A Multi-Year Analysis of Buprenorphine Availability in Co-Occurring Substance Use and Mental Health Treatment Programs

Background/Purpose: Buprenorphine is an essential medicine for the treatment of opioid use disorder and for the prevention of opioid overdose deaths. For people with co-occurring mental health problems and opioid use disorder, it additionally facilitates decreased risk of suicide, both due to its effectiveness in treating opioid use disorder, but also due to direct impacts reducing suicidal ideation. Despite these benefits, buprenorphine has historically been under-prescribed, particularly in clinics relying on public funding. As knowledge of buprenorphine has expanded, with the elimination of waiver requirements to prescribe buprenorphine for opioid use disorder, and with the expansion of the Certified Community Behavioral Health Center program, access to buprenorphine in community mental health and substance use programs may be increasing. This study uses serial cross-sectional data for the years 2021 through 2023 from the National Substance Use and Mental Health Services Survey (NSUMHSS), a survey of behavioral health treatment programs, to identify the availability of buprenorphine in outpatient treatment programs providing both mental health and substance use treatment services.

Methods: NSUMHSS data for 2021, 2022 and 2023 was analyzed using a logistic conditional fixed effects regression model, accounting for clustering of programs within states. Missing data was managed through listwise deletion, resulting in n=10941 respondents. A binary variable representing buprenorphine service provision was regressed onto binary variables indicating clinic type, such as community mental health center and certified community behavioral health center, and the source of funding for the program including Medicaid, Medicare, government grant funding and commercial insurance. The year of data was held constant as a fixed effect with 2021 as the reference variable.

Results: Programs who received private insurance payments (OR= 1.99, p<.001), received Medicare payments (OR= 2.48, p<.001) and received any federal, state, county or local funds (OR= 1.89, p<.001) had great odds of delivering buprenorphine as part of care. The odds of buprenorphine provision increased in 2022 (OR= 1.35, p<.001) and 2023 (OR= 1.62, p<.001), Community mental health centers had almost half the odds of providing buprenorphine, (OR= 0.60, p<.001) and those using Medicaid for funding had less than half the odds of providing buprenorphine (OR= 0.45, p<.001). Certified Community Behavioral Health Clinic designation was not statistically significantly in the model.

Conclusions and Implications: Outpatient treatment programs providing both substance use and mental health treatment increasingly provide buprenorphine as part of treatment. However, publicly funded programs relying on Medicaid for financing, lag behind privately funded programs in providing care, potentially facilitating a gap in treatment that exacerbates class-based health disparities. Certified Community Behavioral Health Clinics had no difference in provision of buprenorphine compared to other outpatient programs, suggesting that additional financial incentives or regulatory mandates may be necessary to facilitate consistent provision of buprenorphine by these programs. Further study is needed to establish whether the elimination of the waiver requirement to provide buprenorphine facilitated increased buprenorphine availability in publicly funded community-based programs.