Increasing Access to Buprenorphine in Rural Primary Care 

Summary

Buprenorphine, methadone, and other medications for opioid use disorder (OUD; MOUD) are highly effective—they reduce overdose risk by more than 60% and also limit the spread of infectious diseases such as HIV and HCV. Despite their efficacy, only 1 in 5 people with OUD in the US receives MOUD. Unlike methadone, buprenorphine can be prescribed in primary care which is critical for rural communities who lack addiction specialists, harm reduction programs, and opioid treatment programs. Primary care is also a less-stigmatizing treatment setting and provides a medical home for other needed services such as infectious disease screening and naloxone distribution. But across the U.S., and especially in rural areas, buprenorphine is underused and difficult to access. 33% of rural residents live in a county without buprenorphine access compared to 2% of urban residents. Although the percentage of primary care professionals (PCPs) prescribing buprenorphine has doubled in the past decade, these gains have been almost entirely in urban areas. Rural PCPs face a number of prescribing barriers such as limited training, stigma toward and misinformation about the medication, and limited contact with other rural buprenorphine prescribers.  

Our community-engaged study will test whether a brief buprenorphine prescribing support program (BPSP), rooted in social contact to reduce stigma, will expand access to buprenorphine in rural communities. Buprenorphine is under-prescribed in rural areas because of stigma. Rural PCPs worry that buprenorphine is unsafe because it is a partial opioid agonist that still produces some opioid effects. PCPS are concerned that their practices will be stigmatized if they offer addiction treatment and fear that patients receiving buprenorphine will be unreliable and potentially violent. These concerns are shaped by practicing in rural areas during the height of the opioid epidemic when pill mills proliferated, buprenorphine was sold at cash-only clinics, and providers were threatened if they refused to provide opioids for chronic pain. 

Building on decades of research on social contact to reduce stigma, we developed the BPSP in collaboration with rural primary care professionals, community leaders, individuals with lived experience of OUD, and policymakers. Our research team brings expertise in buprenorphine, rural health services research, addiction medicine, infectious disease, implementation science, biostatistics, and organizational psychology. The BPSP is a one-hour asynchronous, online module that includes clinical training on buprenorphine and addresses common misinformation about the medication. It facilitates positive contact with other rural PCPs who prescribe buprenorphine and find value in this work, as well as with patients who have experienced remission after taking buprenorphine. It is followed by a live, online booster module facilitated by an addiction-medicine trained family physician where PCPs can ask questions and discuss remaining concerns with prescribing. PCPs also have the opportunity to receive long-term prescribing mentorship.

Significance

Evidence-based medications for opioid use disorder are highly effective at reducing fatal overdoses and infectious disease transmission. But they can only be effective if they are prescribed. The BPSP will benefit science through a better understanding of why PCPs are hesitant to prescribe and whether brief prescribing support, rooted in social contact to reduce stigma, increases access in rural primary care. The BPSP will benefit rural communities by expanding access to this lifesaving medication in a convenient setting where other health care needs can be addressed. The BPSP may also benefit society; studies demonstrate that buprenorphine prescribing is associated with reduced overdose deaths and less child maltreatment. 

Rural residents experience profound health disparities in the U.S., including higher rates of social vulnerability and chronic disease. As a result, rural residents are at greater risk of preventable death compared to urban residents. Social determinants of health such as economic deprivation, unemployment, and limited transportation make enacting healthy lifestyles challenging and limit access to needed healthcare. Our research advances health equity by testing strategies to make evidence-based treatment for OUD more easily available in rural communities. Given the lack of addiction specialists, psychiatrists, and harm reduction organizations in rural communities, the BPSP aims to embed needed healthcare and harm reduction services within rural primary care. 

Benefits

Demonstrated benefits are those that have been observed and are verifiable.

Potential benefits are those logically expected with moderate to high confidence.

Increase rural PCP willingness to provide guideline-driven care with buprenorphine. potential.

Clinical

Guidelines

Increase access to buprenorphine for people in rural areas through embedding treatment in primary care settings. potential.

Community

Health care accessibility

Improve adoption of highly effective medications for the treatment of opioid use disorder.  potential.

Community

Health care delivery

Reduce stigma and support low-threshold prescribing of buprenorphine to improve quality of care for people with opioid use disorder. potential.

Community

Health care quality

Reduce overdose deaths and infectious disease transmission through increased buprenorphine prescribing. potential.

Community

Life expectancy & quality of life

Increase access to life-saving harm reduction services, including naloxone and syringe service programs.  potential.

Community

Public health practices

Limit health care costs to individuals and society through reducing morbidities secondary to opioid use.  potential.

Economic

Societal & financial cost of illness

Encourage changes in clinic-level policies that prohibit buprenorphine prescribing.  potential.

Policy

Policies

This research has clinical, community, economic, and policy implications. The framework for these implications was derived from the Translational Science Benefits Model created by the Institute of Clinical & Translational Sciences at Washington University in St. Louis.

Clinical

The BPSP provides training on prescribing buprenorphine according to guidelines from the American Society of Addiction Medicine. This approach reduces unnecessary barriers to care, such as requiring lengthy paperwork or abstinence from all substances, to receive the medication. Prescribing according to guidelines is associated with better clinical outcomes such as increasing the number of patients who can access the medication and reducing the chances of treatment termination. Our program aims to support appropriate buprenorphine prescribing in rural primary care. 

Community

If the BPSP is effective, there may be a number of benefits to community and public health. The BPSP has the potential to increase access to buprenorphine for people in rural areas and encourage the use of highly effective pharmacotherapy as opposed to less-effective treatments. The BPSP may also improve the quality of care provided for people with opioid use disorder by reducing stigma and supporting low-barrier treatment. The BPSP encourages rural PCPs to distribute naloxone and help patients connect with syringe service programs. We will test whether the BPSP reduces overdose deaths and infectious disease transmission. 

Economic

Untreated opioid use disorder is associated with a number of health consequences including fatal overdose and secondary health problems such as infectious disease transmission that are costly to individuals and society. If the BPSP is effective at retaining patients in care and reducing morbidities secondary to opioid use, there will be financial benefits to individuals and society. Reducing fatal overdoses and secondary health problems can lead to substantial financial benefits by decreasing healthcare costs associated with emergency and long-term treatment, and by preserving productivity that would otherwise be lost to disability or premature death. 

Policy

In developing the BPSP, we learned that many rural primary care clinics enact policies to prevent buprenorphine prescribing because it is perceived to be a risky and challenging medication to manage. The BPSP provides implementation support to integrate buprenorphine into rural primary care and if effective, may encourage changes in clinic-level policies that prohibit buprenorphine prescribing. In addition, if the BPSP improves outcomes for people living with opioid use disorder, the training program could be a model to support buprenorphine prescribing in rural areas nationally. 

Lessons Learned

We could not have developed the BPSP without a multidisciplinary team that included researchers with diverse expertise in stigma reduction, addiction medicine, and implementation science. Collaboration with health care professionals working in primary care, with individuals with lived experience of addiction, and with a health care system dedicated to improving the quality of primary care was essential to our success.