# High-volume buprenorphine prescribers: Examining state policy contexts

## TL;DR

The study explores how state policies influence the number of high-volume buprenorphine prescribers in the U.S. from 2009 to 2018.

## Contribution

This study is the first to analyze how specific state policies correlate with changes in high-volume buprenorphine prescribing patterns.

## Key findings

- Policies requiring behavioral health counseling were linked to increased high-volume buprenorphine prescribing.
- Mandatory PDMP laws were associated with a decline in high-volume prescribers.
- CME requirements and Medicaid expansion showed no significant impact on high-volume prescribing.

## Abstract

Most patients prescribed buprenorphine depend on a small number of high-volume prescribers. However, little is known about how state policies may affect high-volume prescribing.

We used 2009–2018 IQVIA Real World Data – Longitudinal Prescriptions (a national dataset capturing approximately 90 % of U.S. retail pharmacy transactions) to examine associations between four state policies and high-volume buprenorphine prescribing (i.e., clinicians averaging ≥30 active buprenorphine patients/month). Using multivariable event-time linear probability models, we estimated the percentage-point changes in the share of prescribers qualifying as high-volume in the three years following the implementation of: (1) mandatory behavioral health counseling when prescribing buprenorphine, (2) mandatory substance use disorder-related continuing medical education (CME) for licensure, (3) Affordable Care Act (ACA) Medicaid expansion, and (4) mandatory prescription drug monitoring program (PDMP) laws.

Of 109,218 clinicians who prescribed buprenorphine, 8.8 % were classified as high-volume prescribers for at least one year. Both high- and low-volume prescribers increased substantially over the study period, with total prescribers rising nearly 70 %. Policies mandating behavioral health counseling were consistently significantly associated with an increase in the share of high-volume prescribers post-implementation (Y1: +3.4 %age points; Y2: +5.1 %age points; Y3: +3.2 %age points). Conversely, mandatory PDMP laws were correlated with a decreased share of high-volume prescribers (Y1: −1.6 %age points; Y2: −3.2 %age points; Y3: −4.1 %age points). No significant associations were found for mandatory CME or ACA Medicaid expansion.

The proportion of buprenorphine prescribers who are high-volume increased during 2009–2018, reflecting faster growth among high-volume prescribers. Our findings indicate that state policies coincided with differential patterns of growth.

•Nationally, both high- and low-volume prescribers increased, with faster growth among high-volume prescribers.•8.8 % of buprenorphine prescribers qualified as high-volume in at least one year.•Behavioral counseling policies were associated with an increase in high-volume prescribing.•Mandatory PDMP laws were associated with a decrease in high-volume prescribing.•No significant associations observed for CME requirements or Medicaid expansion.

Nationally, both high- and low-volume prescribers increased, with faster growth among high-volume prescribers.

8.8 % of buprenorphine prescribers qualified as high-volume in at least one year.

Behavioral counseling policies were associated with an increase in high-volume prescribing.

Mandatory PDMP laws were associated with a decrease in high-volume prescribing.

No significant associations observed for CME requirements or Medicaid expansion.