1. 1 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

2. 2 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

3. 3 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

4. 4 Conceptual Model for Adoption of Pharmacotherapy in Substance Abuse Treatment Source: Thomas, Wallack, et al, 2003

5. 5 Brandeis Buprenorphine Research Model Physicians Treatment Organizations Knowledge, rules, strategies, culture, incentives, structure, mission, market, funding, patient mix Knowledge, beliefs, training, orientation Adoption

6. 6 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?

7. 7 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

8. 8 Survey Domains Personal characteristics Practice characteristics Patient characteristics Substance abuse treatment philosophy and approaches used Attitudes specifically toward buprenorphine Buprenorphine prescribing practices Networking

9. 9 Receiving the Waiver and Prescribing Buprenorphine

10. 10 MD Practice Characteristics CombinedAddiction Specialists General Psychiatrists Prescribe Yes Prescribe No Prescribe Yes Prescribe No Prescribe Yes Prescribe No Mean years treating addictions 12.715.0*14.512.811.315.2 % 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% % 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

11. 11 Market Area Differences in Adoption Addiction Specialists General Psychiatrists

12. 12 How Did MDs First Learn About Buprenorphine?

13. 13 Organizational Support for Prescribing Buprenorphine is Important Note: 19/32 medical directors are in organizations that do not support

14. 14 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

15. 15 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***2.643.81 Waiver regs a signif. barrier**1.641.92 Unpredictable benefits*2.553.10 Diversion risk3.173.29 Too complex**1.932.50 Would adversely change the makeup of my practice*** 1.932.53 Insufficient evidence regarding efficacy** 1.672.16 *Significant difference between organizations at p<.05 **Significant difference between organizations at p<.01 ***Significant difference between organizations at p<.001

16. 16 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:

17. 17 Why Generalist Psychiatrists may not be Prescribing Buprenorphine Agree very much with: SpecialistsGeneral 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% Consistent with my treatment philosophy91%86% Average number of opiate patients in past*** month (if >0) 726 *Significant difference between organizations at p= <.05 **Significant difference between organizations at p= <.01 ***Significant difference between organizations at p= <.001

18. 18 Top Facilitators and Barriers to Prescribing (Rank order of responses) Barriers (reasons for not prescribing) 1. Does not fit in with my practice 2. Would change patient mix undesirably 3. Do not have samples 4. Prescribing is too complex Facilitators (reasons for prescribing) 1. Knowledge of buprenorphine’s effectiveness 2. Consistent with treatment philosophy 3. Patient requests 4. Local availability 1. Does not fit in with my practice 2. Would change patient mix undesirably 3. Prescribing is too complex 4. Waiver regulation 1. Knowledge of buprenorphine’s effectiveness 2. Consistent with treatment philosophy 3. Local availability 4. Other counseling staff available Addiction Specialists General Psychiatrists

19. 19 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

20. 20 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

21. 21 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

22. Behavioral Health Center, The Schneider Institute for Health Policy, The Heller School for Social Policy and Management, Brandeis University Thank you! Questions?