Conclusions
A challenge facing clinicians in confronting the opioid crisis is how to close treatment gaps including adopting the practice of buprenorphine initiation. Here, we identify that although health care system (and associated system-level factors) is a major factor associated with buprenorphine initiation, these factors may be modifiable through an intervention such as the EMBED CDS tool, as well as social factors relating to observing colleagues adopting a practice. The remaining variability between adoption at a health care system level shows a need for additional efforts to identify barriers to buprenorphine initiation and interventions to target them. These may include robust connection to outpatient clinicians and interventions targeted to change local culture. Furthermore, changes to the X-waiver requirement may impact these barriers. This study identifies not only a role for both top-down systemic efforts to impact buprenorphine initiation rates but how individual clinicians may be able to affect the practice of those around them.