'Secret Shopper' Study Finds Many Who Need Addiction Treatment Can't Get It
When people who are addicted to opioids make the difficult decision to quit, the last thing they need to face are barriers to treatment.
Yet, a new "secret shopper" study suggests most addicts seeking a prescription for buprenorphine -- which helps people stop using opioids -- would have trouble even getting an appointment with a doctor qualified to dispense the drug.
When researchers called doctors' offices posing as addicts who wanted to get a prescription for buprenorphine so they could stop using heroin, 46% of those who said they had Medicaid were denied an appointment, while 38% of those who said they would pay in cash were turned away.
"When people are seeking treatment, you want to make it as easy as possible. But our study showed you have to be quite persistent. That can be tough and might lead to them giving up," said study senior author Dr. Michael Barnett. He's an assistant professor of health policy and management at the Harvard T.H. Chan School of Public Health in Boston.
Barnett said buprenorphine is "a long-acting medication that stimulates the same receptors in the brain as opioids. It helps quash cravings without the euphoria or high of opioids. It lets people get back to their life."
The challenge in prescribing it, however, is that people have to be in mild to moderate withdrawal before they can be given the drug. Paradoxically, if you are high on opioids and you take buprenorphine, it sends you into an immediate and difficult withdrawal. So, it must be carefully administered by someone who's had the right training, Barnett explained.
Providers have to obtain a federal waiver to be able to prescribe buprenorphine. Doctors have to have eight hours of training, and nurse practitioners and physician assistants need 24 hours of training. Fewer than 6% of doctors in the United States have these waivers. And even those who do aren't always actively prescribing the drug.
The U.S. Substance Abuse and Mental Health Services Administration maintains a public list of doctors who agreed to be listed when they obtained their waivers to prescribe buprenorphine.
For the study, two female researchers called the doctors on this list. They posed as heroin addicts seeking an appointment for a buprenorphine prescription. They posed as either a patient with Medicaid or someone who would pay with cash. Each doctor's office was called twice, several weeks apart.
The researchers planned to call nearly 1,100 providers in six states. However, 530 of the providers were culled from the list because they had invalid contact information (such as a non-working phone number) or they were no longer prescribing buprenorphine.
Some of the remaining doctors couldn't be reached. For example, their phone may have gone to voicemail instead of a live person. The researchers completed just over 430 calls as a Medicaid patient, and nearly 420 as a cash payer.
Only between half and two-thirds of doctors scheduling an appointment planned to give a prescription on the first visit.
One bright spot the study found was when researchers did find a doctor willing to book an appointment, the wait time was often less than two weeks.
"We do have a prescriber workforce that is open for business and ready to help, but it may be hard for patients to find these providers in those directories," Barnett said.
As to why people, particularly the Medicaid group, had trouble getting an appointment, Barnett said there are a number of reasons why. One is that Medicaid may put up barriers to prescribing buprenorphine, such as requiring a prior authorization before prescribing the medication. Also, he said, some doctors didn't want to accept cash payments.
And, he said, there may still be a stigma against these patients. "They're just people. It's like treating any other chronic illness, and buprenorphine can literally turn people's lives around," Barnett explained.
The findings were published June 3 in the Annals of Internal Medicine.
Dr. Pooja Lagisetty, an assistant professor at the University of Michigan and a primary care physician herself, co-wrote an editorial that accompanied the study. "There was a big difference between those willing to take Medicaid versus the self-pay patients. It makes you question whether insurance may not be reimbursing enough," she said.
"Addiction is a disease, and people do better on this medication when they're on it long term. We need to make sure providers are being appropriately reimbursed for the care they're providing," Lagisetty said.
Dr. Paul Earley, president of the American Society of Addiction Medicine, said, "What's most disconcerting is that some of the states with the worst opioid overdoses are where people had a harder time getting an appointment."
Earley said in this age of data, it shouldn't be too hard to ask a doctor to be sure to update their information on the list every year, so that people trying to get help aren't frustrated by calling numbers that are out-of-date and aren't working.
He also said that doctors seeking the federal waivers that allow them to prescribe should set up a system for caring for these patients. Earley said they need urine testing to be sure they're taking the medication as they should, and that they need to be called more often with appointment reminders.
"All of those things require a certain amount of work to set up," he said. But it can be done successfully, Earley noted, pointing to the doctors who were able to see patients quickly in this study.
Learn more about buprenorphine from the U.S. Substance Abuse and Mental Health Services Administration.
SOURCES: Michael Barnett, M.D., M.S., assistant professor, health policy and management, Harvard T.H. Chan School of Public Health, and assistant professor, Harvard Medical School, and primary care doctor, Brigham and Women's Hospital, Boston; Pooja Lagisetty, M.D., M.Sc., assistant professor, division of general internal medicine, University of Michigan, Ann Arbor; Paul Earley, M.D., president, American Society of Addiction Medicine; June 3, 2019, Annals of Internal Medicine