Research ArticleResearch

Barriers and facilitators for family physicians prescribing opioid agonist therapy in Saskatchewan

Teresa Nguyen, Julia Bareham and Katelyn Halpape
Canadian Family Physician April 2024; 70 (4) e52-e60; DOI: https://doi.org/10.46747/cfp.7004e52

Abstract

Objective To explore barriers and facilitators for family physicians in Saskatchewan prescribing opioid agonist therapy (OAT).

Design Self-administered postal survey.

Setting Family medicine practices in Saskatchewan.

Participants A total of 218 Saskatchewan family physicians who were not authorized to prescribe OAT as of June 2022.

Main outcome measures Descriptive and inferential statistics of physicians’ self-reported barriers to and facilitators of prescribing OAT for opioid use disorder (OUD).

Results Most respondents (84.8%) had some comfort with diagnosing OUD. However, more than half (58.3%) did not feel confident or knowledgeable about prescribing OAT. Barriers to OAT prescribing included lack of time, incomplete training requirements, lack of interest, insufficient funding or support, feeling overwhelmed, and perceiving that OAT does not work and thus is not necessary. Physicians working in core neighbourhoods and those receiving fee-for-service compensation reported the least available time to prescribe OAT. Conversely, physicians working in interdisciplinary team settings had increased time for OAT prescribing compared with physicians in other settings. Having a close personal relationship with someone with OUD was correlated with increased comfort in diagnosing OUD as well as with knowledge about and confidence in prescribing OAT. Themes identified as facilitators to increasing OAT prescribing included the addition of resources and supports, increased training, more awareness about OUD and OAT, enhanced compensation, and altered prescribing regulations.

Conclusion Despite the presence of several real and perceived barriers limiting OAT prescribing by Saskatchewan family physicians, there are family physicians interested in providing this therapy. Increased clinical resources and support, including increased interdisciplinary practice, are actionable steps that should be considered by policy decision makers to address this issue. Additionally, increased OUD and OAT education, which includes the perspectives of those with lived experience of OUD, would help address physician confidence, knowledge, and awareness in this area.

Canada is experiencing an opioid crisis. Between January 2016 and June 2022, there were 32,632 deaths from apparent opioid toxicity, and the number of deaths per year has increased annually with the exception of 2022.1 The increasing presence of fentanyl and other potent synthetic opioids in the illegal drug supply has contributed to substantial increases in accidental overdose.1 Saskatchewan has not been spared from the opioid crisis, with 1528 confirmed deaths from drug toxicity between 2016 and 2022.2

Opioid use disorder (OUD) is a chronic condition in which patterns of opioid use have negative impacts on personal and public health.3 Opioid agonist therapy (OAT), which includes methadone, buprenorphine, and slow-release oral morphine, are pharmacotherapies for OUD treatment, with buprenorphine being the first-line treatment owing to its benefits at both the individual and the public level.3,4 Opioid agonist therapy has demonstrated a reduction in all-cause and overdose mortality for individuals with OUD.5 It also reduces the harms associated with opioid use, such as the transmission of blood-borne infections (eg, HIV); allows individuals to build their “recovery capital”6; and increases community safety.5-8

In Saskatchewan, access to OAT for individuals with OUD is limited. Saskatchewan family physicians cannot prescribe methadone or buprenorphine OAT for OUD until they are authorized to do so by their regulatory body, the College of Physicians and Surgeons of Saskatchewan (CPSS), by completing specific Saskatchewan-approved training requirements that range from workshops to online prescriber courses. All other opioids, including slow-release oral morphine, can be prescribed without authorization from the CPSS. In Saskatchewan, at the time of this study, a physician could apply to the CPSS for approval to be either an initiating or a maintenance prescriber of methadone or buprenorphine for OUD treatment. To become an initiating prescriber in Saskatchewan, the physician must complete a Saskatchewan-approved educational program and a period of direct training with an approved prescriber. For maintenance prescribers, direct training is not required, but physicians wishing to prescribe must have an ongoing association with an experienced initiating provider.9

As of the first half of 2022, approximately 15% of family physicians in Saskatchewan were authorized to prescribe OAT. As a result, Saskatchewan residents with OUD have limited access to OAT, increasing their risk of opioid-related harm. This is especially concerning as the annual rate of new HIV diagnoses in Saskatchewan is more than double the national average, with intravenous drug use as a primary driver of HIV transmission.10 Opioid agonist therapy prescribing by primary care physicians allows for holistic care of all conditions; patients often have established trusting relationships with their primary care providers and access is convenient. Evidence indicates that OAT prescribing by primary care providers is not only needed by patients but also preferred by patients.11-14 Primary care offers patients an alternative environment in which to receive care (eg, apart from a clinic that exclusively treats substance use disorders) and can result in better retention rates.15,16 Patients report increased feelings of respect, trust, privacy, and empathy from primary care providers.13,14,17 In addition to this, both patients and providers experience positive outcomes (eg, improved patient and overall attitudes toward OUD, including decreased stigma).11,15,18,19

Despite the potential benefits of OAT prescribing in primary care settings, barriers to this exist. General barriers to office-based OUD treatment identified in a recent study based in the United States included limited physician education, limited insurance reimbursement, stigma, and perceptions of “difficult” patients.20 Barriers identified specific to buprenorphine prescribing include lack of awareness of the medication, regulatory restrictions, liability fears, inadequate training, and lack of access to addictions specialists.20-23

The purpose of this study was to obtain the perspectives of Saskatchewan family physicians regarding why they were not prescribing OAT. Additionally, we aimed to identify where efforts should be focused to help support Saskatchewan family physicians in prescribing OAT.

METHODS

Design, setting, and participants

The study was conducted over the summer of 2022, with purposive sampling of all licensed family physicians in Saskatchewan. The CPSS publishes the names and practice addresses of all licensed family physicians in the province, as well as a list of all current OAT prescribers. The lists were cross-referenced to identify the target audience. Filtering was applied by way of 2 eligibility screening questions at the start of the questionnaire. Respondents were eligible to proceed with the survey if they were not currently authorized to prescribe OAT and if they were currently working in a primary care setting as a family physician.

On June 17, 2022, a paper questionnaire was mailed to 998 family physicians within Saskatchewan. The questionnaire was enclosed in a standard business envelope and accompanied by a cover letter and consent form describing the purpose of the study; a handwritten, personalized note thanking participants for their time; and a preaddressed, unmarked, stamped envelope. Participants were asked to return the completed survey to the research team via the preaddressed, stamped envelope. A survey reminder was issued via facsimile on August 2, 2022, and the survey closed on September 29, 2022.

To our knowledge, this was the first survey exploring the barriers to and facilitators of OAT prescribing specific to Saskatchewan family physicians. For this reason, a new questionnaire was developed. Input was sought from a researcher with experience in survey development as well as from clinicians and stakeholders with experience working with OUD. Published studies with a similar focus from other jurisdictions were reviewed.20-25 Demographic characteristic information collected in the survey included number of years in practice, location of medical training, location and type of practice site, compensation model, and patient case load. The questionnaire was revised after pilot-testing by 4 pharmacists, 1 physician, and 1 project manager, all with knowledge and experience related to OAT or survey development. The final questionnaire contained 26 questions (19 check-box and 7 open-ended questions). Approval was obtained from the University of Saskatchewan Behavioural Research Ethics Board.

Data from all the returned paper surveys were entered into an SPSS data set by Canadian Hub for Applied and Social Research staff and were analyzed using descriptive and inferential statistics. The survey consisted of 19 nominal and 7 string variables organized into information on physician practice type and structure, education and training, compensation, barriers and facilitators for prescribing OAT, and personal perspectives on providing services to patients with OUD as they related to OAT. Statistical analysis included frequencies and descriptive statistics, as well as cross-tabulations. Where possible, categories were collapsed into a 2-by-2 contingency table, and Embedded Image2 analysis was applied to determine if significant differences existed. Significance was determined as a P value of <.05. Content analysis was used to identify common themes from free-text responses to the open-ended survey questions.

Main outcome measures

The primary outcomes measured were physician self-reported barriers to and facilitators of prescribing OAT in Saskatchewan.

RESULTS

In total, 242 of 998 surveys were returned. Twenty-four surveys were returned with only the eligibility questions completed, and those respondents indicated they were ineligible to participate. The remaining 218 surveys were included in the analysis (21.8% response rate). Table 1 summarizes the respondents’ demographic characteristic information.

View this table:
Table 1.

Demographic Information characteristic: N=218.

Nearly half of the respondents completed their undergraduate medical training and residency in Canada. The mean (SD) years in practice among respondents was 18.23 (14.1). More than half (50.5%) practised in a physician-only private primary health centre, and 62.8% were paid via the fee-for-service model. Three-quarters (74.8%) indicated that they had at least 1 patient with OUD. Only 11.5% of respondents reported having a close, personal relationship with someone with OUD. Approximately 8% of respondents had previously prescribed OAT but had since stopped.

Less than half (45.5%) of the respondents had received specialized training related to OUD or OAT. Continuing medical education events online (49.5%) or in person (37.9%) were the most commonly reported formats. Many respondents (73.4%) indicated that they were aware of the CPSS standards for becoming an authorized OAT prescriber. Nearly 80% reported not being aware of the compensation available for treating OUD. Among those who were familiar with this compensation, only 6.9% thought that it was adequate.

Most respondents (84.8%) had at least some level of comfort in diagnosing OUD. More than half (58.3%) of the respondents reported not feeling confident or knowledgeable about prescribing OAT. Of the respondents who reported a close, personal relationship with someone diagnosed with OUD, almost all (95.7%) were comfortable with diagnosing OUD. These respondents also reported feeling more knowledgeable and confident in prescribing OAT than those who do not personally know someone (60.0% vs 38.3%, P=.038).

Only 9.2% of respondents reported having time to prescribe OAT for OUD (Figure 1). Time available to treat OUD was found to be different across communities served; 61.7% of family physicians in core neighbourhoods stated they had no time compared with those in remote areas and on reserve lands (44.1% and 30.0%, respectively). Across all practice settings, family physicians working in publicly funded clinics with interdisciplinary teams were most likely to report having adequate time to treat OUD with OAT (14.0%). The highest proportion of Saskatchewan family physicians with no time to treat OUD with OAT was observed among those with a fee-for-service compensation model at 62.5% compared with those with salary, sessional, and contract compensation models (43.4%, 35.7%, and 45.7%, respectively).

Figure 1.
Figure 1.

Time to treat OUD with OAT: N=218.

Nearly two-thirds (62.4%) of the respondents believed that prescribing OAT is within the scope of practice for family physicians. However, 60.6% of respondents indicated they had no interest in prescribing OAT (Figure 2). Among the 135 physicians who believed that OAT was within the scope of family practice, 21.5% had patients with OUD compared with the 31.3% of those who believed that OAT was outside the scope of family practice. This difference was not statistically significant (P=.110). Among those who thought OAT was within the scope of family practice, 46.6% expressed being somewhat or very interested in becoming authorized to prescribe OAT, compared with the 24.4% who thought OAT was out of scope (P<.001). Few respondents reported having access to case workers (26.6%). A total of 75.2% of respondents indicated their patients had access to addictions counsellors; however, many handwritten notes stated access was poor.

Figure 2.
Figure 2.

Interest in prescribing OAT for OUD: N=218.

Through an open-ended question, respondents were asked why they were not currently an authorized OAT prescriber. This question was answered by 190 respondents, and the responses were organized into themes that included lack of time (34.7%), incomplete training requirements (34.2%), lack of interest (27.4%), no patient need (20.5%), insufficient funding or support (10.5%), and other OAT prescribers available to provide treatment (4.7%). Table 2 highlights individual comments within the various themes.

View this table:
Table 2.

Reasons for not being an authorized OAT prescriber: N=190.

Respondents were also asked an open-ended question about how access to OAT could be improved in Saskatchewan. The results are summarized in Table 3. The themes included the need for additional resources and supports (58.9%), more trained prescribers (31.8%), increased physician awareness (15.9%), enhanced compensation (15.2%), and altered prescribing regulations (6.0%). Respondents were also given space to provide any additional comments they had related to OUD and OAT. The comments were organized into themes that are summarized in Table 4. From this question 3 themes provide insight into areas where efforts should or might be focused to facilitate OAT prescribing: need for more funding for OUD (36.5%), perception that OAT is a worthwhile area of study (11.1%), and need for better promotion of OAT education to family physicians to support prescribing (6.3%). Two unrelated themes identified from this question were that physicians are overwhelmed (19.0%) and OAT does not work (4.8%).

View this table:
Table 3.

Ideas to improve access to OAT in Saskatchewan: N=151.

View this table:
Table 4.

Open-ended comments on OUD and OAT: N=63.

DISCUSSION

While many barriers to prescribing OAT exist, the need for optimal management of OUD with OAT remains.1 Family physicians are well positioned to facilitate access to this life-saving therapy.4 Primary care management of OUD is associated with increased patient satisfaction owing to convenience and patient-centredness, and has been found to be cost-effective.13,26-28 However, similar to our findings, several barriers to OAT prescribing in primary care have been identified, including inadequate skills, insufficient comfort with the topic, lack of resources, and not enough time.20-23,29,30 These barriers are reflected in the findings of a recent randomized controlled trial that showed that an individual living with OUD, compared with an individual living with diabetes, had more difficulty accessing family physician care.31 Our study contributes unique information regarding physician interest in prescribing OAT and, to our knowledge, this is the first study of this type in Saskatchewan.

Many respondents indicated that OUD management should occur in a primary care setting, yet a similar percentage indicated no interest. The lack of interest might stem from stigma, including structural stigmas such as prescribing regulations, as 34.1% of respondents reported incomplete training requirements.23 However, only 6.0% of respondents indicated prescribing regulations as an area for improvement. Opioid agonist therapy prescribing regulations differ in each province. In Saskatchewan, physicians receive approval from their regulatory body after completion of a recognized course and mentorship session. In contrast, physicians in Alberta are required to complete virtual training.32 Easing the restrictions might increase the number of physicians willing to prescribe OAT.

A close, personal relationship with someone with OUD was correlated with increased comfort, knowledge, and confidence around OUD and OAT. Although it is not realistic for all clinicians to have a close personal relationship with someone with OUD, including individuals with lived experience in training initiatives can have a positive influence on substance use treatment.25 For example, a study of medical residents found that the inclusion of individuals with lived substance use experience in an educational seminar led to physicians working with more substance use disorder patients and improved attitudes toward addiction.33

A lack of confidence and knowledge related to OAT prescribing was identified throughout the survey, including in the open-ended responses that revealed physician misinformation around OAT effectiveness. Considering that nearly half of the respondents had graduated from medical school more than 18 years ago, education efforts must target practising physicians as well as those currently attending medical school and those completing family medicine residencies. The medical school curriculum at the University of Saskatchewan includes an elective in addictions medicine but does not provide addictions training to all graduates.34

Increased investment by the health system in the overall area of OUD was alluded to by respondents. This investment could include increased funding for physician training and the provision of direct patient care for individuals with OUD. Analogously, increased interdisciplinary practices would allow for more comprehensive patient care that might make providing OAT more accessible and of interest to physicians.

Limitations

There are several limitations to this study, including the overall response rate of 21.8%. Given the nature of this study, it is not possible to rule out volunteer and non-response bias. The questionnaire was not validated but was reviewed by content experts, as well as a research design expert, and it was pretested to assess each question for clarity. However, it is possible that there were variable interpretations of the survey questions that might have impacted the results. Further, the response rate for the section on facilitators of OAT prescribing (Table 3) was reduced to 15.1% (151 of 998 questionnaires mailed). Given the nature of the study, it was not possible to determine why respondents were not interested in this section of the questionnaire. Overall, focus groups or semistructured interviews might have been more appropriate methods to gain richer data.

Conclusion

Despite the presence of several real and perceived barriers limiting OAT prescribing by Saskatchewan family physicians, there are family physicians interested in providing this therapy. Increased clinical resources and supports, including increased interdisciplinary practices, are actionable steps that should be considered by policy decision makers to address this issue. Additionally, increased OUD and OAT education, which includes perspectives of those with lived experience, would help to address physician confidence, knowledge, and awareness in this area.

Footnotes

  • Contributors

    Julia Bareham led the idea generation for this project. Dr Katelyn Halpape and Julia Bareham led the development and delivery of the survey. Dr Katelyn Halpape led the scientific writing process. Teresa Nguyen drafted the initial version of the manuscript. Dr Katelyn Halpape and Julia Bareham reviewed and edited each draft of the manuscript. All authors approved the final version of the manuscript.

  • Competing interests

    Teresa Nguyen reports a relationship with Loblaw Pharmacy that includes employment. Julia Bareham reports a relationship with Shoppers Drug Mart that includes casual employment; a relationship with the Canadian Drug Agency Transition Office that includes consulting or advisory services; a relationship with the Non-Insured Health Benefits Program of Indigenous Services Canada that includes consulting or advisory services; and a relationship with the College of Physicians and Surgeons of Saskatchewan Project ECHO Management of Chronic Pain and Substance Use Disorder that includes consulting or advisory services. Dr Katelyn Halpape reports a relationship with Health Canada Substance Use and Addictions Program that includes the receipt of funding grants; a relationship with Indigenous Services Canada that includes the receipt of funding grants; a relationship with the Clinical Handbook of Psychotropic Drugs that includes consulting or advisory services; a relationship with Saskatchewan Health Research Foundation that includes the receipt of funding grants; and a relationship with Royal University Hospital Community Mental Health Endowment Granting Program that includes the receipt of funding grants.

  • This article has been peer reviewed.

  • Cet article a fait l’objet d’une révision par des pairs.

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Barriers and facilitators for family physicians prescribing opioid agonist therapy in Saskatchewan
Teresa Nguyen, Julia Bareham, Katelyn Halpape
Canadian Family Physician Apr 2024, 70 (4) e52-e60; DOI: 10.46747/cfp.7004e52
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