A systematic review of rural-specific barriers to medication treatment for opioid use disorder in the United States

Figures & data

Figure 1. Study identification flow diagram.

Table 1. Consumer-focused barriers to medication treatment (N = 15 articles).

Study	Sample	Study design	Primary outcomes	Definition of rurality	Findings
Brown et al. (40)	N = 3,892 NAS cases	-Cross-sectional and longitudinal -Quantitative	-Distance to nearest opioid treatment center -NAS births	U.S. Census Bureau	-Rural pregnant women had longer travel times and higher rates of NAS.
DeFlavio et al. (41)	N = 108 rural family physicians	-Cross-sectional -Mixed-methods	-Perceptions and barriers to providing buprenorphine treatment	Specific definition of rurality not provided	-Non-providers were less likely to view patients as motivated and satisfied with BMT; more likely to cite buprenorphine cost as a barrier.
Dick et al. (42)	N not reported (U.S. counties were the unit of analysis)	-Longitudinal -Quantitative	-County-level shortages of opioid treatment programs, waivered physicians, and overall opioid agonist treatment.	-Rural-Urban Continuum Codes	-Availability of treatment increased over time for all county types -Availability increase was smallest in small and medium non-metropolitan counties
Heil et al. (43)	N = 359 pregnant women	-Cross-sectional -Quantitative	-Prior methadone or buprenorphine treatment -Distance to clinic	-Rural setting = Burlington, VT -Urban setting = Baltimore, MD	-Rural women were less likely to live near opioid treatment, and to have had prior methadone treatment -Rural women were marginally less likely to have had prior buprenorphine treatment.
Hirchak & Murphy (44)	N = 803 zip codes in Washington, US	-Cross-sectional -Quantitative	-Number of OAT facilities and DATA-waivered physicians per 10,000 residents.	-Washington State Office of Financial Management -Rural settings were defined as < 100 people per square mile	-Rural zip codes had significantly fewer OAT clinics and marginally fewer DATA-waivered physicians.
Jones (45)	N = 363 health centers	-Cross-sectional -Quantitative	-Availability of substance use and buprenorphine treatment	Self-identified but not clearly defined	-Rural health centers were less likely to offer structured, on-site substance use disorder treatment and medication treatment with buprenorphine.
Kvamme et al. (46)	N = 427 buprenorphine-waivered physicians, n = 51 were in rural settings	-Cross-sectional -Quantitative	-Number of buprenorphine providers and provider to population ratio -Number of treatment slots, treatment slot to population ratio	Rural-Urban Commuting Area (RUCA) Codes 2.0	-Isolated rural areas have the lowest population to provider ratio. -7% of the population (all in rural counties) lived in a county without MMT or BMT -Rural areas had fewer waivered psychiatrists
McCarty et al. (47)	N = 51 rural practitioners	-Longitudinal -Mixed methods	-Intention to utilize buprenorphine at training. -Waiver status 8-months post-training.	Self-identified but not clearly defined	-Eight months after training, 10 of the 17 rural physicians had received waivers and 6 were managing patients on buprenorphine
Meyer et al. (48)	N = 149 pregnant women in rural medication treatment and N = 151 neonates	-Longitudinal -Quantitative	-Methadone treatment positions -Number of physicians able to prescribe buprenorphine. -Prenatal outcomes.	U.S. Census Bureau	-Availability of medication treatment and the number of women in treatment increased over time. -Changes were associated with treatment entry earlier in pregnancy, higher neonate birth weight, greater proportion of infants discharged home to mother and remaining in the mother’s care.
Rosenblatt et al. (49)	N = 18,225 buprenorphine-waivered physicians	-Cross-sectional -Quantitative	Presence of a waivered physician in a county, number and density of waivered-physicians.	The Urban Influence Codes (UIC)	-Rural counties adjacent to metropolitan areas, micropolitan counties, and small and remote rural counties had fewer buprenorphine-waivered physicians, and had a lower ratio of physicians to residents.
Rosenblum et al. (16)	N = 23,141 consumer patients	-Cross-sectional -Quantitative	Travel distance based on zip code centroid to treatment program; cross-state commuting; race differences in travel distance	The Beale Urbanicity Codes (3–9 = rural)	-Patients living in rural areas were more likely to travel farther distances to OTPs and cross state lines
Stein et al. (50)	N = 14,836 consumer treatment episodes	-Cross-sectional and longitudinal -Quantitative	Use of OAT and buprenorphine, office-based treatment among those receiving buprenorphine	Urban community was defined as > 1000 individuals per square mile	-Rural patients were more commonly started on drug-free treatment, and were less likely to receive OAT. -Rural consumers were more likely to receive buprenorphine, and to receive buprenorphine in office-based settings. -Greatest change over time in buprenorphine prescribing occurred for rural residents.
Stein et al. (51)	N not applicable; this study involved several units of analysis that changed over time	-Longitudinal -Quantitative	-Grams of buprenorphine dispensed -Number of 100-patient and 30-patient waivered physicians, OTP services with buprenorphine, substance abuse treatment facilities with buprenorphine per 10,000 residents.	Rural-Urban Continuum Codes (RUCC)	-The number of 100-patient waivered physicians was associated with increased amounts of buprenorphine dispensed per capita. -The increases in the number of facilities providing buprenorphine was smaller in rural counties, but the increase in the number of 100-waivered physicians was greater in rural counties.
Unger et al. (52)	N = 866 pregnant women in medication treatment	-Cross-sectional -Quantitative	-Treatment history -Type of current and last 30-day treatment	Rural sites included Providence, RI; Nashville, TN; Burlington, VT. Urban sites included Detroit, MI, Philadelphia, PA, and Baltimore, MD	-Rural women reported lower percentages of prior methadone treatment or history of any opioid agonist treatment. -More rural women reported prior buprenorphine treatment, recent buprenorphine use, and higher doses for both methadone and buprenorphine.
Wingrove et al. (53)	23,998 buprenorphine-waivered physicians	-Cross-sectional -Quantitative	-Distribution of physicians practicing in rural vs. urban areas overall and by specialty type	Rural-Urban Continuum Codes (RUCC; 4–9 were classified as rural)	−8.5% of waivered physicians practiced in rural areas. -Waivered physicians with specialties in family medicine had the highest concentration in rural settings (18.2%) -The least likely specialty to practice in rural areas was psychiatry.

Table 2. Provider-focused barriers to medication treatment (N = 7 articles).

Study	Sample	Study design	Primary outcomes	Definition of rurality	Findings
Andrilla et al. (54)	N = 1124 rural buprenorphine-waivered physicians	-Cross-sectional -Quantitative -Mail and phone questionnaire	-Buprenorphine prescribing patterns, and barriers to prescribing	-Urban Influence Codes 3–12 defined as rural	-Barriers among non-prescribers included time constraints, lack of specialty backup, lack of patient need, resistance from partners, lack of confidence, DEA concerns, and attraction of drug users
DeFlavio et al. (41)	N = 108 rural family physicians.	-Cross-sectional -Mixed-methods	-Perceptions and barriers to providing buprenorphine treatment	-Participants were recruited from less populated areas in Vermont and New Hampshire	-Provider’s lack of time, office space, and trained staff; regulations were cited as barriers. Themes included lack of knowledge/interest, mistrust. -Non-providers were: less confident in ability to prescribe buprenorphine; less likely to view buprenorphine as effective.
Hutchinson et al. (55)	N = 78 buprenorphine-waivered physicians, 31% (n = 24) rural	-Cross-sectional -Mixed-methods	-Non-prescribing patterns by urbanicity; safety net type	-Classified based on the Health Resources and Services Administration	-No significant rural/urban differences in buprenorphine prescribing -Physicians relying on rural health clinics did not differ in their prescribing patterns
Jones (45)	N = 363 health centers (unspecified number in rural settings)	-Cross-sectional -quantitative	-Interest in adding or expanding buprenorphine treatment	-Self-identified but not clearly defined	-Rural health centers were less likely to express interest in expanding buprenorphine treatment
Kvamme et al. (46)	N = 427 buprenorphine-waivered physicians, 11.9% (n = 51) were large, small, or isolated rural settings	-Cross-sectional -quantitative	-Types of buprenorphine providers	-Rural-urban commuting area (RUCA) codes 2.0 to classify practices as isolated rural, small rural, large rural, or urban	-Buprenorphine-waivered prescriptions were predominately family medicine doctors in rural areas; addiction medicine specialists and psychiatrists were less likely to practice in rural areas
McCarty et al. (47)	N = 51 rural practitioners (physicians: n = 17, 33%)	-Mixed-method	-Attitudes, beliefs, and perceptions regarding buprenorphine and intention to utilize buprenorphine	-Self-identified but not clearly defined	-Rural physician and counselor beliefs/attitudes about buprenorphine improved after training
Quest et al. (56)	N = 24 buprenorphine waivered physicians in rural Washington state	-Cross-sectional -Mixed-methods (quantitative semi-structured telephone survey)	-Prescribing status; patient volume; motivations for obtaining waiver; acceptance of/barriers to buprenorphine prescribing	-Counties classified as “nonmetropolitan” by the 2003 Urban Influence (UIC) codes classified as rural	-All physicians reported buprenorphine as efficacious for opioid addiction -Common barriers included lack of other rural providers, consultants, financial support from Medicaid, local mental health/behavioral addiction services

Table 3. Coding tabulations among the 18 included articles.

Author	Data type	Focus of barriers	Medication treatment type	Rurality definition	Census bureau region for data	Consumer-focused barrier domains	Provider-focused barrier domains	Method	Medication treatment outcomes
Andrilla et al. (54)	Primary	Providers	BUP/BUP-naloxone alone	Established scheme	National	N/A	Availability Accessibility Acceptability	Quant	No
Brown et al. (40)	Secondary	Consumers	BUP/BUP-naloxone varied with other medication tx	Established scheme	South	Accessibility	N/A	Quant	No
DeFlavio et al. (41)	Primary	Both	BUP/BUP-naloxone alone	Self-identified, limited details	Northeast	Accessibility Acceptability	Availability Accessibility Acceptability	Mixed Methods	No
Dick et al. (42)	Secondary	Consumers	BUP/BUP-naloxone varied with other medication tx	Established scheme	National	Availability	N/A	Quant	No
Heil et al. (43)	Primary	Consumers	BUP/BUP-naloxone varied with other medication tx	Self-identified, limited details	Northeast South	Accessibility	N/A	Quant	No
Hirchak & Murphy (44)	Secondary	Consumers	BUP/BUP-naloxone varied with other medication tx	Unestablished scheme with details	West	Availability	N/A	Quant	No
Hutchins et al. (55)	Primary	Providers	BUP/BUP-naloxone alone	Established scheme	West	N/A	Availability	Mixed Methods	No
Jones (45)	Secondary	Both	BUP/BUP-naloxone alone	Self-identified, limited details	National	Availability	Acceptability	Quant	No
Kvamme et al. (46)	Secondary	Both	BUP/BUP-naloxone varied with other mediation tx	Established scheme	West	Availability	Availability	Quant	No
McCarty et al. (47)	Primary	Both	BUP/BUP-naloxone alone	Self-identified, limited details	West	Availability	Acceptability	Quant	No
Meyer et al. (48)	Primary	Consumers	BUP/BUP-naloxone varied with other medication tx	Established scheme	Northeast	Availability	N/A	Quant	No
Quest et al. (56)	Primary	Providers	BUP/BUP-naloxone alone	Established scheme	West	N/A	Availability Acceptability	Mixed Methods	No
Rosenblatt et al. (49)	Secondary	Consumers	BUP/BUP-naloxone alone	Established scheme	National	Availability	N/A	Quant	No
Rosenblum et al. (16)	Primary	Consumers	BUP/BUP-naloxone varied with other medication tx	Established scheme	National	Accessibility	N/A	Quant	No
Stein et al. (50)	Secondary	Consumers	BUP/BUP-naloxone varied with other medication tx	Unestablished scheme with details	Northeast	Availability Acceptability	N/A	Quant	No
Stein et al. (51)	Secondary	Consumers	BUP/BUP-naloxone alone	Established scheme	National	Availability	N/A	Quant	No
Unger et al. (52)	Primary	Consumers	BUP/BUP-naloxone varied with other medication tx	Self-identified, limited details	Northeast Midwest South	Acceptability	N/A	Quant	No
Wingrove et al. (53)	Secondary	Consumers	BUP/BUP-naloxone alone	Established scheme	National	Availability	N/A	Quant	No

BUP = buprenorphine; other medication tx (treatment) = MMT or naltrexone (exclusively MMT in these data); quant = quantitative.

Table 4. Tabulation totals and frequencies among the 18 included articles.

Article Characteristics	Tabulation Totals and Frequencies
Data type	Primary data (n = 9, 50.0%) Secondary data (n = 9, 50.0%)
Focus of barriers	Consumer-focused barriers (n = 11, 61.1%) Both consumer- and provider-focused barriers (n = 4, 22.2%) Provider-focused barriers (n = 3, 16.7%)
Medication treatment type	BUP/BUP-naloxone treatment alone (n = 9, 50.0%) BUP/BUP-naloxone varied with other medication treatment (n = 9, 50.0%) MMT alone (n = 0, 0.0%) Naltrexone treatment alone (n = 0, 0.0%)
Rurality definition	Established scheme (n = 11, 61.1%) Self-identified, limited details (n = 5, 27.8%) Unestablished scheme with details (n = 2, 11.1%)
Census bureau region for the data	National (n = 7, 38.9%) Northeast (n = 5, 27.8%) West (n = 5, 27.8%) South (n = 3, 16.7%) Midwest (n = 1, 5.6%)
Consumer-focused barrier domains	Availability (n = 10, 55.6%) Accessibility (n = 4, 22.2%) Acceptability (n = 3, 16.7%)
Provider-focused barrier domains	Acceptability (n = 5, 27.8%) Availability (n = 4, 22.2%) Accessibility (n = 2, 11.1%)
Method	Quantitative methods alone (n = 15, 83.3%) Mixed methods (n = 3, 16.7%) Qualitative methods alone (n = 0, 0.0%)
Medication treatment outcomes	No medication treatment outcomes (n = 18, 100.0%)

Coding and tabulations displayed in Table 3. BUP = buprenorphine; other medication treatment = methadone maintenance (MMT) or naltrexone (exclusively MMT in these data). Some articles examined data in multiple census bureau regions (60).

Table 5. Barrier domains focused on consumers and providers.

	% (n)	Most common barrier type	Other barriers
Consumer-Focused Barrier Domains (N = 15 articles)
Availability	66.7 (10)	Rural areas consistently more likely (than urban) to lack available medication treatment clinics and waivered practitioners	Rural areas less likely to have concurrent psychosocial services for consumers in medication treatment
Accessibility	26.7 (4)	Rural consumers more likely than urban to have travel hardships (further distance, longer travel, cross-state commute)	Rural providers perceived their rural consumers would view medication treatment as a cost burden
Acceptability	20.0 (3)	Rural consumers offered medication treatment less than urban, perhaps due to concerns treatment wouldn’t work well for rural consumers	Rural providers perceived their rural consumers would view medication treatment for OUD as unsatisfactory
Provider-Focused Barrier Domains (N = 7 articles)
Availability	71.4 (5)	Rural providers cited limited capacity and infrastructure, e.g., lack of staff, specialty backup, and office space	Lack of coordination, i.e., non-family medicine rural clinics less likely to provide BMT
Accessibility	28.6 (2)	A lack of time for rural providers to deliver medication treatment	No other findings
Acceptability	71.4 (5)	Negative provider attitudes: a lack of belief in medication treatment, too complex, view people with SUDs as mistrustful and unmotivated	Regulatory concerns if providing treatment, e.g., audit issues or inability to meet DEA regulations

Tabulation frequencies presented are calculated relative to the 15 consumer-focused articles and 7 provider-focused articles in this review.

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