A qualitative study comparing physician-reported barriers to treating addiction using buprenorphine and extended-release naltrexone in U.S. office-based practices

Abstract

Aim: Our aim was to compare physician-reported barriers to sublingual buprenorphine (BUP) and extended-release naltrexone (XR-NLT) prescribing in U.S. office-based practices, and to identify potential policies for minimizing these barriers. Only one previous qualitative study has examined physician-reported barriers to prescribing XR-NLT and no qualitative study has compared physician-reported barriers between the two medications.

Methods: Researchers conducted individual semi-structured and in-depth interviews with 20 licensed physicians in four U.S. states between January 2016 and May 2017. Interview questions included general barriers to addiction treatment in office-based settings, barriers specific to BUP and XR-NLT prescribing, and potential government policies to decrease barriers. Researchers conducted thematic analysis of transcribed interviews. They developed and pilot tested a coding template based on a sample of transcripts, independently coded transcripts in Dedoose software, conducted consensus coding to eliminate coding discrepancies, and then assessed data for themes using research questions as a guide.

Results: General barriers to office-based OUD treatment included limited physician education, limited insurance reimbursement, stigma, and perceptions of "difficult" patients. Barriers specific to BUP prescribing included regulatory restrictions, liability fears, and restrictions imposed by the criminal justice system. Barriers specific to XR-NLT prescribing included limited access to medically-supervised opioid detoxification, lack of awareness of the medication, and patient fears or disinterest. Participants without experience prescribing either medication emphasized barriers to treating OUD in general. Participants with experience prescribing BUP and/or XR-NLT described barriers to treating OUD in general as well as barriers specific to each medication. Policy makers should increase access to addiction medicine education, mandate insurance coverage of both medications and inpatient detoxification, prohibit excessive insurance prior authorization requirements, increase insurance reimbursement for behavioral healthcare, and incentivize interdisciplinary collaboration.

Conclusions: While overlap exists, some barriers to BUP prescribing differ from barriers to XR-NLT prescribing.

Keywords: Buprenorphine; Extended-release naltrexone; Medication-assisted treatment; Opioid use disorder.