Brief Prescribing Support and Buprenorphine Adoption in Rural Primary Care: A Cluster Randomized Clinical Trial

Although buprenorphine is highly effective at preventing overdose, access is limited in rural areas. Rural primary care is a critical site to expand access; prescribing support tailored for this setting is urgently needed.

To test the feasibility and preliminary effectiveness of a brief buprenorphine prescribing support program (BPSP) tailored for rural primary care professionals (PCPs).

This cluster randomized pilot clinical trial compared 27 Ohio community health centers with 63 PCPs (10 physicians, 50 nurse practitioners, and 3 physician assistants) receiving the support program at baseline and immediately after the intervention with those receiving only copies of the American Society of Addiction Medicine's buprenorphine prescribing guidelines. Data were collected from July 25, 2024, to February 28, 2025.

The BPSP is a brief, hour-long, asynchronous and online training program, followed by an optional, live booster session, that provides clinical skills on buprenorphine prescribing, addresses misinformation on the safety of buprenorphine, and addresses stigma toward buprenorphine. Health centers were randomized with 2 centers allocated to the intervention for every 1 allocated to the control condition.

Primary implementation outcomes were feasibility (measured via the 4-item Feasibility of Intervention Measure [scale of 1 to 5, with higher scores indicating greater feasibility]), acceptability (measured via the 4-item Acceptability of Intervention Measure [scale of 1 to 5, with lhigher scores indicating greater acceptability]), and appropriateness (measured via the 4-item Intervention Appropriateness Measure [scale of 1 to 5, with higher scores indicating greater appropriateness]) of the BPSP; willingness to treat opioid use disorder (OUD) in primary care (using a measure developed and tested with a different sample of PCPs); and likelihood of prescribing buprenorphine in the next 6 months (measured via a 5-point Likert scale ranging from 1.00 [extremely unlikely] to 5.00 [extremely likely]).

Of the 63 participating PCPs, 48 participants were allocated to the intervention condition and 15 to the control condition (49 female [78%]; mean [SD] age, 45.5 [11.4] years). Forty-nine participants (78%) practiced in rural areas and 10 (16%) had ever prescribed buprenorphine. Participants receiving the BPSP rated it as highly feasible (median score, 4.25 [IQR, 4.00-5.00]), acceptable (median score, 4.88 of 5.00 [IQR, 4.00-5.00]), and appropriate (median score, 5.00 of 5.00 [IQR, 4.00-5.00]). Participants receiving the BPSP had significantly higher willingness to treat OUD; 86% of rank comparisons improved post intervention. Intention to prescribe buprenorphine in the next 6 months also significantly increased; 98% of rank comparisons improved post intervention. Participants who completed the BPSP showed significant improvements in having correct information about buprenorphine, had greater confidence treating addiction and prescribing buprenorphine, and had lower stigma and greater empathy toward patients with OUD.

In this cluster randomized clinical trial of the BPSF, brief prescribing support was feasible, acceptable, and appropriate for implementation in rural primary care, and intentions to prescribe buprenorphine increased. A larger trial is needed to confirm preliminary findings.

ClinicalTrials.gov Identifier: NCT05505227.