Long-Acting Injectable Buprenorphine Use and Treatment Attribute Priorities Among U.S. Buprenorphine Prescribers: A National Survey

Technical Summary: Long-Acting Injectable Buprenorphine Use and Treatment Attribute Priorities Among U.S. Buprenorphine Prescribers

Problem Statement
Long-acting injectable buprenorphine (LAI-BUP) is an evidence-based treatment for opioid use disorder (OUD) that offers advantages in adherence, reduced diversion risk, and decreased stigma compared to daily oral formulations. Despite pivotal trials demonstrating its efficacy and safety, real-world utilization in the United States remains significantly low compared to oral buprenorphine. While qualitative data suggests barriers such as administrative complexity, cost, and uncertainty regarding patient selection, there is a lack of quantitative data describing how U.S. prescribers actually utilize LAI-BUP and which specific medication attributes they prioritize when selecting treatments. Understanding the gap between clinical evidence and prescribing behavior is critical for improving implementation.

Methodology
This study presents a secondary analysis of a national, cross-sectional online survey conducted among U.S. physicians who prescribe buprenorphine for OUD.

• Participants: 125 board-certified physicians were recruited from the Sermo medical market research panel. Eligibility required U.S. board certification, direct care for at least 20 adults with OUD on medication treatment in the prior six months, personal initiation of OUD medications, and 3–35 years of post-residency practice. Recruitment quotas targeted specific specialties (adult psychiatry/addiction medicine and adult primary care) and stratified respondents based on their self-reported LAI-BUP prescribing volume.
• Data Collection: The survey assessed provider demographics, OUD clinical caseload, LAI-BUP usage patterns, and attitudes toward key medication attributes (efficacy, safety, ease of administration, ease of prescribing, and administrative requirements).
• Statistical Analysis: Respondents were categorized into three ordered groups based on the percentage of their OUD panel receiving LAI-BUP:
  1. Zero Group: No LAI-BUP use.
  2. Low Group: At least one patient, but below the median split (23.2%).
  3. High Group: Above the median split.
     Group comparisons utilized chi-square (or Fisher's exact) tests for categorical variables and Jonckheere–Terpstra tests for ordinal responses to detect ordered trends across the three groups.

Key Results

• Utilization Rates: Among the 125 respondents, 39 (31.2%) reported zero patients receiving LAI-BUP. The remaining 86 (68.8%) were prescribers, split evenly into Low (34.4%) and High (34.4%) use groups based on a median cut-off of 23.2% of their OUD panel.
• Demographic Correlates: LAI-BUP usage did not differ significantly by specialty, geographic region, or practice setting. However, a strong association was found between OUD caseload size and LAI-BUP use. Providers in the "Zero" group managed the smallest OUD panels, while those in the "High" group managed the largest. The "Low" group managed panels more than twice the size of the "Zero" group.
• Attitudinal Priorities: Ratings of key medication attributes (efficacy, safety, ease of administration, etc.) were uniformly high across all groups. Crucially, the study found no consistent differences in these attitude ratings between the Zero, Low, and High use groups. Measured attitudes toward treatment attributes did not explain the variance in utilization.

Key Contributions

• Quantification of Underutilization: The study confirms that despite safety and efficacy data, LAI-BUP remains underutilized, with nearly one-third of surveyed prescribers not using it at all.
• Caseload as a Predictor: The research identifies that provider OUD caseload size is a more significant predictor of LAI-BUP adoption than specialty type or practice setting. This suggests that infrastructure or experience gained through managing larger patient panels may facilitate the adoption of complex interventions like LAI-BUP.
• Decoupling Attitudes from Behavior: The study demonstrates that negative attitudes toward medication attributes (e.g., doubting efficacy or safety) are not the primary drivers of non-use. Since attitudes were uniformly high across groups, the barriers to adoption likely lie in operational or systemic factors rather than clinical skepticism.

Significance and Claims
The paper concludes that the gap between evidence and implementation for LAI-BUP is likely driven by factors not captured by standard attitudinal surveys, such as clinic workflow, staffing, reimbursement structures, and the administrative burden of Risk Evaluation and Mitigation Strategy (REMS) requirements.

The authors modestly claim that their findings suggest future implementation strategies should move beyond education on clinical efficacy. Instead, interventions should target the operational constraints that prevent clinicians from transitioning from non-use to routine use. Specifically, the authors propose that:

1. Workflow and Systemic Barriers: Research should focus on clinic staffing, space availability, billing workflows, and the specific burdens of REMS participation.
2. Caseload Dynamics: The correlation between larger OUD panels and higher LAI-BUP use suggests that policy changes allowing for larger patient panels (such as the removal of the X-waiver caps) may indirectly support LAI-BUP adoption by allowing providers to build the necessary infrastructure.
3. Implementation Science: Future work should employ mixed-methods trials to test targeted strategies, such as pharmacy-based administration or streamlined REMS processes, to identify what specifically shifts clinicians along the continuum from non-use to high use.

The study does not claim to have identified the definitive "levers" for change but rather highlights that attitudinal surveys alone are insufficient to explain the low uptake, pointing toward modifiable logistical and regulatory constraints as the primary area for intervention.