Background:
Improving access to treatment for opioid use disorder is a national priority, but little is known about the barriers encountered by patients seeking buprenorphine–naloxone (“buprenorphine”) treatment.
Objective:
To assess real-world access to buprenorphine treatment for uninsured or Medicaid-covered patients reporting current heroin use.
Design:
Audit survey (“secret shopper” study).
Setting:
6 U.S. jurisdictions with a high burden of opioid-related mortality (Massachusetts, Maryland, New Hampshire, West Virginia, Ohio, and the District of Columbia).
Participants:
From July to November 2018, callers contacted 546 publicly listed buprenorphine prescribers twice, posing as uninsured or Medicaid-covered patients seeking buprenorphine treatment.
Measurements:
Rates of new appointments offered, whether buprenorphine prescription was possible at the first visit, and wait times.
Results:
Among 1092 contacts with 546 clinicians, schedulers were reached for 849 calls (78% response rate). Clinicians offered new appointments to 54% of Medicaid contacts and 62% of uninsured–self-pay contacts, whereas 27% of Medicaid and 41% of uninsured–self-pay contacts were offered an appointment with the possibility of buprenorphine prescription at the first visit. The median wait time to the first appointment was 6 days (interquartile range [IQR], 2 to 10 days) for Medicaid contacts and 5 days (IQR, 1 to 9 days) for uninsured–self-pay contacts. These wait times were similar regardless of clinician type or payer status. The median wait time from first contact to possible buprenorphine induction was 8 days (IQR, 4 to 15 days) for Medicaid and 7 days (IQR, 3 to 14 days) for uninsured–self-pay contacts.
Limitation:
The survey sample included only publicly listed buprenorphine prescribers.
Conclusion:
Many buprenorphine prescribers did not offer new appointments or rapid buprenorphine access to callers reporting active heroin use, particularly those with Medicaid coverage. Nevertheless, wait times were not long, implying that opportunities may exist to increase access by using the existing prescriber workforce.
Primary Funding Source:
National Institute on Drug Abuse.
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Author, Article, and Disclosure Information
Harvard T.H. Chan School of Public Health, Boston, Massachusetts (T.B.)
Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (B.S.)
Massachusetts General Hospital, Boston, Massachusetts (S.E.W.)
Brigham and Women's Hospital, Boston, Massachusetts (M.G.)
Harvard T.H. Chan School of Public Health and Brigham and Women's Hospital, Boston, Massachusetts (M.L.B.)
Grant Support: By National Institute on Drug Abuse grant K01 DA042139 to Dr. Saloner.
Disclosures: Dr. Barnett reports personal fees from Greylock McKinnon Associates outside the submitted work and is retained as an expert witness for litigation against opioid manufacturers and distributors. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-3457.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Catharine B. Stack, PhD, MS, Deputy Editor, Statistics, reports that she has stock holdings in Pfizer, Johnson & Johnson, and Colgate-Palmolive. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Reproducible Research Statement:Study protocol: Available from Dr. Barnett (e-mail, [email protected]
Corresponding Author: Michael L. Barnett, MD, MS, Harvard T.H. Chan School of Public Health, Department of Health Policy and Management, 677 Huntington Avenue, Kresge 411, Boston, MA 02115; e-mail, [email protected]
Current Author Addresses: Ms. Beetham: Harvard T.H. Chan School of Public Health, Department of Social and Behavioral Sciences, 677 Huntington Avenue, Boston, MA 02115.
Dr. Saloner: Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, 624 North Broadway, Room 344, Baltimore, MD 21205.
Dr. Wakeman: Massachusetts General Hospital, Department of Medicine, 55 Fruit Street, Boston, MA 02114.
Ms. Gaye: Harvard T.H. Chan School of Public Health, Department of Health Policy and Management, 677 Huntington Avenue, Boston, MA 02115.
Dr. Barnett: Harvard T.H. Chan School of Public Health, Department of Health Policy and Management, 677 Huntington Avenue, Kresge 411, Boston, MA 02115.
Author Contributions: Conception and design: T. Beetham, B. Saloner, S.E. Wakeman, M.L. Barnett.
Analysis and interpretation of the data: T. Beetham, B. Saloner, S.E. Wakeman, M.L. Barnett.
Drafting of the article: T. Beetham, B. Saloner, S.E. Wakeman, M.L. Barnett.
Critical revision for important intellectual content: T. Beetham, B. Saloner, M.L. Barnett.
Final approval of the article: T. Beetham, B. Saloner, S.E. Wakeman, M. Gaye, M.L. Barnett.
Statistical expertise: B. Saloner, M.L. Barnett, B. Saloner.
Administrative, technical, or logistic support: M. Gaye.
Collection and assembly of data: T. Beetham, B. Saloner, M. Gaye.
This article was published at Annals.org on 4 June 2019.
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