Expansion of buprenorphine treatment may be limited by a lack of trained providers, limits on the number of patients each physician may treat, restrictions by payers, and the lack of access to counseling and other support services.
Before they can prescribe buprenorphine, physicians must complete 8 hours of special training and obtain a Drug Enforcement Agency (DEA) waiver. External grant funding which supported training courses ended in 2008. Opportunities to complete the training are now significantly more expensive and more limited. Even when physicians complete the training, they are not allowed to treat more than 30 patients with buprenorphine at one time during the first year. After that one-year period, physicians may apply for permission to treat up to a maximum of 100 patients at any time.
The law still restricts buprenorphine prescribing only to physicians. This limits widespread dissemination of the treatment in practice settings that depend on non-physician providers such as nurse practitioners and physician assistants.
Another factor inhibiting the expansion of buprenorphine treatment is that concern over the high cost of buprenorphine has led some insurers to restrict access. Managed care organizations often impose restrictions on the duration of buprenorphine treatment, as they have done with methadone in the past (McCarty, Frank, et al. 1999; Schackman, Merrill, et al. 2006). A recent study of private insurers found that one-third did not cover buprenorphine and that more than half placed it in the most expensive cost-sharing category (Horgan, Reif, et al. 2008). Many Medicare prescription drug plans also require higher co-payments for buprenorphine than for other medications.
Access to buprenorphine through Medicaid has been shown to be the primary driver in making this new treatment available to patients (Ducharme and Abraham 2008). Most states include buprenorphine in their Medicaid formularies, but many require prior authorization for buprenorphine treatment (Schackman, Merrill, et al. 2006). And, as the number of patients in treatment and the overall cost of the medication have increased, so have Medicaid program restrictions on its use. At least one state has mandated participation in structured treatment programs in order for Medicaid beneficiaries to receive buprenorphine treatment (Schackman, Merrill, et al. 2006). Other procedural barriers include dose restrictions, as well as limits on treatment duration, the number of pills that can be dispensed, and the number of prescription refills allowed (Schackman, Merrill, et al. 2006).
Finally, a number of recent studies have shown that physician and practice resource issues may need to be addressed to encourage further treatment expansion. Addiction treatment specialists (Thomas, Reif, et al. 2008)) and primary care physicians (Walley, Alperen, et al. 2008)) were more likely to provide buprenorphine treatment than general psychiatrists. A lack of trained staff, access to counseling, and office or institutional support are regularly cited by physicians as barriers to offering this treatment (Netherland, Botsko, et al. 2008; Thomas, Reif, et al. 2008; Walley, Alperen, et al. 2008).