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Presentation to the Academy Health Annual Research Meeting 2006

Brandeis University Schneider Institute for Health Policy

June 26, 2006

Research supported by the National Institute on Drug Abuse Grant no. 5RO1 DA014578-02

Adoption of Buprenorphine by Clinical Providers

Cindy Parks Thomas, Sayeda Haq, Sharon Reif, Alex Hoyt, Jon Chilingerian,Stanley S. Wallack

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Background: Buprenorphine in Office-Based Practice

• Drug Abuse Treatment Act of 2000 approved buprenorphine (Subutex®, Suboxone®) for office-based treatment of opioid addiction

• Major goal of legislation: to increase access to treatment, encourage providers to address this problem

• Past MD surveys show barriers to widespread use: lack of insurance coverage, cost, availability of the medication, statutory limit to the number of patients an MD can treat at once

• Context of other SA meds: naltrexone did not widely diffuse; organizational role important

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Brandeis Study: Diffusion of Innovation Research

• Buprenorphine research funded by NIDA

• Diffusion models examine adoption, identify barriers and predict facilitators

• Context of MD survey: within larger study to examine role of organizational/treatment setting factors and interaction between MDs and organizations Survey of general psychiatrists and addiction specialists

Survey of treatment organizations

• Identify the clinician, technology, environmental factors and organizational strategies predicting adoption

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Conceptual Model for Adoption of Pharmacotherapy in Substance Abuse Treatment

Clinician characteristics:DemographicsTreatment orientationTraining and educationKnowledgeAttitudePrior experience

Char. of the technologyMarket informationCost, effectiveness

Org. acceptanceDecision to adopt/not adoptDecision to make availableDecision to encourage

Provider/patient acceptance

Prescribe Yes/No

Patients use

Patient attitudesand Characteristics

System characteristics:Public policy

Disease prevalenceService capacity and util

Market factors

Org.characteristicsTreatment orientationStructure, FinancingFocus of organizationPatient baseRules/policies

Source: Thomas, Wallack, et al, 2003

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Brandeis Buprenorphine Research Model

PhysiciansTreatment

Organizations

Knowledge, rules, strategies, culture, incentives, structure, mission,

market, funding, patient mix

Knowledge, beliefs, training, orientation

Adoption

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Research Questions & Hypotheses

• What factors are associated with MDs’ decisions to adopt buprenorphine in office-based practice?

Addiction specialists versus general psychiatrists MD personal characteristics MD treatment philosophy, attitudes and knowledge

Perceived benefits and costs are associated with adoption

Exposure to marketing and academic information Primary affiliation with organizations that support adoption

Particularly if the organization has strategies to influence MDs.

• What is the relationship between MDs’ adoption of buprenorphine and the treatment organizations in which they practice?

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Methods

• Mail and internet survey of MDs in four major market areas: Addiction specialists and sample of general psychiatrists Boston, Miami, San Francisco, Chicago

• N=286 addiction specialists (69% response rate); N=224 general psychiatrists (55% response rate); N=32 MD facility directors

• Bivariate and multivariate analysis of organization factors and MD factors (separate models)

• Integrated model of interaction between MDs and organizations

• Network analysis of MDs

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Survey Domains

• Personal characteristics

• Practice characteristics

• Patient characteristics

• Substance abuse treatment philosophy and approaches used

• Attitudes specifically toward buprenorphine

• Buprenorphine prescribing practices

• Networking

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Receiving the Waiver and Prescribing Buprenorphine

55.6%

90.6%

12.8%

89.5%

4.0%

64.8% 65.6%

35.3%

0%

20%

40%

60%

80%

100%

Total sample(n=495)

Addictionspecialists

(n=239)

FacilityDirectors

(n=32)

Generalpsychiatrists

(n=224)

Percent trainedor receivedwaiverPercentprescribing

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MD Practice CharacteristicsCombined Addiction

SpecialistsGeneral

Psychiatrists

Prescribe Yes

Prescribe No

PrescribeYes

PrescribeNo

PrescribeYes

PrescribeNo

Mean years treating addictions

12.7 15.0* 14.5 12.8 11.3 15.2

% clinical time treating addictions vs. other clinical

33.5% 12.8%* 34.3% 31.8% 20.0% 5.4%*

% time specialty SA facility

12.7% 5.3%* 13.5% 17.5% 0.6% 0.6%

% time solo practice 27.6% 33.6% 27.9% 28.2% 22.2% 35.7%

% time group practice 18.2% 9.8%* 19.2% 7.6%* 2.2% 10.6%*

% Heroin user clients 21.5% 9.5%* 22.2% 27.7% 9.0% 4.3%

% Rx opiate user clients 25.0% 10.3%* 29.8% 22.2%* 13.4% 7.0%

•Note small numbers for general psychiatrist prescribers!! *Significant difference between prescribers and nonprescribers at p<.05

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Market Area Differences in Adoption

0%

20%

40%

60%

80%

100%

Boston

Chicag

o

Mia

mi

San F

ranci

sco

Percent trained or received waiver Percent prescribing

0%

20%

40%

60%

80%

100%

Addiction Specialists General Psychiatrists

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0%

10%

20%

30%

40%

50%

60%

Jour

nal a

rticl

es

Profe

ssio

nal o

rgs

SAMHSA/C

SAT

Colleag

ues o

utsi

de org

Colleag

ues in

org

Sales

rep

News

med

ia

Patie

nts

Other

Had n

ot hea

rd o

f it

Addiction Specialists General Psychiatrists

How Did MDs First Learn About Buprenorphine?

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Organizational Support for Prescribing Buprenorphine is Important

Prescriben=10375%

Do not prescriben=3425%

Prim ary organization supportsN=137

51%

Prescriben=6750%

Do not prescriben=6750%

Prim ary organization does not supportN=134

49%

271 Specialist Physicians and Medical Directors

Note: 19/32 medical directors are in organizations that do not support

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Physician Perceptions of their Organizations

Organization features (Percent Agree )

Organization supports

Organization does not support

Medical director engages providers***

78% 36%

Strong identification with org. mission ***

92% 73%

General agreement on treatment *** methods

90% 61%

Clinical decisions are affected by costs

53% 63%

New treatment methods are rewarded ***

83% 33%

Organization spends time and $ on

professional activities ***

67% 37%

*Significant difference across rows at p =< .05 **Significant difference across rows at p =< .01***Significant difference across rows at p =< .001

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Importance of Organizations and Information: “Less negative” attitudes among nonprescribers

Barriers(1=disagree, 6=agree)

Organization Supports

Organization does not Support

Does not fit with my practice*** 2.64 3.81

Waiver regs a signif. barrier** 1.64 1.92

Unpredictable benefits* 2.55 3.10

Diversion risk 3.17 3.29

Too complex** 1.93 2.50

Would adversely change the makeup of my practice***

1.93 2.53

Insufficient evidence regarding efficacy**

1.67 2.16

*Significant difference between organizations at p<.05**Significant difference between organizations at p<.01***Significant difference between organizations at p<.001

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What Can Organizations do to Promote Prescribing?

• Org recommends

• Recommend + encourage training

• Recommend + encourage training + medical director engages

79%

83%

85%

Percent of MDs getting waiver:

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Why Generalist Psychiatrists may not be Prescribing Buprenorphine

Agree very much with: Specialists General psychiatrists

Had not heard of it before survey*** 0.42% 16%

Prescribe meds to reduce craving** 65% 48%

Does not fit in with my practice* 45% 60%

Org recommends use of bup*** 52% 22%

Org strongly encourages training*** 55% 13%

Drugs play very large role in SA treatment*** 92% 73%

Buprenorphine is effective*** 96% 72%

Consistent with rx philosophy of my organization

89% 89%

Consistent with my treatment philosophy 91% 86%

Average number of opiate patients in past*** month (if >0)

72 6

*Significant difference between organizations at p= <.05 **Significant difference between organizations at p= <.01***Significant difference between organizations at p= <.001

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Top Facilitators and Barriers to Prescribing (Rank order of responses)

Barriers (reasons for not prescribing)1. Does not fit in with my practice2. Would change patient mix

undesirably3. Do not have samples 4. Prescribing is too complex

Facilitators (reasons for prescribing)1. Knowledge of buprenorphine’s

effectiveness2. Consistent with treatment

philosophy3. Patient requests 4. Local availability

1. Does not fit in with my practice2. Would change patient mix

undesirably3. Prescribing is too complex4. Waiver regulation

1. Knowledge of buprenorphine’s

effectiveness2. Consistent with treatment

philosophy3. Local availability 4. Other counseling staff available

Addiction Specialists General Psychiatrists

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Results Summary• Adoption by generalist psychiatrists very limited to

date

• Adoption differs by market area: Why?

• Adoption greater if organization supports use Similar MD approaches to treatment, or is the organization doing

something to promote more adoption?

• Organizations have an effect on improving attitudes toward buprenorphine, even for non-prescribers

• Strongest factors for adoption (preliminary model): Organization support, learned from CSAT, employed patients, belief in

effectiveness, more recently trained

• Information dissemination differs between addiction specialists and general psychiatrists

Fewer general psychiatrists know about buprenorphine Professional organizations and CSAT less often source of information for

general psychiatrists

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Policy Implications

• Organizations are critical for physicians to complete adoption Aligned approaches and beliefs Organizational support and engaged medical director

• Even with organizational support, some MDs may be very late adopters

• General psychiatrists not engaged Are the outreach resources sufficient? How strong is the stigma or difficulty? Is this the target of the legislation? Will they adopt?

• Barriers (complexity, interest) may be mitigated with additional experience as medication diffuses, information disseminates and patients request it

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Next Steps in Research

• Network analysis of physician communication and adoption patterns

• Examine the market and organizational factors contributing to adoption

• Model the effect of the organization’s policies and strategies on adoption

• International supplement: compare use and attitudes in France and other countries to U.S.

• Additional application of surveys in Singapore

Behavioral Health Center,The Schneider Institute for Health Policy,The Heller School for Social Policy and Management,Brandeis University

Thank you!

Questions?