This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

Opioid use disorder is a serious public health problem. Management with buprenorphine is an effective, office-based, medication-assisted treatment, but 60.1% of rural counties in the United States lack a physician with a Drug Enforcement Agency waiver to prescribe buprenorphine. This national study surveyed all rural physicians who have received a waiver in the United States and found that those who were not actively prescribing buprenorphine reported significantly more barriers than those who were, regardless of whether they were treating the maximum number of patients their waiver allowed. These findings suggest the need for tailored strategies to address barriers to providing buprenorphine for opioid use disorder and to support physicians who are adding or maintaining this service. INTRODUCTIONT he opioid abuse epidemic is a serious and persistent public health problem. In 2015 an estimated 2.0 million people had a pain reliever use disorder, and 828,000 people had used heroin in the previous year.1 Buprenorphine maintenance treatment is effective for opioid use disorder, 2 and major efforts have been made to expand its availability. The Drug Addiction Treatment Act of 2000 allows physicians who complete training to obtain a Drug Enforcement Agency (DEA) waiver that permits prescribing buprenorphine to treat opioid use disorder. Despite a more than threefold increase in the number of physicians with a DEA waiver since 2006, 3 60.1% of rural counties lack a physician with a waiver. 4 Access to treatment continues to be a challenge for rural populations. Many physicians with a waiver are not using it to its full extent or at all. 5,6 A few studies, limited to 1 or only a few states, have looked at the barriers physicians face providing buprenorphine maintenance treatment, but none has examined nationally the differences between physician groups who are and are not actively using their waivers or accepting new patients.7-10 This study's purpose was to understand the barriers physicians with waivers face in providing buprenorphine maintenance treatment. METHODSWe surveyed all rurally located physicians in the United States on the DEA list (April 2016) who had received waivers to prescribe buprenorphine. We categorized physicians as rural using the Federal Information Processing Standards county code of the physicians' address if they had an Urban Influence Code of 3 through 12. 360nonrespondents using DEA, American Medical Association, National Provider Identifier, or Google Search result addresses until the physician's practice was found. Participants received the questionnaire at that address twice more, 2 weeks apart, followed by an abbreviated version of the questionnaire as a tear-off return postcard 1 month after follow-up began. Physicians responding to the tear-off postcard were not asked the barriers question. We telephoned nonrespondents up to 3 times, at 2-week intervals. Data collection occurred from July through November 2016.Physicians were classified into 4 categories based on whether the...

This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

Community paramedicine (CP) uses emergency medical services (EMS) providers to help rural communities increase access to primary care and public health services. This study examined goals, activities, and outcomes of 31 rural-serving CP programs through structured interviews of program leaders and document review. Common goals included managing chronic disease (90.3%); and reducing emergency department visits (83.9%), hospital admissions/readmissions (83.9%), and costs (83.9%). Target populations included the chronically ill (90.3%), post-hospital discharge patients (80.6%), and frequent EMS users (64.5%). Community paramedicine programs engaged in bi-directional referrals most often with primary care facilities (67.7%), hospitals (54.8%), and home health (38.7%). Programs provided assessment, testing, preventive care, and post-discharge services. Reported outcomes were promising, but few programs used rigorous evaluation methods. Rural-serving CP programs provided services to shift costs to less expensive settings and provide appropriate care where vulnerable patients live, but more evidence is needed that care is safe, effective, and economical.

The United States is experiencing an opioid use disorder epidemic. The Comprehensive Addiction and Recovery Act allows nurse practitioners (NPs) and physician assistants (PAs) to obtain a Drug Enforcement Administration waiver to prescribe medication-assisted treatment (MAT) for opioid use disorder. This study projected the potential increase in MAT availability provided by NPs and PAs for rural patients. Using workforce and survey data, and state scope of practice regulations, the number of treatment slots that could be provided by NPs and PAs was estimated for rural areas. NPs and PAs are projected to increase the number of rural patients treated with buprenorphine by 10,777 (15.2%). Census Divisions varied substantially in the number of projected new treatment slots per 10,000 population (0.8-10.6). The New England and East South Central Census Divisions are projected to have the largest population-adjusted increase. NPs and PAs have considerable potential to reduce substantial MAT access disparities.