Despite scientific evidence that the medication buprenorphine/naloxone (or Suboxone) effectively treats opioid use disorder (OUD), only one-sixth of Texas clinicians surveyed in 2019 and early 2020 said they were prescribing the lifesaving medication, according to a study from The University of Texas Health Science Center at San Antonio (UT Health San Antonio) published May 12 in JAMA Network Open.
“The U.S. Food and Drug Administration approved buprenorphine in 2002. It’s 2022 and we still see problems,” said Jennifer Sharpe Potter, PhD, MPH, the study senior author. Dr. Potter is professor of psychiatry and behavioral sciences, executive director of Be Well Texas, and vice president for research at UT Health San Antonio.
“Unfortunately, our data are consistent with reports using other methods that suggest lack of certified prescribers is a national problem,” Dr. Potter said.
The Drug Addiction Treatment Act (DATA) of 2000 made it possible for health care workers to obtain an “X-waiver” to prescribe buprenorphine. To be eligible, physicians needed to complete eight hours of qualified training before prescribing buprenorphine, and advanced practice providers including physician assistants, clinical nurse specialists and nurse practitioners needed to complete 24 hours of training.
UT Health San Antonio researchers sent surveys to more than 600 clinicians who attended X-waiver training courses offered statewide between March 2019 and February 2020. The team received responses from 126 clinicians, including 81 physicians, 37 nurse practitioners and eight physician assistants.
Among the 126 respondents, less than half (61) had received an X-waiver after attending the waiver training. Of those, almost two dozen were prescribing buprenorphine. Only 17% of survey respondents (22 of 126) were prescribing the lifesaving medication after attending the X-waiver training. This study contributes new evidence that X-waiver training is only part of the puzzle when it comes to understanding the barriers that clinicians must overcome to begin prescribing buprenorphine.
Policy change last year
During the COVID-19 pandemic, in April 2021, the U.S. Department of Health and Human Services published new practice guidelines to reduce the training burden for treating opioid use disorder with buprenorphine. According to the U.S. Substance Abuse and Mental Health Services Administration website, the revised guidelines “exempt eligible practitioners from certification requirements related to training and the provision of psychosocial services, which were previously necessary when dispensing or prescribing buprenorphine for the treatment of OUD to 30 or fewer patients.”
More than relief of training burden is needed
Dr. Potter and the team believe more than this exemption is needed to expand access to best practices in OUD care. Obstacles to adoption cited by survey respondents included, “Complexity of the X-waiver process,” “Perceived lack of professional support and referral network,” and “Getting started with prescribing buprenorphine.”
“The failure to treat OUD is part of the reason that we have the current rate of overdose deaths,” Dr. Potter said. “At a time of unprecedented opioid-related overdose deaths, there is now relief from the training burden of obtaining the X-waiver to prescribe buprenorphine, a medication that reduces the risk of overdose by 50%.”
A demonstrated need
Nearly 1,900 opioid overdose deaths were documented in Texas in 2020, according to the National Center for Health Statistics. In the JAMA Network Open paper, the authors cited sources that stated:
- Texas has the highest number of people in the country living outside of a 10-mile radius from a waivered clinician.
- Texas is among the top three states with the most individuals with OUD and the lowest number of X-waivered clinicians.
- The GetWaiveredTX Program, a Texas Health and Human Services-funded initiative, trained more than 700 Texas-based clinicians as qualified buprenorphine prescribers.
“If we are going to address the epidemic levels of overdose from drugs in the United States, we need to implement a comprehensive approach that includes making it easier for clinicians to treat OUD and reduce the burdens on providing this level of care,” Dr. Potter said.
“We can’t just provide relief from the waiver,” she added. “We must provide support so that clinicians know how to incorporate this into their practices in a way that is feasible for them.”
Survey of Barriers and Facilitators to Prescribing Buprenorphine and Clinician Perceptions on the Drug Addiction Treatment Act of 2000 Waiver
Holly J. Lanham, PhD, MBA; Jennifer Papac, MD; Daniela I. Olmos, BA; Emily L. Heydemann, MSW; Nathalia Simonetti, BS; Susanne Schmidt, PhD; Jennifer S. Potter, PhD, MPH
First published: May 12, 2022, JAMA Network Open