Patients struggling with opioid use disorder (OUD) often face numerous treatment barriers.
Only 10–20% of patients with opioid addiction receive evidence-based medication treatment with buprenorphine/naloxone (Suboxone), methadone, or naltrexone (Vivitrol).
Common barriers to Suboxone treatment include the following:
- Supply limitations
- Insurance Coverage
- Patient Stigma
- Physician Stigma
- Diversion concerns
- Licensure Requirements
Common Barriers to Treatment
Below we will discuss different barriers that patients experience when attempting to access Suboxone treatment.
Current Drug Enforcement Administration (DEA) regulations require wholesalers to detect and report suspicious orders of opioids, which means that some pharmacies that dispense too much of this medication may be audited. This can disincentivize pharmacies from supplying too much of this medication to patients, even if they justifiably have a large number of patients on legitimate maintenance therapy. [1-3]
Dr. Brian Clear, Chief Medical Officer at Bicycle Health, explains the effects of these regulations: "The DEA treats buprenorphine in exactly the same way as it does the higher risk opioids, and this has the nonsensical effect of trying to control a disease by restricting the treatment for it. If anything, too little buprenorphine prescribing should be a warning sign that the health care system isn't doing enough to identify and address problems with opioid use."
While these regulations are slowly being addressed, supply limitations still remain a barrier to treatment in some locations, particularly rural areas.
All states are required to have Medicaid coverage of Suboxone, however this varies state to state in terms of the quantity and formulation of Suboxone that will be covered. For example, some Medicaid programs in some states will cover the strip form of Suboxone, but not the tablets. Some other states require “prior authorization” from prescribers to document the medical necessity of Suboxone, which adds an additional step/barrier to starting treatment.
Additionally, private insurance companies are not mandated to provide coverage of MAT (although most do). Therefore, insurance coverage can be a barrier to getting treatment for certain individuals.
Patient Stigma about Suboxone
Over the past several decades, information about Suboxone between patients as well as online has exploded. Patients may have heard a lot of misinformation about opioid medications as well as Suboxone therapy. This can lead some of them to be wary of trying Suboxone either because they fear side effects of the medication or even just the stigma of being on MAT for OUD.
Physician/Health Professional Stigma about Suboxone
Some physicians or health professionals may also be susceptible to myths and misinformation about Suboxone. They may subsequently impose barriers or burdens on their patients such as frequent drug testing. Some may even refuse to continue Suboxone therapy in their patients whose drug screens show other substances, in spite of the fact that most authorities on addiction treatment advocate against the use of drug screens as a means for “punishing” patients or withholding legitimate treatment for OUD. While most physicians who treat patients with OUD are abandoning these out-of-date practices, some physicians or their organizations still insist on additional requirements like drug screens, frequent visits, or drug use contracts that complicate the patient’s ability to get treatment.
Concerns About Diversion
Suboxone is a partial opioid and therefore has a potential for abuse, meaning it can be diverted for profit. Of all diversion reports, methadone and buprenorphine represent about 15% compared to 67% represented by oxycodone and hydrocodone. Of those who do misuse buprenorphine products, 97% report they are not trying to simply “get high”, but are attempting to gain access to treatment for a legitimate opioid use disorder .
While of course some Suboxone diversion may occur, the vast majority of patients are using their prescription appropriately. Many people also divert HIV drugs,, however we would never withhold HIV treatment to a patient because we thought they were diverting their HIV medications. Likewise, we need to move away from the practice of withholding treatment for OUD for fear of diversion.
Historically, providers needed a special license called a “Suboxone waiver” in order to prescribe Suboxone. This waiver required 8 hours of additional training. In 2021, Just 66,000 doctors nationwide could prescribe Suboxone. This additional licensing requirement added an additional barrier to treatment, and many states have done away with the waiver requirement. However, some states still insist that doctors jump through additional hoops in order to prescribe this medication.
Reducing Barriers to Suboxone Treatment
While all these obstacles pose barriers to making MAT available to so many patients that need it, there is hope:
The pandemic has increased the accessibility of telehealth visits which minimizes the need for transportation to clinics to obtain treatment. Many states have done away with mandated Suboxone waiver training in order to increase the number of physicians who are able to prescribe Suboxone. The DEA has largely eliminated “caps” on the number of patients that each physician is allowed to treat with Suboxone.
At Bicycle Health, we recognize the barriers our patients may face. As Bicycle Health CEO Ankit Gupta explains, "We have a dedicated team at Bicycle Health focused on ensuring our patients get timely access to their medications. Patients can reach out to us through our smartphone app if they encounter barriers at the pharmacy, and we will work to quickly address them."