Comparing Buprenorphine-Prescribing Physicians Across Nonmetropolitan and Metropolitan Areas in the United States

Lewei (Allison) Lin; Hannah K. Knudsen

doi:10.1370/afm.2384

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Table 1

Characteristics of US Buprenorphine Prescribers Across Locations of Practice

	Large Metropolitan Area	Small Metropolitan Area	Nonmetropolitan Area	N	χ² or F	P Value
Medical specialty, No. (%)				1,149	39.09	<.001
Primary care	215 (33.4)	162 (42.9)	78 (60.9)
Addiction/psychiatry	353 (54.9)	171 (45.2)	36 (28.1)
Other	75 (11.7)	45 (11.9)	14 (10.9)
Practice, No. (%)				1,155	22.07	<.001
Individual medical practice	361 (55.6)	183 (48.4)	43 (33.6)
Other	288 (44.4)	195 (51.6)	85 (66.4)
Years prescribing buprenorphine, mean (SD)	7.0 (3.9)^a,^b	6.4 (3.9)	6.1 (3.7)	1,124	4.90	.008
Waiver type, No. (%)				1,174	5.50	.06
30-patient limit	296 (44.8)	143 (37.4)	57 (43.2)
100-patient limit	364 (55.2)	239 (62.6)	75 (56.8)
Payment type for office visits, No. (%)				1,141	36.61	<.001
Cash only	140 (21.9)	67 (17.9)	16 (12.4)
Private insurance but not Medicaid	170 (26.7)	88 (23.5)	14 (10.9)
Medicaid (with or without private insurance)	292 (45.8)	205 (54.8)	95 (73.6)
Other	36 (5.6)	14 (3.7)	4 (3.1)
Age, mean (SD), y	55.3 (12.1)	55.4 (10.7)	56.4 (9.4)	1,164	0.51	.60
Sex, No. (%)				1,165	2.13	.35
Male	493 (75.5)	300 (78.9)	105 (79.5)
Female	160 (24.5)	80 (21.1)	27 (20.5)
Race, No. (%)				1,148	18.70	.001
White	466 (72.0)	302 (81.0)	110 (85.9)
Asian	100 (15.5)	34 (9.1)	10 (7.8)
Other	81 (12.5)	37 (9.9)	8 (6.3)
Census division, No. (%)				1,174	81.66	<.001
New England	62 (9.4)	47 (12.3)	17 (12.9)
Middle Atlantic	143 (21.7)	37 (9.7)	15 (11.4)
East North Central	81 (12.3)	49 (12.8)	21 (15.9)
West North Central	17 (2.6)	17 (4.5)	6 (4.5)
South Atlantic	129 (19.5)	85 (22.3)	16 (12.1)
East South Central	24 (3.6)	34 (8.9)	14 (10.6)
West South Central	45 (6.8)	29 (7.6)	5 (3.8)
Mountain	31 (4.7)	44 (11.5)	11 (8.3)
Pacific	128 (19.4)	40 (10.5)	27 (20.5)

US = United States.
Note: Groups were compared using analysis of variance (F statistic) or χ² tests. Percentage may not sum to 100% due to rounding. Not all prescribers responded to all items; the N column represents the number of prescribers with valid data for each item.
↵a Significant difference with Bonferroni correction between physicians in large metropolitan areas and small metropolitan areas.
↵b Significant difference with Bonferroni correction between physicians in large metropolitan areas and nonmetropolitan areas.

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Table 2

Buprenorphine Treatment Characteristics and Practices Among Physicians Across Locations of Practice

	Large Metropolitan Area	Small Metropolitan Area	Nonmetropolitan Area	N	χ² or F	P Value
New patients, in-office induction, mean % (SD)	43.2 (41.9)	47.0 (42.2)	47.5 (41.4)	1,141	1.23	.29
New patients, at-home induction, mean % (SD)	37.1 (41.6)	35.2 (41.3)	28.3 (38.4)	1,137	2.46	.09
New patients already using street buprenorphine, mean % (SD)	19.2 (23.2)^a,^b	23.7 (24.4)	25.0 (26.2)	1,136	6.05	.002
Patients in past year with heroin use disorder, mean % (SD)	26.5 (23.5)^a,^b	20.4 (20.1)	17.9 (20.8)	1,135	13.41	<.001
Patients in past year with prescription opioid use disorder, mean % (SD)	51.9 (27.2)^a,^b	57.1 (27.0)	60.0 (27.4)	1,134	7.30	<.001
Patients in past year with both heroin and prescription opioid use disorders, mean % (SD)	22.7 (19.7)	22.1 (19.5)	24.7 (22.2)	1,133	0.82	.44
Typical frequency of office visits in initial treatment (ie, first 60 days), No. (%)				1,131
≥Every week	149 (23.4)	121 (32.9)	31 (24.8)		12.95	.012
Every 2 weeks	246 (38.6)	112 (30.4)	43 (34.4)
≤Once a month	243 (38.1)	135 (36.7)	51 (40.8)
Typical frequency of office visits in maintenance treatment (ie, after 60 days) for stable patients, No. (%)				1,127	2.32	.68
≥Every 2 weeks	93 (14.7)	65 (17.7)	18 (14.4)
Once a month	473 (74.5)	260 (70.8)	91 (72.8)
≤Every 2 months	69 (10.9)	42 (11.4)	16 (12.8)
Typical visit frequency in maintenance treatment for unstable patients (eg, continued opioid use, misusing benzodiazepines), No. (%)				1,130	5.12	.53
Every week	239 (37.6)	151 (41.0)	50 (39.7)
Every 2 weeks	258 (40.6)	136 (37.0)	41 (32.5)
≤Once a month	105 (16.5)	58 (15.8)	27 (21.4)
Patient would no longer be seen	34 (5.3)	23 (6.3)	8 (6.3)
Typical buprenorphine dose for stable patients in maintenance treatment, No. (%)				1,115	11.46	.08
≤8 mg	188 (30.0)	104 (28.7)	31 (24.6)
9-12 mg	182 (29.0)	78 (21.5)	36 (28.6)
14-16 mg	230 (36.7)	161 (44.5)	50 (39.7)
>16 mg	27 (4.3)	19 (5.2)	9 (7.1)
Maximum buprenorphine dose for stable patients in maintenance treatment, No. (%)				1,102	5.76	.45
<16 mg	78 (12.5)	35 (9.8)	19 (15.3)
16 mg	204 (32.8)	123 (34.6)	43 (34.7)
17-24 mg	263 (42.3)	156 (43.8)	43 (34.7)
>24 mg	77 (12.4)	42 (11.8)	19 (15.3)

Note: Comparisons were made using χ² tests or 1-way analysis of variance (F statistic). Not all prescribers responded to all items; the N column represents the number of prescribers with valid data for each item.
↵a Significant difference with Bonferroni correction between physicians in large metropolitan areas and small metropolitan areas.
↵b Significant difference with Bonferroni correction between physicians in large metropolitan areas and nonmetropolitan areas.

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Table 3

Psychosocial Treatment Use and Perceptions Among Buprenorphine Prescribers Across Locations of Practice

	Large Metropolitan Areas	Small Metropolitan Areas	Nonmetropolitan Areas	N	χ² or F	P Value
Patients in past year who received counseling from the respondent, mean % (SD)	53.8 (43.1)	52.6 (45.0)	54.8 (45.1)	1,119	0.14	.87
Patients in past year who received counseling from clinicians in the respondent’s practice, mean % (SD)	35.1 (40.0)^a	42.2 (41.8)	40.5 (44.2)	1,108	3.63	.03
Patients in past year who received counseling	39.0 (32.3)^b	35.9 (31.7)^c	46.9 (36.3)	1,096	5.20	.006
from clinicians outside of respondent’s practice, mean % (SD)
Patients in past year who received no psychosocial counseling, mean % (SD)	13.8 (21.1)	10.8 (19.1)	10.0 (17.0)	1,079	3.60	.03
Patients in past year referred to more intensive level of care, mean % (SD)	17.8 (20.0)	15.9 (19.8)	14.2 (15.3)	1,136	2.38	.09
Setting has resources to provide medical services for patients with complex medical problems, mean (SD)^d	3.3 (1.5)^a	3.6 (1.4)	3.6 (1.4)	1,148	3.93	.02
Setting has resources to provide psychiatric services for patients with complex psychiatric problems (eg, serious/persistent mental illness), mean (SD)^d	3.3 (1.5)^b	3.2 (1.5)	2.9 (1.4)	1,148	4.88	.008
Setting has resources to provide social services for patients with complex social problems (eg, unstable housing, criminal justice involvement, unemployment), mean (SD)^d	2.7 (1.3)	2.7 (1.3)	2.7 (1.3)	1,142	0.19	.82

Note: Comparisons were made using χ² tests or 1-way analysis of variance (F statistic). Not all prescribers responded to all items; the N column represents the number of prescribers with valid data for each item.
↵a Significant difference with Bonferroni correction between physicians in large metropolitan areas and small metropolitan areas.
↵b Significant difference with Bonferroni correction between physicians in large metropolitan areas and nonmetropolitan areas.
↵c Significant difference with Bonferroni correction between physicians in small metropolitan areas and nonmetropolitan areas.
↵d Likert scale ranging from 1 = strongly disagree to 5 = strongly agree.

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Table 4

Negative Binomial Regression Models of Location of Practice and Physician Characteristics and Association With Buprenorphine Treatment

	Model 1 Patients in Past Year With Heroin Use Disorder IRR (95% CI)	Model 2 Patients in Past Year With Prescription Opioid Use Disorder IRR (95% CI)	Model 3 Patients in Past Year Who Received Counseling From Clinicians in the Respondent’s Practice IRR (95% CI)	Model 4 Patients in Past Year Who Received No Counseling IRR (95% CI)
Rural-urban continuum
Large metropolitan area	Reference	Reference	Reference	Reference
Small metropolitan area	0.753 (0.651, 0.869)^a	1.076 (1.000, 1.158)^c	1.219 (1.021, 1.455)^c	0.732 (0.570, 0.942)^c
Nonmetropolitan area	0.641 (0.506, 0.812)^a	1.227 (1.118, 1.347)^a	1.094 (0.886, 1.351)	0.675 (0.447, 1.020)
Medical specialty
Primary care	Reference	Reference	Reference	Reference
Addiction or psychiatry	1.113 (0.965, 1.284)	0.917 (0.872, 0.966)^b	1.927 (1.591, 2.333)^a	0.383 (0.308, 0.475)^a
Other	0.804 (0.587, 1.100)	1.117 (1.000, 1.248)	1.177 (0.895, 1.548)	0.933 (0.755, 1.152)
Practice
Individual medical practice	0.879 (0.767, 1.007)	1.105 (1.020, 1.197)^c	0.486 (0.418, 0.566)^a	1.045 (0.819, 1.332)
Other	Reference	Reference	Reference	Reference
Years prescribing buprenorphine	0.989 (0.973, 1.005)	1.006 (0.998, 1.015)	0.985 (0.968, 1.003)	1.003 (0.978, 1.029)
Waiver type
30-patient limit	Reference	Reference	Reference	Reference
100-patient limit	1.206 (1.037, 1.402)^c	0.939 (0.887, 0.993)^c	1.094 (0.971, 1.232)	1.218 (0.968, 1.534)
Payment type for office visits
Cash only	Reference	Reference	Reference	Reference
Private insurance but not Medicaid	0.837 (0.682, 1.028)	1.115 (1.023, 1.215)^c	1.114 (0.799, 1.553)	0.960 (0.720, 1.279)

Medicaid (with or without private insurance)	1.246 (1.045, 1.484)^c	0.873 (0.803, 0.950)^b	1.409 (0.981, 2.024)	0.998 (0.751, 1.326)
Other	0.954 (0.696, 1.306)	0.940 (0.799, 1.104)	1.330 (0.956, 1.851)	1.394 (0.713, 2.724)
Age	0.999 (0.994, 1.004)	1.001 (0.999, 1.003)	0.998 (0.993, 1.003)	0.988 (0.977, 0.999)^c
Sex
Male	Reference	Reference	Reference	Reference
Female	1.099 (0.969, 1.246)	0.978 (0.916, 1.044)	0.992 (0.853, 1.154)	0.752 (0.556, 1.016)
Race
White	Reference	Reference	Reference	Reference
Asian	0.898 (0.767, 1.051)	1.026 (0.969, 1.087)	0.893 (0.716, 1.113)	1.119 (0.848, 1.477)
Other	1.107 (0.872, 1.406)	0.976 (0.877, 1.086)	0.770 (0.615, 0.964)c	0.894 (0.630, 1.268)
Census division
New England	Reference	Reference	Reference	Reference
Middle Atlantic	1.057 (0.796, 1.403)	1.024 (0.850, 1.233)	0.910 (0.706, 1.173)	0.937 (0.662, 1.327)
East North Central	0.943 (0.684, 1.299)	1.160 (0.910, 1.478)	1.074 (0.849, 1.359)	0.852 (0.477, 1.521)
West North Central	0.668 (0.492, 0.908)^c	1.400 (1.156, 1.695)^a	0.900 (0.694, 1.167)	0.891 (0.546, 1.452)
South Atlantic	0.683 (0.476, 0.979)^c	1.313 (1.035, 1.667)^c	1.082 (0.883, 1.326)	1.359 (0.879, 2.101)
East South Central	0.580 (0.332, 1.015)	1.429 (1.107, 1.845)^b	1.365 (0.975, 1.913)	1.057 (0.488, 2.288)
West South Central	0.592 (0.435, 0.807)^b	1.527 (1.278, 1.826)^a	1.237 (0.803, 1.904)	1.517 (1.037, 2.219)^c
Mountain	0.918 (0.633, 1.332)	1.212 (0.992, 1.482)	0.923 (0.729, 1.168)	1.050 (0.672, 1.640)
Pacific	0.993 (0.705, 1.400)	1.168 (0.963, 1.415)	0.923 (0.773, 1.102)	1.380 (0.961, 1.981)
Constant	29.374 (20.616, 41.853)	41.332 (33.698, 50.696)	30.001 (18.583, 48.433)	30.427 (12.756, 72.573)

IRR = incidence rate ratio.
Note: These models present adjusted analyses in which locations of practice remained significant after controlling for other physician characteristics (ie, variables in Table 1). Models represent the pooled estimates from 20 imputed data sets (n = 1,174). Robust standard errors were used to adjust for physician clustering within states.
↵a P = <.001 (2-tailed tests).
↵b P = <.01 (2-tailed tests).
↵c P = <.05 (2-tailed tests).

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The Article in Brief

Comparing Buprenorphine-Prescribing Physicians Across Nonmetropolitan and Metropolitan Areas in the United States

Lewei (Allison) Lin , and colleagues

Background As the United States undertakes intense efforts to increase the number of prescribers of buprenorphine for opioid use disorder, it is critical to understand who currently provides such treatment and how.

What This Study Found In nonmetropolitan areas, buprenorphine is almost twice as likely to be provided by a primary care physician, compared to large metropolitan areas where specialists in addiction or psychiatry provide a majority of treatment. In a survey of a national random sample of buprenorphine physician prescribers (N = 1,174), 11% (N = 132) practiced in nonmetropolitan/rural areas, 33% (N = 382) practiced in small metropolitan areas, and 56% (N = 660) were located in large metropolitan areas. Buprenorphine prescribers in nonmetropolitan areas were much more likely to be primary care physicians, accept Medicaid, and less likely to work in an individual practice. Overall, buprenorphine prescribers across the rural/urban continuum were similar in many of their treatment practices, including frequency of visits and dosing.

Implications

The authors recommend further research to understand variation in treatment practices and quality and how treatment relates to patient perceptions and outcomes.