Expanding Buprenorphine Use in Primary Care: Changing the Culture

Despite concerted media and public health attention, opioid overdose remains the leading cause of accidental death among young adults in the United States. ¹ Evidence shows that the most effective treatment for opioid use disorder (OUD) is opioid agonist treatment (OAT). ² OAT has been shown to be twice as effective at preventing relapse as behavioral treatment without OAT. ³ Despite these compelling results, the gap between maximum OAT capacity and treatment need is on the order of a million individuals in the United States. ⁴ Buprenorphine has limited abuse and overdose potential because its partial agonism it does not reach the same euphoric effects compared to full opioid agonists, and combining it with naloxone voids any effect if snorted or used intravenously. These characteristics make it an excellent choice in the outpatient setting. We describe the successful initiation of a primary care based OAT program at our academic, safety net medical center in a Midwest city. We have one hospital that is associated with eight federally qualified health centers.

In order to adequately address OUD, we must make OAT widely accessible through primary care clinics such as these. Yet, primary care physicians rarely prescribe buprenorphine. ^5,6 Why is it so underutilized? Commentators often point to the additional regulation placed on buprenorphine compared to other prescription medications. ^7,8 In the United States, prescribing buprenorphine is limited by a monthly cap and requires special permission (an “X-waiver”), which was accompanied by an 8-hour training requirement for physicians. Although, in 2021, the education requirement was removed, the requirement of a special waiver perpetuates an insistence on separating substance use disorders from other medical problems, stigmatizing its sufferers and fragmenting their care. In France, where these medications do not have additional restrictions, 91–99% of OAT is prescribed by primary care physicians. ⁹

American physicians often think of OUD as “a messy problem in a messy population” and, for these reasons, prefer patients get treatment in a specialist clinic. ^7,8,10 Like other maladies, OUD may require specialist consultation in complex cases. However, it would be unheard of for a primary care clinician to turn away a patient with type 2 diabetes with the explanation that they do not treat that disorder. Diabetic patients often return to clinic with a hemoglobin A1C greater than 10%. We do not typically refer these patients to on specialists because they have difficulty making the necessary lifestyle modifications. The existence of the X-waiver normalizes this attitude toward OUD.

This attitude is also propagated by the centrality of abstinence-based programs in the ecosystem of substance use disorder clinics. Such programs have been resistant to adopting medication for OUD at all. ^11,12 This community often believes administering buprenorphine or another opioid agonist merely exchanges one opioid for another, rather than treating the patient with OUD. ¹² This perspective has shaped physicians’ treatment of this disorder. Some do not accept OAT as a valid treatment, although this attitude is receding. ^7,10-12 Even among its proponents, OAT has been called “medication-assisted treatment” for much of its existence. We would not call lifestyle counseling in conjunction with insulin therapy “medication-assisted treatment” for type 2 diabetes. Before we can provide adequate treatment to the millions of Americans with OUD, we must eliminate the mental and cultural barrier we have erected between this disorder and others we treat on a regular basis.

Furthermore, most waivered physicians believe that OAT works, yet many prescribe far below their allowed capacity and others not at all. ⁵ Waivered physicians have cited information about counseling services, the mentorship of a physician experienced in OAT, and additional continuing medical education resources as items which would make them more willing to prescribe to additional patients. ⁶ These sentiments correspond to other data showing that physicians who do not prescribe buprenorphine, despite possessing a waiver, point to lack of counseling services, time constraints, and lack of confidence as the top three reasons for this decision. ⁵

To some extent, these anxieties are based on inaccurate beliefs. Though primary care physicians lack confidence in their abilities, they provide high-quality OAT with results that meet or exceed those of specialty clinics. ¹³ In the first 7 years after France began its successful drive to encourage primary care physicians to provide buprenorphine, overdose deaths decreased by approximately 80%. ¹⁴ The desire for better information about counseling resources likely reflects the paradigm that counseling is the primary treatment for OUD, to which OAT serves as a supplement. We believe the reverse is true. Multiple randomized controlled trials have shown that regular medical management is identical in opioid usage and retention in treatment when compared to medication with additional counseling of various kinds. ^15-18 Social workers and other specialists strengthen our program immeasurably, but our experience has reflected the data that simply seeing patients regularly in clinic and providing them with appropriate OAT is the single most important intervention.

Broadly speaking, the concerns identified by the clinicians above are rooted in the fear of being on their own and legally liable when it comes to OAT. This is understandable, especially after the medico-cultural whiplash of being cajoled into readily providing opiates for chronic pain and then implicated as the spark for our current surge in OUD. One aspect of this fear that we have observed is the mistaken sentiment that clinicians are individually obligated to ensure their patients are also enrolled in a traditional substance use treatment program. Our system has excellently integrated these options, yet we do not insist that all our patients on OAT use them. Although physicians ought to ensure that such resources are available in the community, we do not believe it would be ethically or clinically justifiable to withhold OAT on the grounds that we cannot guarantee nonpharmacologic treatment. To do so would be akin to refusing to prescribe metformin to patients with type 2 diabetes unless they enroll in intensive dietary counseling. Formal adoption of the guidelines published by the Substance Abuse and Mental Health Services Administration outlining criteria for treatment, starting doses, and titrating doses is one means by which health care organizations may ameliorate these concerns. Nonetheless, to achieve the best outcomes, local hospital systems must provide clinicians with the material resources necessary to treat OUD and to build their confidence in managing OAT.

When our institution began the push to provide OAT in primary care in 2017, only a small fraction of physicians were interested. A key step in changing their minds was the institutional decision to purchase 10% of one physician’s time to act as a champion and change agent in the process. This was coupled with hiring several social workers specifically to roll out a primary care buprenorphine program. This “institutional champion” strategy has been demonstrated to be effective, but it requires up-front investment from administrators. ¹⁰ Our physician champion was able to win over many colleagues who had previously been skeptical of buprenorphine. Doing so took persistent face-to-face relationship building with other clinicians in primary care, as well as those in emergency medicine and inpatient services. Additionally, one of the social workers had years of experience in OAT. She worked with interested physicians to support them as they developed confidence in their management skills. As they gradually increased the number of OUD patients they cared for, they found that integrating these patients into primary care was straightforward. Over time, these experiences permeated the system and changed the culture around OAT.

Beyond national treatment capacity, we have observed distinct advantages to treating OUD in the primary care setting. In our experience, patients with OUD often face inflexible work schedules and transportation issues. Primary care clinics often have longer hours than specialist offices, which ameliorates those problems. These patients often have other unaddressed health problems. By seeing them regularly in clinic, we have been able to build rapport and address their other chronic medical conditions.

Although we believe primary care management of OAT is key to adequate treatment of OUD, this requires buy-in from multiple departments. Health care systems must enlist clinicians in the hospital setting to facilitate a smooth transition to outpatient OAT with primary care. At our institution, monthly interdepartmental meetings and the aforementioned relationships with emergency medicine and hospitalist clinicians led to a system whereby these teams could provide five days of buprenorphine before discharging patients, and the primary care team could guarantee an appointment in that time frame. The Emergency Department started a program with onsite peer recovery coaches. The informatics team created a referral system that made it easy for the hospital-based clinicians to make urgent OAT referrals without unduly increasing their workload. The systemwide commitment to this mission was such that the Chief Medical Officer encouraged all physicians to become waivered and was available for call if none of the on-call physicians were waivered.

Beyond the day-to-day concerns, the grant writing department obtained additional funds for a social work position. Our hospital system also has a robust community mental health clinic, to which we were able to refer our most complicated OUD patients for a higher level of care when indicated. After some time, our system expanded our referral resources by hiring an addiction specialist who started a program specifically for pregnant women. To provide better care for the growing number of patients on OAT, our system eventually hired additional social workers. Although we took advantage of a grant early on, it quickly became apparent that the program was self-sustaining. Most patients in our system qualify for Medicaid, which covers clinician visits, counseling with social workers, and urine drug testing. Social workers can bill for therapy, and, therefore, do not require grant funding. A primary care office-based OAT program in Massachusetts found that the nurse care managers integral to their system generated over twice as much revenue as overhead. ¹⁹ Without the systemwide interventions to build support and coordinate these efforts at the outset, individual clinicians who wanted to provide OAT would have largely failed to create such sustainable change.

Two years after initiation of the program, over 200 people have been treated for OUD with buprenorphine within our primary care system. Now, 4 years after its inception, the program is currently treating over 375 patients. We have been able to sustain such a large program at a Federally Qualified Health Center in Indiana, a state that did not expand Medicaid under the Affordable Care Act. The success of this endeavor under these circumstances proves that the key ingredient in primary care OAT is the organizational commitment to break through cultural and clinical barriers. At the outset of its use in the United States, buprenorphine was mostly available in private practices to White, wealthy patient populations. ⁸ Black patients are still much less likely to receive buprenorphine than White patients. ²⁰ This threatens to recapitulate the broader pattern of substance use the United States. As emblematized by the “War on Drugs,” the use of intoxicants aside from alcohol, tobacco, and caffeine carries tremendous social stigma laden with racial and class associations. Though the current wave of opioid overdose deaths is widely referred to as the opioid epidemic, this nomenclature is misleading. Epidemics of OUD have occurred before, for example the surge in heroin use in the 1970 s among Black and Latino urban populations. Only now that prescription medications and White patients are at the center of the epidemic have greater medical resources been brought to bear on the problem. ⁸ FQHCs have a moral responsibility to take the lead in OUD treatment. We must show that appropriate therapy for OUD does not require inordinate financial or technical resources. Only when OAT is available to marginalized patients can we begin to repair the damage done by decades of unjust public drug policy and social stigmatization.