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This Master’s Project explores if barriers to creating and managing opioid treatment
programs and office-based opioid treatment programs in literature are accurately reflected
in reality. The research question of this Master’s Project is: What are the barriers
facing care providers to becoming OBOT and OTP associated providers? What are barriers
to treating insured and uninsured patients in OBOTs and OTPs?
The opioid epidemic is a societal health dilemma in the United States and the state
of North Carolina. Nearly half of all United States opioid overdose deaths in 2016
involved prescription opioids. From 1999 to 2008, overdose death rates, sales, and
substance abuse treatment admissions related to opioid pain relievers all increased
substantially. Drug overdoses have since become the leading cause of death of Americans
under 50, with two-thirds of those deaths from opioids. In 2016, more than 64,000
Americans died from drug overdoses with opioid addiction spurring the increase from
52,404 Americans in 2015. The sharpest increase occurred among deaths related to fentanyl
and fentanyl analogs (synthetic opioids) with over 20,000 overdose deaths. In 2015
in the United States, about 63% of all 52,404 overdose deaths were related to opioids.
One effective treatment of opioid addicts used in the past are medication-assisted
treatments (MAT). MAT, specifically treating opioid addiction, comes in two variations:
Office-Based Opioid Treatment Programs (OBOT) and Opioid Treatment Programs (OTP).
An OTP is a treatment program federally certified by the Substance Abuse and Mental
Health Services Administration (SAMHSA) according to 42 CFR § 8, to provide supervised
assessment and medication assisted treatment for beneficiaries who have an opioid
use disorder diagnosis. OTPs require registration with the US Drug Enforcement Association
(DEA) and licensure by the Division of Health Service Regulation (DHSR).
Under current federal and state policies, it is legal for practitioners, registered
by the DEA to prescribe methadone for addiction treatment only within a licensed OTP
setting. Methadone can only be dispensed by practitioners within the OTP settings.
Practitioners within the OTP setting can also prescribe buprenorphine, by using the
DEA number of the OTP, rather than the required waiver, to prescribe buprenorphine.
Buprenorphine can be dispensed by practitioners within the OTP and OBOT settings.
Due to less stringent federal and state regulations, buprenorphine has become a popular
alternative to methadone. OBOTs can only prescribe and dispense buprenorphine, like
OTP settings. However, OBOTs cannot legally prescribe or dispense methadone, unlike
the OTP settings. Practitioners within OBOTs can prescribe buprenorphine for addiction
treatment, if waivered and registered under a special DEA number.
An OBOT is the treatment of opioid addiction with a medication in an office, belonging
to, or not to, a physician. No limitation exists on the type of practice an OBOT practitioner
is associated with. OBOTs are defined by the function of a practice, treating patients
with buprenorphine for substance use disorders, rather than defined by a type of practice.
OBOTs can appear within, or outside of, OTP settings.
The treatment settings utilize specially-metered doses of these medications to help
the body through opioid withdrawal. Both are provided in inpatient and outpatient
treatment settings. A combination of medications and psychological treatment is provided
to address the root of the addiction with emphasis on finding alternative ways to
cope and learning the tools needed to avoid relapse in the future. Treatment settings
for opioid addiction, with methadone and buprenorphine, will be within the scope of
this paper; naloxone will not be expanded upon in this paper. Likewise, methadone
and buprenorphine prescribed for pain will not be expanded upon in this paper.
Methodology
A literature review and six qualitative interviews, from North Carolina-based opioid
treatment programs and office-based opioid treatment programs, were analyzed to determine
if barriers interviewees mentioned matched barriers mentioned in literature. Literature
on barriers within the United States was analyzed, with a focus on barriers North
Carolina providers and patients face. The versus coding process was applied to analyze
the six interviews.
Findings
Barriers literature addressed included: Reimbursement and Lack of Incentive, Medicaid
Expansion, & Stigma.
Barriers interviewees addressed included: Reimbursement and Lack of Incentive, Stigma,
Medicaid Expansion, Federal Cures Grant and Reimbursement Codes, Changing Insurance
Coverage, & DEA Auditing Barrier.
Very few barriers mentioned by interviewees were accurately reflected in literature.
The literature has a physician-focus, and often does not consider barriers faced by
registered nurses and others that can prescribe medications.
Limitations
Given the sampling in the qualitative phase, the researcher cannot say with confidence
the sample will be representative of the PCP population. Practitioners most interested
in barriers to creating and implementing OBOTs and OTPs are likely to be the most
responsive. Due to the nature of qualitative research, the data obtained may be subject
to different interpretations by different readers. Because of the interpretative nature
of the qualitative research, the researcher may introduce her bias into the qualitative
analysis results. Practitioners are subject to strict schedules, making call and meeting
time limited. This could impact quality of information provided in interviews.
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