Different forms of stigma and rural primary care professionals’ willingness to prescribe buprenorphine

Abstract

Introduction:

Buprenorphine and other medications for opioid use disorder (MOUD) are highly effective but substantially under prescribed in the rural United States. Among the most cited barriers to buprenorphine prescribing is stigma, yet little progress has been made in developing successful strategies to reduce stigma and increase access to life-saving medication. One of the key challenges to developing successful implementation strategies is understanding the different types of stigma that limit implementation.

Methods:

This study draws from qualitative interviews with 23 primary care professionals (PCPs) in rural Ohio. We conducted semi-structured interviews focused on prior experiences with buprenorphine, willingness to prescribe it, prior buprenorphine training, and barriers to prescribing. Thematic analysis resulted in 3 forms of stigma that must be addressed to improve implementation.

Results:

PCPs discussed 3 key forms of stigma that limit buprenorphine prescribing in rural areas: 1) stigma towards patients—PCPs feared being harmed by patients with opioid use disorder (OUD) if they began prescribing buprenorphine; 2) stigma towards providers—PCPs believed their clinics would be stigmatized if they began treating addiction; and 3) stigma towards buprenorphine—PCPs worried they might unintentionally harm patients through prescribing a partial opioid agonist.

Conclusions:

Stigma remains a critical barrier to buprenorphine prescribing among rural PCPs but is not limited to negative attitudes towards people with OUD. Buprenorphine is also stigmatized and PCPs fear becoming stigmatized if they prescribe the medication. Implementation research is urgently needed to test whether multicomponent stigma-reduction strategies increase access to buprenorphine in rural communities.

1. Introduction

Medications for opioid use disorder (MOUD) are highly effective for reducing mortality and infectious disease transmission (Larochelle et al., 2018; McNamara et al., 2021), but despite their known efficacy, they are substantially under-prescribed (Mauro et al., 2022). Access is particularly limited in rural areas of the US, creating a significant implementation challenge (Andrilla et al., 2019; Andrilla and Patterson, 2022). Among MOUD, buprenorphine has the potential to expand access to addiction treatment in rural areas because it is available in outpatient primary care settings, which are critical in areas where specialists are limited. Yet, more than half of rural counties do not have a single buprenorphine prescriber and buprenorphine prescribing is also less common in rural hospitals (Franz et al., 2023), in rural federally qualified health centers (Jones, 2018), and in specialty opioid treatment programs (Edmond et al., 2015).

Though efforts to expand buprenorphine access have focused heavily on structural barriers to prescribing, early studies on the weakening and ultimate removal of the X-waiver suggest that de-regulation has not substantially increased access to the medication (Ali et al., 2023; ASPE, 2022; Chua et al., 2024; Roy et al., 2024; Spetz et al., 2022). Likely numerous other barriers to prescribing buprenorphine exist in rural primary care above and beyond regulation, including inadequate training of primary care providers (PCPs) (Fenstemaker et al., 2024; Lai et al., 2022) and limited organizational support (Andrilla et al., 2017; Hutchinson et al., 2014; Jacobson et al., 2020). Among the most commonly cited barriers to buprenorphine prescribing is stigma, including stigma towards people with OUD (Cheetham et al., 2022; Crapanzano et al., 2019; Judd et al., 2023; Tsai et al., 2019) and stigma towards MOUD (Allen et al., 2019; Madden et al., 2021, 2022). To design successful implementation strategies to address stigma and increase buprenorphine prescribing, identifying the different types of stigma that matter for implementation in rural primary care is critical.

Stigma has been defined as an ‘attribute that is deeply discrediting’ (Goffman 1963, p. 3). Indeed, much of the literature on stigma in the context of substance use disorders has focused on the individual patient who is discredited (Muncan et al., 2020; Paquette et al., 2018; Perry et al., 2020). But stigma has also been documented towards buprenorphine and other MOUD. These medications have themselves become discredited by health care professionals, judicial officials, and patients, because they are lumped together with other opioids that have caused tremendous harm (Dickson-Gomez et al., 2022; Madden et al., 2021; Olsen and Sharfstein, 2014; Wakeman and Rich, 2017). But whether primary care professionals (PCPs) do not prescribe buprenorphine because of stigma towards people with OUD, the medications, or both is unclear. Further, we must understand whether unique forms of stigma towards people with OUD or buprenorphine exist within the rural context and whether stigma is exacerbated by PCP experiences within heavily affected rural communities.

The aim of this study is to outline the different forms of stigma that limit buprenorphine prescribing among rural primary care providers. Understanding the type of stigma that limits buprenorphine prescribing in rural communities is integral to implementation efforts. For example, many stigma reduction strategies focus on improving attitudes towards individual patients, such as through facilitating positive contact (Bakos-Block et al., 2022; Mort et al., 2021) and improving empathy (Kahriman et al., 2016; Moudatsou et al., 2020). But if stigma towards the medications is more prominent, new implementation strategies are needed to address concerns about the medications being an appropriate treatment for OUD. Given the unique impact of opioid prescribing in rural communities, and the acute need for buprenorphine in these areas, stigma-reduction strategies are urgently needed to increase access to this highly effective medication.

2. Methods

2.1. Study population and data collection

This study draws from interview data with 23 PCPs in rural Ohio (Table 1). Two authors, BF and CF, conducted in-depth, semi-structured interviews as part of a broader clinic trial planning study to develop a brief, online training to increase buprenorphine prescribing for the treatment of OUD in rural Federally Qualified Health Centers (FQHCs) in Ohio. We asked participants about prior experiences with buprenorphine for the treatment of addiction only and not chronic pain. We also asked participants about their willingness to prescribe, prior buprenorphine training, and barriers to prescribing.

Table 1.

Characteristics of interview participants and clinics (N = 23).

Participant characteristic	N (%)
Sex, female	14 (60.9)
Credential
Physician	14 (60.9)
Physician assistant	4 (17.4)
Nurse practitioner	5 (21.7)
Buprenorphine prescriber	12 (52.2)
Clinic characteristic
Rural or partially rural	19 (82.6)
FQHC	15 (65.2)

Study participants included physicians, nurse practitioners (NPs), and physician associates (PAs) who practice in rural or partially rural Ohio counties, as defined by the Ohio Department of Health (Ohio Department of Health, 2020), or who hold leadership positions for rural primary care systems. Participants had no formal relationships with the study team prior to the study and were recruited with the help of the Clinical and Translational Research Unit at Ohio University. After interviewing initial participants, we recruited additional participants using a snowball sampling approach (Goodman, 1961). Specifically, we asked each participant to provide the names and email addresses of additional rural PCPs. All participants were invited to participate via email. We also engaged in theoretical sampling (Glaser and Strauss, 2017) to increase the diversity of our sample. One team member tracked participant characteristics, including practice type, county, training credentials, gender, and race, throughout the recruitment process. Using this information, we identified gaps in representation and recruited additional participants accordingly.

Two study members conducted interviews between December 2022 and March 2023 by using a standardized interview guide. Interviews lasted between 30 and 60 min, were conducted virtually, and were audio-recorded. Interviews continued until we reached theoretical saturation, when the emerging categories were thoroughly fleshed out by the data collected. Interviews were conducted via Zoom and all participants gave verbal informed consent prior to beginning the interview. We received approval from the institutional review board at Ohio University. All other universities agreed to cede review to the primary research site’s IRB. Participants were compensated with $30 Amazon gift cards.

2.2. Analytic approach

The study professionally transcribed interviews were and uploaded them to the qualitative analysis software, Dedoose (Dedoose, 2021). An initial codebook was developed using a modified grounded theory, inductive approach. Four team members coded transcripts, with at least two team members coding each transcript. The team met biweekly to review the codebook, merge codes, and resolve any inconsistencies in coding. To further explore the codes related to stigma, one team member flagged relevant codes for further review and sorting. Following the three-stage coding process outlined in grounded theory methodology (Charmaz, 2014), the full study team engaged in a final iterative process in which they wrote detailed memos for relevant codes and continuously refined through ongoing meetings and collaborative writing to reach a final set of themes related to stigma as a barrier to buprenorphine prescribing.

3. Results

3.1. Sample demographics

Twenty-three PCPs participated in this study. Of these participants, roughly 22 % (n = 5) were NPs, 61 % (n = 14) were physicians, and 17 % (n = 4) were PAs. Approximately 61 % of participants (n = 14) identified as female and 39 % identified as male. The majority of participants (57 %, n = 13) were PCPs working full-time in clinical positions in family medicine. A small number of participants (9 %, n = 2) were physicians working full-time in addiction medicine. One participant worked fulltime in clinical leadership at a state-wide health system, three participants worked full-time in clinical leadership at the clinic level, one participant worked full-time in academic leadership for a PA program, and two participants worked in leadership for a family medicine residency program. Slightly more than half of participants (52 %, n = 12) prescribed buprenorphine at the time of the study. The vast majority of participants were located in a rural area (83 % n = 19). The remaining participants worked in clinical leadership at health systems and clinics that served rural areas. Nearly two-thirds of participants (63 %, n = 15) practiced in federally qualified health centers (FQHCs). Participants came from all five regions of Ohio, with 56.5 % (n = 13) in the southeast region, 21.7 % (n = 5) in the central region, 13 % (n = 3) in the northwest region, 4.3 % (n = 1) in the northeast region, and 4.3 % (n = 1) in the southwest region.

3.2. Thematic results

PCPs described 3 unique forms of stigma that limited buprenorphine prescribing (Fig. 1): 1) stigma towards patients—PCPs feared being harmed by patients with opioid use disorder (OUD) if they began prescribing buprenorphine; 2) stigma towards providers—PCPs believed their clinics would be stigmatized if they began treating addiction; and 3) stigma towards buprenorphine—PCPs were opposed to opioid prescribing in general and worried they might unintentionally harm patients through prescribing buprenorphine because it is a partial opioid agonist. Participants who currently prescribe buprenorphine described efforts to overcome stigma within their organizations to increase comfort with the medication. PCPs who have not yet prescribed, described stigma-related concerns as a remaining barrier.

Fig. 1.

Thematic structure of different types of stigma affecting buprenorphine implementation.

3.2.1. Stigma towards patients limits willingness to prescribe buprenorphine

3.2.1.1. People with OUD will put PCPs in danger.

When considering whether to expand their practice to include buprenorphine prescribing for OUD, PCPs who did not currently prescribe buprenorphine expressed concerns that this patient population was dangerous and could threaten the safety of health care professionals and clinic staff. In some cases, these concerns were rooted in negative experiences they had personally lived through or had heard about during the years of high opioid prescribing. For example, one physician described being threatened by a patient:

Burnout is absolutely real, and we all get frustrated, and I think most of us, in the rural setting, have been threatened by people like this too. I have had to get a restraining order for a patient in the past, that’s threatened me, because I wouldn’t prescribe medication for them.

(#8, family medicine physician, non-prescriber)

The same physician shared that a local physician was killed for not prescribing pain medication and suggested that most providers in the rural setting would have heard similar stories.

Well, we had a physician just across the border in Indiana, that actually got shot and killed. He wouldn’t prescribe pain medication, and so the patient went out and got his gun and came in and killed him and another person in the clinic. And the physician was a relative, our practice manager was a brother. It hits home. So yeah, there’s a lot of stigma, but there’s a lot of where people are scared too, to get too involved in those situations.

(#8, family medicine physician, non-prescriber)

A PA shared similar concerns about safety if they were to start prescribing buprenorphine:

I think if I were to talk to my husband, for example, and say, “I think I’m going to start prescribing Suboxone,” I think he would be like, “No, I don’t want people showing up to our doorstep asking for it.” I think there’s that connotation behind it still. And so, I think that there’s still a lot of growth that needs to happen even personally with it, because that would still be a hesitation for me.

(#20, family medicine PA, non-prescriber)

Other PCPs felt safer knowing they worked in clinical spaces that did not contain controlled substances. For example, one NP explained: “I don’t think it would be safe to have buprenorphine on hand at our clinic just because of the nature of our clients. I think that would just create, if people knew that was there, it’s just not really a secure area”

(#1, family NP, non-prescriber)

Among PCPs who did prescribe buprenorphine, there was an acknowledgement that stigma towards patients remained a barrier to prescribing. One physician described the work they have done at their own clinic to address concerns about safety and expanding the treatments offered for OUD: “We did a lot of education about these people already being in our building. There’s also always a concern with staff safety. So, we had to do a lot of stigma training. We actually hired a public relations firm to help us with our community, as well as with our staff”

(#10, family physician in clinical leadership role, buprenorphine prescriber)

Current prescribers described the need to address stigma, particularly the belief that patients with OUD are unsafe that developed from witnessing or hearing about challenges with patients when prescription opioids fueled the opioid epidemic.

3.2.2. Treating people with OUD will stigmatize the providers and negatively impact clinics

3.2.2.1. Prescribing buprenorphine will change the character of waiting rooms.

Among PCPs that had yet to prescribe buprenorphine, there was a common concern that opening their practice to patients with OUD would bring unwanted patients into the practice and potentially upset other patients waiting for appointments. One physician who does not prescribe buprenorphine recollected a clear warning they received not to begin prescribing from another provider:

“He kept saying over and over again, “This will change the character of your waiting rooms””

(#18, family medicine physician working in clinical leadership, non-prescriber)

PCPs that had prescribed buprenorphine described the challenges of getting staff and other providers on board with prescribing due to similar concerns. As one physician explained, these worries created a need for training to get both providers and staff on board:

“Yeah. I would say it’s taken a lot of time and culture shifts. It’s not something that was easily received overnight. There was stigma amongst the staff. It was, “We don’t want these people in our building””

(#10, family physician in clinical leadership role, buprenorphine prescriber)

An NP shared similar challenges with expanding the practice to include OUD treatment with buprenorphine:

“No one wants them in their waiting rooms, and it can be challenging”

(#15, family NP, buprenorphine prescriber)

3.2.2.2. Primary care practices will be overrun by people in need of buprenorphine.

Among the most significant concerns was that once a PCP started prescribing buprenorphine, word would spread quickly in heavily affected rural communities, and their practice would quickly be overrun by patients seeking buprenorphine. One physician prescriber recalled the frequent phone calls at the height of prescription opioid prescribing and described the concerns that had to be overcome in order to begin prescribing buprenorphine:

We must have had phone calls for months…because we were prescribing opioids, so we had all kinds of calls for new patients who wanted to come in. In fact, we’ve had the nice folks from the FDA [U. S. Food and Drug Administration] and the DEA [Drug Enforcement Administration] and the State of Ohio out before to say, ‘Oh, by the way, just so you know, your percentages are really high…Well, let me tell you where I work and what I do.’ I said…but our biggest concern was if we started doing the Suboxone, then are we going to get an influx of other people’s folks who didn’t want to do it for them?

(#6, family medicine physician, buprenorphine prescriber)

Another physician prescriber reported hearing similar concerns:

“I know that the other physician who has [buprenorphine] training…received comments like, ‘Well, once you start, then that population’s going to come trickling in, and then our clinic is going to be all that.’”

(#19, family medicine physician, buprenorphine prescriber)

Similarly, PCPs who had not begun prescribing buprenorphine expressed concerns that there was so much need in rural areas that prescribing buprenorphine would change their patient panel entirely and leave no room for primary care:

I think a lot of people were very hesitant to do the Suboxone training because, oh my gosh, then I’m going to have to prescribe it, and I’m going to see all these people, and I don’t have time, I don’t have the capabilities, I don’t have the infrastructure to take on a whole new patient panel

(#8, family medicine physician, non-prescriber)

3.2.2.3. PCPs and clinics will be stigmatized for providing buprenorphine.

In addition to changing the nature of rural primary care practice, some participants who prescribed buprenorphine acknowledged that stigma towards clinics that offer buprenorphine is a reality that must be accepted. As one rural addiction medicine physician explained, patients often spread the word about where they are receiving medication and primarily view the provider and clinic as only a place to receive medication for OUD:

“when you talk about doctors that do addiction medicine, mostly nowadays has evolved to opioid use disorder and buprenorphine and Suboxone…he’s a ‘sub doctor.’ And that creates a stigma, a perception that these doctors, that’s all they do”

(#4, addiction medicine physician, buprenorphine prescriber)

A different physician described efforts to keep their primary care clinic from being seen as only a substance use disorder clinic:

Due to our desire to provide medication-assisted treatment services to our community we have been pigeonholed into the community seeing us as the clinic that ONLY provides medication-assisted treatment services, and we constantly strive to let the community know we offer many more services

(#13, family physician working in clinical leadership, buprenorphine prescriber)

Thus, in addition to stigma directed towards people with OUD, PCPs expressed stigma that their clinics have received for offering buprenorphine and the need to address these concerns among PCPs considering prescribing in rural primary care.

3.2.3. Buprenorphine is stigmatized because of similarity to other prescription opioids that fueled a prescription opioid epidemic in rural communities

3.2.3.1. For-profit clinics contribute to negative attitudes towards buprenorphine.

Some participants felt that for-profit buprenorphine clinics which had popped up in their communities were just newer versions of pill mills. For example, one NP who practices in a community heavily affected by opioid overdoses explained that because these clinics only provide “minimum care,” they are not respected and undermine the legitimacy of buprenorphine. Another NP added:

I definitely still think there’s a stigmatism to it…I think Suboxone set itself up for that by doing these freestanding clinics where you came in and paid cash instead of treating it like a treatment like you would any other disease process. I think there’s still a lot of stigma around it for sure. I don’t know how to fix that, to be honest

(#22, family NP, non-prescriber)

Even current buprenorphine prescribers acknowledged the challenge of increasing support for buprenorphine prescribing in rural areas when these for-profit clinics were commonplace:

Everybody knows that that is, you pay your 200 bucks and you’re going to get a script, and there’s not going to be anything added to that. And again, it’s a little bit of a cash grab. People aren’t ignorant to that because they went through it with the pain clinics, the pill mills, if you will. People have circumvented that pill mill into something else. And for every one of those that’s doing that, there are some solid treatment facilities that are really trying to do whatever they can to help a population that, without them, [I] have no idea where we would be, to be honest

(#15, family NP, buprenorphine prescriber)

3.2.3.2. Lack of trust in the FDA and pharmaceutical companies that manufacture buprenorphine.

Among non-prescribers, one of the most pressing concerns regarding buprenorphine is whether safety data can be trusted given the potential economic motives of pharmaceutical companies. Many participants recalled the unethical practices of pharmaceutical companies who pressured health care professionals to prescribe opioids for chronic pain and falsely claimed that the medications were not habit-forming; this history contributed to hesitancy around prescribing buprenorphine. For one rural NP, it was difficult to know whether this drug could be trusted since pharmaceutical companies were profiting from it:

I guess my big issue is I really don’t trust the FDA and I don’t trust pharmaceutical companies anymore. I worry that they’re doing exactly what they did last time that got us to where we are and who has the time to go back to those original research studies that say buprenorphine really works and are they legit? And so, I do worry that they’re just replacing one opiate with another. But I also think it’s still better than people being on the street. So, I have a real quandary because I don’t trust the regulators at this point.

(#1, family NP, non-prescriber)

The same NP stated that she has interacted with patients who wanted to discontinue buprenorphine but have not been able to which has further contributed to concerns that pharmaceutical companies just want to get patients hooked on the medication:

“what they’re telling us from the pharmaceutical perspective is, ‘Oh, it’s probably for life.’ And I’ve had so many patients come to me and say, ‘I want off of this, but I can’t get off of it.’ And then they’re stuck taking it”

(#1, family NP, non-prescriber)

A physician leader of a rural primary care clinic expressed skepticism about buprenorphine and mentioned his discomfort with the way that the x-waiver training approached the medication:

“the training, at least with the DATA waiver, is really do not focus on discontinuation, which is, I think, where the big pharma part comes into that. They’re trying to say something very different, which is don’t focus on this…question the motives of people who come in and say, “I’ve got to get off of this”, “if they’re otherwise doing well”.”

(#18, family physician working in clinical leadership, non-prescriber)

The same provider shared that his organization had been influenced by these concerns and had ultimately enacted a ban on buprenorphine prescribing altogether. “A physician got the ear of our chief medical officer and said: ‘this is all just big pharma. It’s a lot of risks, and they have co-opted, even the federal government, to selling something that’s dangerous and comes with lots of risk and that sort of thing.’”

These participants shared concerns that pharmaceutical companies are pushing long term use of buprenorphine in order to increase profits and questioned whether they could trust data indicating the safety of the medication. Viewed from within the history of the predatory pharmaceutical practices during the opioid epidemic, the encouragement non-prescribers have received to prescribe buprenorphine and continue the medication indefinitely, only reinforced their concerns about the medication.

3.2.3.3. As a result of the opioid epidemic, PCPs avoid prescribing opioids at all costs.

Many rural PCPs expressed concerns about the dangers of opioid medications when used long-term to treat pain and vowed to avoid prescribing opioids altogether which technically includes buprenorphine, a partial opioid agonist. These PCPs often lived through the height of prescription opioid prescribing and the subsequent reversal and monitoring of opioid prescribing or were mentored by individuals who did. One PA practicing in a rural area recalled their physician mentor’s approach to controlled substance prescribing and admitted that it affected their own views towards buprenorphine:

He would never, ever, ever on his dying bed prescribe [buprenorphine]…he saw this opioid epidemic explode in his face. And for him, from the get-go before this even started, he said, ‘We are not the office that does chronic pain meds. We’re not going to do benzodiazepines. We’re not going to do these controlled substances…’ So he was not wanting me to even go after that [X-waiver] license.

(#20, family medicine PA, non-prescriber)

A younger physician who oversees a rural family medicine residency described the cognitive dissonance of being told that opioids were bad and knowing that buprenorphine is also an opioid:

Well and so newer docs…don’t prescribe opioids. We went from, ‘Everybody gets them’ to, ‘You better have a great reason.’ So now the pendulum has swung all the way and now we just need to come back just a little bit so we can do that [prescribe buprenorphine]. Because I know there is a lot of fear…You’ll have a residency [where the preceptor says], ‘this patient has a broken leg, I’m just going to give him Tylenol.’”

(#7, family medicine residency director, non-prescriber)

A physician and public health leader in rural Ohio described how the introduction of prescription drug monitoring programs created substantial stigma around prescribing opioids and ultimately prevented a colleague from prescribing buprenorphine:

When they initially put out the report how many morphine equivalents there was for buprenorphine to morphine, he had in his mind that I’m not going to write anything more than 80 Morphine equivalent per day. And buprenorphine was way over that initially. Now they’ve walked that back, but he quit seeing this one patient of his, and I still see this guy. I’m like, Dr. [redacted], you could still do this. You could still see this guy, but he doesn’t want to take on that stigma of writing too much Morphine

(#16, Addiction medicine physician, buprenorphine prescriber)

4. Discussion

We explored different forms of stigma related to buprenorphine prescribing among rural PCPs in Ohio who do and do not prescribe buprenorphine. PCPs agreed that three key forms of stigma were critical to deciding whether to prescribe and must be addressed in future implementation work. Stigma towards people with OUD remains common, particularly concerns that people with OUD are unsafe, unpredictable, and make unreliable patients (Corrigan et al., 2009; Janulis et al., 2013; Judd et al., 2023). PCPs also described stigma towards clinics and health care professionals that treat addiction as a barrier to prescribing. Finally, the classification of buprenorphine as an opioid contributed to stigma towards the medication itself and unwillingness to prescribe it.

Importantly, PCPs suggested that these diverse forms of stigma were uniquely affected by the prescription drug epidemic in rural communities and traumatic events they have heard about or experienced. For example, the fact that PCPs had been threatened for not filling opioid prescriptions contributed to fears that all people with OUD had the potential to be violent. Although these fears were rooted in real events, the resulting stereotypes that prescribers broadly applied to an entire patient population constitute an important form of stigma (Link and Phelan, 2001). That is, though these fears have origins in experienced or retold events, they become stigmatizing when they are assumed to be true of all patients seeking OUD treatment.

In addition, aggressive marketing of prescription opioids by pharmaceutical companies during the last two decades (Van Zee, 2009) led to skepticism about buprenorphine since it also had the potential to increase profits for pharmaceutical companies. Many of the measures intended to counter the harm caused by over-prescribing of opioids for chronic pain, such as prescription drug monitoring programs (Allen et al., 2020), also contributed to stigma towards the medication which has been found among other health care professionals such as pharmacists (Cooper et al., 2020). For example, many PCPs worked for clinics that prohibited prescribing opioids altogether or were trained by mentors to limit opioid prescribing as much as possible, which includes buprenorphine. Although concerns about buprenorphine are rooted in factual information, such as the drug being a partial opioid-agonist and that pharmaceutical companies have in the past used unethical practices to increase profits, the result is that many PCPs do not trust any opioid medications.

Finally, PCPs identified a less commonly described form of stigma, the fear of stigma by association if they were to prescribe buprenorphine. Because the medication was so highly stigmatized as well as the patients who receive it, there were fears that other patients would stop seeing them for their primary care. This type of stigma may be unique to rural communities with fewer PCPs and denser social networks and may require tailored forms of stigma reduction to address these concerns. Indeed, a recent study found that stigma-reduction worked differently in urban vs. rural communities and worked less in rural communities overall (Ashworth et al., 2024).

4.1. Tailoring stigma reduction for rural PCPs

Many stigma-reduction interventions have relied on two evidence-based techniques for reducing negative attitudes towards stigmatized groups: 1) facilitating positive contact with members of the minoritized group (Christ et al., 2014) and 2) improving knowledge (Allport et al., 1954). These strategies are likely important for improving attitudes towards people with OUD and willingness to prescribe buprenorphine but must be tailored for rural PCPs.

Our results suggest that positive contact interventions are needed to counteract stereotypes about individuals with OUD and about buprenorphine prescribers. For example, one promising strategy to counteract PCP concerns may be to facilitate contact with other PCPs who have prescribed buprenorphine without serious repercussions to their practice or safety. For example, PCPs could be exposed to PCPs who describe their own comfort prescribing the medication, that they feel safe doing so, and that they have not inadvertently harmed patients through prescribing buprenorphine even though it is a partial opioid-agonist. Peer PCPs could also describe any practice changes needed to prescribe the medication and address concerns that their waiting rooms or patient panels will be negatively affected. Indeed, participants in this study described their own role in helping to reduce stigma among their peers. Contact with people who are receiving the medication without negative consequences may also help relieve concerns that the medication will lead to addiction, diversion, or other negative consequences. These are important avenues for future research to determine if facilitating contact with peer PCPs who prescribe buprenorphine, along with patients who have received the medication, improves confidence in the medication and willingness to treat addiction in rural primary care.

Educational interventions across the career course can also leverage the findings from the current study to better improve buprenorphine prescribing. Namely, educational interventions must be developed to address misinformation surrounding buprenorphine, including concerns that patients receiving the medication are easily distinguishable in waiting rooms and that the medication is dangerous (Dydyk et al., 2023). Some of the most common concerns among PCPs were related to buprenorphine being a partial opioid. Because of this classification, some rural PCPs questioned whether buprenorphine was safe to prescribe which supports other published findings on reluctance to prescribe this medication (Allen et al., 2019; Madden et al., 2021; Treloar et al., 2022; Wakeman and Rich, 2018). These concerns appear to be at least partially connected to the unethical practices that shaped prescribing behaviors during the early years of the opioid epidemic (The Role of the Sackler Family and Purdue Pharma in the Opioid Epidemic, 2020; Van Zee, 2009) and efforts to alleviate these concerns requires sensitivity to that historical context. Successful interventions will require that facilitators build trust with PCPs before encouraging the prescription of specific medications such as buprenorphine. Otherwise, educational interventions risk being reminiscent of when PCPs were targeted for increasing prescription opioid analgesic sales (The Role of the Sackler Family and Purdue Pharma in the Opioid Epidemic, 2020; GAO-04-110, 2003).

Stigma reduction among PCPs is critically needed, but participants also described stigma among organizational staff and community members that likely also needs to be addressed to support buprenorphine access in rural communities. PCPs also expressed concerns about their capacity to provide treatment given limited prescribers in rural areas. Implementation strategies that address organizational capacity and support for buprenorphine in rural primary care must be prioritized alongside stigma reduction (Ford et al., 2017; McCarty and Chandler, 2009; Ober et al., 2017).

4.2. Limitations

The conclusions from the current study are limited in at least two ways. First, participants were recruited from a single state and from within rural areas. Though there is a pressing need to understand barriers to prescribing in these contexts, it is unclear if the current findings are transferable to PCPs working in other contexts. Similarly, we did not segment by demographic information — perceptions and attitudes may fluctuate based on age, politics, training, or other characteristics. Future research is needed that explores the presence and underpinnings of stigma towards buprenorphine in larger samples and more diverse populations of PCPs. Second, given the qualitative nature of our data, we are unable to draw causal conclusions about the connection between stigma towards people with OUD and/or buprenorphine and prescribing behaviors. However, PCPs described in their own words that the forms of stigma identified served as critical barriers to their prescribing of buprenorphine. Future research should explore whether stigma reduction improves implementation of buprenorphine prescribing in rural primary care.

5. Conclusion

Stigma remains a critical barrier to buprenorphine prescribing among rural primary care professionals. Stigma is not limited to negative attitudes towards people with OUD, however; it extends to stigma towards buprenorphine and stigma towards PCPs that prescribe these medications. Further, stigma among rural PCPs was exacerbated by the strain of practicing through the prescription opioid epidemic in rural communities. Implementation research is urgently needed to determine if strategies which address each form of stigma can effectively increase access to buprenorphine in rural areas.