Fewer than one in 10 primary care providers in the U.S. can prescribe the opioid-addiction medication buprenorphine, and access is even more scarce in rural counties hardest hit by overdoses, a new study suggests.

Since 2000, physicians have been able to seek waivers from the federal government to prescribe buprenorphine, seen as an alternative to methadone dispensed at federally approved clinics, said study co-author Ryan McBain of the RAND Corporation in Boston. More recently, nurse practitioners and physician assistants have been allowed to seek waivers, too, helping to drive a four-fold increase in the number of clinicians nationwide able to prescribe buprenorphine.

From 2007 to 2017, the number of providers with waivers to prescribe buprenorphine climbed from 3.8 for every 100,000 people in the population to 17.3 per 100,000, researchers report in Annals of Internal Medicine. Still, less than 10 percent of primary care providers could prescribe the drug by the end of the study period.

“Over the same period, opioid deaths skyrocketed from about 16,500 per year to 46,000 per year,” McBain said by email. “So we see that need for treatment also ballooned.”

As of 2017, almost 95 percent of clinicians with waivers to prescribe buprenorphine were physicians. About 4 percent were nurse practitioners and about 1 percent were physician assistants, the analysis of government data found.

Among those with waivers, 72 percent were approved to treat up to 30 patients, while 22 percent could treat up to 100 patients and 6 percent could treat a maximum of 275 patients.

The number of clinicians who could prescribe buprenorphine climbed fastest in communities with the most opioid overdose deaths per capita, the study found. The proportion of waivered providers climbed about five-fold in communities with the most overdose deaths, compared to about a three-fold increase in places with the fewest overdose deaths.

However, even after researchers accounted for need based on overdose death rates, they still found rural counties didn’t gain as many providers able to prescribe the drug.

Counties with more college graduates gained more providers able to prescribe buprenorphine than communities with fewer college graduates, the study also found.
The researchers lacked data on how many prescriptions clinicians with waivers actually wrote, or how many patients they treated.

Still, the results suggest gains in access to buprenorphine aren’t keeping pace with needs, said Dr. Stefan Kertesz of the University of Alabama at Birmingham School of Medicine.

“The kind of doctor most people actually get to see is legally prohibited from offering the most accessible and effective form of treatment for opioid addiction,” Dr. Kertesz, who wasn’t involved in the study, said by email. “The fact that most of our health care workforce is not ready to treat a devastating and treatable disease is a tragedy that we need to fix.”

Other medication options include methadone, which can only be obtained through licensed clinics, and naltrexone, which any doctor can prescribe but many don’t know how to use, Dr. Kertesz said.

These hurdles for people with opioid use disorder aren’t encountered by patients with other chronic health problems, said Dr. Pooja Lagisetty of the University of Michigan Medical School and the VA Ann Arbor Healthcare System.

“With other diseases, we meet patients where they are at, and tailor treatment to their preferences and needs,” Dr. Lagisetty, who wasn’t involved in the study, said by email.

For many chronic diseases, there are a dozen medication treatment options, she added.
“But with opioid use disorder, we have three,” Dr. Lagisetty said. “With so few options, we have to make all of them readily available for all patients, not just those living in certain communities.”