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Policy Pathways to Address Provider Workforce Barriers to Buprenorphine Treatment

      At least 2.3 million people in the U.S. have an opioid use disorder, less than 40% of whom receive evidence-based treatment. Buprenorphine used as part of medication-assisted treatment has high potential to address this gap because of its approval for use in non-specialty outpatient settings, effectiveness at promoting abstinence, and cost effectiveness. However, less than 4% of licensed physicians are approved to prescribe buprenorphine for opioid use disorder, and approximately 47% of counties lack a buprenorphine-waivered physician. Existing policies contribute to workforce barriers to buprenorphine provision and access. Providers are reticent to prescribe buprenorphine because of workforce barriers, such as (1) insufficient training and education on opioid use disorder treatment, (2) lack of institutional and clinician peer support, (3) poor care coordination, (4) provider stigma, (5) inadequate reimbursement from private and public insurers, and (6) regulatory hurdles to obtain the waiver needed to prescribe buprenorphine in non-addiction specialty treatment settings. Policy pathways to addressing these provider workforce barriers going forward include providing free and easy-to-access education for providers about opioid use disorders and medication-assisted treatment, eliminating buprenorphine waiver requirements for those licensed to prescribe controlled substances, enforcing insurance parity requirements, requiring coverage of evidence-based medication-assisted treatment as essential health benefits, and providing financial incentives for care coordination across healthcare professional types—including behavioral health counselors and other non-physicians in specialty and non-specialty settings.

      Supplement information

      This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

      Introduction

      Opioid misuse and overdose continue to escalate, contributing to the growing population with opioid use disorders (OUDs) in need of treatment. The opioid-related overdose death rate increased from 6.1 to 16.3 deaths per 100,000 people from 1999 to 2015, totaling 33,091 deaths in the U.S. in 2015.
      • Rudd R.A.
      • Aleshire N.
      • Zibbell J.E.
      • Gladden R.M.
      Increases in drug and opioid overdose deaths—United States, 2000–2014.
      • Rudd R.A.
      • Seth P.
      • David F.
      • Scholl L.
      Increases in drug and opioid-involved overdose deaths—United States, 2010–2015.
      Rates of opioid-related substance use treatment admissions have followed a similar trajectory.
      Centers for Disease Control and Prevention (CDC)
      Vital signs: overdoses of prescription opioid pain relievers–United States, 1999–2008.
      Despite recent abatements in prescription opioid dispensing and use,
      • Guy G.P.
      • Zhang K.
      • Bohm M.K.
      • et al.
      Vital signs: changes in opioid prescribing in the United States, 2006–2015.
      prescribing contributes heavily to those who are misusing opioids.
      • Lankenau S.E.
      • Teti M.
      • Silva K.
      • Bloom J.J.
      Initiation into prescription opioid misuse amongst young injection drug users.
      HHS. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings
      HHS Publication No. (SMA) 11-4658.
      • Cicero T.J.
      • Ellis M.S.
      • Surratt H.L.
      • Kurtz S.P.
      The changing face of heroin use in the United States: a retrospective analysis of the past 50 years.
      • Muhuri P.K.
      • Gfroerer J.C.
      • Davies M.C.
      Associations of nonmedical pain reliever use and initiation of heroin use in the United States.
      • Jones C.M.
      Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers—United States, 2002–2004 and 2008–2010.
      Moreover, overdoses and infectious diseases resulting from opioid injection drug use continue to climb, and are increasingly attributed to heroin and potent synthetic opioids, such as fentanyl.
      • Rudd R.A.
      • Aleshire N.
      • Zibbell J.E.
      • Gladden R.M.
      Increases in drug and opioid overdose deaths—United States, 2000–2014.
      • Rudd R.A.
      • Seth P.
      • David F.
      • Scholl L.
      Increases in drug and opioid-involved overdose deaths—United States, 2010–2015.
      • Peters P.J.
      • Pontones P.
      • Hoover K.W.
      • et al.
      HIV infection linked to injection use of oxymorphone in Indiana, 2014–2015.
      Meeting the clinical criteria for an OUD—or a “problematic pattern of opioid use leading to clinically significant impairments or distress,”
      American Psychiatric Association
      —increases a person’s risk of early death (typically from overdose, trauma, suicide, or infectious disease transmission) by a factor of 20.
      • Degenhardt L.
      • Larney S.
      • Kimber J.
      • et al.
      The impact of opioid substitution therapy on mortality post-release from prison: retrospective data linkage study.
      • Teesson M.
      • Marel C.
      • Darke S.
      • et al.
      Long-term mortality, remission, criminality and psychiatric comorbidity of heroin dependence: 11-year findings from the Australian Treatment Outcome Study.
      • Evans E.
      • Li L.
      • Min J.
      • et al.
      Mortality among individuals accessing pharmacological treatment for opioid dependence in California.
      • Hser Y.-I.
      • Saxon A.J.
      • Huang D.
      • et al.
      Treatment retention among patients randomized to buprenorphine/naloxone compared to methadone in a multi-site trial.
      • Spiller M.W.
      • Broz D.
      • Wejnert C.
      • Nerlander L.
      • Paz-Bailey G.
      HIV infection and HIV-associated behaviors among injecting drug users–20 cities, United States.
      The prevalence of OUDs has increased significantly over time, from approximately 1.5 million in 2003 to more than 2.3 million in 2015.
      • Jones C.M.
      • Campopiano M.
      • Baldwin G.
      • McCance-Katz E.
      National and state treatment need and capacity for opioid agonist medication-assisted treatment.
      Substance Abuse and Mental Health Services Administration (SAMHSA). Results from the 2016 National Survey on Drug Use and Health: Detailed Tables Prevalence Estimates, Standard Errors, P Values, and Sample Sizes. Published 2017.
      Despite the risks of untreated OUD, the gap between OUD prevalence and evidence-based medication-assisted treatment (MAT) capacity was close to 1 million in 2012.
      • Jones C.M.
      • Campopiano M.
      • Baldwin G.
      • McCance-Katz E.
      National and state treatment need and capacity for opioid agonist medication-assisted treatment.
      Buprenorphine, one of three medications used as part of MAT, has high potential to address the persistent OUD treatment gap. Buprenorphine is approved for use in non-specialty outpatient settings,
      • Amato L.
      • Davoli M.
      • Perucci C.A.
      • et al.
      An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform clinical practice and research.
      has demonstrated effectiveness at promoting abstinence and reducing opioid-related overdoses,
      • Amato L.
      • Davoli M.
      • Perucci C.A.
      • et al.
      An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform clinical practice and research.
      • Nielsen S.
      • Larance B.
      • Lintzeris N.
      Opioid agonist treatment for patients with dependence on prescription opioids.
      • Schuckit M.A.
      Treatment of opioid-use disorders.
      • Fiellin D.A.
      • Schottenfeld R.S.
      • Cutter C.J.
      • Moore B.A.
      • Barry D.T.
      • O’Connor P.G.
      Primary care-based buprenorphine taper vs maintenance therapy for prescription opioid dependence: a randomized clinical trial.
      • Mattick R.P.
      • Breen C.
      • Kimber J.
      • Davoli M.
      Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence.
      • Sordo L.
      • Barrio G.
      • Bravo M.J.
      • et al.
      Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies.
      and is cost effective.
      • Schackman B.R.
      • Leff J.A.
      • Polsky D.
      • Moore B.A.
      • Fiellin D.A.
      Cost-effectiveness of long-term outpatient buprenorphine-naloxone treatment for opioid dependence in primary care.
      However, according to the Substance Abuse and Mental Health Services Administration (SAMHSA), less than 4% of licensed physicians were approved to prescribe buprenorphine in 2017. In 2016, overall 47% of counties—and 72% of rural counties—lacked a buprenorphine-waivered physician.

      The President’s Commission on Combatting Drug Addiction and the Opioid Crisis. Final Report of The President’s Commission on Combating Drug Addiction and the Opioid Crisis. www.whitehouse.gov/sites/whitehouse.gov/files/images/Final_Report_Draft_11-1-2017.pdf. Published 2017.

      Although buprenorphine capacity has increased since 2002—when it was first approved for OUD treatment in office-based settings—the treatment gap has not significantly narrowed because of the increasing population with OUDs.
      • Jones C.M.
      • Campopiano M.
      • Baldwin G.
      • McCance-Katz E.
      National and state treatment need and capacity for opioid agonist medication-assisted treatment.
      Moreover, many buprenorphine-approved prescribers treat far fewer than the number of patients allowed by regulations.
      • Jones C.M.
      • Campopiano M.
      • Baldwin G.
      • McCance-Katz E.
      National and state treatment need and capacity for opioid agonist medication-assisted treatment.
      • Stein B.D.
      • Gordon A.J.
      • Dick A.W.
      • et al.
      Supply of buprenorphine waivered physicians: the influence of state policies.
      • Sigmon S.C.
      The untapped potential of office-based buprenorphine treatment.
      Estimates range, but suggest that only 20%–40% of people with OUDs are receiving MAT.
      • Jones C.M.
      • Campopiano M.
      • Baldwin G.
      • McCance-Katz E.
      National and state treatment need and capacity for opioid agonist medication-assisted treatment.
      • Lembke A.
      • Chen J.H.
      Use of opioid agonist therapy for Medicare patients in 2013.
      • Saloner B.
      • Karthikeyan S.
      Changes in substance abuse treatment use among individuals with opioid use disorders in the United States, 2004–2013.
      Despite some recent policy successes in expanding buprenorphine treatment insurance coverage, funding, and provider capacity, significant provider and policy barriers remain and must be addressed to capitalize on this promising treatment at a time of dire public health need. This article provides a brief history of MAT and the factors contributing to buprenorphine’s promise. It then outlines persistent provider workforce barriers to buprenorphine provision in the U.S. and policy recommendations to address them.

      Brief History of Medication-Assisted TREATMENT

      By definition, MAT combines behavioral therapy and medications to treat OUDs.
      • Volkow N.D.
      • Frieden T.R.
      • Hyde P.S.
      • Cha S.S.
      Medication-assisted therapies—tackling the opioid overdose epidemic.
      The Food and Drug Administration (FDA) has approved three medications for the indication of opioid dependence: methadone, buprenorphine, and naltrexone. Methadone and buprenorphine are full and partial opioid agonists, respectively, which bind to the μ-opioid receptor. These long-term opioid maintenance therapies reduce painful symptoms associated with opioid withdrawal and block the euphoric effects of other drugs.
      • Schuckit M.A.
      Treatment of opioid-use disorders.

      Medication-assisted treatment improves outcomes for patients with opioid use disorder. www.pewtrusts.org/~/media/assets/2016/11/medicationassistedtreatment_v3.pdf. Published 2016.

      Because buprenorphine is only a partial agonist, it has a ceiling effect; in other words, its euphoric effects plateau rather than increase with heightened dosing.
      • Schuckit M.A.
      Treatment of opioid-use disorders.

      Medication-assisted treatment improves outcomes for patients with opioid use disorder. www.pewtrusts.org/~/media/assets/2016/11/medicationassistedtreatment_v3.pdf. Published 2016.

      Methadone and buprenorphine are Schedule II and III drugs on the Drug Enforcement Agency’s Controlled Substances Schedules, meaning they have high or some potential for abuse, respectively, which may lead to physical or psychological dependence.

      Title 21 United States Code (USC) Controlled Substances Act—Section 801. www.deadiversion.usdoj.gov/21cfr/21usc/801.htm. Accessed June 21, 2017.

      Naltrexone is not a controlled substance and works as an opioid antagonist—meaning it blocks the μ-opioid receptor and negates the effects of opioids.
      • Schuckit M.A.
      Treatment of opioid-use disorders.

      Medication-assisted treatment improves outcomes for patients with opioid use disorder. www.pewtrusts.org/~/media/assets/2016/11/medicationassistedtreatment_v3.pdf. Published 2016.

      Methadone was the first MAT medication available. A synthetic opioid developed in Germany in 1937, methadone was initially used as an analgesic.

      Rinaldo SG, Rinaldo DW. Advancing access to addiction medication: implications for opioid addiction treatment. www.asam.org/docs/default-source/advocacy/aaam_implications-for-opioid-addiction-treatment_final. Published 2013.

      The FDA approved methadone for addiction treatment in 1972. Its provision in opioid treatment programs (OTPs) is federally regulated, for example, requiring some patient counseling and national accreditation, and subject to additional state oversight.

      Rinaldo SG, Rinaldo DW. Advancing access to addiction medication: implications for opioid addiction treatment. www.asam.org/docs/default-source/advocacy/aaam_implications-for-opioid-addiction-treatment_final. Published 2013.

      42 CFR 8.12 Federal Opioid Treatment Standards. 2001:65-69. U.S. Government Publishing Office. www.gpo.gov/fdsys/granule/CFR-2002-title42-vol1/CFR-2002-title42-vol1-sec8-12.

      Methadone is a long-acting opioid taken once daily under OTP supervision, in part because of concerns over diversion, although certain stabilized patients may take the medication offsite. The supply of OTPs has remained relatively constant over time, with around 1,500 facilities accredited in 2017.
      • Jones C.M.
      • Campopiano M.
      • Baldwin G.
      • McCance-Katz E.
      National and state treatment need and capacity for opioid agonist medication-assisted treatment.

      Substance Abuse and Mental Health Services Administration (SAMHSA). Opioid Treatment Program Directory. http://dpt2.samhsa.gov/treatment/directory.aspx. Published 2017. Accessed June 28, 2017.

      Methadone has a strong evidence base establishing its effectiveness at increasing treatment retention and reducing opioid use, mortality, and risky behaviors that increase HIV and hepatitis transmission.
      • Amato L.
      • Davoli M.
      • Perucci C.A.
      • et al.
      An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform clinical practice and research.
      • Schuckit M.A.
      Treatment of opioid-use disorders.
      • Mattick R.P.
      • Breen C.
      • Kimber J.
      • Davoli M.
      Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence.
      • Sordo L.
      • Barrio G.
      • Bravo M.J.
      • et al.
      Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies.
      • Schwartz R.P.
      • Gryczynski J.
      • O’Grady K.E.
      • et al.
      Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995–2009.
      • Tsui J.I.
      • Evand J.L.
      • Lum P.J.
      • Hahn J.A.
      • Page K.
      Association of opioid agonist therapy with lower incidence of hepatitis C virus infection in young adult injection drug users.
      • Strang J.
      • Babor T.
      • Caulkins J.
      • Fischer B.
      • Foxcroft D.
      • Humphreys K.
      Drug policy and the public good: evidence for effective interventions.
      • Timko C.
      • Schultz N.R.
      • Cucciare M.A.
      • Vittorio L.
      • Garrison-Diehn C.
      Retention in medication-assisted treatment for opiate dependence: a systematic review.
      • Nielsen S.
      • Larance B.
      • Degenhardt L.
      • Gowing L.
      • Kehler C.
      • Lintzeris N.
      Opioid agonist treatment for pharmaceutical opioid dependent people.
      • Mattick R.P.
      • Breen C.
      • Kimber J.
      • Davoli M.
      Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence.
      • Metzger D.S.
      • Woody G.E.
      • McLellah A.T.
      • et al.
      Human immunodeficiency virus seroconversion among intravenous drug users in-and out-of-treatment: an 18-month prospective follow-up.
      Barriers to methadone treatment provision and access are numerous, however, and include a shortage of providers; waitlists for treatment; stigma and patient costs of treatment (daily time, transportation); drug–drug interaction risks; and stringent regulatory requirements.
      • Jones C.M.
      • Campopiano M.
      • Baldwin G.
      • McCance-Katz E.
      National and state treatment need and capacity for opioid agonist medication-assisted treatment.
      • Schuckit M.A.
      Treatment of opioid-use disorders.
      • Volkow N.D.
      • Frieden T.R.
      • Hyde P.S.
      • Cha S.S.
      Medication-assisted therapies—tackling the opioid overdose epidemic.

      Rinaldo SG, Rinaldo DW. Advancing access to addiction medication: implications for opioid addiction treatment. www.asam.org/docs/default-source/advocacy/aaam_implications-for-opioid-addiction-treatment_final. Published 2013.

      • Gryczynski J.
      • Schwartz R.P.
      • O’Grady K.E.
      • Restivo L.
      • Mitchell S.G.
      • Jaffe J.H.
      Understanding patterns of high-cost health care use across different substance user groups.
      • Rosenblum A.
      • Cleland C.M.
      • Fong C.
      • Kayman D.J.
      • Tempalski B.
      • Parrino M.
      Distance traveled and cross-state commuting to opioid treatment programs in the United States.
      • Olsen Y.
      • Sharfstein J.M.
      Confronting the stigma of opioid use disorder—and its treatment.
      Naltrexone is a newer drug to the market for OUD treatment. The FDA initially approved a once-daily naltrexone tablet in 1984. In 2010, the FDA approved an injectable product, Vivitrol, to be administered once monthly for OUD treatment, which now dominates the naltrexone market.

      Rinaldo SG, Rinaldo DW. Advancing access to addiction medication: implications for opioid addiction treatment. www.asam.org/docs/default-source/advocacy/aaam_implications-for-opioid-addiction-treatment_final. Published 2013.

      Any licensed prescriber can provide this noncontrolled substance. Insurance increasingly covers the costs for naltrexone.

      Rinaldo SG, Rinaldo DW. Advancing access to addiction medication: implications for opioid addiction treatment. www.asam.org/docs/default-source/advocacy/aaam_implications-for-opioid-addiction-treatment_final. Published 2013.

      In addition, the drug avoids the addiction, diversion, and drug interaction concerns presented by opioid agonist therapies.
      • Volkow N.D.
      • Frieden T.R.
      • Hyde P.S.
      • Cha S.S.
      Medication-assisted therapies—tackling the opioid overdose epidemic.
      It holds appeal for some policymakers and providers who espouse abstinence-only approaches to OUD recovery, based on longstanding philosophical beliefs about addiction with little empirical support.

      Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC. https://addiction.surgeongeneral.gov/surgeon-generals-report.pdf. Published 2016.

      Robust evidence establishing naltrexone’s effects on increasing treatment retention and reducing overdose risk is developing, although its effectiveness over the longer term and among patients whose OUD symptoms are not stable has yet to be established.
      • Schuckit M.A.
      Treatment of opioid-use disorders.
      • Minozzi S.
      • Amato L.
      • Vecchi S.
      • Davoli M.
      • Kirchmayer U.
      • Verster A.
      Oral naltrexone maintenance treatment for opioid dependence.
      • Comer S.D.
      • Sullivan M.A.
      • Elmer Y.
      • et al.
      Injectable, sustained-release naltrexone for the treatment of opioid dependence: a randomized, placebo-controlled trial.
      • Tanum L.
      • Solli K.K.
      • Latif Z.-H.
      • et al.
      The effectiveness of injectable extended-release naltrexone vs daily buprenorphine-naloxone for opioid dependence: a randomized clinical noninferiority trial.
      • Lee J.D.
      • Nunes E.V.
      • Novo P.
      • et al.
      Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT): a multicentre, open-label, randomised controlled trial.
      Patients must be abstinent for approximately 7 days, without acute withdrawal symptoms, to commence naltrexone treatment, presenting a significant patient barrier for many; moreover, it can complicate opioid pain treatment because it blocks the μ-opioid receptor.
      • Schuckit M.A.
      Treatment of opioid-use disorders.
      Behavioral health therapy that accompanies MAT can include counseling, family therapy, and peer support programs, among other forms.

      Pew Charitable Trusts. The case for medication-assisted treatment. www.pewtrusts.org/~/media/assets/2017/02/thecasemedicationassistedtreatment.pdf. Published 2017.

      Although behavioral health therapy when used to treat OUDs alone or in combination with MAT medications has not been shown in rigorous trials to reduce opioid use or increase adherence to treatment,
      • Nielsen S.
      • Larance B.
      • Lintzeris N.
      Opioid agonist treatment for patients with dependence on prescription opioids.
      • Fiellin D.A.
      • Pantalon M.V.
      • Chawarski M.C.
      • et al.
      Counseling plus buprenorphine–naloxone maintenance therapy for opioid dependence.
      • Fiellin D.A.
      • Barry D.T.
      • Sullivan L.E.
      • et al.
      A randomized trial of cognitive behavioral therapy in primary care-based buprenorphine.
      these services are recommended to accompany MAT medication and considered best practices.
      • Volkow N.D.
      • Frieden T.R.
      • Hyde P.S.
      • Cha S.S.
      Medication-assisted therapies—tackling the opioid overdose epidemic.

      Pew Charitable Trusts. The case for medication-assisted treatment. www.pewtrusts.org/~/media/assets/2017/02/thecasemedicationassistedtreatment.pdf. Published 2017.

      American Society of Addiction Medicine. National practice guideline for the use of medications in the treatment of addiction involving opioid use. https://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf?sfvrsn=24. Published 2015.

      • Lagisetty P.
      • Klasa K.
      • Bush C.
      • Heisler M.
      • Chopra V.
      • Bohnert A.
      Primary care models for treating opioid use disorders: what actually works? a systematic review.

      Buprenorphine’s Promise

      The third MAT medication, buprenorphine, was first available only in tablet form; now it is also delivered by once-daily sublingual films, injection, and implantable devices. Both tablets and films are available as buprenorphine-alone products and buprenorphine–naloxone combination products.

      Rinaldo SG, Rinaldo DW. Advancing access to addiction medication: implications for opioid addiction treatment. www.asam.org/docs/default-source/advocacy/aaam_implications-for-opioid-addiction-treatment_final. Published 2013.

      Buprenorphine–naloxone deters abuse because naloxone attenuates buprenorphine’s partial agonist effects, thereby making the product less desirable to misuse for a euphoric high. In 2016, the FDA approved Probuphine, an implantable buprenorphine device, which lasts for 6 months.
      Buprenorphine implants (Probuphine) for opioid dependence.
      Probuphine is recommended for patients who have established a stable oral dose of less than 8 mg daily of buprenorphine for maintenance therapy.

      Drugs.com. Probuphine dosage. www.drugs.com/dosage/probuphine.html. Published 2017. Accessed October 27, 2017.

      In late 2017, the FDA approved a monthly buprenorphine injectable, Sublocade, indicated for patients who have been on a stable dose of buprenorphine treatment for at least 7 days, and other injectable forms are in the pipeline.

      Food and Drug Administration. Press release: FDA approves first once-monthly buprenorphine injection, a medication-assisted treatment option for opioid use disorder. www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm587312.htm. Published November 30, 2017.

      Buprenorphine has demonstrated effectiveness in increasing treatment retention, reducing opioid use, reducing mortality, and reducing the transmission of HIV and hepatitis C.
      • Nielsen S.
      • Larance B.
      • Lintzeris N.
      Opioid agonist treatment for patients with dependence on prescription opioids.
      • Fiellin D.A.
      • Schottenfeld R.S.
      • Cutter C.J.
      • Moore B.A.
      • Barry D.T.
      • O’Connor P.G.
      Primary care-based buprenorphine taper vs maintenance therapy for prescription opioid dependence: a randomized clinical trial.
      • Mattick R.P.
      • Breen C.
      • Kimber J.
      • Davoli M.
      Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence.
      • Sordo L.
      • Barrio G.
      • Bravo M.J.
      • et al.
      Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies.
      • Schwartz R.P.
      • Gryczynski J.
      • O’Grady K.E.
      • et al.
      Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995–2009.
      • Tsui J.I.
      • Evand J.L.
      • Lum P.J.
      • Hahn J.A.
      • Page K.
      Association of opioid agonist therapy with lower incidence of hepatitis C virus infection in young adult injection drug users.
      • Timko C.
      • Schultz N.R.
      • Cucciare M.A.
      • Vittorio L.
      • Garrison-Diehn C.
      Retention in medication-assisted treatment for opiate dependence: a systematic review.
      • Nielsen S.
      • Larance B.
      • Degenhardt L.
      • Gowing L.
      • Kehler C.
      • Lintzeris N.
      Opioid agonist treatment for pharmaceutical opioid dependent people.
      • Fiellin D.A.
      • Pantalon M.V.
      • Chawarski M.C.
      • et al.
      Counseling plus buprenorphine–naloxone maintenance therapy for opioid dependence.
      • Weiss R.D.
      • Potter J.S.
      • Griffin M.L.
      • et al.
      Long-term outcomes from the National Drug Abuse Treatment Clinical Trials Network Prescription Opioid Addiction Treatment Study.
      • Ling W.
      • Mooney L.
      • Torrington M.
      Buprenorphine for opioid addiction.

      Hancock C, Mennenga H, King N, Andrilla H, Larson E, Schou P. National Rural Health Association Policy Brief: treating the rural opioid epidemic. www.ruralhealthweb.org/NRHA/media/Emerge_NRHA/Advocacy/Policy%20documents/Treating-the-Rural-Opioid-Epidemic_Feb-2017_NRHA-Policy-Paper.pdf. Published 2017.

      • Winstock A.R.
      • Lea T.
      • Sheridan J.
      Prevalence of diversion and injection of methadone and buprenorphine among clients receiving opioid treatment at community pharmacies in New South Wales, Australia.
      Buprenorphine in medium to high doses is as effective as methadone at increasing treatment retention and reducing illicit opioid use.
      • Schuckit M.A.
      Treatment of opioid-use disorders.
      • Mattick R.P.
      • Breen C.
      • Kimber J.
      • Davoli M.
      Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence.
      Buprenorphine–naloxone also has been shown to be cost effective in long-term, office-based settings compared with no treatment, with a cost-effectiveness ratio of $35,100 per quality-adjusted life year.
      • Schackman B.R.
      • Leff J.A.
      • Polsky D.
      • Moore B.A.
      • Fiellin D.A.
      Cost-effectiveness of long-term outpatient buprenorphine-naloxone treatment for opioid dependence in primary care.
      Although the medication cost of buprenorphine is higher than that for methadone, when administrative costs of running stand-alone OTPs and transportation costs for patients receiving methadone are factored in, buprenorphine’s cost may actually be lower.

      Hancock C, Mennenga H, King N, Andrilla H, Larson E, Schou P. National Rural Health Association Policy Brief: treating the rural opioid epidemic. www.ruralhealthweb.org/NRHA/media/Emerge_NRHA/Advocacy/Policy%20documents/Treating-the-Rural-Opioid-Epidemic_Feb-2017_NRHA-Policy-Paper.pdf. Published 2017.

      As outpatient access to buprenorphine has expanded, concerns about associated increases in diversion and overdose deaths (particularly among children) have been raised.
      • Winstock A.R.
      • Lea T.
      • Sheridan J.
      Prevalence of diversion and injection of methadone and buprenorphine among clients receiving opioid treatment at community pharmacies in New South Wales, Australia.
      • Macy B.
      Addicted to a treatment for addiction.
      However, much of the diversion and death evidence comes from other countries, and the magnitude of adverse outcomes is small in comparison to that of other prescribed opioids.
      • Winstock A.R.
      • Lea T.
      • Sheridan J.
      Prevalence of diversion and injection of methadone and buprenorphine among clients receiving opioid treatment at community pharmacies in New South Wales, Australia.
      • Lofwall M.R.
      • Walsh S.L.
      A review of buprenorphine diversion and misuse: the current evidence base and experiences from around the world.
      • Manchikanti L.
      • Whitfield E.
      • Pallone F.
      Evolution of the National All Schedules Prescription Electronic Reporting Act (NASPER): a public law for balancing treatment of pain and drug abuse and diversion.
      Moreover, those misusing buprenorphine often do so to reduce withdrawal symptoms rather than experience euphoria.
      • Lofwall M.R.
      • Walsh S.L.
      A review of buprenorphine diversion and misuse: the current evidence base and experiences from around the world.
      • Sarpatwari A.
      Just say no: the case against the reclassification of buprenorphine.
      • Daniulaityte R.
      • Falck R.
      • Carlson R.G.
      Illicit use of buprenorphine in a community sample of young adult non-medical users of pharmaceutical opioids.
      Office-based prescribers, including primary care physicians, can prescribe buprenorphine. Buprenorphine was the first drug to be prescribed under the Drug Addiction Treatment Act of 2000 (DATA 2000), intended to make MAT available to more diverse geographic populations and from general practitioners.
      • Jones C.M.
      • Campopiano M.
      • Baldwin G.
      • McCance-Katz E.
      National and state treatment need and capacity for opioid agonist medication-assisted treatment.

      106th U.S. Congress. Drug Addiction Treatment Act of 2000. www.gpo.gov/fdsys/pkg/PLAW-106publ310/pdf/PLAW-106publ310.pdf.

      Under DATA 2000, qualified physicians may apply for a SAMHSA waiver from the Controlled Substances Act requirement that opioid dependency treatment with scheduled drugs be conducted within an OTP.

      106th U.S. Congress. Drug Addiction Treatment Act of 2000. www.gpo.gov/fdsys/pkg/PLAW-106publ310/pdf/PLAW-106publ310.pdf.

      To be waiver eligible, DATA 2000 requires that physicians have a demonstrated or certified ability to treat and manage opiate-dependent patients, for example, by completing at least 8 hours of training; and be in a practice with the capacity to refer patients for counseling and other ancillary services.

      106th U.S. Congress. Drug Addiction Treatment Act of 2000. www.gpo.gov/fdsys/pkg/PLAW-106publ310/pdf/PLAW-106publ310.pdf.

      Initially, physicians could prescribe approved MATs under DATA 2000 for up to 30 patients.

      106th U.S. Congress. Drug Addiction Treatment Act of 2000. www.gpo.gov/fdsys/pkg/PLAW-106publ310/pdf/PLAW-106publ310.pdf.

      As of 2007, physicians could apply to increase that panel after the first year to 100 patients.

      109th U.S. Congress. Office of the National Drug Control Policy Reauthorization Act of 2006. www.congress.gov/109/plaws/publ469/PLAW-109publ469.pdf.

      As of August 2016, physicians could apply to increase their patient panels to 275 after a year, provided they either (1) have additional credentialing in addiction medicine or addiction psychiatry from a specialty medical board or professional society, or (2) work in a qualified practice setting that provides comprehensive MAT.
      Substance Abuse and Mental Health Services Administration (SAMHSA)
      Medication assisted treatment for opioid use disorders; final rule.
      A further rule was implemented as a part of the Comprehensive Addiction and Recovery Act of 2016, allowing nurse practitioners and physician assistants to prescribe buprenorphine until October 1, 2021, for up to 30 patients if they complete 24 hours of addiction treatment training.

      114th U.S. Congress. Comprehensive Addiction and Recovery Act of 2016. www.gpo.gov/fdsys/pkg/PLAW-114publ198/pdf/PLAW-114publ198.pdf.

      Policymaker goals in passing these latest laws were to expand buprenorphine access, increase OUD treatment quality, and limit diversion potential.
      • Jones C.M.
      • Campopiano M.
      • Baldwin G.
      • McCance-Katz E.
      National and state treatment need and capacity for opioid agonist medication-assisted treatment.
      Substance Abuse and Mental Health Services Administration (SAMHSA)
      Medication assisted treatment for opioid use disorders; final rule.

      114th U.S. Congress. Comprehensive Addiction and Recovery Act of 2016. www.gpo.gov/fdsys/pkg/PLAW-114publ198/pdf/PLAW-114publ198.pdf.

      In summary, buprenorphine offers a number of relative advantages over other MAT medications in treating OUDs. This is especially true for patients who are able to self-manage their medications between medical visits, as opposed to benefiting from daily visits in an OTP program. Buprenorphine potentially benefits from lower overdose risk and fewer drug interaction concerns than methadone, given its partial agonist status and abuse-deterrent formulations. Buprenorphine also has greater demonstrated effectiveness than naltrexone at increasing treatment retention and reducing overdoses and illicit opioid use, although the evidence base for naltrexone is growing. Importantly, buprenorphine is more accessible than methadone to the general population, including in rural areas, because qualified providers, including primary care physicians, can prescribe it in office-based settings. Because buprenorphine can be delivered in non-specialty settings also providing other types of care, it can be less stigmatizing for patients, better integrated with other medical care, maintained under a long-term primary care–patient relationship, and available to special populations—including those involved in criminal justice and pregnant women (in the buprenorphine-only form). In short, buprenorphine carries the promise of abuse-deterrence, effectiveness, and widespread availability in OUD treatment.

      Persistent Workforce Barriers to Buprenorphine Treatment Provision

      Despite buprenorphine’s tremendous potential in effectively bridging the OUD treatment gap and mitigating the opioid epidemic, persistent and substantial barriers—many of which revolve around the workforce—have thwarted full realization of this promise. Many more providers are eligible to obtain waivers to prescribe buprenorphine, but even among those with waivers, there is capacity for increased buprenorphine prescribing.
      • Jones C.M.
      • Campopiano M.
      • Baldwin G.
      • McCance-Katz E.
      National and state treatment need and capacity for opioid agonist medication-assisted treatment.
      • Walley A.Y.
      • Alperen J.K.
      • Cheng D.M.
      • et al.
      Office-based management of opioid dependence with buprenorphine: clinical practices and barriers.
      • Stein B.D.
      • Sorbero M.
      • Dick A.W.
      • Pacula R.L.
      • Burns R.M.
      • Gordon A.J.
      Physician capacity to treat opioid use disorder with buprenorphine-assisted treatment.
      • Rosenblatt R.A.
      • Andrilla C.H.A.
      • Catlin M.
      • Larson E.H.
      Geographic and specialty distribution of U.S. physicians trained to treat opioid use disorder.
      Categories of workforce barriers contributing to buprenorphine underutilization include (1) insufficient training, education, and experience; (2) lack of institutional and clinician peer support; (3) poor care coordination; (4) provider stigma; (5) inadequate or burdensome reimbursement; and (6) burdensome regulatory procedures. This article summarizes studies that have evaluated physician barriers to buprenorphine prescribing using surveys and qualitative interviews below along these six categories.

      Insufficient Training, Education, and Experience

      A prominent barrier cited by a majority of physicians surveyed in primary care and addiction specialties alike in the years since buprenorphine approval revolve around a lack of knowledge, training, education, and experience in buprenorphine prescribing.
      • Gunderson E.W.
      • Wang X.-Q.
      • Fiellin D.A.
      • Bryan B.
      • Levin F.R.
      Unobserved versus observed office buprenorphine/naloxone induction: a pilot randomized clinical trial.
      • Cunningham C.O.
      • Kunins H.V.
      • Roose R.J.
      • Elam R.T.
      • Sohler N.L.
      Barriers to obtaining waivers to prescribe buprenorphine for opioid addiction treatment among HIV physicians.
      • Cunningham C.O.
      • Sohler N.L.
      • McCoy K.
      • Kunins H.V.
      Attending physicians’ and residents’ attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital.
      • Deflavio J.
      • Rolin S.
      • Nordstrom B.
      • Kazal L.
      Analysis of barriers to adoption of buprenorphine maintenance therapy by family physicians.
      • Barry D.T.
      • Irwin K.S.
      • Jones E.S.
      • et al.
      Integrating buprenorphine treatment into office-based practice: a qualitative study.
      • Gordon A.J.
      • Kavanagh G.
      • Krumm M.
      • et al.
      Facilitators and barriers in implementing buprenorphine in the Veterans Health Administration.
      • Mendoza S.
      • Rivera-Cabrero A.S.
      • Hansen H.
      Shifting blame: buprenorphine prescribers, addiction treatment, and prescription monitoring in middle-class America.
      • Netherland J.
      • Botsko M.
      • Egan J.E.
      • et al.
      Factors affecting willingness to provide buprenorphine treatment.
      • Yang A.
      • Arfken C.L.
      • Johanson C.E.
      Steps physicians report taking to reduce diversion of buprenorphine.
      • Van Boekel L.C.
      • Brouwers E.P.M.
      • Van Weeghel J.
      • Garretsen H.F.L.
      Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review.
      Among buprenorphine-waivered physicians in New York City, training in addiction medicine and the waiver certification process were both viewed as deficient in providing knowledge and confidence in buprenorphine prescribing.
      • Mendoza S.
      • Rivera-Cabrero A.S.
      • Hansen H.
      Shifting blame: buprenorphine prescribers, addiction treatment, and prescription monitoring in middle-class America.
      This suggests that the waiver process is not enough to provide the necessary training, and that such education needs to start much earlier and be reinforced often during ongoing training.

      Lack of Institutional and Clinician Peer Support

      A related common barrier to lack of training is the lack of institutional and clinician peer support in buprenorphine prescribing.
      • Walley A.Y.
      • Alperen J.K.
      • Cheng D.M.
      • et al.
      Office-based management of opioid dependence with buprenorphine: clinical practices and barriers.
      • Deflavio J.
      • Rolin S.
      • Nordstrom B.
      • Kazal L.
      Analysis of barriers to adoption of buprenorphine maintenance therapy by family physicians.
      • Gordon A.J.
      • Kavanagh G.
      • Krumm M.
      • et al.
      Facilitators and barriers in implementing buprenorphine in the Veterans Health Administration.
      • Mendoza S.
      • Rivera-Cabrero A.S.
      • Hansen H.
      Shifting blame: buprenorphine prescribers, addiction treatment, and prescription monitoring in middle-class America.
      • Hutchinson E.
      • Catlin M.
      • Andrilla C.H.A.
      • Baldwin L.-M.
      • Rosenblatt R.A.
      Barriers to primary care physicians prescribing buprenorphine.
      Without an adequately trained workforce for OUD treatment at all levels, clinician peer support in the form of sharing expertise and mentoring is less likely. Physician willingness to prescribe buprenorphine is improved when there are other buprenorphine prescribers within their practices.
      • Hutchinson E.
      • Catlin M.
      • Andrilla C.H.A.
      • Baldwin L.-M.
      • Rosenblatt R.A.
      Barriers to primary care physicians prescribing buprenorphine.
      Moreover, an institutional champion/role-model approach to buprenorphine care has been demonstrated to facilitate buprenorphine prescribing.
      • Gordon A.J.
      • Kavanagh G.
      • Krumm M.
      • et al.
      Facilitators and barriers in implementing buprenorphine in the Veterans Health Administration.
      Given that physicians commonly view the population of patients with OUD as challenging and complex to treat,
      • Deflavio J.
      • Rolin S.
      • Nordstrom B.
      • Kazal L.
      Analysis of barriers to adoption of buprenorphine maintenance therapy by family physicians.
      • Barry D.T.
      • Irwin K.S.
      • Jones E.S.
      • et al.
      Integrating buprenorphine treatment into office-based practice: a qualitative study.
      • Mendoza S.
      • Rivera-Cabrero A.S.
      • Hansen H.
      Shifting blame: buprenorphine prescribers, addiction treatment, and prescription monitoring in middle-class America.
      • Quest T.L.
      • Merrill J.O.
      • Roll J.
      • Saxon A.J.
      • Rosenblatt R.A.
      Buprenorphine therapy for opioid addiction in rural Washington: the experience of the early adopters.
      a lack of within-practice support to treat these patients serves as a barrier to waivered and non-waivered physicians in actually engaging in buprenorphine prescribing.

      Poor Care Coordination

      Another key dimension of buprenorphine prescribing support involves the ability to refer patients for additional behavioral health therapies, particularly counseling, as needed. Indeed, physicians must assert that they have this ability when applying for a buprenorphine waiver.

      106th U.S. Congress. Drug Addiction Treatment Act of 2000. www.gpo.gov/fdsys/pkg/PLAW-106publ310/pdf/PLAW-106publ310.pdf.

      Both physicians who do and do not prescribe buprenorphine frequently cite the lack of a consultant to manage complex patients and the lack of ability to refer patients for mental health and substance abuse counseling as barriers to buprenorphine prescribing.
      • Cunningham C.O.
      • Kunins H.V.
      • Roose R.J.
      • Elam R.T.
      • Sohler N.L.
      Barriers to obtaining waivers to prescribe buprenorphine for opioid addiction treatment among HIV physicians.
      • Barry D.T.
      • Irwin K.S.
      • Jones E.S.
      • et al.
      Integrating buprenorphine treatment into office-based practice: a qualitative study.
      • Gordon A.J.
      • Kavanagh G.
      • Krumm M.
      • et al.
      Facilitators and barriers in implementing buprenorphine in the Veterans Health Administration.
      • Mendoza S.
      • Rivera-Cabrero A.S.
      • Hansen H.
      Shifting blame: buprenorphine prescribers, addiction treatment, and prescription monitoring in middle-class America.
      • Netherland J.
      • Botsko M.
      • Egan J.E.
      • et al.
      Factors affecting willingness to provide buprenorphine treatment.
      • Yang A.
      • Arfken C.L.
      • Johanson C.E.
      Steps physicians report taking to reduce diversion of buprenorphine.
      • Hutchinson E.
      • Catlin M.
      • Andrilla C.H.A.
      • Baldwin L.-M.
      • Rosenblatt R.A.
      Barriers to primary care physicians prescribing buprenorphine.
      • Quest T.L.
      • Merrill J.O.
      • Roll J.
      • Saxon A.J.
      • Rosenblatt R.A.
      Buprenorphine therapy for opioid addiction in rural Washington: the experience of the early adopters.
      For some physicians, a lack of time contributes to their unwillingness to prescribe buprenorphine, which could be alleviated with the help of non-physician providers, such as nurse case managers, to help coordinate care and provide more frequent follow-up.
      • Cunningham C.O.
      • Sohler N.L.
      • McCoy K.
      • Kunins H.V.
      Attending physicians’ and residents’ attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital.
      • Deflavio J.
      • Rolin S.
      • Nordstrom B.
      • Kazal L.
      Analysis of barriers to adoption of buprenorphine maintenance therapy by family physicians.
      • Barry D.T.
      • Irwin K.S.
      • Jones E.S.
      • et al.
      Integrating buprenorphine treatment into office-based practice: a qualitative study.
      • Gordon A.J.
      • Kavanagh G.
      • Krumm M.
      • et al.
      Facilitators and barriers in implementing buprenorphine in the Veterans Health Administration.

      Provider Stigma

      Provider stigma towards the patient population with OUDs also contributes to underprovision of buprenorphine. Many physicians explicitly cite this as a barrier,
      • Cunningham C.O.
      • Kunins H.V.
      • Roose R.J.
      • Elam R.T.
      • Sohler N.L.
      Barriers to obtaining waivers to prescribe buprenorphine for opioid addiction treatment among HIV physicians.
      • Deflavio J.
      • Rolin S.
      • Nordstrom B.
      • Kazal L.
      Analysis of barriers to adoption of buprenorphine maintenance therapy by family physicians.
      • Gordon A.J.
      • Kavanagh G.
      • Krumm M.
      • et al.
      Facilitators and barriers in implementing buprenorphine in the Veterans Health Administration.
      • Mendoza S.
      • Rivera-Cabrero A.S.
      • Hansen H.
      Shifting blame: buprenorphine prescribers, addiction treatment, and prescription monitoring in middle-class America.
      • Yang A.
      • Arfken C.L.
      • Johanson C.E.
      Steps physicians report taking to reduce diversion of buprenorphine.
      • Kissin W.
      • McLeod C.
      • Sonnefeld J.
      • Stanton A.
      Experiences of a national sample of qualified addiction specialists who have and have not prescribed buprenorphine for opioid dependence.
      although stigma is likely underquantified in surveys because of underreporting and difficulty framing this concept.

      White WL. Long-term strategies to reduce the stigma attached to addiction, treatment, and recovery within the city of Philadelphia (with particular reference to medication-assisted treatment/recovery). Philadelphia, PA; 2009. www.williamwhitepapers.com/pr/2009Stigma%26methadone.pdf.

      Negative perceptions of patients with OUDs exist, even today, among providers,
      • Olsen Y.
      • Sharfstein J.M.
      Confronting the stigma of opioid use disorder—and its treatment.
      • Van Boekel L.C.
      • Brouwers E.P.M.
      • Van Weeghel J.
      • Garretsen H.F.L.
      Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review.

      White WL. Long-term strategies to reduce the stigma attached to addiction, treatment, and recovery within the city of Philadelphia (with particular reference to medication-assisted treatment/recovery). Philadelphia, PA; 2009. www.williamwhitepapers.com/pr/2009Stigma%26methadone.pdf.

      • Clark R.E.
      • Baxter J.D.
      Responses of state Medicaid programs to buprenorphine diversion.
      who may believe that this patient population is difficult, deceitful, untrustworthy, noncompliant with therapy, and likely to divert buprenorphine.

      Inadequate or Burdensome Reimbursement

      Reimbursement concerns are another frequently mentioned barrier to buprenorphine prescribing, particularly among physicians actually engaged in such prescribing.
      • Barry D.T.
      • Irwin K.S.
      • Jones E.S.
      • et al.
      Integrating buprenorphine treatment into office-based practice: a qualitative study.
      • Netherland J.
      • Botsko M.
      • Egan J.E.
      • et al.
      Factors affecting willingness to provide buprenorphine treatment.
      • Quest T.L.
      • Merrill J.O.
      • Roll J.
      • Saxon A.J.
      • Rosenblatt R.A.
      Buprenorphine therapy for opioid addiction in rural Washington: the experience of the early adopters.
      • Arfken C.L.
      • Johanson C.E.
      • di Menza S.
      • Schuster C.R.
      Expanding treatment capacity for opioid dependence with office-based treatment with buprenorphine: national surveys of physicians.
      • Gunderson E.W.
      • Levin F.R.
      • Kleber H.D.
      • Fiellin D.A.
      • Sullivan L.E.
      Evaluation of a combined online and in person training in the use of buprenorphine.
      Some of these concerns are specific to Medicaid, the largest third-party source of coverage for OUD treatment.
      • Quest T.L.
      • Merrill J.O.
      • Roll J.
      • Saxon A.J.
      • Rosenblatt R.A.
      Buprenorphine therapy for opioid addiction in rural Washington: the experience of the early adopters.
      Although Medicaid coverage of buprenorphine treatment has increased in recent years, so have qualifications around that coverage (e.g., prior authorization and lifetime limit requirements), which continue to act as barriers for providers in obtaining reimbursement.
      • Clark R.E.
      • Baxter J.D.
      Responses of state Medicaid programs to buprenorphine diversion.
      • Clark R.E.
      • Samnaliev M.
      • Baxter J.D.
      • Leung G.Y.
      The evidence doesn’t justify steps by state Medicaid programs to restrict opioid addiction treatment with buprenorphine.
      • Clark R.E.
      • Baxter J.D.
      • Barton B.A.
      • Aweh G.
      • O’Connell E.
      • Fisher W.H.
      The impact of prior authorization on buprenorphine dose, relapse rates, and cost for Massachusetts Medicaid beneficiaries with opioid dependence.
      • Burns R.M.
      • Pacula R.L.
      • Bauhoff S.
      • et al.
      Policies related to opioid agonist therapy for opioid use disorders: the evolution of state policies from 2004 to 2013.
      • Grogan C.M.
      • Andrews C.
      • Abraham A.
      • et al.
      Survey highlights differences in Medicaid coverage for substance use treatment and opioid use disorder medications.
      Potentially contributing to suboptimal care, physicians may experience pressure to limit their patient visits to reimbursable time frames and services.
      • Gordon A.J.
      • Kavanagh G.
      • Krumm M.
      • et al.
      Facilitators and barriers in implementing buprenorphine in the Veterans Health Administration.
      • Netherland J.
      • Botsko M.
      • Egan J.E.
      • et al.
      Factors affecting willingness to provide buprenorphine treatment.

      Burdensome Regulatory Procedures

      Finally, some physicians cite burdensome regulatory requirements as a barrier to their prescribing.
      • Deflavio J.
      • Rolin S.
      • Nordstrom B.
      • Kazal L.
      Analysis of barriers to adoption of buprenorphine maintenance therapy by family physicians.
      • Mendoza S.
      • Rivera-Cabrero A.S.
      • Hansen H.
      Shifting blame: buprenorphine prescribers, addiction treatment, and prescription monitoring in middle-class America.
      • Kissin W.
      • McLeod C.
      • Sonnefeld J.
      • Stanton A.
      Experiences of a national sample of qualified addiction specialists who have and have not prescribed buprenorphine for opioid dependence.
      These regulatory burdens include the process of obtaining a waiver, record-keeping requirements, the 30-patient panel limit (before that limit was expanded), and a general perception that regulatory agencies impede rather than facilitate prescribing.
      • Deflavio J.
      • Rolin S.
      • Nordstrom B.
      • Kazal L.
      Analysis of barriers to adoption of buprenorphine maintenance therapy by family physicians.
      • Mendoza S.
      • Rivera-Cabrero A.S.
      • Hansen H.
      Shifting blame: buprenorphine prescribers, addiction treatment, and prescription monitoring in middle-class America.
      • Kissin W.
      • McLeod C.
      • Sonnefeld J.
      • Stanton A.
      Experiences of a national sample of qualified addiction specialists who have and have not prescribed buprenorphine for opioid dependence.

      Policy Pathways to Increase Buprenorphine Treatment Provision

      In recent years, several policy facilitators have sought to address certain barriers to robust buprenorphine provision. Leaders from the federal executive and legislative branches—in particular from SAMHSA, National Institute on Drug Abuse, and HHS—have pursued strategies to encourage the provision of quality OUD treatment, including with buprenorphine.

      Food and Drug Administration. Press release: FDA approves first once-monthly buprenorphine injection, a medication-assisted treatment option for opioid use disorder. www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm587312.htm. Published November 30, 2017.

      • Saloner B.
      • Sharfstein J.M.
      A stronger treatment system for opioid use disorders.
      As an increasing number of patients with OUDs have behavioral health insurance coverage, more patients may be accessing care, including in physician offices.
      • Saloner B.
      • Karthikeyan S.
      Changes in substance abuse treatment use among individuals with opioid use disorders in the United States, 2004–2013.

      Maclean JC, Saloner B. The effect of public insurance expansions on substance use disorder treatment: evidence from the Affordable Care Act. NBER Working Paper No. 23342. www.nber.org/papers/w23342. Published 2017.

      Beronio K, Po R, Skopec L, Glied S. ASPE research brief: Affordable Care Act expands mental health and substance use disorder benefits and federal parity protections for 62 million Americans. https://aspe.hhs.gov/report/affordable-care-act-expands-mental-health-and-substance-use-disorder-benefits-and-federal-parity-protections-62-million-americans. Published 2013. Accessed June 28, 2017.

      • Beronio K.
      • Glied S.
      • Frank R.
      How the Affordable Care Act and Mental Health Parity and Addiction Equity Act greatly expand coverage of behavioral health care.
      • Saloner B.
      • Akosa Antwi Y.
      • Maclean J.C.
      • Cook B.
      Access to health insurance and utilization of substance use disorder treatment: evidence from the Affordable Care Act dependent coverage provision.
      However, robust evidence does not yet establish clearly improved behavioral health outcomes attributable to these policy changes, perhaps because further follow-up time is needed.

      Maclean JC, Saloner B. The effect of public insurance expansions on substance use disorder treatment: evidence from the Affordable Care Act. NBER Working Paper No. 23342. www.nber.org/papers/w23342. Published 2017.

      Also, the treatment gap remains because of the growing population of patients with OUDs and persistently low number of providers.
      Recently implemented policies designed to augment buprenorphine prescribing among the workforce fall into three categories: increased MAT coverage and funding for innovative care models, expanded provider capacity to prescribe buprenorphine, and innovation to develop effective MATs. Although these policies address many provider workforce barriers to buprenorphine prescribing, dire public health need warrants further work to capitalize on buprenorphine’s promise.

      Medication-Assisted Treatment Coverage and Funding

      Several federal and state policies have enhanced buprenorphine treatment coverage in the past decade and address provider concerns around reimbursement, care coordination, and institutional/clinician peer support. The first was the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), which required that mental health and substance use disorder care be covered on par with medical/surgical care.
      U.S. Congress
      Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008.
      Interim Final Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008.
      U.S. Department of the Treasury, U.S. Department of Labor, HHS
      Final Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008.
      The Affordable Care Act (ACA) then extended parity benefit protections to at least 62 million additional people covered by individual/small group and Medicaid plans.

      Beronio K, Po R, Skopec L, Glied S. ASPE research brief: Affordable Care Act expands mental health and substance use disorder benefits and federal parity protections for 62 million Americans. https://aspe.hhs.gov/report/affordable-care-act-expands-mental-health-and-substance-use-disorder-benefits-and-federal-parity-protections-62-million-americans. Published 2013. Accessed June 28, 2017.

      • Beronio K.
      • Glied S.
      • Frank R.
      How the Affordable Care Act and Mental Health Parity and Addiction Equity Act greatly expand coverage of behavioral health care.
      Also under the ACA, plans are required to cover ten essential health benefits (EHBs), including (1) mental health and substance use disorder services and (2) a prescription drug benefit. People covered by the Medicaid expansions in 32 states (including the District of Columbia), including more than 2 million with substance use disorders, also must be offered EHBs. Coverage details in the EHB categories vary from state to state, where a state’s benchmark plan sets the baseline. But plans are required to cover at least one drug in every category and class of the U.S. Pharmacopeia, which has helped to facilitate buprenorphine coverage now required in all states for the purposes of Medicaid, under Medicare, and among the vast majority of private insurers.

      Rinaldo SG, Rinaldo DW. Advancing access to addiction medication: implications for opioid addiction treatment. www.asam.org/docs/default-source/advocacy/aaam_implications-for-opioid-addiction-treatment_final. Published 2013.

      • Burns R.M.
      • Pacula R.L.
      • Bauhoff S.
      • et al.
      Policies related to opioid agonist therapy for opioid use disorders: the evolution of state policies from 2004 to 2013.

      The National Center on Additional and Substance Abuse. Uncovering coverage gaps: a review of addiction benefits in ACA plans. www.centeronaddiction.org/addiction-research/reports/uncovering-coverage-gaps-review-of-addiction-benefits-in-aca-plans. Published 2016.

      These EHB and parity policies have greatly improved the proportion of Americans with OUDs who enjoy insurance coverage of some generosity, particularly under the largest third-party payer for behavioral health and OUD treatment, Medicaid (Table 1).
      Table 1Key Coverage Expansions and Funding Affecting Buprenorphine Treatment, 2008–2017
      PolicyDatePopulations targetedKey provisions
      Mental Health Parity and Addiction Equity Act of 2008Plan years starting July 1, 2010
      • Private group health plans (50+ employees)
      • Expanded to Medicaid (2014)
      • Expanded to individual/small group plans offered on ACA insurance exchanges (2014)
      Parity between physical and behavioral health benefit coverage (including MAT) along 3 dimensions:
      • Financial limitations (e.g., copays, deductibles),
      • Quantitative treatment limitations (e.g., treatment caps), and
      • Nonquantitative treatment limitations (e.g., prior authorization, fail-first therapies).
      ACA: Essential Health BenefitsJanuary 1, 2014
      • Medicaid plans
      • Medicare plans
      • Individual/small group plans offered on the ACA insurance exchanges
      Plans must cover 10 essential health benefits, including: (i) mental health and substance use disorder services, and (ii) prescription drug benefit.
      • Coverage specifics vary by state, where benchmark plans set a floor.
      • ACA limits cost-sharing and prohibits annual/lifetime limits on EHB coverage.
      • Plans must cover at least one drug in every category and class of U.S. Pharmacopeia, so buprenorphine is often covered.
      ACA: Medicaid ExpansionsJanuary 1, 2014
      • Medicaid expansion covered populations
      Two million Americans with substance use disorders gained coverage in 31 states that expanded Medicaid to adults up to 138% of the federal poverty level.
      • All 50 state Medicaid programs provide coverage for buprenorphine.
      • Section 1115 demonstrations allow states to receive federal funds to transform and innovate in their substance use disorder delivery systems.
      Comprehensive Addiction and Recovery Act2017–2021
      • Funding to states (appropriated each year)
      • Authorizes $181M in funding for programs designed to reduce the impact of OUDs, including $25M/year for MAT expansion in high-OUD areas.
      • SAMHSA made $28M in grants available to communities and healthcare providers to treat people with OUDs with MAT.
      21st Century Cures Act2017–2022
      • Funding to states
      $1B provided to states in 2017–2018 to combat the opioid crisis. Disbursed State Targeted Response to the Opioid Crisis Grants, which
      • require states to perform needs assessments and develop strategic plans for increasing MAT provision under a chronic care model,
      • periodically review performance data reported to SAMHSA, and
      • develop quality MAT programs.
      Requires three federal agencies to release compliance guidance on MHPAEA requirements and enhance/improve MHPAEA compliance enforcement efforts.
      ACA, Affordable Care Act; B, billion; EHB, Essential Health Benefits; M, million; MAT, medication-assisted treatment; MHPAEA, Mental Health Parity and Addiction Equity Act; OUD, opioid use disorder; SAMHSA, Substance Abuse and Mental Health Services Agency.
      The ACA has taken further steps to help integrate care—for example, in implementing accountable care organizations that incentivize a patient’s primary provider to coordinate care and deliver better health outcomes. Repeal of any of these ACA components would have dire consequences for OUD patients and their providers’ ability to obtain reimbursement to treat them (Table 2). In addition, ACA repeal or retrenchment would worsen care continuity critical for patients with chronic OUDs and often many comorbidities (Table 2). But the ACA and insurance policy could go further to generously reimburse for and incentivize behavioral health therapy and case management services for buprenorphine care.
      Table 2Policy Recommendations to Address Barriers to Buprenorphine Prescribing
      Provider barriersPolicy recommendationExamples of implementation
      1. Insufficient training, education, and experience
      Incorporate MAT training into general medical education to increase knowledge and confidence around buprenorphine provision
      Incorporate MAT training into continuing medical education requirements and mentoring services to increase knowledge and confidence around buprenorphine provision
      Audit feedback and reviews of physician buprenorphine prescribing at the provider/insurer levels to increase safety and knowledge
      Incentivize medical and other clinician students to enter addiction specialties or engage in buprenorphine prescribing, particularly in rural areas
      • Proposed to be included in National Health Service Corps, which provides loan forgiveness and debt repayment for people who work in underserved communities for at least 2 years at eligible facilities
        • Donnelly J.
        Strengthening the Addiction Treatment Workforce Act.
      2. Lack of institutional and clinician-peer support
      Incorporate MAT training into general medical education to increase mentorship and shared expertise opportunities around buprenorphine provision
      Incorporate MAT training into continuing medical education requirements and opportunities to increase mentorship and shared expertise opportunities around buprenorphine provision
      Encourage loan forgiveness for qualified providers who engage in OUD treatment, particularly in rural areas given need

      The President’s Commission on Combatting Drug Addiction and the Opioid Crisis. Final Report of The President’s Commission on Combating Drug Addiction and the Opioid Crisis. www.whitehouse.gov/sites/whitehouse.gov/files/images/Final_Report_Draft_11-1-2017.pdf. Published 2017.

      Hancock C, Mennenga H, King N, Andrilla H, Larson E, Schou P. National Rural Health Association Policy Brief: treating the rural opioid epidemic. www.ruralhealthweb.org/NRHA/media/Emerge_NRHA/Advocacy/Policy%20documents/Treating-the-Rural-Opioid-Epidemic_Feb-2017_NRHA-Policy-Paper.pdf. Published 2017.

      • Proposed to be included in National Health Service Corps, which provides loan forgiveness and debt repayment for people who work in underserved communities for at least 2 years at eligible facilities
        • Donnelly J.
        Strengthening the Addiction Treatment Workforce Act.
      Reimbursement for/fund office space, champion/role-model, and education on buprenorphine prescribing
      Incentivize improved health outcomes in reimbursement models, to encourage institutional buy-in around buprenorphine prescribing, including at the primary care level and behavioral care levels
      • ACA accountable care organization model
      3. Poor care coordination
      Vigorously enforce MHPAEA parity requirements to ensure equitable coverage and reimbursement for MAT provision, including for buprenorphine and behavioral health therapies
      • Funds available from 21st Century Cures Act
      Continue elements of ACA promoting integrated care models such as accountable care organizations at the primary care level
      Provide financial incentives for care coordination across provider types (including physician and non-physician providers), and settings (including addiction specialty and non-addiction specialty)
      • Funds available from 21st Century Cures Act and ACA
      Promote collaborative care agreements between physicians and pharmacists and use of drug therapy management models that can lead to safer prescribing with multi-disciplinary care and checks/balances• Maryland collaborative model
      • DiPaula B.A.
      • Menachery E.
      • et al.
      Physician-pharmacist collaborative care model for buprenorphine-maintained opioid-dependent patients.
      4. Provider stigma
      Incorporate MAT training into general medical education to reduce stigma around buprenorphine provision
      Incorporate MAT training into continuing medical education requirements and opportunities to increase mentorship and shared expertise opportunities around buprenorphine provision• Online mentorship services through PCSS MAT
      • Egan J.E.
      • Casadonte P.
      • Gartenmann T.
      • et al.
      The physician clinical support system-buprenorphine (PCSS-B): A novel project to expand/improve buprenorphine treatment.
      Implement prior authorization for high buprenorphine doses only, to limit patient diversion• Massachusetts model
      • Clark R.E.
      • Baxter J.D.
      • Barton B.A.
      • Aweh G.
      • O’Connell E.
      • Fisher W.H.
      The impact of prior authorization on buprenorphine dose, relapse rates, and cost for Massachusetts Medicaid beneficiaries with opioid dependence.
      Funding for/innovation for safer MAT formulations, vaccines that require less frequent visits and may be taken more safely by patients. Also these products reduce misuse and diversion that contributes to provider stigma• NIDA partnerships with private sector
      • Volkow N.D.
      • Collins F.S.
      The role of science in addressing the opioid crisis.
      5. Inadequate or burdensome reimbursement
      Vigorously enforce MHPAEA parity requirements to ensure equitable coverage and reimbursement for MAT provision, including buprenorphine and behavioral health therapies• Funds available from 21st Century Cures Act and enforcement task force
      Maintain ACA coverage expansions to Medicaid populations, individual/small group plan members, which include EHB and MHPAEA requirements
      Explicitly require that states cover buprenorphine and behavioral therapy, without stringent managed care policies (e.g., blanket prior authorization, annual/lifetime limits, fail first policies) as EHBs
      Adopt pay-for-performance reimbursement models from other disease states to fund non-physician providers or physician providers
      Reduce cost of buprenorphine to improve reimbursement and insurance coverage, particularly of implantable and newer tamper-resistant forms that come to market• Drug Competition Action Plan under development by FDA to improve competition by bringing generics to market

      Food and Drug Administration. Administering the Hatch-Waxman amendments: ensuring a balance between innovations and access: public meeting; request for comments. www.fda.gov/Drugs/NewsEvents/ucm563986.htm. Published 2017.

      6. Burdensome regulatory procedures
      Eliminate buprenorphine waiver requirement
      Lift 30 patient limit for nurse practitioners and physician assistants once safety of their prescribing is established via quality metrics
      Increase training requirements for all opioid prescribing (not just MAT)
      ACA, Affordable Care Act; ECHO, Extension for Community Healthcare Outcomes; FDA, U.S. Food and Drug Administration; MAT, medication-assisted treatment; MHPAEA, Mental Health Parity and Addiction Equity Act; EHB, Essential Health Benefits; NIDA, National Institute on Drug Abuse; OUD, opioid use disorders.
      Moreover, MHPAEA has suffered from noncompliance complaints. In violation of MHPAEA, insurance plans are allegedly requiring inequitable medical necessity determinations; utilization review (e.g., prior authorization); provider networks; and fail first therapies, including with respect to substance use disorder treatment.

      The Mental Health and Substance Use Disorder Parity Task Force: Final Report. Washington, DC. www.hhs.gov/sites/default/files/mental-health-substance-use-disorder-parity-task-force-final-report.pdf. Published 2016.

      The federal government has recognized the need to monitor MHPAEA compliance carefully, and set aside money and a plan to that end in the 21st Century Cures Act. If MHPAEA is rigorously enforced and plans are required to be transparent about their practices, then the idea of equitable coverage for MAT may be realized (Table 2).
      Similar concerns about increases in the use of managed care techniques to limit care and reduce diversion have been raised in the context of Medicaid coverage of buprenorphine.
      • Clark R.E.
      • Baxter J.D.
      Responses of state Medicaid programs to buprenorphine diversion.
      • Clark R.E.
      • Samnaliev M.
      • Baxter J.D.
      • Leung G.Y.
      The evidence doesn’t justify steps by state Medicaid programs to restrict opioid addiction treatment with buprenorphine.
      • Clark R.E.
      • Baxter J.D.
      • Barton B.A.
      • Aweh G.
      • O’Connell E.
      • Fisher W.H.
      The impact of prior authorization on buprenorphine dose, relapse rates, and cost for Massachusetts Medicaid beneficiaries with opioid dependence.
      • Burns R.M.
      • Pacula R.L.
      • Bauhoff S.
      • et al.
      Policies related to opioid agonist therapy for opioid use disorders: the evolution of state policies from 2004 to 2013.
      One study found that instead of broad managed care barriers, a more targeted prior authorization policy in Massachusetts only related to high-dose buprenorphine prescribing was effective at reducing the use of higher than recommended doses, without increasing the risk of relapses over the long term.
      • Clark R.E.
      • Baxter J.D.
      • Barton B.A.
      • Aweh G.
      • O’Connell E.
      • Fisher W.H.
      The impact of prior authorization on buprenorphine dose, relapse rates, and cost for Massachusetts Medicaid beneficiaries with opioid dependence.
      Such targeted techniques consistent with best public health and clinical practices should be pursued over blanket limitations on care—such as lifetime or annual limits, which can be inconsistent with OUD maintenance therapy (Table 2).

      American Society of Addiction Medicine. National practice guideline for the use of medications in the treatment of addiction involving opioid use. https://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf?sfvrsn=24. Published 2015.

      Explicit federal requirements that States cover buprenorphine and behavioral health therapy as EHBs, absent stringent managed care limitations, also could ensure that third-party coverage for buprenorphine treatment is robust (Table 2).
      At the same time as insurance coverage generosity has expanded, the Comprehensive Addiction and Recovery Act and 21st Century Cures Act fund increased OUD treatment desperately needed in certain states.

      114th U.S. Congress. Comprehensive Addiction and Recovery Act of 2016. www.gpo.gov/fdsys/pkg/PLAW-114publ198/pdf/PLAW-114publ198.pdf.

      Food and Drug Administration. Administering the Hatch-Waxman amendments: ensuring a balance between innovations and access: public meeting; request for comments. www.fda.gov/Drugs/NewsEvents/ucm563986.htm. Published 2017.

      Many of these funding mechanisms address provider barriers to buprenorphine prescribing, such as reimbursement and care coordination, including within primary care–based settings (Table 1, Table 2). However, robust additional funding for MAT is desperately needed.

      The President’s Commission on Combatting Drug Addiction and the Opioid Crisis. Final Report of The President’s Commission on Combating Drug Addiction and the Opioid Crisis. www.whitehouse.gov/sites/whitehouse.gov/files/images/Final_Report_Draft_11-1-2017.pdf. Published 2017.

      • Goodnough A.
      $45 billion to fight opioid abuse? That’s much too little, experts say.

      Provider Capacity

      As discussed, a recent SAMHSA rule increased buprenorphine-waivered physician patient panels from 100 to 275 patients. Although this increase was well intentioned, it is unlikely to greatly affect most buprenorphine prescribers, who prescribe to a median monthly panel of 13 patients.
      • Stein B.D.
      • Sorbero M.
      • Dick A.W.
      • Pacula R.L.
      • Burns R.M.
      • Gordon A.J.
      Physician capacity to treat opioid use disorder with buprenorphine-assisted treatment.
      Even in Vermont—a leader in buprenorphine treatment—physicians prescribed to an average of almost 15 patients over a 3-month period in 2014.
      • Sigmon S.C.
      The untapped potential of office-based buprenorphine treatment.
      Eliminating the waiver process for physicians altogether, when complemented by policies to increase provider education during graduate school and in continuing medical education, would be more impactful than expanding the patient panel limits. Although the training received during the 8-hour course is helpful to prescribing clinicians, the hurdles of identifying, taking, and paying for the course on top of a busy clinical practice are likely to discourage participation.
      • Deflavio J.
      • Rolin S.
      • Nordstrom B.
      • Kazal L.
      Analysis of barriers to adoption of buprenorphine maintenance therapy by family physicians.
      • Mendoza S.
      • Rivera-Cabrero A.S.
      • Hansen H.
      Shifting blame: buprenorphine prescribers, addiction treatment, and prescription monitoring in middle-class America.
      • Kissin W.
      • McLeod C.
      • Sonnefeld J.
      • Stanton A.
      Experiences of a national sample of qualified addiction specialists who have and have not prescribed buprenorphine for opioid dependence.
      Moreover, the asymmetry between physicians’ ability to prescribe any other prescription opioid for pain, including methadone, without any special education stands in stark contrast to this heightened buprenorphine prescribing requirement—particularly when non-MAT prescription opioids are much more commonly misused, diverted, and responsible for overdoses.
      Buprenorphine prescriber training would be more effective if mandated as a part of graduate school education, similar to training commonly incorporated for other medications with complicated dosing (e.g., warfarin), and offered as a part of continuing medical education (Table 2). Some innovative medical schools
      • McCance-Katz E.F.
      • George P.
      • Scott N.A.
      • Dollase R.
      • Tunkel A.R.
      • McDonald J.
      Access to treatment for opioid use disorders: medical student preparation.
      and states, like Massachusetts, are undertaking steps to incorporate MAT training into medical education, but national graduate school accreditation requirements would have more widespread impact. Although the American Medical Association recently voted not to support the elimination of the buprenorphine waiver requirement, it can consider incorporating buprenorphine prescribing training into its newly required additional opioid training requirements and continuing medical education requirements to generate a more educated, knowledgeable workforce.
      The Comprehensive Addiction and Recovery Act very recently allowed nurse practitioners and physician assistants to prescribe buprenorphine to up to 30 patients. This represented an important step toward increasing the number of trained professionals with prescribing knowledge and expertise, and consequently increasing the likelihood that multiple prescribers are available in the same clinic to provide support to one another. To further increase prescriber capacity, allied health professionals could be exempted from the waiver process as well, so long as they have demonstrated safe prescribing along established metrics and are trained in their initial or continuing education, similar to physicians.

      114th U.S. Congress. Comprehensive Addiction and Recovery Act of 2016. www.gpo.gov/fdsys/pkg/PLAW-114publ198/pdf/PLAW-114publ198.pdf.

      This step could increase provider capacity in rural and underserved areas, where physicians with waivers and addiction specialists are more scarce.
      • Rosenblatt R.A.
      • Andrilla C.H.A.
      • Catlin M.
      • Larson E.H.
      Geographic and specialty distribution of U.S. physicians trained to treat opioid use disorder.

      Treatment Innovation

      The National Institute on Drug Abuse and the FDA are working together and with private entities to spur innovation of safer opioid formulations, including for MATs, and even vaccines for opioids, heroin, and fentanyl.
      • Volkow N.D.
      • Collins F.S.
      The role of science in addressing the opioid crisis.

      Food and Drug Administration. Remarks from FDA Commissioner Scott Gottlieb, M.D., as prepared for oral testimony before the House Committee on Energy and Commerce Hearing, “Federal Efforts to Combat the Opioid Crisis: A Status Update on CARA and Other Initiatives.” www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm582031.htm. Published 2017. Accessed October 25, 2017.

      These represent promising steps toward reducing diversion and provider stigma related thereto. The FDA also is developing a measure that would reduce the time for generic drugs to come to market, in the interest of spurring competition and safer, less expensive products to market.

      Food and Drug Administration. Administering the Hatch-Waxman amendments: ensuring a balance between innovations and access: public meeting; request for comments. www.fda.gov/Drugs/NewsEvents/ucm563986.htm. Published 2017.

      If passed, this measure could also contribute to lower diversion, misuse, and costs of buprenorphine. In the nearer term, congressional inquiries into drug costs and FDA approval of brand-name buprenorphine competitors could spur lower prices for tamper-resistant products like the buprenorphine implants and injectable forms, which may not be covered by insurance because of their prices (Table 2).
      Buprenorphine implants (Probuphine) for opioid dependence.
      Other policies in addition to the above recommendations and steps already taken would further address provider barriers to buprenorphine prescribing. Beyond continuing education about MAT prescribing, providers could benefit from institutional reviews of, feedback about, and education around their own prescribing practices, to bolster institutional support and provider knowledge. Loan forgiveness for those medical students who go on to practice as addiction specialists or regular buprenorphine prescribers in rural or heavily opioid-impacted areas for at least 2 years, as has been proposed recently in Congress,
      • Donnelly J.
      Strengthening the Addiction Treatment Workforce Act.
      would further incentivize trainees to enter the workforce and provide desperately needed services.

      Conclusions

      There is an urgent need to address the OUD treatment gap in the U.S., and increasing provision of buprenorphine has tremendous potential to ensure effective treatment is available. Although the current policy environment has opened the door to this potential, by facilitating buprenorphine prescribing outside of traditional treatment settings and covering some treatment, further policy changes could address persistent professional workforce barriers to expanding buprenorphine treatment. Key changes include increasing buprenorphine prescriber education, from graduate education throughout practice; eliminating the waiver process for qualified prescribers; providing loan repayment for physicians and other allied health professionals who regularly prescribe buprenorphine; reimbursing for buprenorphine treatment and behavioral health therapies without blanket managed care limitations; and encouraging care coordination and clinician peer support through incentives and reimbursement models.

      Acknowledgments

      This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by the Substance Abuse and Mental Health Services Administration, Health Resources and Services Administration, U.S. Department of Health and Human Services or the U.S. Government.
      Drs. Haffajee, Bohnert, and Lagisetty each contributed to the intellectual content of the paper, in the form of conception and design. Dr. Haffajee generated the first draft of this manuscript, and all authors participated in the critical revision of the manuscript for important intellectual content.
      Dr. Haffajee’s work on this article was supported by funding from the National Center for Advancing Translational Sciences of the National Institutes of Health (grant #KL2TR002241), the Centers for Disease Control and Prevention for the University of Michigan Injury Prevention Center (grant #3R49CE002099-05S1, and the Health Resources Services Administration for the University of Michigan Behavioral Health Workforce Research Center (grant #U81HP29300).
      No financial disclosures were reported by the authors of this paper.

      Supplement Note

      This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under U81HP29300-03-02, Behavioral Health Workforce Research Center.

      References

        • Rudd R.A.
        • Aleshire N.
        • Zibbell J.E.
        • Gladden R.M.
        Increases in drug and opioid overdose deaths—United States, 2000–2014.
        MMWR Morb Mortal Wkly Rep. 2016; 64: 1378-1382https://doi.org/10.15585/mmwr.mm6450a3
        • Rudd R.A.
        • Seth P.
        • David F.
        • Scholl L.
        Increases in drug and opioid-involved overdose deaths—United States, 2010–2015.
        MMWR Morb Mortal Wkly Rep. 2016; 65: 1445-1452https://doi.org/10.15585/mmwr.mm655051e1
        • Centers for Disease Control and Prevention (CDC)
        Vital signs: overdoses of prescription opioid pain relievers–United States, 1999–2008.
        MMWR Morb Mortal Wkly Rep. 2011; 60 (Accessed June 21, 2017): 1487-1492
        • Guy G.P.
        • Zhang K.
        • Bohm M.K.
        • et al.
        Vital signs: changes in opioid prescribing in the United States, 2006–2015.
        MMWR Morb Mortal Wkly Rep. 2017; 66: 697-704https://doi.org/10.15585/mmwr.mm6626a4
        • Lankenau S.E.
        • Teti M.
        • Silva K.
        • Bloom J.J.
        Initiation into prescription opioid misuse amongst young injection drug users.
        Int J Drug Policy. 2012; 23: 37-44https://doi.org/10.1016/j.drugpo.2011.05.014
        • HHS. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings
        HHS Publication No. (SMA) 11-4658.
        Published. 2014;
        • Cicero T.J.
        • Ellis M.S.
        • Surratt H.L.
        • Kurtz S.P.
        The changing face of heroin use in the United States: a retrospective analysis of the past 50 years.
        JAMA Psychiatry. 2014; 71: 821-826https://doi.org/10.1001/jamapsychiatry.2014.366
        • Muhuri P.K.
        • Gfroerer J.C.
        • Davies M.C.
        Associations of nonmedical pain reliever use and initiation of heroin use in the United States.
        CBHSQ Data Rev. 2013;August; : 1-17
        • Jones C.M.
        Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers—United States, 2002–2004 and 2008–2010.
        Drug Alcohol Depend. 2013; 132: 95-100https://doi.org/10.1016/j.drugalcdep.2013.01.007
        • Peters P.J.
        • Pontones P.
        • Hoover K.W.
        • et al.
        HIV infection linked to injection use of oxymorphone in Indiana, 2014–2015.
        N Engl J Med. 2016; 375: 229-239https://doi.org/10.1056/NEJMoa1515195
        • American Psychiatric Association
        Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Publishing, Arlington, VA2013
        • Degenhardt L.
        • Larney S.
        • Kimber J.
        • et al.
        The impact of opioid substitution therapy on mortality post-release from prison: retrospective data linkage study.
        Addiction. 2014; 109: 1306-1317https://doi.org/10.1111/add.12536
        • Teesson M.
        • Marel C.
        • Darke S.
        • et al.
        Long-term mortality, remission, criminality and psychiatric comorbidity of heroin dependence: 11-year findings from the Australian Treatment Outcome Study.
        Addiction. 2015; 110: 986-993https://doi.org/10.1111/add.12860
        • Evans E.
        • Li L.
        • Min J.
        • et al.
        Mortality among individuals accessing pharmacological treatment for opioid dependence in California.
        Addiction. 2015; 110: 996-1005https://doi.org/10.1111/add.12863
        • Hser Y.-I.
        • Saxon A.J.
        • Huang D.
        • et al.
        Treatment retention among patients randomized to buprenorphine/naloxone compared to methadone in a multi-site trial.
        Addiction. 2014; 109: 79-87https://doi.org/10.1111/add.12333
        • Spiller M.W.
        • Broz D.
        • Wejnert C.
        • Nerlander L.
        • Paz-Bailey G.
        HIV infection and HIV-associated behaviors among injecting drug users–20 cities, United States.
        MMWR Morb Mortal Wkly Rep. 2012; 61: 133-138
        • Jones C.M.
        • Campopiano M.
        • Baldwin G.
        • McCance-Katz E.
        National and state treatment need and capacity for opioid agonist medication-assisted treatment.
        Am J Public Health. 2015; 105: e55-e63https://doi.org/10.2105/AJPH.2015.302664
      1. Substance Abuse and Mental Health Services Administration (SAMHSA). Results from the 2016 National Survey on Drug Use and Health: Detailed Tables Prevalence Estimates, Standard Errors, P Values, and Sample Sizes. Published 2017.
        • Amato L.
        • Davoli M.
        • Perucci C.A.
        • et al.
        An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform clinical practice and research.
        J Subst Abuse Treat. 2005; 28: 321-329https://doi.org/10.1016/j.jsat.2005.02.007
        • Nielsen S.
        • Larance B.
        • Lintzeris N.
        Opioid agonist treatment for patients with dependence on prescription opioids.
        JAMA. 2017; 317: 967-968https://doi.org/10.1001/jama.2017.0001
        • Schuckit M.A.
        Treatment of opioid-use disorders.
        N Engl J Med. 2016; 375: 357-368https://doi.org/10.1056/NEJMra1604339
        • Fiellin D.A.
        • Schottenfeld R.S.
        • Cutter C.J.
        • Moore B.A.
        • Barry D.T.
        • O’Connor P.G.
        Primary care-based buprenorphine taper vs maintenance therapy for prescription opioid dependence: a randomized clinical trial.
        JAMA Intern Med. 2014; 174: 1947-1954https://doi.org/10.1001/jamainternmed.2014.5302
        • Mattick R.P.
        • Breen C.
        • Kimber J.
        • Davoli M.
        Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence.
        Cochrane Database Syst Rev. 2014; 2: CD002207https://doi.org/10.1002/14651858.CD002207.pub4
        • Sordo L.
        • Barrio G.
        • Bravo M.J.
        • et al.
        Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies.
        BMJ. 2017; 357: j1550https://doi.org/10.1136/bmj.j1550
        • Schackman B.R.
        • Leff J.A.
        • Polsky D.
        • Moore B.A.
        • Fiellin D.A.
        Cost-effectiveness of long-term outpatient buprenorphine-naloxone treatment for opioid dependence in primary care.
        J Gen Intern Med. 2012; 27: 669-676https://doi.org/10.1007/s11606-011-1962-8
      2. The President’s Commission on Combatting Drug Addiction and the Opioid Crisis. Final Report of The President’s Commission on Combating Drug Addiction and the Opioid Crisis. www.whitehouse.gov/sites/whitehouse.gov/files/images/Final_Report_Draft_11-1-2017.pdf. Published 2017.

        • Stein B.D.
        • Gordon A.J.
        • Dick A.W.
        • et al.
        Supply of buprenorphine waivered physicians: the influence of state policies.
        J Subst Abuse Treat. 2015; 48: 104-111https://doi.org/10.1016/j.jsat.2014.07.010
        • Sigmon S.C.
        The untapped potential of office-based buprenorphine treatment.
        JAMA Psychiatry. 2015; 72: 395-396https://doi.org/10.1001/jamapsychiatry.2014.2421
        • Lembke A.
        • Chen J.H.
        Use of opioid agonist therapy for Medicare patients in 2013.
        JAMA Psychiatry. 2016; 73: 990-992https://doi.org/10.1001/jamapsychiatry.2016.1390
        • Saloner B.
        • Karthikeyan S.
        Changes in substance abuse treatment use among individuals with opioid use disorders in the United States, 2004–2013.
        JAMA. 2015; 314: 1515-1517https://doi.org/10.1001/jama.2015.10345
        • Volkow N.D.
        • Frieden T.R.
        • Hyde P.S.
        • Cha S.S.
        Medication-assisted therapies—tackling the opioid overdose epidemic.
        N Engl J Med. 2014; 370: 2063-2066https://doi.org/10.1056/NEJMp1402780
      3. Medication-assisted treatment improves outcomes for patients with opioid use disorder. www.pewtrusts.org/~/media/assets/2016/11/medicationassistedtreatment_v3.pdf. Published 2016.

      4. Title 21 United States Code (USC) Controlled Substances Act—Section 801. www.deadiversion.usdoj.gov/21cfr/21usc/801.htm. Accessed June 21, 2017.

      5. Rinaldo SG, Rinaldo DW. Advancing access to addiction medication: implications for opioid addiction treatment. www.asam.org/docs/default-source/advocacy/aaam_implications-for-opioid-addiction-treatment_final. Published 2013.

      6. 42 CFR 8.12 Federal Opioid Treatment Standards. 2001:65-69. U.S. Government Publishing Office. www.gpo.gov/fdsys/granule/CFR-2002-title42-vol1/CFR-2002-title42-vol1-sec8-12.

      7. Substance Abuse and Mental Health Services Administration (SAMHSA). Opioid Treatment Program Directory. http://dpt2.samhsa.gov/treatment/directory.aspx. Published 2017. Accessed June 28, 2017.

        • Schwartz R.P.
        • Gryczynski J.
        • O’Grady K.E.
        • et al.
        Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995–2009.
        Am J Public Health. 2013; 103: 917-922https://doi.org/10.2105/AJPH.2012.301049
        • Tsui J.I.
        • Evand J.L.
        • Lum P.J.
        • Hahn J.A.
        • Page K.
        Association of opioid agonist therapy with lower incidence of hepatitis C virus infection in young adult injection drug users.
        JAMA Intern Med. 2015; 174: 1974-1981https://doi.org/10.1001/jamainternmed.2014.5416
        • Strang J.
        • Babor T.
        • Caulkins J.
        • Fischer B.
        • Foxcroft D.
        • Humphreys K.
        Drug policy and the public good: evidence for effective interventions.
        Lancet. 2012; 379: 71-83https://doi.org/10.1016/S0140-6736(11)61674-7
        • Timko C.
        • Schultz N.R.
        • Cucciare M.A.
        • Vittorio L.
        • Garrison-Diehn C.
        Retention in medication-assisted treatment for opiate dependence: a systematic review.
        J Addict Dis. 2016; 35: 22-35https://doi.org/10.1080/10550887.2016.1100960
        • Nielsen S.
        • Larance B.
        • Degenhardt L.
        • Gowing L.
        • Kehler C.
        • Lintzeris N.
        Opioid agonist treatment for pharmaceutical opioid dependent people.
        Cochrane Database Syst Rev. 2016; 5: CD011117https://doi.org/10.1002/14651858.CD011117.pub2
        • Mattick R.P.
        • Breen C.
        • Kimber J.
        • Davoli M.
        Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence.
        Cochrane Database Syst Rev. 2009; 3: CD002209https://doi.org/10.1002/14651858.CD002209.pub2
        • Metzger D.S.
        • Woody G.E.
        • McLellah A.T.
        • et al.
        Human immunodeficiency virus seroconversion among intravenous drug users in-and out-of-treatment: an 18-month prospective follow-up.
        J Acquir Immune Defic Syndr. 1993; 6: 1048-1056
        • Gryczynski J.
        • Schwartz R.P.
        • O’Grady K.E.
        • Restivo L.
        • Mitchell S.G.
        • Jaffe J.H.
        Understanding patterns of high-cost health care use across different substance user groups.
        Health Aff (Millwood). 2016; 35: 12-19https://doi.org/10.1377/hlthaff.2015.0618
        • Rosenblum A.
        • Cleland C.M.
        • Fong C.
        • Kayman D.J.
        • Tempalski B.
        • Parrino M.
        Distance traveled and cross-state commuting to opioid treatment programs in the United States.
        J Environ Public Health. 2011; 2011: 948789https://doi.org/10.1155/2011/948789
        • Olsen Y.
        • Sharfstein J.M.
        Confronting the stigma of opioid use disorder—and its treatment.
        JAMA. 2014; 311: 1393-1394https://doi.org/10.1001/jama.2014.2147
      8. Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC. https://addiction.surgeongeneral.gov/surgeon-generals-report.pdf. Published 2016.

        • Minozzi S.
        • Amato L.
        • Vecchi S.
        • Davoli M.
        • Kirchmayer U.
        • Verster A.
        Oral naltrexone maintenance treatment for opioid dependence.
        Cochrane Database Syst Rev. 2011; 2: CD001333https://doi.org/10.1002/14651858.CD001333.pub3
        • Comer S.D.
        • Sullivan M.A.
        • Elmer Y.
        • et al.
        Injectable, sustained-release naltrexone for the treatment of opioid dependence: a randomized, placebo-controlled trial.
        Arch Gen Psychiatry. 2006; 63: 210-218https://doi.org/10.1001/archpsyc.63.2.210
        • Tanum L.
        • Solli K.K.
        • Latif Z.-H.
        • et al.
        The effectiveness of injectable extended-release naltrexone vs daily buprenorphine-naloxone for opioid dependence: a randomized clinical noninferiority trial.
        JAMA Psychiatry. 2017; 74: 1197-1205https://doi.org/10.1001/jamapsychiatry.2017.3206
        • Lee J.D.
        • Nunes E.V.
        • Novo P.
        • et al.
        Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT): a multicentre, open-label, randomised controlled trial.
        Lancet. 2018; 391: 309-318https://doi.org/10.1016/S0140-6736(17)32812-X
      9. Pew Charitable Trusts. The case for medication-assisted treatment. www.pewtrusts.org/~/media/assets/2017/02/thecasemedicationassistedtreatment.pdf. Published 2017.

        • Fiellin D.A.
        • Pantalon M.V.
        • Chawarski M.C.
        • et al.
        Counseling plus buprenorphine–naloxone maintenance therapy for opioid dependence.
        N Engl J Med. 2006; 355: 365-374https://doi.org/10.1056/NEJMoa055255
        • Fiellin D.A.
        • Barry D.T.
        • Sullivan L.E.
        • et al.
        A randomized trial of cognitive behavioral therapy in primary care-based buprenorphine.
        Am J Med. 2013; 126: 74.e11-74.e17https://doi.org/10.1016/j.amjmed.2012.07.005
      10. American Society of Addiction Medicine. National practice guideline for the use of medications in the treatment of addiction involving opioid use. https://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf?sfvrsn=24. Published 2015.

        • Lagisetty P.
        • Klasa K.
        • Bush C.
        • Heisler M.
        • Chopra V.
        • Bohnert A.
        Primary care models for treating opioid use disorders: what actually works? a systematic review.
        PLoS One. 2017; 12: e0186315https://doi.org/10.1371/journal.pone.0186315
      11. Buprenorphine implants (Probuphine) for opioid dependence.
        JAMA. 2016; 316: 1820-1821https://doi.org/10.1001/jama.2016.10899
      12. Drugs.com. Probuphine dosage. www.drugs.com/dosage/probuphine.html. Published 2017. Accessed October 27, 2017.

      13. Food and Drug Administration. Press release: FDA approves first once-monthly buprenorphine injection, a medication-assisted treatment option for opioid use disorder. www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm587312.htm. Published November 30, 2017.

        • Weiss R.D.
        • Potter J.S.
        • Griffin M.L.
        • et al.
        Long-term outcomes from the National Drug Abuse Treatment Clinical Trials Network Prescription Opioid Addiction Treatment Study.
        Drug Alcohol Depend. 2015; 150: 112-119https://doi.org/10.1016/j.drugalcdep.2015.02.030
        • Ling W.
        • Mooney L.
        • Torrington M.
        Buprenorphine for opioid addiction.
        Pain Manag. 2012; 2: 345-350https://doi.org/10.2217/pmt.12.26
      14. Hancock C, Mennenga H, King N, Andrilla H, Larson E, Schou P. National Rural Health Association Policy Brief: treating the rural opioid epidemic. www.ruralhealthweb.org/NRHA/media/Emerge_NRHA/Advocacy/Policy%20documents/Treating-the-Rural-Opioid-Epidemic_Feb-2017_NRHA-Policy-Paper.pdf. Published 2017.

        • Winstock A.R.
        • Lea T.
        • Sheridan J.
        Prevalence of diversion and injection of methadone and buprenorphine among clients receiving opioid treatment at community pharmacies in New South Wales, Australia.
        Int J Drug Policy. 2008; 19: 450-458https://doi.org/10.1016/j.drugpo.2007.03.002
        • Macy B.
        Addicted to a treatment for addiction.
        New York Times, May 28, 2016
        • Sontag D.
        Addiction treatment with a dark side.
        New York Times, November 16, 2016
        • Lofwall M.R.
        • Walsh S.L.
        A review of buprenorphine diversion and misuse: the current evidence base and experiences from around the world.
        J Addict Med. 2014; 8: 315-326https://doi.org/10.1097/ADM.0000000000000045
        • Manchikanti L.
        • Whitfield E.
        • Pallone F.
        Evolution of the National All Schedules Prescription Electronic Reporting Act (NASPER): a public law for balancing treatment of pain and drug abuse and diversion.
        Pain Physician. 2005; 8: 335-347
        • Sarpatwari A.
        Just say no: the case against the reclassification of buprenorphine.
        University of Maryland Law Journal of Race, Religion, Gender and Class. 2012; 12: 377-395
        • Daniulaityte R.
        • Falck R.
        • Carlson R.G.
        Illicit use of buprenorphine in a community sample of young adult non-medical users of pharmaceutical opioids.
        Drug Alcohol Depend. 2012; 122: 201-207https://doi.org/10.1016/j.drugalcdep.2011.09.029
      15. 106th U.S. Congress. Drug Addiction Treatment Act of 2000. www.gpo.gov/fdsys/pkg/PLAW-106publ310/pdf/PLAW-106publ310.pdf.

      16. 109th U.S. Congress. Office of the National Drug Control Policy Reauthorization Act of 2006. www.congress.gov/109/plaws/publ469/PLAW-109publ469.pdf.

        • Substance Abuse and Mental Health Services Administration (SAMHSA)
        Medication assisted treatment for opioid use disorders; final rule.
        Fed Regist. 2016; 81: 44712-44739
      17. 114th U.S. Congress. Comprehensive Addiction and Recovery Act of 2016. www.gpo.gov/fdsys/pkg/PLAW-114publ198/pdf/PLAW-114publ198.pdf.

        • Walley A.Y.
        • Alperen J.K.
        • Cheng D.M.
        • et al.
        Office-based management of opioid dependence with buprenorphine: clinical practices and barriers.
        J Gen Intern Med. 2008; 23: 1393-1398https://doi.org/10.1007/s11606-008-0686-x
        • Stein B.D.
        • Sorbero M.
        • Dick A.W.
        • Pacula R.L.
        • Burns R.M.
        • Gordon A.J.
        Physician capacity to treat opioid use disorder with buprenorphine-assisted treatment.
        JAMA. 2016; 316: 1211-1212https://doi.org/10.1001/jama.2016.10542
        • Rosenblatt R.A.
        • Andrilla C.H.A.
        • Catlin M.
        • Larson E.H.
        Geographic and specialty distribution of U.S. physicians trained to treat opioid use disorder.
        Ann Fam Med. 2015; 13: 23-26https://doi.org/10.1370/afm.1735
        • Gunderson E.W.
        • Wang X.-Q.
        • Fiellin D.A.
        • Bryan B.
        • Levin F.R.
        Unobserved versus observed office buprenorphine/naloxone induction: a pilot randomized clinical trial.
        Addict Behav. 2010; 35: 537-540https://doi.org/10.1016/j.addbeh.2010.01.001
        • Cunningham C.O.
        • Kunins H.V.
        • Roose R.J.
        • Elam R.T.
        • Sohler N.L.
        Barriers to obtaining waivers to prescribe buprenorphine for opioid addiction treatment among HIV physicians.
        J Gen Intern Med. 2007; 22: 1325-1329https://doi.org/10.1007/s11606-007-0264-7
        • Cunningham C.O.
        • Sohler N.L.
        • McCoy K.
        • Kunins H.V.
        Attending physicians’ and residents’ attitudes and beliefs about prescribing buprenorphine at an urban teaching hospital.
        Fam Med. 2006; 38: 336-340
        • Deflavio J.
        • Rolin S.
        • Nordstrom B.
        • Kazal L.
        Analysis of barriers to adoption of buprenorphine maintenance therapy by family physicians.
        Rural Remote Health. 2015; 15 (Accessed June 9, 2017): 3019
        • Barry D.T.
        • Irwin K.S.
        • Jones E.S.
        • et al.
        Integrating buprenorphine treatment into office-based practice: a qualitative study.
        J Gen Intern Med. 2009; 24: 218-225https://doi.org/10.1007/s11606-008-0881-9
        • Gordon A.J.
        • Kavanagh G.
        • Krumm M.
        • et al.
        Facilitators and barriers in implementing buprenorphine in the Veterans Health Administration.
        Psychol Addict Behav. 2011; 25: 215-224https://doi.org/10.1037/a0022776
        • Mendoza S.
        • Rivera-Cabrero A.S.
        • Hansen H.
        Shifting blame: buprenorphine prescribers, addiction treatment, and prescription monitoring in middle-class America.
        Transcult Psychiatry. 2016; 53: 465-487https://doi.org/10.1177/1363461516660884
        • Netherland J.
        • Botsko M.
        • Egan J.E.
        • et al.
        Factors affecting willingness to provide buprenorphine treatment.
        J Subst Abuse Treat. 2009; 36: 244-251https://doi.org/10.1016/j.jsat.2008.06.006
        • Yang A.
        • Arfken C.L.
        • Johanson C.E.
        Steps physicians report taking to reduce diversion of buprenorphine.
        Am J Addict. 2013; 22: 184-187https://doi.org/10.1111/j.1521-0391.2012.00335.x
        • Van Boekel L.C.
        • Brouwers E.P.M.
        • Van Weeghel J.
        • Garretsen H.F.L.
        Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review.
        Drug Alcohol Depend. 2013; 131: 23-35https://doi.org/10.1016/j.drugalcdep.2013.02.018
        • Hutchinson E.
        • Catlin M.
        • Andrilla C.H.A.
        • Baldwin L.-M.
        • Rosenblatt R.A.
        Barriers to primary care physicians prescribing buprenorphine.
        Ann Fam Med. 2014; 12: 128-133https://doi.org/10.1370/afm.1595
        • Quest T.L.
        • Merrill J.O.
        • Roll J.
        • Saxon A.J.
        • Rosenblatt R.A.
        Buprenorphine therapy for opioid addiction in rural Washington: the experience of the early adopters.
        J Opioid Manag. 2012; 8: 29-38https://doi.org/10.5055/jom.2012.0093
        • Kissin W.
        • McLeod C.
        • Sonnefeld J.
        • Stanton A.
        Experiences of a national sample of qualified addiction specialists who have and have not prescribed buprenorphine for opioid dependence.
        J Addict Dis. 2006; 25: 91-103https://doi.org/10.1300/J069v25n04_09
      18. White WL. Long-term strategies to reduce the stigma attached to addiction, treatment, and recovery within the city of Philadelphia (with particular reference to medication-assisted treatment/recovery). Philadelphia, PA; 2009. www.williamwhitepapers.com/pr/2009Stigma%26methadone.pdf.

        • Clark R.E.
        • Baxter J.D.
        Responses of state Medicaid programs to buprenorphine diversion.
        JAMA Intern Med. 2013; 173: 1571-1572https://doi.org/10.1001/jamainternmed.2013.9059
        • Arfken C.L.
        • Johanson C.E.
        • di Menza S.
        • Schuster C.R.
        Expanding treatment capacity for opioid dependence with office-based treatment with buprenorphine: national surveys of physicians.
        J Subst Abuse Treat. 2010; 39: 96-104https://doi.org/10.1016/j.jsat.2010.05.004
        • Gunderson E.W.
        • Levin F.R.
        • Kleber H.D.
        • Fiellin D.A.
        • Sullivan L.E.
        Evaluation of a combined online and in person training in the use of buprenorphine.
        Subst Abus. 2006; 27: 39-45https://doi.org/10.1300/J465v27n03_06
        • Clark R.E.
        • Samnaliev M.
        • Baxter J.D.
        • Leung G.Y.
        The evidence doesn’t justify steps by state Medicaid programs to restrict opioid addiction treatment with buprenorphine.
        Health Aff (Millwood). 2011; 30: 1425-1433https://doi.org/10.1377/hlthaff.2010.0532
        • Clark R.E.
        • Baxter J.D.
        • Barton B.A.
        • Aweh G.
        • O’Connell E.
        • Fisher W.H.
        The impact of prior authorization on buprenorphine dose, relapse rates, and cost for Massachusetts Medicaid beneficiaries with opioid dependence.
        Health Serv Res. 2014; 49: 1964-1979https://doi.org/10.1111/1475-6773.12201
        • Burns R.M.
        • Pacula R.L.
        • Bauhoff S.
        • et al.
        Policies related to opioid agonist therapy for opioid use disorders: the evolution of state policies from 2004 to 2013.
        Subst Abus. 2016; 37: 63-69https://doi.org/10.1080/08897077.2015.1080208
        • Grogan C.M.
        • Andrews C.
        • Abraham A.
        • et al.
        Survey highlights differences in Medicaid coverage for substance use treatment and opioid use disorder medications.
        Health Aff (Millwood). 2016; 35: 2289-2296https://doi.org/10.1377/hlthaff.2016.0623
        • Saloner B.
        • Sharfstein J.M.
        A stronger treatment system for opioid use disorders.
        JAMA. 2016; 315: 2165-2166https://doi.org/10.1001/jama.2016.3674
      19. Maclean JC, Saloner B. The effect of public insurance expansions on substance use disorder treatment: evidence from the Affordable Care Act. NBER Working Paper No. 23342. www.nber.org/papers/w23342. Published 2017.

      20. Beronio K, Po R, Skopec L, Glied S. ASPE research brief: Affordable Care Act expands mental health and substance use disorder benefits and federal parity protections for 62 million Americans. https://aspe.hhs.gov/report/affordable-care-act-expands-mental-health-and-substance-use-disorder-benefits-and-federal-parity-protections-62-million-americans. Published 2013. Accessed June 28, 2017.

        • Beronio K.
        • Glied S.
        • Frank R.
        How the Affordable Care Act and Mental Health Parity and Addiction Equity Act greatly expand coverage of behavioral health care.
        J Behav Health Serv Res. 2018; 27: 50-75https://doi.org/10.1007/s11414-014-9412-0
        • Saloner B.
        • Akosa Antwi Y.
        • Maclean J.C.
        • Cook B.
        Access to health insurance and utilization of substance use disorder treatment: evidence from the Affordable Care Act dependent coverage provision.
        Health Econ. 2018; 27: 50-75https://doi.org/10.1002/hec.3482
        • U.S. Congress
        Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008.
        House of Representatives, 2008
      21. Interim Final Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008.
        Fed Regist. 2010; 75: 5410-5451
        • U.S. Department of the Treasury, U.S. Department of Labor, HHS
        Final Rules Under the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008.
        Fed Regist. 78. 2013: 68239-68296
      22. The National Center on Additional and Substance Abuse. Uncovering coverage gaps: a review of addiction benefits in ACA plans. www.centeronaddiction.org/addiction-research/reports/uncovering-coverage-gaps-review-of-addiction-benefits-in-aca-plans. Published 2016.

        • McCance-Katz E.F.
        • George P.
        • Scott N.A.
        • Dollase R.
        • Tunkel A.R.
        • McDonald J.
        Access to treatment for opioid use disorders: medical student preparation.
        Am J Addict. 2017; 26: 316-318https://doi.org/10.1111/ajad.12550
        • Komaromy M.
        • Duhigg D.
        • Metcalf A.
        Project ECHO (Extension for Community Healthcare Outcomes): A new model for educating primary care providers about treatment of substance use disorders..
        Subst Abus. 2016; 37: 20-24https://doi.org/10.1080/08897077.2015.1129388
        • Egan J.E.
        • Casadonte P.
        • Gartenmann T.
        • et al.
        The physician clinical support system-buprenorphine (PCSS-B): A novel project to expand/improve buprenorphine treatment.
        J Gen Intern Med. 2010; 25: 936-941https://doi.org/10.1007/s11606-010-1377-y
        • Donnelly J.
        Strengthening the Addiction Treatment Workforce Act.
        115th Congress, 2017
        • DiPaula B.A.
        • Menachery E.
        • et al.
        Physician-pharmacist collaborative care model for buprenorphine-maintained opioid-dependent patients.
        J Am Pharm Assoc. 2015; 55: 187-192https://doi.org/10.1331/JAPhA.2015.14177
        • Volkow N.D.
        • Collins F.S.
        The role of science in addressing the opioid crisis.
        N Engl J Med. 2017; 377: 391-394https://doi.org/10.1056/NEJMsr1706626
      23. Food and Drug Administration. Administering the Hatch-Waxman amendments: ensuring a balance between innovations and access: public meeting; request for comments. www.fda.gov/Drugs/NewsEvents/ucm563986.htm. Published 2017.

      24. The Mental Health and Substance Use Disorder Parity Task Force: Final Report. Washington, DC. www.hhs.gov/sites/default/files/mental-health-substance-use-disorder-parity-task-force-final-report.pdf. Published 2016.

      25. Upton F. 21st Century Cures Act.
        114th Congress, 2015
        • Goodnough A.
        $45 billion to fight opioid abuse? That’s much too little, experts say.
        New York Times, July 1, 2017
      26. Food and Drug Administration. Remarks from FDA Commissioner Scott Gottlieb, M.D., as prepared for oral testimony before the House Committee on Energy and Commerce Hearing, “Federal Efforts to Combat the Opioid Crisis: A Status Update on CARA and Other Initiatives.” www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm582031.htm. Published 2017. Accessed October 25, 2017.