Opioid use disorder treatment in rural settings: The primary care perspective.

Valerie S Harder, University of Vermont, Center on Rural Addiction
Andrea C Villanti, University of Vermont, Center on Rural Addiction
Sarah H Heil, University of Vermont, Center on Rural Addiction
Mary Lindsey Smith, University of Southern Maine
Diann E Gaalema, University of Vermont, Center on Rural Addiction
Marjorie C Meyer, University of Vermont, Center on Rural Addiction
Nathaniel H Schafrick, University of Vermont, Center on Rural Addiction
Stacey C Sigmon, University of Vermont, Center on Rural Addiction

This project was supported by the Health Resources and Services Administration (HRSA) (grant number UD9RH33633) from the U.S. Department of Health and Human Services (HHS). DG and SS were also supported in part by National Institute of General Medical Sciences (NIGMS; grant number P20 GM103644). SH was also supported in part by the National Institute on Drug Abuse (NIDA; grant numbers R01 DA036670, R01 DA047867). SS was also supported in part by NIDA (R01 DA042790) and the Laura and John Arnold Foundation. The study sponsors had no involvement in the study design; collection, analysis and interpretation of data; the writing of the manuscript; or the decision to submit the manuscript for publication. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, HRSA, HHS or the U.S. Government.


Despite the efficacy of medications for treating opioid use disorder (OUD), they are underutilized, especially in rural areas. Our objectives were to determine the association between primary care practitioners (PCPs) rurality and concerns for patient substance use, and to identify factors associated with PCP comfort treating OUD, focusing on barriers to treatment. We developed a web-based survey completed by 116 adult-serving PCPs located in Vermont's rural and non-rural counties between April-August 2020. The instrument included PCP-identified concerns for substance use among patients, barriers to treating patients with OUD, and current level of comfort treating patients with OUD. On a scale from 0 to 10, rural PCPs reported higher concern for heroin (mean difference; Mdiff = 1.38, 95% CI: 0.13 to 2.63), fentanyl (Mdiff = 1.52, 95% CI: 0.29 to 2.74), and methamphetamine (Mdiff = 1.61, 95% CI: 0.33 to 2.90) use among patients compared to non-rural PCPs, and practitioners in both settings expressed high concern regarding their patients' use of tobacco (7.6 out of 10) and alcohol (7.0 out of 10). There was no difference in reported comfort in treating patients with OUD among rural vs. non-rural PCPs (Mdiff = 0.65, 95%CI: 0.17 to 1.46; P = 0.119), controlling for higher comfort among male PCPs and those waivered to prescribe buprenorphine (Ps < 0.05). Lack of training/experience and medication diversion were PCP-identified barriers associated with less comfort treating OUD patients, while time constraints was associated with more comfort (Ps < 0.05). Taken together, these data highlight important areas for dissemination of evidence-based training, support, and resources to expand OUD treatment capacity in rural communities.