Barriers Rural Physicians Face Prescribing Buprenorphine for Opioid Use Disorder

Abstract

Opioid use disorder is a serious public health problem. Management with buprenorphine is an effective, office-based, medication-assisted treatment, but 60.1% of rural counties in the United States lack a physician with a Drug Enforcement Agency waiver to prescribe buprenorphine. This national study surveyed all rural physicians who have received a waiver in the United States and found that those who were not actively prescribing buprenorphine reported significantly more barriers than those who were, regardless of whether they were treating the maximum number of patients their waiver allowed. These findings suggest the need for tailored strategies to address barriers to providing buprenorphine for opioid use disorder and to support physicians who are adding or maintaining this service. INTRODUCTIONT he opioid abuse epidemic is a serious and persistent public health problem. In 2015 an estimated 2.0 million people had a pain reliever use disorder, and 828,000 people had used heroin in the previous year.1 Buprenorphine maintenance treatment is effective for opioid use disorder, 2 and major efforts have been made to expand its availability. The Drug Addiction Treatment Act of 2000 allows physicians who complete training to obtain a Drug Enforcement Agency (DEA) waiver that permits prescribing buprenorphine to treat opioid use disorder. Despite a more than threefold increase in the number of physicians with a DEA waiver since 2006, 3 60.1% of rural counties lack a physician with a waiver. 4 Access to treatment continues to be a challenge for rural populations. Many physicians with a waiver are not using it to its full extent or at all. 5,6 A few studies, limited to 1 or only a few states, have looked at the barriers physicians face providing buprenorphine maintenance treatment, but none has examined nationally the differences between physician groups who are and are not actively using their waivers or accepting new patients.7-10 This study's purpose was to understand the barriers physicians with waivers face in providing buprenorphine maintenance treatment. METHODSWe surveyed all rurally located physicians in the United States on the DEA list (April 2016) who had received waivers to prescribe buprenorphine. We categorized physicians as rural using the Federal Information Processing Standards county code of the physicians' address if they had an Urban Influence Code of 3 through 12. 360nonrespondents using DEA, American Medical Association, National Provider Identifier, or Google Search result addresses until the physician's practice was found. Participants received the questionnaire at that address twice more, 2 weeks apart, followed by an abbreviated version of the questionnaire as a tear-off return postcard 1 month after follow-up began. Physicians responding to the tear-off postcard were not asked the barriers question. We telephoned nonrespondents up to 3 times, at 2-week intervals. Data collection occurred from July through November 2016.Physicians were classified into 4 categories based on whether the...

Overcoming Barriers to Prescribing Buprenorphine for the Treatment of Opioid Use Disorder: Recommendations from Rural Physicians

“…Many rural physicians around the country have been able to successfully incorporate MAT treatment into their practices, despite the numerous barriers that have been previously cited . This study's findings on the practices of waivered providers who have successfully incorporated MAT into their practices may be useful to providers considering offering MAT to their patients.…”

“…Although our respondents mirrored the Census Region distribution of rural physicians with a DEA waiver, we did not have an adequate sample size to statistically test the distribution at the Census Division level. This may be important because the rate that physicians reported some barriers did vary by Census Division in the prior study from which this study's sample was drawn …”

Prescribing Practices of Nurse Practitioners and Physician Assistants Waivered to Prescribe Buprenorphine and the Barriers They Experience Prescribing Buprenorphine

“…At the same time, 1 in 5 (19.7%) NPs and PAs with a waiver indicated they had never prescribed buprenorphine, greater than the 11% of rural physicians in 2016 who had never used their waiver . The barriers that nonprescribing NPs and PAs (never and former prescribers) cited at a higher rate than prescribing NPs and PAs (Table ) were also reported more often by nonprescribing physicians than by prescribing physicians . These patterns suggest that successful interventions to address these barriers may cut across profession types and maximally increase the participation rate of the entire waivered provider workforce.…”

Now is the Time to Address Substance Use Disorders in Primary Care

“…[11][12][13][14] The research brief by Andrilla outlines the multiple barriers 14 that rural physicians face in prescribing buprenorphine for opioid use disorders, such as regulatory requirements for a waiver to prescribe buprenorphine. 15 There are resources to promote the confidence and skill of the practitioner. For example, the Physician Clinical Support System (PCSS) 16,17 provides consultation and mentoring while the ECHO model 18 is becoming more widely available and may be particularly well-suited for rural physicians.…”