Cash only

Outside of very rural areas, I’ve often scratched my head when advocates express concern about access to buprenorphine. I mean, there are a lot of prescribers in most areas.

I had a conversation yesterday that prompted a google search that led me to this. (OBT refers to office-based treatment with buprenorphine.)

Access to OBT in Ohio is far lower than what the 466 listed physicians suggests. Nearly 1 in 5 of those physicians are not active OBT prescribers, and 1 in 2 active prescribers do not accept insurance for OBT. Further research is needed to determine whether practices who do not accept insurance provide care consistent with CSAT guidelines and whether such practice patterns contribute to buprenorphine diversion. [emphasis mine]

50% of prescribers do not accept insurance? (And, Ohio’s a big state, which makes it a lot less likely that there’s a small ‘n’ that skews strangely.)

So what is going on? Why are so many prescribers not accepting insurance?

Since the introduction of office-based therapy (OBT), the number of eligible prescribers has increased from 9000 in 2006 to more than 20 000 in 2012, and the total sales of buprenorphine/naloxone have increased 10-fold to peak at $1.4 billion (28th best-selling prescription drug in the United States).¹^–³

Nationally, there is increasing concern that buprenorphine misuse and abuse are on the rise.¹^–⁴ Even the lay press is reporting on buprenorphine abuse.⁵^,⁶ Concern is increasing over a pattern of excessive doses of buprenorphine being prescribed, either by design or because of exaggeration of withdrawal symptoms by the patients, enabling this abuse phenomenon. There is the obvious risk that physicians can charge high fees for office visits, whereas the patients can divert the excess medication.²^,⁷^,⁸ There is greater concern that practices who do not accept insurance for OBT and require direct payment from patients may be over-represented in this diversion phenomenon.⁵

This study is important because the news reports expressing concern about this are dismissed as unjustly disparaging, anecdotal, bourgeois stigmatizing, fearmongering, and tragically discouraging legitimate prospective prescribers.

50%!

That is not a small problem. That’s not an anecdote. It’s a real story.

A quick search turns up a lot of stories in local media. Here, here and here are a few examples.

It’s striking that the national media is not covering this story when they are putting so much time and coverage into the opioid crisis.

There’s a lot of media and institutional pressure on non-maintenance treatment providers and mutual aid groups to change and integrate maintenance treatments and maintenance patients into their programming, residences, and groups. It’s appropriate to ask questions and encourage people/programs to interrogate themselves. That’s healthy. And, it’s important for us to remember that there are a lot of shady practices among non-maintenance providers.

However, it’s worth asking, why is there so little pressure on maintenance providers to provide recovery housing, social support, and other services to promote recovery and improve quality of life?

At any rate, this also helps shed some light on why there may be access issues when there are a lot of prescribers.