Drug overdose and substance use treatment admissions data indicate that opioid use is problematic in Kentucky, but little information exists about the geographic availability of buprenorphine treatment across the state. Furthermore, there is even less information about the characteristics of the physicians prescribing buprenorphine. This report describes the availability of buprenorphine treatment in Kentucky

Borders, Tyrone F.

Myers, Elijah T.

English

University of Kentucky

University of KentuckyUKnowledgeInstitute for Rural Health Policy Reports Institute for Rural Health Policy11-21-2016Availability of Buprenorphine Treatment inKentuckyElijah T. MyersUniversity of Kentucky, elijah.myers@uky.eduTyrone F. BordersUniversity of Kentucky, ty.borders@uky.eduRight click to open a feedback form in a new tab to let us know how this document benefits you.Follow this and additional works at: https://uknowledge.uky.edu/irhp_reportsPart of the Community Health and Preventive Medicine Commons, and the Health ServicesResearch CommonsThis Report is brought to you for free and open access by the Institute for Rural Health Policy at UKnowledge. It has been accepted for inclusion inInstitute for Rural Health Policy Reports by an authorized administrator of UKnowledge. For more information, please contactUKnowledge@lsv.uky.edu.Repository CitationMyers, Elijah T. and Borders, Tyrone F., "Availability of Buprenorphine Treatment in Kentucky" (2016). Institute for Rural HealthPolicy Reports. 2.https://uknowledge.uky.edu/irhp_reports/2Institute for Rural Health Policy Report :   Availability of Buprenorphine Treatment   1           Institute for  Rural Health Policy      November 21, 2016 Authors: Elijah T. Myers  Chellgren Student Fellow and Undergraduate Candidate, University of Kentucky  Tyrone F. Borders, Ph.D. Foundation for a Healthy Kentucky Endowed Chair in Rural Health Policy Co-Director, University of Kentucky Institute for Rural Health Policy Director, Rural and Underserved Health Research Center (RUHRC) Professor, Health Management and Policy, University of Kentucky College of Public Health  Note:  Mr. Myers completed much of this report to fulfill the requirement of a Chellgren Student Fellow project under the mentorship of Dr. Borders.  Suggested Citation: Myers ET, Borders TF.  Availability of Buprenorphine Treatment in Kentucky.  Lexington, KY:  University of Kentucky Institute for Rural Health Policy, 2016.  About the Institute for Rural Health Policy (IRHP):   The IRHP was founded in 2013 as a joint effort by Ty Borders and Brady Reynolds serving as Co-Directors and Foundation for a Healthy Kentucky Endowed Chairs in Rural Health Policy.  It conducts rural health services and policy research to inform rural health practitioners, managers, and policy makers in Kentucky.    “Availability of Buprenorphine  Treatment in Kentucky”  Institute for Rural Health Policy Report :   Availability of Buprenorphine Treatment   2       Background on Opioid Use and Buprenorphine  According to the Centers for Disease Control and Prevention (CDC), drug overdose deaths involving opioids have more than quadrupled in the past 15 years, driven by increases in both prescription and illicit opioid abuse.1  The state of Kentucky is no exception to the growing prevalence of opioid abuse.  Since 2000, Kentucky resident drug overdose deaths by prescription opioids and heroin have steadily increased, and from 1999 to 2008 admissions to substance abuse treatment programs for opioid addiction increased by 900%.2,3  Rates of hospitalizations and deaths due to opioid abuse are highest in rural counties, particularly those in eastern Kentucky.2,4  In 2000, the United States Congress approved the Drug Addiction Treatment Act (DATA) to provide physicians more independence to prescribe buprenorphine to treat opioid addiction.5  Buprenorphine is an opioid partial agonist that diminishes dependency to opioids, has lower potential for misuse than methadone, and is much safer in the case of drug overdose.5   Buprenorphine can be prescribed in a variety of medical settings and treatment is administered in 3 phases.5  The induction phase is within 12 to 24 hours of the patient refraining from opioid use and is monitored in the physician’s practice setting.5 Next is the stabilization phase in which the patient’s withdrawal symptoms are minimal.5  During this phase, buprenorphine doses can be adjusted or taken on an alternating schedule.5 The maintenance phase is then used to standardize dosage and set a personal schedule for treatment completion.5  After completing an 8-hour online training through the Substance Abuse and Mental Health Services Administration (SAMHSA) and approval by the DEA, physicians are able to treat up to 30 patients within the first year of certification or up to 100 patients thereafter.5  A recent federal regulation raised the limit to 275 patients among physicians who already had a 100-patient waiver and had a history of prescribing buprenorphine to 100 patients for a minimum of 1 year.6  As of February 2015, only 2.2% of U.S. physicians possessed a waiver to prescribe buprenorphine.7  A national survey found that physicians often do not maximize their waiver limit, with an average of 39 patients being treated by a physician with a 100-patient waiver.8  In terms of distribution, 53.4% of U.S. counties are without a waivered physician, leaving approximately 30 million Americans with potentially limited access to buprenorphine treatment.7  Additionally, waivered physicians are predominant in the specialties of psychiatry and primary care at 41.6% and 36.7%, respectively.7  In a separate study in the state of Washington, it was found that primary care physicians represent the plurality of waivered physicians in urban areas and the majority of waivered physicians in rural counties. Also, almost all specialists were located in urban counties.9     Purpose of the Report Drug overdose and substance use treatment admissions data indicate that opioid use is problematic in Kentucky, but little information exists about the geographic availability of buprenorphine treatment across the state.  Furthermore, there is even less information about the characteristics of the physicians prescribing buprenorphine.  This report describes the availability of buprenorphine treatment in Kentucky.    Institute for Rural Health Policy Report :   Availability of Buprenorphine Treatment   3       Methods  Information on DATA-Waivered Physicians We obtained the name, type of medical degree, and practice telephone number and address for each DATA-waivered physician from the Substance Abuse and Mental Health Services Administration (SAMHSA) publicly available buprenorphine treatment physician locator database. Of the 643 waivered physicians in the state of Kentucky as of October 2015, 424 (65.9%) were publicly listed in the SAMHSA database (located at www.samhsa.gov/medication-assisted-treatment/physician-program-data/treatment-physician-locator).  We obtained additional information about these physicians, including their age, gender, specialty, and additional locations of practice, from the publicly available Healthgrades website (located at www.healthgrades.com).  Using these 2 data sources, we categorized physician practices into primary care or specialty care categories.  The specialty category was further divided into 7 subgroups for selected analyses.  Availability by Metropolitan, Micropolitan, and Other Non-Metropolitan Areas To determine the availability of buprenorphine treatment in all 120 Kentucky counties, each physician’s city was matched to a corresponding county.  Counties were categorized as metropolitan, micropolitan, or other non-metropolitan according to U.S. Office of Management and Budget definitions as shown in Figure 1.10  Metropolitan counties include an urban core of at least 50,000 persons.  Micropolitan counties are those with a population of at least 10,000 but fewer than 50,000, and other non-metropolitan rural counties are those with a population of fewer than 10,000 persons.  Of the 120 counties in Kentucky, 35 are designated as metropolitan, 27 as micropolitan, and 58 as other.  Figure 1.  Metropolitan, Micropolitan, and Other Non-Metro Counties in Kentucky   Analysis We calculated the number of DATA-waivered physicians per 10,000 persons residing in each of Kentucky’s 120 counties.  We then compared the mean number of waivered physicians per 10,000 persons and the percentage of counties with at least one waivered physician across metropolitan, micropolitan, and other non-metropolitan status.  Lastly, we compared the specialty composition across metropolitan, micropolitan, and other non-metropolitan areas.  Institute for Rural Health Policy Report :   Availability of Buprenorphine Treatment   4      Results   Waivered Physicians by Metro/Micro/Other Non-Metro Areas  As shown in Figure 2, 57% of metropolitan, 70% of micropolitan, and 45% of other non-metropolitan counties had 1 or more waivered physicians in 2015.  Figure 2.  Percentage of Counties with a DATA-Waivered Physician   Moreover, as shown in Figure 3, micropolitan counties had the highest mean number of waivered physicians per 10,000 persons (1.03), followed by means of 0.60 and 0.79 waivered physicians per 10,000 persons in metropolitan and other non-metropolitan counties, respectively.    Figure 3.  Mean # of Waivered Physicians by Metro/Micro/Other Status   Institute for Rural Health Policy Report :   Availability of Buprenorphine Treatment   5      Waivered Physicians by Specialty As shown in Table 1, 41.3% of waivered physicians were primary care physicians; the remaining 58.7% were other specialists.  Psychiatry represented 23.3% of all waivered physicians in Kentucky in 2015.  Table 1.  Number and % of Waivered Physicians by Primary Specialty Total = 424, % Specialty, # in specialty Category # (%) in specialty  Primary Care, n=175 (41.3%) Family Medicine, 102 General Practice, 2 Geriatric Medicine, 1 Hospital Medicine, 1 Internal Medicine, 68 Pediatrics, 1  Primary Care  175 (41.3%) Specialty Care, n=249 (58.7%) Addiction Psychiatry, 5 Adult Psychiatry, 1  Child & Adolescent Psychiatry, 13 Clinical Psychiatry, 1 Forensic Psychiatry, 3 General Psychiatry, 1 Psychiatry, 75  Psychiatry 99 (23.3%)  Obstetrics & Gynecology, 18 Reproductive Endocrinology & Infertility, 1 Maternal-Fetal Medicine, 3 Neonatal/Perinatology, 1 Reproductive Medicine 23 (5.4%)  Diagnostic Radiology, 5 Radiology, 2 Nuclear Radiology, 1 Vascular & Intervention Radiology, 1 Radiology 9 (2.1%)  Anesthesiology, 35 Pain Medicine, 5 Pain Management 40 (9.4%)  Critical Care Medicine, 2 Emergency Medicine, 25 Emergency Medicine 27 (6.4%)  Bariatric Surgery, 1 General Surgery, 7 Orthopedic Surgery, 8 Surgery 16 (3.8%)  Addiction Medicine, 4 Anatomic & Clinical Pathology, 1 Cardiology, 1 Endocrinology, Diabetes & Metabolism, 1 Infectious Disease Medicine, 1 Nephrology, 3 Neurology, 2 Opthalmology, 1 Osteopathic Manipulative Therapy, 4 Physical Medicine & Rehabilitation, 5 Preventive Medicine, 2 Psychosomatic Medicine, 1 Pulmonology, 1 Radiation Oncology, 1 Rheumatology, 2 Sleep Medicine, 1 Sports Medicine, 1 Urology, 3 Other 35 (8.3%) Institute for Rural Health Policy Report :   Availability of Buprenorphine Treatment   6       Waivered Physician Specialists by Metro/Micro/Other Rural Areas Table 2 describes the distribution of specialists among metropolitan, micropolitan, and other non-metropolitan counties.  In other non-metro counties, 71.95% of waivered physicians were primary care physicians, compared to 45.78% and 30.12% in micropolitan and metropolitan counties, respectively.  In other words, the majority of waivered physicians in metropolitan and micropolitan counties were specialists, with 29.73% of waivered physicians in metropolitan counties being psychiatrists.   Table 2.  Waivered Physician Specialists by Metro/Micro/Other Non-Metro Status Specialty Metropolitan n=259, (61.1%) Micropolitan n=83, (19.6%) Other n=82, (19.3%) Total n=424, (100%) Primary Care 78 (30.12%) 38 (45.78%) 59 (71.95%) 175 (41.3%) Psychiatry 77 (29.73%) 16 (19.28%) 6 (7.32%) 99 (23.3%) Reproductive Medicine 14 (5.41%) 4 (4.82%) 5 (6.10%) 23 (5.4%) Radiology 7 (2.70%) 2 (2.41%) 0 (0%) 9 (2.1%) Pain Management 33 (12.74%) 6 (7.23%) 1 (1.22%) 40 (9.4%) Emergency Medicine 18 (6.95%) 6 (7.23%) 3 (3.66%) 27 (6.4%) Surgery 10 (3.86%) 2 (2.41%) 4 (4.88%) 16 (3.8%) Other 22 (8.49%) 9 (10.84%) 4 (4.88%) 35 (8.3%)   Conclusion    Nearly half (46%) of Kentucky’s counties do not have a waivered physician; approximately 1 million Kentuckians, or a quarter of the population, are without immediate access to buprenorphine.  Moreover, potential access to buprenorphine is not well-distributed across metropolitan, micropolitan, and other non-metropolitan areas within the state.  Nationally, 41.6% of waivered physicians are psychiatrists.7  However, only 23.3% of waivered physicians in Kentucky are psychiatrists and 77.8% of those practice in metropolitan counties.  Thus, many micropolitan and other non-metropolitan residents may face greater barriers to buprenorphine treatment from psychiatrists, which are arguably the best-trained physician group for diagnosing and treating substance abuse.   Because SAMHSA allows physicians the option to publicly post their information on the SAMHSA database, we only had access to information for approximately two-thirds of waivered physicians.  Thus, we likely underestimated the average number of waivered physicians.  Additional research is warranted to further investigate the availability of and demand for buprenorphine in Kentucky.  In conclusion, several steps could be taken to improve the availability of buprenorphine treatment across Kentucky.  Physicians who have a waiver should be encouraged to maximize the number of patients they may treat.  Currently non-waivered physicians practicing in areas with high rates of opioid abuse may need additional training on how to provide buprenorphine and associated counseling services.    Institute for Rural Health Policy Report :   Availability of Buprenorphine Treatment   7      References 1. Centers for Disease Control and Prevention. (2016, March 14). Opioid Data Analysis. Retrieved April 4, 2016, from http://www.cdc.gov/drugoverdose/data/analysis.html  2. Slavova, S., Bunn, T. L., & Gao, W. (2015). Drug Overdose Deaths in Kentucky, 2000 - 2013. Kentucky Injury Prevention and Research Center, 2-17. Retrieved November, 2015, from http://www.mc.uky.edu/kiprc/projects/ddmarpdak/pdf/KyDrugOverdoseDeaths-2000-2013.pdf  3. Smith, C., Cambron, S., Baker, A., Centers, I., Clayton, R., Crouch, R., & Wilson, R. (2011). Prescription Drug Trends in Kentucky Short Report. Kentucky State Epidemiological Outcomes Workgroup, 2-9. Retrieved November, 2015, from http://chfs.ky.gov/NR/rdonlyres/87074E8C-69F5-426D-A3E2-5BA341F7252A/0/PrescriptionDrugTrendsinKentuckyShortReport.pdf  4. Akers, D., Slavova, S., & Bunn, T. L. (2016). Drug Overdose Inpatient Hospitalizations in Kentucky, 2000 - 2014. Kentucky Injury Prevention and Research Center, 2-22. Retrieved February, 2016, from http://www.mc.uky.edu/kiprc/programs/kdopp/Drug-Overdose-Hospitalizations-2000-2014.pdf  5. Substance Abuse and Mental Health Services Administration. (2015, September 25). Buprenorphine. Retrieved October 9, 2015, from http://www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine  6. Substance Abuse and Mental Health Services Administration. (2015, September 25). Buprenorphine. Retrieved October 9, 2015, from http://www.samhsa.gov/medication-assisted-treatment/buprenorphine-waiver-management/increase-patient-limits  7. Rosenblatt, R. A., Andrilla, C. A., Catlin, M., & Larson, E. H. (2015). Geographic and Specialty Distribution of US Physicians Trained to Treat Opioid Use Disorder. Annals of Family Medicine, 13(1), 23-26.  8. Arfken, C. L., Johanson, C. E., Di Menza, S., & Schuster, C. R. (2010). Expanding treatment capacity for opioid dependence with office-based treatment with buprenorphine: National surveys of physicians. Journal of Substance Abuse Treatment, 39, 96-104.  9. Kvamme, E., Catlin, M., Banta-Green, C., Roll, J., & Rosenblatt, R. (2013). Who prescribes buprenorphine for rural patients? The impact of specialty, location and practice type in Washington State. Journal of Substance Abuse Treatment, 44, 355-360.  10. Nussle, J. (2008). OMB Bulletin No. 09-01 (pp. 1-148) (United States of America, Executive Office of the President, Office of Management and Budget). Washington, D.C. Retrieved April 10, 2016, from https://www.whitehouse.gov/sites/default/files/omb/assets/omb/bulletins/fy2009/09-01.pdf   

Availability of Buprenorphine Treatment in Kentucky

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Availability of Buprenorphine Treatment in Kentucky

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