Acad Psychiatry DOI 10.1007/s40596-015-0313-1
IN BRIEF REPORT
Training in Buprenorphine and Office-Based Opioid Treatment: A Survey of Psychiatry Residency Training Programs Joji Suzuki & Tatyana V. Ellison & Hilary S. Connery & Charles Surber & John A. Renner
Received: 4 August 2014 / Accepted: 3 February 2015 # Academic Psychiatry 2015
Abstract Objective Psychiatrists are well suited to provide office-based opioid treatment (OBOT), but the extent to which psychiatry residents are exposed to buprenorphine training and OBOT during residency remains unknown. Methods Psychiatry residency programs in the USA were recruited to complete a survey. Results Forty-one programs were included in the analysis for a response rate of 23.7 %. In total, 75.6 % of the programs currently offered buprenorphine waiver training and 78.1 % provided opportunities to treat opioid dependence with buprenorphine under supervision. Programs generally not only reported favorable beliefs about OBOT and buprenorphine waiver training but also reported numerous barriers. Conclusions The majority of psychiatry residency training programs responding to this survey offer buprenorphine waiver training and opportunities to treat opioid-dependent patients, but numerous barriers continue to be cited. More research is needed to understand the role residency training plays in impacting future practice of psychiatrists. Keywords Psychiatry residents . Opioid dependence . Office-based opioid treatment . Buprenorphine J. Suzuki (*) Brigham and Women’s Hospital, Boston, MA, USA e-mail: [email protected] H. S. Connery McLean Hospital, Belmont, MA, USA T. V. Ellison Kaiser Permanente Southern California, Ontario, CA, USA C. Surber University of Michigan, Ann Arbor, MI, USA J. A. Renner VA Boston HealthCare System, Boston, MA, USA
In 2012, approximately 2.5 million individuals met the criteria for opioid abuse or dependence in the USA, resulting in an estimated economic burden of over 8.6 billion dollars [1, 2]. Physicians have had the ability to treat opioid dependence in office-based settings using buprenorphine since 2002, a treatment option that has a strong evidence base and demonstrated efficacy [3, 4]. Federal law requires physicians to complete an 8-h training course to qualify for a Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine. Because opioid use disorders commonly co-occur with mood and anxiety disorders, psychiatrists are well suited to provide officebased opioid treatment (OBOT) [5]. As of 2009, 19,000 physicians had obtained the waiver, approximately 28 % of those being psychiatrists [6, 7]. Access to this effective treatment remains elusive for many patients due to the limited number of prescribers [8]. Therefore, training psychiatry residents to prescribe buprenorphine during residency may be an important strategy to ensure that adequate numbers of psychiatrists are offering this treatment. However, no prior studies have examined the extent to which psychiatry residents in the USA are exposed to buprenorphine training and OBOT during residency. As such, the aims of this study were to identify the following: (1) whether buprenorphine waiver training is offered to residents, (2) whether residents have an opportunity to treat opioid dependence with buprenorphine under supervision, and (3) training program beliefs and perceived barriers towards OBOT and incorporating buprenorphine training into the residency curricula.
Methods The Partners Human Research Committee approved the study. The study population included all psychiatry residency training programs in the USA. All 188 accredited psychiatry residency programs were identified from the ACGME website to
Acad Psychiatry
extract contact information for each program. Between October of 2013 and March of 2014, residency training directors were contacted to seek their participation in an anonymous online survey. Up to five reminder e-mails were sent at least a month apart to potential survey participants. Potential participants received an e-mail that contained a link to the on-line survey created through www.surveymonkey.com. The survey asked a series of questions including the size and geographic location of the program, presence of any affiliated fellowship programs, descriptions of the ACGME-required addiction rotation (level of care and whether residents had supervised practice with buprenorphine for either detoxification or maintenance), whether buprenorphine waiver training is offered to residents, proportion of residents who do or do not take the buprenorphine training, beliefs about OBOT, and perceived barriers to offering buprenorphine trainings. The degree to which respondents agreed to the following statements about OBOT were assessed using a 7-point scale (1=not at all true, 4=somewhat true, 7=very true): “Residents in this program receive adequate training in treating substance use disorders”; “Residents in this program receive adequate training in treating opioid use disorders”; “Every psychiatry resident should be offered buprenorphine training to quality for the xwaiver”; “If available, x-waivered faculty should supervise residents to treat opioid dependence with buprenorphine”; “Buprenorphine is an effective treatment for opioid dependence”; “There is a need for more buprenorphine prescribers in this community”; “Preparing residents to treat opioid dependence is important”; and “Only addiction specialists should prescribe buprenorphine.” In addition, respondents were asked to select barriers to offering buprenorphine training from a list of possible barriers (e.g., no trained faculty to offer training and too costly). The survey was structured so that all responses remained anonymous. Respondents were offered a chance to win a $100 gift card from Amazon.com, as part of a reward system administered through the on-line survey program. Descriptive statistics were used to summarize the results. Residency programs were categorized as “High buprenorphine programs” or “HP group” if half or more of the residents completed any buprenorphine training, or “Low buprenorphine programs” or “LP group” if less than half the residents completed any buprenorphine training. Chi-square and Fisher’s exact test were performed for categorical data analysis, and t tests were used for continuous data analysis to compare variables between HP group and LP group.
Results Of 188 eligible programs, 15 were excluded due to the lack of contact information available on the ACGME and/or residency website. Of the remaining 173 programs, 41 completed the survey, representing a response rate of 23.7 %.
The survey results are summarized in Tables 1, 2 and 3. The majority of respondents were training directors, with the largest proportion of responding programs from the northeast (41.5 %) and south (29.3 %). Thirty-nine percent and 43.9 % of the programs offered their addiction rotation during PGY1 and PGY2 year, respectively. The rotation was 1 month in duration for 70.7 % of the programs. Inpatient detoxification was the setting for the addiction rotation in 56.1 % of the programs, while buprenorphine clinic was the setting in 26.8 % of the programs. Respondents indicated that 68.1 % of programs
Table 1
Summary of program characteristics
Individual responding to the survey Training director Associate training director Other Size of program 10 Location Northeast South Midwest West Affiliated fellowship Child/adolescent Addiction Psychosomatic Geriatric Forensic Setting of addiction rotation Inpatient detoxification Residential
Total (n=41)
Percentage
30 2 9
73.2 4.9 22.0
5 25 11
12.2 61.0 26.8
17 12 6 6
41.5 29.3 14.6 14.6
31 15 15 11 8
75.6 36.6 36.6 26.8 19.5
23 11
56.1 26.8
Partial or IOP 12 Outpatient addiction clinic 18 Outpatient psychiatric clinic 2 Inpatient consultation-liaison 9 Buprenorphine clinic 11 Methadone clinic 7 Residents offered opportunity to use buprenorphine under supervision for: Detoxification 28 Maintenance treatment 32 Buprenorphine training course offered Required as part of the residency 6 Optional 25 Not offered 10
29.3 43.9 4.9 22.0 26.8 17.1
68.3 78.1 14.6 61.0 24.4
Acad Psychiatry Table 1 (continued) Total (n=41) If training is required or optional, what proportion of residents actually complete the training None 2 A few 10 About half 9 Most 8 Do not know 2
Percentage
6.5 32.3 29.0 25.8 6.5
Northeast: CT Connecticut, ME Maine, MA Massachusetts, NJ New Jersey, NY New York, PA Pennsylvania, RI Rhode Island, VT Vermont. South: AL Alabama, AR Arkansas, DC Washington D.C., DE Delaware, FL Florida, GA Georgia, KY Kentucky, LA Louisiana, MD Maryland, MS Mississippi, NC North Carolina, OK Oklahoma, SC South Carolina, TN Tennessee, TX Texas, VA Virginia, WV West Virginia. Midwest: IL Illinois, IN Indiana, IA Iowa, KA Kansas, MI Michigan, MN Minnesota, MO Montana, NE Nebraska, ND North Dakota, OH Ohio, SD South Dakota, WI Wisconsin. West: AK Alaska, AZ Arizona, CA California, CO Colorado, HI Hawaii, ID Idaho, MT Montana, NV Nevada, NM New Mexico, OR Oregon, UT Utah, WA Washington, WY Wyoming
provide residents with experience using buprenorphine for detoxification and 78.1 % with experience using buprenorphine for maintenance treatment. In total, 14.6 % required that residents complete buprenorphine training as part of the residency, 61.0 % offered the training but they were optional, and 24.4 % did not offer any training. If the training was offered, overall, more than half the residents were noted to have completed the course. Ninety percent of those programs currently not offering any buprenorphine training indicated their desire to do so in the future. Program characteristics that differed between the HP and LP groups are summarized in Table 4. The HP group was more likely to require residents to complete the training (33.3 vs 0 %, p
IN BRIEF REPORT
Training in Buprenorphine and Office-Based Opioid Treatment: A Survey of Psychiatry Residency Training Programs Joji Suzuki & Tatyana V. Ellison & Hilary S. Connery & Charles Surber & John A. Renner
Received: 4 August 2014 / Accepted: 3 February 2015 # Academic Psychiatry 2015
Abstract Objective Psychiatrists are well suited to provide office-based opioid treatment (OBOT), but the extent to which psychiatry residents are exposed to buprenorphine training and OBOT during residency remains unknown. Methods Psychiatry residency programs in the USA were recruited to complete a survey. Results Forty-one programs were included in the analysis for a response rate of 23.7 %. In total, 75.6 % of the programs currently offered buprenorphine waiver training and 78.1 % provided opportunities to treat opioid dependence with buprenorphine under supervision. Programs generally not only reported favorable beliefs about OBOT and buprenorphine waiver training but also reported numerous barriers. Conclusions The majority of psychiatry residency training programs responding to this survey offer buprenorphine waiver training and opportunities to treat opioid-dependent patients, but numerous barriers continue to be cited. More research is needed to understand the role residency training plays in impacting future practice of psychiatrists. Keywords Psychiatry residents . Opioid dependence . Office-based opioid treatment . Buprenorphine J. Suzuki (*) Brigham and Women’s Hospital, Boston, MA, USA e-mail: [email protected] H. S. Connery McLean Hospital, Belmont, MA, USA T. V. Ellison Kaiser Permanente Southern California, Ontario, CA, USA C. Surber University of Michigan, Ann Arbor, MI, USA J. A. Renner VA Boston HealthCare System, Boston, MA, USA
In 2012, approximately 2.5 million individuals met the criteria for opioid abuse or dependence in the USA, resulting in an estimated economic burden of over 8.6 billion dollars [1, 2]. Physicians have had the ability to treat opioid dependence in office-based settings using buprenorphine since 2002, a treatment option that has a strong evidence base and demonstrated efficacy [3, 4]. Federal law requires physicians to complete an 8-h training course to qualify for a Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine. Because opioid use disorders commonly co-occur with mood and anxiety disorders, psychiatrists are well suited to provide officebased opioid treatment (OBOT) [5]. As of 2009, 19,000 physicians had obtained the waiver, approximately 28 % of those being psychiatrists [6, 7]. Access to this effective treatment remains elusive for many patients due to the limited number of prescribers [8]. Therefore, training psychiatry residents to prescribe buprenorphine during residency may be an important strategy to ensure that adequate numbers of psychiatrists are offering this treatment. However, no prior studies have examined the extent to which psychiatry residents in the USA are exposed to buprenorphine training and OBOT during residency. As such, the aims of this study were to identify the following: (1) whether buprenorphine waiver training is offered to residents, (2) whether residents have an opportunity to treat opioid dependence with buprenorphine under supervision, and (3) training program beliefs and perceived barriers towards OBOT and incorporating buprenorphine training into the residency curricula.
Methods The Partners Human Research Committee approved the study. The study population included all psychiatry residency training programs in the USA. All 188 accredited psychiatry residency programs were identified from the ACGME website to
Acad Psychiatry
extract contact information for each program. Between October of 2013 and March of 2014, residency training directors were contacted to seek their participation in an anonymous online survey. Up to five reminder e-mails were sent at least a month apart to potential survey participants. Potential participants received an e-mail that contained a link to the on-line survey created through www.surveymonkey.com. The survey asked a series of questions including the size and geographic location of the program, presence of any affiliated fellowship programs, descriptions of the ACGME-required addiction rotation (level of care and whether residents had supervised practice with buprenorphine for either detoxification or maintenance), whether buprenorphine waiver training is offered to residents, proportion of residents who do or do not take the buprenorphine training, beliefs about OBOT, and perceived barriers to offering buprenorphine trainings. The degree to which respondents agreed to the following statements about OBOT were assessed using a 7-point scale (1=not at all true, 4=somewhat true, 7=very true): “Residents in this program receive adequate training in treating substance use disorders”; “Residents in this program receive adequate training in treating opioid use disorders”; “Every psychiatry resident should be offered buprenorphine training to quality for the xwaiver”; “If available, x-waivered faculty should supervise residents to treat opioid dependence with buprenorphine”; “Buprenorphine is an effective treatment for opioid dependence”; “There is a need for more buprenorphine prescribers in this community”; “Preparing residents to treat opioid dependence is important”; and “Only addiction specialists should prescribe buprenorphine.” In addition, respondents were asked to select barriers to offering buprenorphine training from a list of possible barriers (e.g., no trained faculty to offer training and too costly). The survey was structured so that all responses remained anonymous. Respondents were offered a chance to win a $100 gift card from Amazon.com, as part of a reward system administered through the on-line survey program. Descriptive statistics were used to summarize the results. Residency programs were categorized as “High buprenorphine programs” or “HP group” if half or more of the residents completed any buprenorphine training, or “Low buprenorphine programs” or “LP group” if less than half the residents completed any buprenorphine training. Chi-square and Fisher’s exact test were performed for categorical data analysis, and t tests were used for continuous data analysis to compare variables between HP group and LP group.
Results Of 188 eligible programs, 15 were excluded due to the lack of contact information available on the ACGME and/or residency website. Of the remaining 173 programs, 41 completed the survey, representing a response rate of 23.7 %.
The survey results are summarized in Tables 1, 2 and 3. The majority of respondents were training directors, with the largest proportion of responding programs from the northeast (41.5 %) and south (29.3 %). Thirty-nine percent and 43.9 % of the programs offered their addiction rotation during PGY1 and PGY2 year, respectively. The rotation was 1 month in duration for 70.7 % of the programs. Inpatient detoxification was the setting for the addiction rotation in 56.1 % of the programs, while buprenorphine clinic was the setting in 26.8 % of the programs. Respondents indicated that 68.1 % of programs
Table 1
Summary of program characteristics
Individual responding to the survey Training director Associate training director Other Size of program 10 Location Northeast South Midwest West Affiliated fellowship Child/adolescent Addiction Psychosomatic Geriatric Forensic Setting of addiction rotation Inpatient detoxification Residential
Total (n=41)
Percentage
30 2 9
73.2 4.9 22.0
5 25 11
12.2 61.0 26.8
17 12 6 6
41.5 29.3 14.6 14.6
31 15 15 11 8
75.6 36.6 36.6 26.8 19.5
23 11
56.1 26.8
Partial or IOP 12 Outpatient addiction clinic 18 Outpatient psychiatric clinic 2 Inpatient consultation-liaison 9 Buprenorphine clinic 11 Methadone clinic 7 Residents offered opportunity to use buprenorphine under supervision for: Detoxification 28 Maintenance treatment 32 Buprenorphine training course offered Required as part of the residency 6 Optional 25 Not offered 10
29.3 43.9 4.9 22.0 26.8 17.1
68.3 78.1 14.6 61.0 24.4
Acad Psychiatry Table 1 (continued) Total (n=41) If training is required or optional, what proportion of residents actually complete the training None 2 A few 10 About half 9 Most 8 Do not know 2
Percentage
6.5 32.3 29.0 25.8 6.5
Northeast: CT Connecticut, ME Maine, MA Massachusetts, NJ New Jersey, NY New York, PA Pennsylvania, RI Rhode Island, VT Vermont. South: AL Alabama, AR Arkansas, DC Washington D.C., DE Delaware, FL Florida, GA Georgia, KY Kentucky, LA Louisiana, MD Maryland, MS Mississippi, NC North Carolina, OK Oklahoma, SC South Carolina, TN Tennessee, TX Texas, VA Virginia, WV West Virginia. Midwest: IL Illinois, IN Indiana, IA Iowa, KA Kansas, MI Michigan, MN Minnesota, MO Montana, NE Nebraska, ND North Dakota, OH Ohio, SD South Dakota, WI Wisconsin. West: AK Alaska, AZ Arizona, CA California, CO Colorado, HI Hawaii, ID Idaho, MT Montana, NV Nevada, NM New Mexico, OR Oregon, UT Utah, WA Washington, WY Wyoming
provide residents with experience using buprenorphine for detoxification and 78.1 % with experience using buprenorphine for maintenance treatment. In total, 14.6 % required that residents complete buprenorphine training as part of the residency, 61.0 % offered the training but they were optional, and 24.4 % did not offer any training. If the training was offered, overall, more than half the residents were noted to have completed the course. Ninety percent of those programs currently not offering any buprenorphine training indicated their desire to do so in the future. Program characteristics that differed between the HP and LP groups are summarized in Table 4. The HP group was more likely to require residents to complete the training (33.3 vs 0 %, p
