# Buprenorphine Prescribing and Challenges Faced Among National Health Service Corps Clinicians

## TL;DR

The study finds that expanding the NHSC Loan Repayment Program increased buprenorphine access for opioid use disorder but highlights ongoing challenges like staffing shortages and lack of counseling.

## Contribution

Quantifies the impact of NHSC LRP expansion on buprenorphine prescribing and identifies persistent barriers in rural and nonrural areas.

## Key findings

- Buprenorphine prescriptions for Medicaid beneficiaries increased by 123,422 after NHSC LRP expansion.
- 70% of clinicians reported challenges like lack of addiction counseling and staffing shortages.
- Prescribing increased more in rural and socially vulnerable areas compared to nonrural regions.

## Abstract

What is the association between the National Health Service Corps (NHSC) Loan Repayment Program (LRP) expansion and access to medication for opioid use disorder (MOUD), and what challenges to providing MOUD may NHSC clinicians and sites continue to face?

In this cross-sectional study of Medicaid claims data for 7828 NHSC clinicians and survey data from 3297 clinicians and 4732 sites, at least 123 422 additional Medicaid beneficiaries were provided with MOUD over the first 2.5 years following the LRP expansion. However, 70% of clinicians reported a lack of addiction counseling to accompany treatment with MOUD as well as other staffing shortages.

These findings suggest that additional clinicians and training are needed to increase access to comprehensive treatment with MOUD.

This cross-sectional study examines buprenorphine prescribing to Medicaid beneficiaries and associated challenges faced by National Health Services Corps Loan Repayment Program clinicians.

The National Health Service Corps (NHSC) Loan Repayment Program (LRP) expansion in fiscal year (FY) 2019 intended to improve access to medication for opioid use disorder (MOUD) by adding more clinicians who could prescribe buprenorphine. However, some clinicians still face barriers to prescribing, which may vary between rural and nonrural areas.

To examine the growth in buprenorphine prescribing by NHSC clinicians for Medicaid beneficiaries during the NHSC LRP expansion and describe the challenges to prescribing that persist in rural and nonrural areas.

This cross-sectional study analyzed preexpansion and postexpansion Medicaid claims data to evaluate the percentage of prescriptions of buprenorphine filled during FY 2017 through 2021. This study also analyzed challenges and barriers to prescribing MOUD between rural and urban areas, using results from annual surveys conducted with NHSC clinicians and sites from FY 2019 through FY 2021.

Prescribing of buprenorphine by NHSC clinicians.

The main outcomes were the percentage and number of Medicaid beneficiaries with opioid use disorder (OUD) who filled a prescription for buprenorphine before and after the LRP expansion and the challenges NHSC clinicians and sites faced in providing substance use disorder and OUD services. Survey results were analyzed using descriptive statistics.

During FYs 2017 through 2021, 7828 NHSC clinicians prescribed buprenorphine (standard LRP: mean [SD] age, 38.1 [8.4] years and 4807 females [78.9%]; expansion LRPs: mean [SD] age, 39.4 [8.1] years and 1307 females [75.0%]). A total of 3297 NHSC clinicians and 4732 NHSC sites responded to at least 1 survey question to the 3 surveys. The overall percentage of Medicaid beneficiaries with OUD who filled a prescription for buprenorphine during the first 2.5 years post expansion increased significantly from 18.9% before to 43.7% after expansion (an increase of 123 422 beneficiaries; P < .001). The percentage more than doubled among beneficiaries living in areas with a high Social Vulnerability Index score (from 17.0% to 36.7%; an increase of 31 964) and among beneficiaries living in rural areas (from 20.8% to 55.7%; an increase of 45 523). However, 773 of 2140 clinicians (36.1%; 95% CI, 33.6%-38.6%) reported a lack of mental health services to complement medication for OUD treatment, and 290 of 1032 clinicians (28.1%; 95% CI, 24.7%-31.7%) reported that they did not prescribe buprenorphine due to a lack of supervision, mentorship, or peer consultation.

These findings suggest that although the X-waiver requirement has been removed and Substance Abuse and Mental Health Services Administration guidelines encourage all eligible clinicians to screen and offer patients with OUD buprenorphine, as permissible by state law, more trained health care workers and improved care coordination for counseling and referral services are needed to support comprehensive OUD treatment.