The source of the innovation, the strength and quality of the evidence supporting it, the relative advantages the innovation provides, and its adaptability, trial-ability, complexity, design quality and packaging, and cost.
Source and Perceived Strength of Evidence
Treating SUDs with medications is commonly viewed by PCPs as incompatible with the predominant addiction treatment model: abstinence.350, 351, 352 Reickmann et al.350 found that the orientation of state substance use agencies toward pharmacotherapy influenced the receptivity of PCPs and specialists to using medications.337, 353 A survey of PCPs and substance use treatment specialists about their perceptions of medication use found that most viewed pharmacotherapy as not effective, even when used in conjunction with psychosocial therapy,350 despite evidence to the contrary337, 353 and despite treatment guidelines.354 PCPs are generally uninformed about pharmacotherapy for substance use,355 and they have little understanding of pharmacotherapy treatment adherence.355 In contrast to this finding, several FQHC staff who participated in the site visits expressed support for MAT and an understanding of its effectiveness alone and in combination with psychosocial therapy. Moreover, they suggested that more attention be paid to strategies for overcoming provider lack of awareness, provider resistance, and fear surrounding the use of Suboxone and other medications.
The perceived complexity of pharmacotherapy for addiction and PCPs' perceptions that substance-dependent patients are more difficult to treat for their medical and/or substance use problems are consistently reported as reasons that PCPs are reluctant to implement pharmacotherapy.356, 357, 358 In their systematic review of barriers to pharmacotherapy in primary care, Becker and Fiellin356 found that PCPs expressed concerns about increased workload, disruption to workflow, patient safety, inability to meet this population's multiple needs, and poor medication adherence. Buprenorphine induction and dose titration are time-intensive, requiring observed dosing and multiple follow-up assessments, which PCPs perceive as burdensome.351, 355, 359, 360 Saxon and McCarty,361 in a systematic review of pharmacotherapy, describe the atypical administration of buprenorphine induction, the possibility that administering the medication can trigger withdrawal, and the requirement that physicians receive eight hours of training in order to be certified to prescribe as reasons that physicians are slow to use this medication.351, 359
Physicians express concern that adopting pharmacotherapy to treat their patients with SUDs will disadvantage them, with many believing that use of buprenorphine will harm their practices356 and endanger their existing patients.356, 362 Physicians have expressed concern about the possible diversion of buprenorphine,357, 363, 364, 365, 366 although evidence is minimal that the medication is being diverted for its euphoric effect.366
The cost to set up and maintain pharmacotherapy practice is modest. Only physicians are permitted to prescribe buprenorphine, and the number of patients who can receive the medication in a physician's practice is capped. Physicians must participate in a free eight-hour training to be certified to prescribe the medication, and only accredited methadone programs can use that medication to treat opioid dependence. The other FDA-approved pharmacotherapies--naltrexone, acamprosate and disulfiram--do not impose any unusual costs on PCPs or practice sites.