Summary

In a secret shopper study of addiction treatment providers in Philadelphia, rapid access to buprenorphine for opioid use disorder (OUD) was possible, but most clinics could not provide information on important things to know when choosing treatment—such as whether the medical provider would quickly provide a buprenorphine prescription and program requirements to remain in medication treatment. This study simulated the experience of a real-world patient seeking care, revealing opportunities for policy and care delivery changes that could improve patients’ ability to access and remain in treatment.

Key Recommendations

1. Clinical providers and treatment programs should increase adoption of evidence-based practices that provide rapid access to medication initiation for OUD and clearly communicate these policies to consumers seeking care.
2. Health care facilities should adopt policies that encourage a “medication first” approach among providers.
3. Health care payers, including Medicaid programs and their managed care plans, should create reimbursement incentives that prioritize rapid and consistent access to medication for OUD.

Research Question

Although overdose deaths dropped last year, an estimated 80,000 people died in 2024 in the United States from drug overdose, and even more experience illness or death related to opioid use disorder.¹ Lifesaving medications such as buprenorphine and methadone cut the risk of death from overdose and all other causes by half or more.² Despite the effectiveness of these medications, only 25% of people across the U.S. receive medication treatment for OUD.^3,4 This low rate of uptake persists despite efforts to expand access to this treatment in both primary care and in specialized treatment programs. While research and policy has focused on reducing regulatory, insurance, and pharmacy barriers, less attention has been paid to the impact of the day-to-day experiences of patients attempting to access and stay in treatment.^5-8 In particular, little is known about the real-world experiences of patients seeking to start treatment, and barriers they may face when attempting to make appointments.

This study aimed to understand the treatment landscape for one lifesaving OUD treatment—buprenorphine—in Philadelphia. The researchers used secret shopper methods to measure adoption of evidence-based clinical practices that streamline access to buprenorphine care.

Research Methods

The team chose to conduct this research in Philadelphia because it’s a city that’s highly impacted by the opioid epidemic and a place where multiple strategies have been implemented to improve access to OUD care. Pennsylvania is also a Medicaid expansion state with robust behavioral health coverage for buprenorphine.

The team identified 130 eligible clinics using publicly available data sources from the Substance Abuse and Mental Health Services Administration, large local health systems, and professional networks. The team then verified each clinic or program with an initial phone call.

Using a secret shopper methodology, also known as an audit study, a researcher called each eligible clinic posing as a case manager helping a patient who had recently overdosed and was seeking buprenorphine treatment. This approach simulates the real-world experience of seeking care and addressed challenges found in traditional survey models, such as low response rates and response bias.

The caller asked questions to determine appointment availability and whether each clinic’s treatment approach was a good fit for the patient. The team recorded the days until the first available appointment as well as any friction involved in making the calls (e.g., being put on hold, needing multiple callbacks, or having to leave voicemails). The caller also inquired about specific clinical practices that could impact access or retention in care, including whether a buprenorphine prescription could be provided at the first visit, whether counseling was required, and whether the clinics had a zero-tolerance approach towards ongoing drug use.

Findings

The secret shopper reached 107 out of 130 eligible clinics; half were primary care offices and half were specialty substance use treatment providers. A high percentage of programs queried were accepting new patients (90%). However, the simulated case manager was often able to obtain only limited information about key clinical policies, such as whether a patient could receive a buprenorphine prescription at their first visit or whether participation in therapy was required to receive treatment (Table 1).

The median wait time for an appointment was three business days. Eighteen percent of clinics accepted walk-ins, and 28% provided appointments within one or two days. While there is no gold standard for acceptable wait times, these results suggest shorter wait periods compared to a similar 2018 study conducted in states with a high overdose burden.⁹

Despite relatively rapid access to an appointment, 45% of clinics could not provide information about whether a patient could receive medication at their first visit, and 38% could not provide information about whether counseling was required to continue receiving medication treatment. About half (54%) were unable to provide information about abstinence requirements. This is essential information for a patient seeking care, particularly following a recent nonfatal overdose, and it directly affects their ability to access care quickly and remain in treatment.

Among programs that could provide information about clinical care, adoption of evidence-based practices varied across both primary care and specialty addiction providers. Compared to primary care clinics, specialty addiction programs were more likely to share information about practices and requirements in their programs. However, specialty programs were also more likely to impose stringent requirements for receiving medication, such as mandated abstinence or counseling. Overall, only about one in eight programs (13%) could confirm that all the low-barrier clinical practices queried were in place.

Implications

Rapid access to medication is critical for patients who have suffered a nonfatal overdose, a scenario with a one-year mortality rate of 5%, comparable to that of a heart attack.¹⁰ Patients who receive treatment as soon as possible are more likely to remain in treatment.^11,12 This study shows that in Philadelphia, while rapid access to treatment was often available, barriers remain.

Even though medications like buprenorphine are the standard of care for OUD, only 43% of clinics could confirm the possibility of a buprenorphine prescription at the initial visit.¹³ Half of clinics could not provide information about whether counseling was required as part of buprenorphine treatment. And of those able to provide information, adoption of the most up-to-date evidence-based practices was mixed. These findings underscore how the treatment system makes it hard for patients with OUD to start and remain in care, both in terms of the availability of information about their care and the ability to access medication. Rapid and consistent access to medication is lifesaving, yet layers of requirements can create barriers to initiating and remaining in treatment. Whether due to administrative requirements such as waiting periods, frequent visits to receive treatment, or unrealistic definitions of success, many programs make it unnecessarily difficult to remain in care, hampering access to medication.

The reasons for variability in treatment program policies are likely complex, and the research team is continuing to explore this issue. Slow adoption of new approaches to care is a challenge across clinical medicine. However, stigma may play a unique role in substance use care and the persistence of overly restrictive treatment requirements. Substance use disorders have rates of adherence and remission similar to those of other chronic diseases such as diabetes or asthma.¹⁴ As with those conditions, medications can be effective even without perfect adherence and without frequent clinical visits. Yet requirements for abstinence, counseling, or other hurdles persist in addiction spaces.¹⁵ Disentangling and influencing deeply held beliefs that contradict evidence about best practices is important for future work.¹⁶

Additional Considerations

This research points to several possible measures that providers, policymakers, and payers that could use to support broader access to buprenorphine.

Providers

Providers should prioritize the adoption and implementation of current evidence-based practices that support low-barrier treatment access. An important first step would be to train front desk and scheduling staff in these practices to ensure clear communication of these policies to patients. In addition, providing clinicians with up-to-date guidance on appropriate prescribing, including continuing treatment in the setting of ongoing substance use, could help to increase comfort with evidence-based practices and improve engagement and retention of non-abstinent patients.

Policymakers

Local public health agencies could disseminate current treatment guidelines through clinical training and continuing medical education, and develop additional strategies to support provider education and awareness about the importance of rapid access to treatment.

Professional societies could issue new guidelines emphasizing lower-threshold treatment using models from organizations such as the Substance Abuse and Mental Health Services Administration and the American Society of Addiction Medicine.^17,18

Prior research has cited fear of legal repercussions or Drug Enforcement Administration (DEA) scrutiny leading to hesitation among prescribers. Enforcement agencies could clarify which prescribing practices do and do not generate enforcement concern.

Licensing agencies could explore adding adoption of evidence-based practices to state licensing regulations. For example, offering same-day medication starts could be required for specialty behavioral health treatment programs, and training for individual clinician licensure could incorporate up-to-date OUD treatment recommendations.

Payers

Payers should consider ensuring that coverage and reimbursement policies align with evidence-based treatment. This includes avoiding unnecessary barriers such as mandatory counseling requirements across all care settings and dosing requirements, allowing reimbursement for medication treatment that occurs independent of counseling, and creating reimbursement incentives, such as higher rates for initiating medication for opioid use disorder, to encourage rapid treatment initiation.

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Source Publication: Lowenstein, M., Davis, M.H., Aronowitz, S.V., Seeburger, E., Grande, D. March 2025, “Real-World Access to Buprenorphine Treatment in Philadelphia: A Secret Shopper Study.” Drug and Alcohol Dependence. https://doi.org/10.1016/j.drugalcdep.2025.112586

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References

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