Many Rural Americans Have No Access to Buprenorphine

    Nearly a third of rural Americans live in a county without access to buprenorphine—the gold standard for treating opioid use disorder, according to a new Pew fact sheet.

    In contrast, almost all (97.8 percent) of urban-dwelling Americans live in cities that do have buprenorphine providers.

    In order to be able to legally prescribe and dispense buprenorphine—one form of Medication Assisted Treatment (MAT)—clinicians must complete eight hours of mandatory training, apply for a waiver online, and maintain detailed records of prescribing and treatment activity.

    Pew recognizes that lack of access to buprenorphine is part of a larger problem—people nationwide do not have adequate access to opioid treatment programs (facilities that offer MAT and other concurrent services like counseling). And with OTPs, too, rural areas experience a particular dearth, with around 88.6 percent of “large rural counties lack[ing] a sufficient number of OTPs.”

    This disparity has been illustrated for Filter by Dr. Elizabeth Ryan. In September 2018, she wrote that the “disproportionate distribution of opioid use to rural areas is reflected by the alarming fact that patients from no fewer than 17 counties have come to [REACH, the clinic in Ithaca, NY where she works] for MAT” in the six months after it opened in early 2018.

    “This initially surprised us greatly. But they are coming because there is simply no help where they live,” Ryan concluded.

    According to a Federal Office of Rural Health Policy survey of physicians, a concern about “diversion or medication misuse” was the most commonly stated reason (endorsed by 48 percent of respondents) for not incorporating buprenorphine into their clinical practice. “Time constraints” (40.2 percent) and “lack of available mental health or psychosocial support services” (44.4 percent) were also frequently cited in the survey.

    Additionally, in an interview with Filter in December 2018, Dr. Kim Sue of Harm Reduction Coalition recognized that even “doctors who get the waiver to prescribe buprenorphine [sometimes] ultimately don’t end up prescribing it. There’s a lot of fear, there are a lot of misconceptions, and that’s a product of the weird regulatory system we have around it.”

    But the federal government and advocates are working to close the gap in access to waivers. For one thing, the buprenorphine-prescribing workforce is being expanded. In January 2018, the once-temporary policy of allowing physicians’ assistants and nurse practitioners to prescribe buprenorphine after receiving training was made permanent; clinical nurse specialists were also added to this cohort.

    As a result of this expansion, along with more physicians accessing the prescribing waiver, the number of providers able to prescribe buprenorphine per 100,000 residents has doubled in rural counties. Telemedicine is also being used to connect more patients with qualified providers.

    Supporters of this policy argue that medical professionals should be able to prescribe a medicine that reduces the potential harms of other drugs they prescribe. “If you’re allowed to do one, you should be able to do the other,” Stanford psychiatrist Keith Humphreys told Pacific Standard. 

    Photo: “Sublingual Suboxone (Buprenorphine / Naloxone 8mg / 2mg) Tablets” by Jr de Barbosa, licensed under the Creative Commons Attribution-Share Alike 3.0 Generic license, CC BY-SA 3.0

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