine treatment at the time of the call (Fig. 1). Of the 11 programs unable to accept new patients, six were not currently accepting new intakes, two were no longer providing buprenorphine treatment, two clinics had closed, and one staff person was unsure.

During the audit calls, we also collected measures of administrative friction in prior to being offered an appointment (Table 2), which included requirements for multiple calls as well as holds or transfers before the appointment was offered. Of the 130 programs in the original sample, 42 % were able to be reached and provide an available appointment with a single call. The rate was 35 % for primary care programs and 49 % for specialty care programs, but this difference was not statistically significant. 26 % were unreachable, 38 % required one or more callbacks, and 31 % required one or more voicemails to be left and returned before an appointment was offered. The caller was placed on hold in 28 % and transferred in 31 % of calls prior to appointments being offered. Primary care programs were less likely to have call transfers than specialty care programs (22 % vs 41 %, p = 0.026), but otherwise there were no significant differences in administrative friction between primary care and specialty programs.

Table 2.

Appointment scheduling metrics.

Measures of Administrative Friction	Total (n = 130)	Primary Care (n = 71)	Specialty Care (n = 59)	p-value
First Call Resolution Rate	54 (42 %)	25 (35 %)	29 (49 %)	p = 0.108
Unreachable	21 (18 %)	15 (21 %)	8 (14 %)	p = 0.260
Multiple callbacks required	50 (38 %)	28 (56 %)	22 (44 %)	p = 0.230
≥ 1 Voicemails required	40 (31 %)	20 (28 %)	20 (34 %)	p = 0.481
≥ 1 Call transfers	40 (31 %)	16 (22 %)	24 (41 %)	p = 0.026
≥ 1 Times Placed on Hold	36 (28 %)	21 (30 %)	15 (25 %)	p = 0.598
Appointment Scheduling Metrics	Total (n = 88)	Primary Care (n = 46)	Specialty Care (n = 41)	p-value
Business Days to Appointment, Mean (SD)	13.3	16.8	9.4	p = 0.128
Business Days to Appointment, Median (IQR)	3	7	2	p = 0.004
Practice Categories
Accepts Walk-Ins	16 (18 %)	3 (7 %)	13 (32 %)	p = 0.015
1–2 Days	25 (28 %)	12 (26 %)	13 (32 %)
3–7 Days	18 (20 %)	10 (22 %)	8 (20 %)
8–30 Days	16 (18 %)	12 (26 %)	3 (7 %)
> 30 Days	13 (15 %)	9 (20 %)	4 (10 %)

For those programs accepting new patients, we collected appointment wait times for 88 of those programs (Table 2), with the remaining 8 programs unable to provide information about appointment availability without specific patient insurance information. Median time to available appointment was 3 business days, ranging from 0 to 120 days. 16 programs (18 %) accepted walk-ins, and 67 % of programs could schedule an initial appointment within a week. A minority of programs (18 %) could schedule within a month, and 15 % had wait times of more than 30 days. Specialty care programs had shorter median days to appointment compared to primary care (2 days vs. 7 days, p = 0.004) and were more likely to accept walk-in appointments.

For those programs reached during the audit call stage, we inquired about key buprenorphine prescribing practices and program requirements (Table 3). Only 42 % of programs reached could confirm the possibility of receiving a buprenorphine prescription on the first visit. 12 % never provided a prescription on intake and 44 % were unsure whether this was available. Nearly half of programs (48 %) could not report whether counseling was required to receive buprenorphine; 21 % reported requiring counseling or behavioral health services to receive buprenorphine treatment and 30 % did not. Continuation of treatment in the setting of ongoing substance use, including opioid use, was also mixed. 45 % of programs reported willingness to continue buprenorphine treatment when participants had ongoing substance use, and 29 % reported willingness to continue treatment if a participant returned to opioid use. A minority reported discontinuation of buprenorphine treatment in instances of non-opioid substance use (10 %) or return to opioid use (14 %), while many others were not able to provide this information to the caller. When we compared primary care versus specialty SUD treatment programs, primary care-based programs were more likely to report being unsure about practices overall. Specialty care models were more likely to provide information about the possibility of a medication on the first visit and to offer telehealth, but also more likely to require counseling and or discontinue buprenorphine with ongoing substance use. When looking at adoption of low-barrier practices overall (Fig. 2), a low proportion of programs adopted all the assessed low-barrier practices. Twenty-nine (27 %) programs could verify the possibility of a prescription on the first visit and confirm that behavioral health was not required to the caller. Only 14 programs (13 %) could verify those criteria plus confirm they would consider ongoing treatment in the setting of concurrent substance use.

Table 3.

Program requirements for buprenorphine treatment.

Policies		Total Responses (n = 107)		Primary Care (n = 56)		Specialty SUD (n = 51)		p-value
Is it possible to get medication prescribed on the first visit?	Yes	46	(43 %)	21	(38 %)	25	(49 %)	p = 0.002
	No	13	(12 %)	3	(5 %)	12	(24 %)
	Unsure	48	(45 %)	32	(57 %)	14	(27 %)
Is counseling or psychiatry care required?	Yes	28	(26 %)	2	(4 %)	26	(51 %)	p < 0.001
	No	38	(36 %)	22	(39 %)	16	(31 %)
	Unsure	41	(38 %)	32	(57 %)	9	(18 %)
Is telehealth possible?	Yes	33	(31 %)	10	(18 %)	23	(45 %)	p = 0.009
	No	14	(13 %)	8	(14 %)	6	(12 %)
	Unsure	60	(56 %)	38	(68 %)	22	(43 %)
How is return to opioid use addressed?	Discontinue buprenorphine or require higher LOC	16	(15 %)	5	(9 %)	12	(24 %)	p = 0.010
	Continue buprenorphine	30	(28 %)	12	(21 %)	18	(35 %)
	Unsure	58	(54 %)	39	(70 %)	21	(41 %)
How is other substance use addressed?	Discontinue buprenorphine or require higher LOC	10	(9 %)	3	(5 %)	7	(14 %)	p = 0.155
	Continue buprenorphine	25	(23 %)	11	(20 %)	14	(27 %)
	Unsure	72	(67 %)	42	(75 %)	30	(59 %)

LOC = level of care

Fig. 2.

Flowchart of programs adopting low-barrier policies.

4. Discussion

In this audit study of buprenorphine treatment programs in Philadelphia, median time-to-appointment was 3 business days for a simulated case manager trying to access care on behalf of a patient with a recent, nonfatal overdose. Although wait times were shorter than prior work, we found high levels of variability in clinical procedures that impact access and retention in buprenorphine treatment, limited transparency about these practices, and administrative friction associated with appointment scheduling, all of which present additional barriers to care. Despite the fact that buprenorphine is the standard of care for OUD and reduces mortality by more than 50 %, (National Academies of Science Engineering and Medicine, 2019) only four in ten clinics in our sample could confirm the possibility of a buprenorphine prescription at the initial visit. Half of clinics could not provide information about whether counseling was required as part of buprenorphine treatment, and only 13 % could confirm all assessed low-barrier practices were in place. Our findings come from a large urban epicenter of the overdose crisis, where access to treatment is critical and substantial efforts have been made to promote adoption of buprenorphine throughout the city’s treatment system (Stewart et al., 2021).

This study adds to the literature in several important ways. First, it simulates real-world experiences trying to access care. Prior work has shown that patients seeking addiction treatment are more likely to be engaged if they are seen on the same day compared to waiting two or more days (Roy et al., 2021). We started with a sample of 265 potentially eligible programs and were able to confirm buprenorphine prescribing in less than half. Approximately one quarter of the clinics were unreachable for audit calls despite confirmation of eligibility during the initial phone screen, demonstrating significant fluctuations in availability even during a short time period. Many others required multiple calls, voicemails, transfers, or long hold times prior to offering the appointment. In simulating the experience of real-world callers, this represents many dead ends or missed opportunities. Among those clinics who could schedule a visit, median wait time for an initial appointment in our study was three business days, and only 16 % of programs provided same-day or walk-in appointments. While this was shorter than Beetham et al. found in their study, (Beetham et al., 2019) the high degree of variability in timing and administrative friction in scheduling may still limit initial access to care when it is urgently needed. There was also substantial variability in whether and what type of insurance was accepted across programs, and other factors, such as requiring photo identification, were also seen in many of the programs in our study and may preclude treatment engagement or retention among the most marginalized patients.

We also saw a high degree of variability and limited transparency about clinical practices among our sample. A recent nonfatal overdose, the scenario in our audit call, is an urgent condition with an estimated 5.5 % mortality within a year (Weiner et al., 2020). Understanding requirements for treatment is critical for a patient seeking care, and being unable to meet expectations, especially in higher-barrier care models, sets patients up for poor retention (Gertner et al., 2022). Further, our study likely represents the best case scenario in terms of transparency. We made the choice to have our caller pose as a case manager, but patients seeking care likely have lower access to information. We also allowed for multiple calls, call transfers, voicemails, and other more liberal criteria in our study compared to other audit studies (Beetham et al., 2019), which may have allowed us to gather more detailed information than a typical patient or case manager would.

While more attention has been paid in the literature to barriers at the regulatory, payor, and pharmacy level, (Nguemeni Tiako et al., 2023; Hill et al., 2022; Mackey et al., 2020) there has been less focus on the ways day-to-day clinical practice impacts treatment engagement and retention. Our results suggest that adoption of the most updated buprenorphine treatment evidence is highly variable, with a small but notable minority of programs failing to provide buprenorphine on the first visit or endorsing discontinuing buprenorphine treatment in the setting of concurrent substance use (Substance Abuse and Mental Health Services Administration, 2021; Martin et al., 2018). Many other clinics in our study could not provide this information. There is evidence that high-barrier clinical policies and practices may lead to poor treatment retention (Gertner et al., 2022). Drivers of this practice variability are likely multifold. Some may be related to delays in adopting evidence-based practices that are seen throughout general clinical care, but some may be more specific to buprenorphine, including lack of knowledge and concerns about safety or legal repercussions, (Mackey et al., 2020) particularly worries about buprenorphine diversion despite evidence that non-prescribed buprenorphine is usually taken for treatment purposes (Rubel et al., 2023). Attitudes towards people with OUD, program culture, and organizational norms also likely play a significant role (Mackey et al., 2020). For example, in a survey of Missouri buprenorphine prescribers, more favorable views of people with OUD were associated with self-reported low-barrier prescribing practices, and positive attitudes towards OUD and medication treatment have been associated with higher uptake of MOUDs in other studies conducted in the Philadelphia behavioral health system (Stewart et al., 2021, 2023). Addressing drivers of adoption of evidence-based care will likely involve addressing outdated practices and risk aversion related to buprenorphine prescribing as well as more deeply held beliefs and stigma related to people who use drugs and addiction care.

Our findings have important implications for policy and practice. First, from the perspective and experience of patients seeking care, providing more transparency about how and where buprenorphine is offered should be a critical aspect of patient-centered care. One relatively simple strategy is for clinics offering buprenorphine to educate frontline staff about basic program policies and requirements. This was particularly true for primary care-based practices, which were less likely to be able to provide information to potential patients. Second, clinical practice continues to lag behind the evidence, and implementation and dissemination efforts of updated guidelines and quality measures is urgent. National, state, and local organizations can also disseminate clear guidance to providers about appropriate standards of care, including providing rapid access to buprenorphine without a waiting period or continuing care for patients in the event there is a return to substance use. Similarly, creating clearer guidance on elements that need not be required as part of buprenorphine treatment could help promote de-adoption of historical norms that are not backed by evidence. Finally, while the removal of DATA 2000 waiver, or X-waiver, was a promising step towards wider buprenorphine access, we have yet to see substantial increases in evidence of buprenorphine dispensing (Chua et al., 2024). Increasing buprenorphine access and retention will likely require addressing more subtle barriers to treatment, particularly among those already providing care. This could be accomplished through regulatory efforts, such as requirements for rapid medication access without a waiting period and greater transparency about program expectations as part of program accreditation or licensure. Although Philadelphia has a requirement that all publicly-funded specialty SUD treatment programs offer MOUDs (either through prescribing or referral), there could be benchmarks or quality measures that focus on patient uptake of MOUD and retention in care to better incentivize adoption. Payors should remove prior authorizations and other obstacles that disincentivize evidence-based practices, including allowing for appropriate dosing without prior authorization and removing counseling requirements for ongoing buprenorphine coverage (Nguemeni Tiako et al., 2023). Finally, wider adoption of in-person and virtual bridge clinic models is a promising step to reduce treatment disruptions (Lowenstein et al., 2022; Taylor et al., 2023). These models prioritize treatment on-demand and can accommodate walk-in and same-day treatment access more easily than traditional clinics, serving urgent needs and then referring patients back to their longitudinal prescriber.

This study has several important limitations. It was conducted in a single city at a single time point and may not represent the landscape or experience of buprenorphine treatment in other locations. Some programs may have been missed on the initial phone screen and therefore excluded from our study. Since we could not report on access or clinical practices among unreachable programs, this may bias our results as these programs may be more likely to be capacity-constrained or not offer buprenorphine treatment. We also cannot assess the support for buprenorphine among program staff and whether clients are encouraged or discouraged from buprenorphine treatment. Further, the caller was simulating a case manager role rather than a patient and may not reflect potential additional challenges that a patient would face in seeking care. Finally, not all providers or programs could answer all the questions, leaving us with missing data. However, because the focus of this study was understanding ease of access to buprenorphine and replicating the real-world experience of individuals seeking care, these limitations are all reflective of real-world experience and provide important information.

5. Conclusion

In conclusion, our secret shopper study revealed significant variability and limited same-day or next day access to buprenoprhine in Philadelphia, as well as persistence of policies that impose barriers to buprenorphine treatment despite the need for rapid, evidence-based care for people with OUD. Our findings underscore the need for transparency and adoption of evidence-based practices that facilitate patient engagement and retention in care. These challenges likely contribute to gaps in buprenorphine care, and addressing these issues will require targeted efforts to update clinical practice, ensuring that guidelines reflect the most current evidence. Future work to increase patient receipt of buprenorphine should address these clinician, practice, and system-level barriers.