Geographic and Specialty Distribution of US Physicians Trained to Treat Opioid Use Disorder

DISCUSSION

Despite the availability of office-based therapy for the treatment for opioid use disorder—and despite efforts to expand its availability—only 2.2% of American physicians have obtained the waivers required to prescribe buprenorphine to treat opioid use disorders. We found that 90.4% of these physicians were practicing in urban counties, leaving the majority of US counties (53.4%)—most of them rural—with no physician with a DEA DATA waiver.

The relative paucity of these physicians in rural areas is a major barrier to office-based outpatient treatment for opioid use disorder. The per capita supply of physicians with waivers in the most rural counties is one-half the supply in urban settings. Although primary care physicians are the predominant providers of health care in rural America, very low percentages of family physicians and general internists (3.0%) have obtained a DEA DATA waiver. Psychiatrists, who comprise more than 40% of the physicians with waivers, are rare or nonexistent in rural America.⁷

Additionally, obtaining a waiver to prescribe buprenorphine does not ensure that physicians will incorporate this modality into their treatment of opioid use disorder. The presence of a physician who has obtained a waiver does not necessarily mean that buprenorphine treatment is available.^8–10 In the only national study of this issue, the average physician with a waiver was currently treating 26 patients (mean) with buprenorphine,¹¹ and 25% of the physicians had not treated any patients since obtaining their waiver. Other studies found that those physicians actually prescribing buprenorphine were treating a relatively small number of patients.^12,13

The low rate of young physicians with waivers suggests that they are not being trained during residency in the treatment of opioid use disorders. Obtaining a waiver for buprenorphine and mastering some of the nuances of treatment during residency could increase the likelihood that these future practitioners would identify and treat opioid use disorder.

The complexity and stigma surrounding office-based treatment of patients with opioid use disorder dissuade many physicians from adopting buprenorphine as a treatment option.¹⁴ Barriers to providing buprenorphine therapy include a lack of institutional support, inadequate support from nursing and office staff, a lack of mental health practitioners, payment issues, and opposition from practice partners.^12,14 Coordinated efforts to train and support teams of clinicians in specific rural practices, including mental health clinicians comfortable with on-site harm-reduction therapies, and reimbursing this care at a reasonable amount would be promising first steps to addressing these barriers.

This study is limited by several factors. First, although we had access to information about the amount of opioids prescribed in all 50 states, there were no data on the number of patients who would meet the criteria for addiction or benefit from buprenorphine therapy. Thus it is possible that some counties that had one or more physicians with waivers may have a greater need for additional buprenorphine-prescribing physicians than counties with physicians with no waivers at all. Second, it was not possible using the DEA DATA Waived Physician List to determine whether buprenorphine treatment was available for patients with opioid use disorder in the county where they live, as obtaining a waiver does not guarantee that the physicians will add this treatment option to their practices.

The distribution of physicians with DEA DATA waivers across US counties leaves rural counties with little or no access to office-based opioid use disorder treatment. Rural counties, especially more isolated ones, have a substantially lower supply of buprenorphine-prescribing physicians per 100,000 residents. Office-based treatment of opioid use disorder with buprenorphine has been effective in expanding the options available to patients and physicians. Increasing the number of physicians with DEA DATA waivers could improve access to treatment for patients—particularly in rural America—and is a promising strategy to address the rising rates of opioid use disorder and lethal unintentional overdoses.