RAND Corporation, Arlington, VA, USA.
RAND Corporation, Boston, MA, USA.
Subst Abus. 2023 Jul;44(3):136-145. doi: 10.1177/08897077231179824. Epub 2023 Jul 4.
Increasing buprenorphine access is critical to facilitating effective opioid use disorder treatment. Buprenorphine prescriber numbers have increased substantially, but most clinicians who start prescribing buprenorphine stop within a year, and most active prescribers treat very few individuals. Little research has examined state policies' association with the evolution of buprenorphine prescribing clinicians' patient caseloads.
Our retrospective cohort study design derived from 2006 to 2018 national pharmacy claims identifying buprenorphine prescribers and the number of patients treated monthly. We defined persistent prescribers based on results from a -clustering approach and were characterized by clinicians who did not quickly stop prescribing and had average monthly caseloads greater than 5 patients for much of the first 6 years after their first dispensed prescription. We examined the association between persistent prescribers (dependent variable) and Medicaid coverage of buprenorphine, prior authorization requirements, and mandated counseling policies (key predictors) that were active within the first 2 years after a prescriber's first observed dispensed buprenorphine prescription. We used multivariable logistic regression analyses and entropy balancing weights to ensure better comparability of prescribers in states that did and did not implement policies.
Medicaid coverage of buprenorphine was associated with a smaller percentage of new prescribers becoming persistent prescribers (OR = 0.72; 95% CI = 0.53, 0.97). There was no evidence that either mandatory counseling or prior authorization was associated with the odds of a clinician being a persistent prescriber with estimated ORs equal to 0.85 (95% CI = 0.63, 1.16) and 1.13 (95% CI = 0.83, 1.55), respectively.
Compared to states without coverage, states with Medicaid coverage for buprenorphine had a smaller percentage of new prescribers become persistent prescribers; there was no evidence that the other state policies were associated with changes in the rate of clinicians becoming persistent prescribers. Because buprenorphine treatment is highly concentrated among a small group of clinicians, it is imperative to increase the pool of clinicians providing care to larger numbers of patients for longer periods. Greater efforts are needed to identify and support factors associated with successful persistent prescribing.
增加丁丙诺啡的可及性对于促进有效的阿片类药物使用障碍治疗至关重要。丁丙诺啡的处方数量大幅增加，但大多数开始开丁丙诺啡的临床医生在一年内停止，大多数活跃的处方医生只治疗很少的患者。很少有研究探讨州政策与丁丙诺啡处方临床医生患者病例量演变之间的关系。
我们的回顾性队列研究设计源自 2006 年至 2018 年的全国药房索赔，确定了丁丙诺啡的处方医生和每月治疗的患者人数。我们根据聚类分析的结果定义了持续处方医生，并将其特征描述为那些不会迅速停止处方且在首次开出丁丙诺啡处方后的头 6 年中的大部分时间内平均每月病例数超过 5 例的临床医生。我们检查了持续处方医生（因变量）与丁丙诺啡的医疗补助覆盖范围、事先授权要求和强制性咨询政策（主要预测因素）之间的关联，这些政策在处方医生首次观察到开出丁丙诺啡处方后的头 2 年内生效。我们使用多变量逻辑回归分析和熵平衡权重来确保在实施和未实施政策的州的医生之间进行更好的可比性。
丁丙诺啡的医疗补助覆盖范围与新处方医生成为持续处方医生的比例较小（OR=0.72；95%CI=0.53，0.97）有关。没有证据表明强制性咨询或事先授权与临床医生成为持续处方医生的几率有关，估计 OR 分别等于 0.85（95%CI=0.63，1.16）和 1.13（95%CI=0.83，1.55）。
与没有覆盖范围的州相比，有丁丙诺啡医疗补助覆盖范围的州中，新处方医生成为持续处方医生的比例较小；没有证据表明其他州政策与临床医生成为持续处方医生的比率变化有关。由于丁丙诺啡治疗高度集中在少数临床医生中，因此必须增加提供护理的临床医生人数，并为更多患者提供更长时间的护理。需要更大的努力来确定和支持与成功持续处方相关的因素。
