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Barriers to MOUD in Rural Areas

While some rural communities have built extensive capacity to treat opioid use disorder (OUD) in response to the opioid crisis, some face barriers to accessing OUD treatment. Barriers include a lack of treatment facilities that offer medication for opioid use disorder (MOUD) or other treatment options, requiring patients to travel farther to access care. According to the Pew Charitable Trusts, almost 90% of rural communities lack the number of opioid treatment programs needed to meet demand, and approximately 30% of rural Americans live in counties without any buprenorphine providers. For comparison, only 2% of urban Americans live in counties without any buprenorphine providers.

Transportation

Many rural patients with OUD will have to travel outside their community to access MOUD due to the limited treatment options available in most rural communities. Many rural residents seeking MOUD face transportation barriers, including lack of a driver's license, lack of access to a car, and lack of public transportation in the community. Additionally, transportation time and costs have been shown to be barriers to care. Patients may need to rely on friends or family to take them to appointments if they do not have a license or other means of transportation. These transportation barriers can jeopardize follow-up visits and adherence to treatment. To reduce this burden, providers can consider prescribing medication that can be administered unsupervised at home and can consider telehealth options to prescribe medication, communicate with patients, and counsel patients virtually.

Provider Knowledge, Attitudes, and Beliefs

In many rural communities, primary care providers serve large geographic areas and double as mental health and substance use disorder treatment providers to address a shortage of specialty care. Yet, very few rural primary care providers have obtained waivers to prescribe medication for the treatment of OUD. A provider's willingness to become waivered and provide MOUD may be influenced by other unique rural barriers, including:

  • Time constraints
  • Financial and reimbursement concerns
  • Resistance from practice partner(s)
  • Limited availability of specialty care providers
  • Lack of mental and behavioral health support services
  • Lack of confidence in clinical skills to manage OUD
  • Perceived lack of need for MOUD services

Many providers express a lack of confidence in their knowledge of substance use disorders and their ability to treat patients with OUD. Very few medical schools require coursework or competencies treating substance use disorders. Even with a basic understanding of substance use treatment, providers may not have the expertise needed to treat more complex patients. To overcome this barrier, providers may refer patients to local opioid treatment programs, where available, or use telehealth to connect patients with specialists or other MOUD supports.

Prescribing Limits

Once a provider has a waiver to prescribe buprenorphine for the treatment of OUD, there are additional limitations on the licensed provider's ability to prescribe medication. The regulations have changed over time and provide a limit on the number of patients a single provider can treat with MOUD at any one time. After the first year, a licensed provider can become eligible to increase the patient limit. More information on waivers and prescribing limits is included in Module 4.

Stigma

Stigma can be a significant barrier to seeking treatment for OUD. Patients may decide not to seek treatment out of fear of losing their job or jeopardizing relationships with friends and family. Providers and local organizations can be important advocates for reducing stigma by discussing substance use disorders as chronic brain diseases, sharing the evidence that supports using medication for treatment, and building awareness, knowledge, and support for MOUD programs in their local communities. Additional information and program considerations for addressing stigma is available in Module 4.

Technology

Technology can improve access and quality of MOUD programs, and it can also present unique challenges for rural communities. Both patients and providers may lack the technology infrastructure needed to use health information technology (HIT) systems or telehealth, such as limited internet access and availability of devices like laptops or cell phones. Adopting new technologies requires significant financial investment that can be a barrier for many rural patients and practices. For more information, see the Rural Telehealth Toolkit.

Resources to Learn More

Medications for Opioid Use Disorder Improve Patient Outcomes
Document
Provides an overview of opioid use disorder (OUD) and discusses FDA-approved medications for treating OUD and their effectiveness. Emphasizes the importance of psychosocial treatment and discusses barriers to accessing treatment.
Organization(s): The Pew Charitable Trusts
Date: 12/2020