The Heller School for Social Policy and Management, Brandeis University
Background: Buprenorphine
in Office-Based Practice
Adoption of Buprenorphine by
Clinical Providers
• Drug Abuse Treatment Act of 2000 approved
buprenorphine (Subutex®, Suboxone®) for officebased treatment of opioid addiction
Cindy Parks Thomas, Sayeda Haq,
Sharon Reif, Alex Hoyt, Jon Chilingerian,
Stanley S. Wallack
• Major goal of legislation: to increase access to
treatment, encourage providers to address this
problem
• Past MD surveys show barriers to widespread use:
Presentation to the Academy Health Annual Research Meeting
2006
lack of insurance coverage, cost, availability of the
medication, statutory limit to the number of patients
an MD can treat at once
Brandeis University
Schneider Institute for Health Policy
• Context of other SA meds: naltrexone did not widely
diffuse; organizational role important
June 26, 2006
Research supported by the National Institute on Drug Abuse
Grant no. 5RO1 DA014578-02
1
2
Conceptual Model for
Adoption of Pharmacotherapy
in Substance Abuse Treatment
Brandeis Study: Diffusion of
Innovation Research
• Buprenorphine research funded by NIDA
:
Clinician characteristics
Demographics
Treatment orientation
Training and education
Knowledge
Attitude
Prior experience
• Diffusion models examine adoption, identify barriers
and predict facilitators
• Context of MD survey: within larger study to examine
Org.characteristics
Treatment orientation
Structure, Financing
Focus of organization
Patient base
Rules/policies
role of organizational/treatment setting factors and
interaction between MDs and organizations
¾
Survey of general psychiatrists and addiction specialists
¾
Survey of treatment organizations
Public policy
Disease prevalence
Service capacity and util
Market factors
Provider/patient
acceptance
Patients
use
Prescribe Yes/No
Patient attitudes
and
Characteristics
Char. of the technology
and organizational strategies predicting adoption
Market information
Cost, effectiveness
3
Source: Thomas, Wallack, et al, 2003
4
Research Questions & Hypotheses
Brandeis Buprenorphine
Research Model
Physicians
Decision to adopt/not adopt
Decision to make available
Decision to encourage
:
System characteristics
• Identify the clinician, technology, environmental factors
Knowledge, beliefs,
training, orientation
Org. acceptance
•
Treatment
Organizations
What factors are associated with MDs’ decisions to adopt
buprenorphine in office-based practice?
¾
Addiction specialists versus general psychiatrists
¾
MD personal characteristics
¾
MD treatment philosophy, attitudes and knowledge
9
¾
¾
Knowledge, rules, strategies,
culture, incentives,
structure, mission,
market, funding, patient mix
Primary affiliation with organizations that support adoption
9
•
Perceived benefits and costs are associated with adoption
Exposure to marketing and academic information
Particularly if the organization has strategies to influence MDs.
What is the relationship between MDs’ adoption of
buprenorphine and the treatment organizations in which they
practice?
Adoption
5
www.sihp.brandeis.edu • 781-736-3921 • cthomas@brandeis.edu
6
The Heller School for Social Policy and Management, Brandeis University
Methods
Survey Domains
• Mail and internet survey of MDs in four major
market areas: Addiction specialists and sample of
general psychiatrists
¾
Boston, Miami, San Francisco, Chicago
• N=286 addiction specialists (69% response rate);
N=224 general psychiatrists (55% response rate);
N=32 MD facility directors
• Bivariate and multivariate analysis of organization
factors and MD factors (separate models)
• Integrated model of interaction between MDs and
organizations
• Personal characteristics
• Practice characteristics
• Patient characteristics
• Substance abuse treatment philosophy
and approaches used
• Attitudes specifically toward buprenorphine
• Buprenorphine prescribing practices
• Networking
• Network analysis of MDs
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MD Practice Characteristics
Receiving the Waiver and
Prescribing Buprenorphine
100%
89.5%
Combined
64.8%
65.6%
Percent trained
or received
waiver
Percent
prescribing
55.6%
35.3%
40%
12.8%
20%
4.0%
0%
Total sample Addiction
(n=495)
specialists
(n=239)
Facility
Directors
(n=32)
General
psychiatrists
(n=224)
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Market Area Differences in Adoption
Addiction
Specialists
General
Psychiatrists
Prescribe
Yes
Prescribe
No
Prescribe
Yes
Prescribe
No
Prescribe
Yes
12.7
15.0*
14.5
12.8
11.3
15.2
% clinical time treating
addictions vs. other
clinical
33.5%
12.8%*
34.3%
31.8%
20.0%
5.4%*
% time specialty SA
facility
12.7%
5.3%*
13.5%
17.5%
0.6%
0.6%
% time solo practice
27.6%
33.6%
27.9%
28.2%
22.2%
35.7%
% time group practice
18.2%
9.8%*
19.2%
7.6%*
2.2%
10.6%*
% Heroin user clients
21.5%
9.5%*
22.2%
27.7%
9.0%
4.3%
% Rx opiate user clients
25.0%
10.3%*
29.8%
22.2%*
13.4%
7.0%
Mean years treating
addictions
90.6%
80%
60%
8
Prescribe
No
•Note small numbers for general psychiatrist prescribers!!
*Significant difference between prescribers and nonprescribers at p<.05
10
How Did MDs First Learn
About Buprenorphine?
60%
Addiction Specialists
Percent trained or received waiver
60%
40%
40%
20%
20%
10%
0%
0%
0%
40%
30%
an
Fr
n
Sa
General Psychiatrists
11
Jo
ur
na
la
Pr
rt
of
ic
es
le
si
s
on
al
SA
or
C
gs
M
ol
H
le
SA
ag
/C
ue
SA
s
ou
T
ts
C
id
ol
e
le
or
ag
g
ue
s
in
or
g
Sa
le
s
re
N
p
ew
s
m
ed
ia
Pa
tie
nt
s
H
ad
O
no
th
er
th
ea
rd
of
it
ci
ia
sc
m
o
i
go
M
ic
a
Ch
st
on
20%
Bo
M
ia
m
Sa
n
Ch
B
i
60%
Fr
an
ci
sc
o
80%
ic
ag
o
100%
80%
os
to
n
100%
Addiction Specialists
General Psychiatrists
50%
Percent prescribing
www.sihp.brandeis.edu • 781-736-3921 • cthomas@brandeis.edu
12
The Heller School for Social Policy and Management, Brandeis University
Physician Perceptions of their
Organizations
Organizational Support for
Prescribing Buprenorphine is
Important
Organization features
(Percent Agree )
271 Specialist Physicians and Medical Directors
Primary organization supports
N=137
51%
Prescribe
n=103
75%
Primary organization does not support
N=134
49%
Do not prescribe
n=34
25%
Prescribe
n=67
50%
Do not prescribe
n=67
50%
Organization
supports
Organization
does not
support
Medical director engages
providers***
78%
36%
Strong identification with org.
mission ***
92%
73%
General agreement on treatment
*** methods
90%
61%
Clinical decisions are affected by
costs
53%
63%
New treatment methods are
rewarded ***
83%
33%
Organization spends time and $ on
professional activities ***
67%
37%
Note: 19/32 medical directors are in organizations that do not support
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Importance of Organizations and
Information: “Less negative”
attitudes among nonprescribers
Organization
Supports
Organization does
not Support
Does not fit with my practice***
2.64
3.81
Waiver regs a signif. barrier**
1.64
1.92
Unpredictable benefits*
2.55
3.10
Diversion risk
3.17
3.29
Too complex**
1.93
2.50
Would adversely change the
makeup of my practice***
1.93
2.53
Insufficient evidence regarding
efficacy**
1.67
2.16
Barriers
(1=disagree, 6=agree)
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What Can Organizations do to
Promote Prescribing?
Percent of MDs getting waiver:
• Org recommends
79%
• Recommend +
83%
encourage training
• Recommend +
encourage training +
medical director engages
*Significant difference between organizations at p<.05
**Significant difference between organizations at p<.01
***Significant difference between organizations at p<.001
85%
15
Why Generalist Psychiatrists may not
be Prescribing Buprenorphine
Agree very much with:
*Significant difference across rows at p =< .05
**Significant difference across rows at p =< .01
***Significant difference across rows at p =< .001
Specialists
General
psychiatrists
Had not heard of it before survey***
0.42%
16%
Prescribe meds to reduce craving**
65%
48%
Does not fit in with my practice*
45%
60%
Org recommends use of bup***
52%
22%
Org strongly encourages training***
55%
13%
Drugs play very large role in SA treatment***
92%
73%
Buprenorphine is effective***
96%
72%
Consistent with rx philosophy of my
organization
89%
89%
Consistent with my treatment philosophy
91%
86%
72
6
Average number of opiate patients in past***
month (if >0)
*Significant difference between organizations at p= <.05
**Significant difference between organizations at p= <.01
***Significant difference between organizations at p= <.001
16
Top Facilitators and Barriers to
Prescribing (Rank order of
responses)
Addiction Specialists
General Psychiatrists
Barriers (reasons for not prescribing)
1.
2.
3.
4.
Does not fit in with my practice
Would change patient mix
undesirably
Do not have samples
Prescribing is too complex
1.
2.
3.
4.
Does not fit in with my practice
Would change patient mix
undesirably
Prescribing is too complex
Waiver regulation
Facilitators (reasons for prescribing)
1.
2.
3.
4.
Knowledge of buprenorphine’s
effectiveness
Consistent with treatment
philosophy
Patient requests
Local availability
1.
2.
3.
4.
Knowledge of buprenorphine’s
effectiveness
Consistent with treatment
philosophy
Local availability
Other counseling staff available
17
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18
The Heller School for Social Policy and Management, Brandeis University
Results Summary
• Adoption by generalist psychiatrists very limited to
date
• Organizations are critical for physicians to
• Adoption differs by market area: Why?
• Adoption greater if organization supports use
¾
complete adoption
¾
¾
Similar MD approaches to treatment, or is the organization doing
something to promote more adoption?
• Organizations have an effect on improving attitudes
toward buprenorphine, even for non-prescribers
• Strongest factors for adoption (preliminary model):
¾
Organization support, learned from CSAT, employed patients, belief in
effectiveness, more recently trained
• Information dissemination differs between addiction
specialists and general psychiatrists
¾
¾
Policy Implications
Fewer general psychiatrists know about buprenorphine
Professional organizations and CSAT less often source of information
for general psychiatrists
Aligned approaches and beliefs
Organizational support and engaged medical director
• Even with organizational support, some MDs may
be very late adopters
• General psychiatrists not engaged
¾
¾
¾
¾
Are the outreach resources sufficient?
How strong is the stigma or difficulty?
Is this the target of the legislation?
Will they adopt?
• Barriers (complexity, interest) may be mitigated
with additional experience as medication diffuses,
information disseminates and patients request it
19
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Next Steps in Research
• Network analysis of physician
communication and adoption patterns
Thank you!
• Examine the market and organizational
factors contributing to adoption
• Model the effect of the organization’s policies
and strategies on adoption
• International supplement: compare use and
attitudes in France and other countries to
U.S.
• Additional application of surveys in
Singapore
Questions?
Behavioral Health Center,
The Schneider Institute for Health Policy,
The Heller School for Social Policy and Management,
Brandeis University
21
www.sihp.brandeis.edu • 781-736-3921 • cthomas@brandeis.edu