The economic, political, and social contexts within which an organization resides (e.g., constrained funding, billing rules, and the influence of policies related to treatment and targeted populations).
Patient Needs and Resources
A factor that affects PCPs' lack of enthusiasm for pharmacotherapy is a perceived lack of demand, interest, or expression of need from their patients.352, 363, 367 Providers report that few patients inquire about medications to treat substance use. Surveys of patients who have SUDs find that, if asked, they prefer receiving substance use treatment in primary care over specialty care.363, 366
Cosmopolitanism, Specialty Referral, and Outer Organizational Buy-in
The absence of readily accessible referral options for primary care patients with SUDs is a common complaint.351, 355, 356, 357, 358, 362, 364, 365, 368 Oliva et al.,351 in their systematic review of barriers to pharmacotherapy in primary care, found that PCPs consider the difficulty in referring patients to specialty substance use treatment and problems coordinating care with specialty programs to be their biggest obstacles. The absence of SUD treatment programs that can help PCPs manage pain patients with co-occurring opioid dependence is a widespread problem.365 PCPs report lack of support or encouragement of pharmacotherapy from external organizations such as the specialty substance use treatment system, governments, and law enforcement as limitations to their willingness to adopt medical treatments for SUD.337, 350 The slow uptake of pharmacotherapy in primary care also has the paradoxical effect of proving to the pharmaceutical industry that there is a lack of demand for the products, resulting in smaller marketing forces promoting the medications.351, 358
Regulations and Policies
There are many government and insurance policies that: (1) restrict who can prescribe; (2) limit the settings in which pharmacotherapy can be provided; (3) limit mandated prescribing practices and ancillary services; (4) restrict the number of patients who can receive treatment from a single provider; (5) limit the pharmacotherapies covered by formularies; (6) constrain the length of time patients may be treated and the number of pharmacotherapy episodes permitted; and (7) require that other, treatments be attempted and fail before medications may be used.337, 346, 350, 351, 357, 359, 361, 362, 363, 368, 369 Two systematic reviews of pharmacotherapy adoption in primary care point to the U.S. Drug Enforcement Agency (DEA) mandate of eight hours of training as a significant obstacle to treating patients with buprenorphine.346, 351, 363 To treat opioid-dependent patients with buprenorphine, a physician must hold a current state medical license and a valid DEA registration number and either hold a subspecialty board certification in addiction psychiatry or addiction medicine or have completed not less than eight hours of authorized training on the treatment or management of opioid-dependent patients. An office-based setting provides increased access to medication-assisted treatment for opioid dependence in a less stigmatized environment and enables integrating primary medical care with the treatment of SUDs.344
Reimbursement has been one of the most frequently reported barriers to pharmacological treatment implementation.351, 356, 357, 358, 362, 363, 364, 365, 368 Systematic reviews of pharmacotherapy uptake in primary care point directly and consistently to payment issues--reimbursement is too low to compensate medical care providers for the costs of delivering pharmacotherapy services.351, 356, 363, 364 In their systematic review of barriers to pharmacotherapy for addiction disorders, Oliva and colleagues351 found a web of third-party reimbursement obstacles, including complex Medicaid coverage rules, insurance plan exclusion of pharmacotherapy, limitations on the duration of covered maintenance treatment, formulary restrictions, and failure to cover methadone maintenance and the depot naltrexone.351, 352, 364, 367 Providers frequently voice concerns about patients' ability to afford medications and payers' willingness to reimburse the prescriber.347, 351, 356, 362, 363, 365, 367, 368