Abstract
Background: Buprenorphine is a partial µ-opioid agonist approved by the Food and Drug Administration (FDA) for the treatment of chronic pain and opioid use disorder (OUD). Despite its favorable safety profile compared with other opioids and the 2022 US Department of Veterans Affairs and Department of Defense guideline recommending it as first-line opioid for patients with chronic pain requiring daily opioids, its adoption among primary care clinicians (PCCs) remains limited. This survey aims to evaluate PCCs' familiarity with and interest in prescribing and/or transitioning patients to buprenorphine for chronic pain and OUD. In addition, we assessed their interest in using an electronic Consult (eConsult) platform to support buprenorphine prescribing.
Methods: An anonymized electronic survey was distributed to our institution’s PCCs working across 53 clinics in rural southern Minnesota and western Wisconsin. Our survey was deployed for 2 weeks. We received 146 responses (31.7% response rate).
Results: Only 37% of respondents currently prescribe buprenorphine, and 19% prescribed it for both OUD and chronic pain. Despite this, 72% expressed interest in prescribing buprenorphine in the future. Key barriers to prescribing included insufficient knowledge (76%) and lack of confidence (78%). Additional concerns included cost, insurance challenges, stigma, patient resistance, and inadequate training. Notably, 89% of respondents expressed interest in using an eConsult platform for buprenorphine initiation and transition.
Conclusion: These findings suggest a need for enhanced education, resource access, and institutional support to help PCCs incorporate buprenorphine into their practices, potentially improving the management of chronic pain and OUD.
- Buprenorphine
- Chronic Pain
- Community Medicine
- Family Medicine
- Opioid Use Disorder
- Primary Health Care
- Remote Consultation
- Surveys and Questionnaires
Introduction
Buprenorphine is a partial µ-opioid receptor agonist approved by the FDA for the treatment of opioid use disorder (OUD) as well as both acute and chronic pain.1 Unlike traditional pure µ-agonists, buprenorphine’s unique mechanism of action offers significant advantages, including a reduced risk of overdose, misuse, and adverse effects.2 The term “partial” agonist does not signify reduced efficacy; rather, buprenorphine is a full agonist at the opioid receptor-like receptor (ORL1) and has high affinity at the µ-receptor, which contributes to its prolonged analgesic effects.3,4 In addition, it acts as an antagonist at the δ- and κ-opioid receptors, reducing side effects such as constipation, dysphoria, and misuse potential, while also lowering the risk of depression.4,5 On the µ-receptor, buprenorphine exhibits low intrinsic signaling, reaching an analgesic threshold but with a ceiling effect for respiratory depression, thereby significantly reducing the risk of overdose.3–5
Regarding pain management, in 2022, the US Department of Veterans Affairs and Department of Defense updated its, recommending buprenorphine as the first-line opioid for chronic pain severe enough to warrant guideline chronic opioid therapy after failed conservative management, citing its effectiveness and superior safety profile over conventional opioids.2 Despite this guideline, buprenorphine remains underutilized in primary care, where prescribing is still dominated by pure µ-opioid agonists.6,7 This underuse is likely due to insufficient clinician knowledge, training, and institutional support, including inadequately trained support staff, and insufficient time.8–10 Concurrently, the updated opioid prescribing guidelines from the Centers for Disease Control and Prevention in 2022 emphasize taking a patient-centered approach,11 which may add further stress to a primary care workforce that was previously reported to feel unprepared and hesitant to treat patients with chronic pain.12
Historically, although prescribing buprenorphine for pain did not require additional training, clinicians had to obtain a DATA-2000 waiver from the Substance Abuse and Mental Health Services Administration to prescribe buprenorphine for OUD. However, Section 1262 of the Consolidated Appropriations Act of 2023, known as the Mainstreaming Addiction Treatment (MAT) Act, removed this requirement for prescribers with a valid Drug Enforcement Administration registration with a goal to improve OUD treatment access.13,14 To date, buprenorphine initiation has seen only modest increases; its overall usage has remained relatively stagnant.15
Despite recent declines, fatal drug overdoses16 remain notably higher compared with pre-Covid years.16 An estimated 15% of the 50.2 million US adults with chronic pain are using opioids,17 and only 20% of those with OUD receive Medications for Opioid Use Disorder (MOUD).18 Coupled with a predicted worsening shortage in pain medicine specialists from recent declines in fellowship training applications,19 there is a critical need for primary care to take a greater role in chronic pain and opioid use disorder management.
Electronic consultations (eConsults) are an emerging tool in some health systems, including our own, where clinicians can consult with experts asynchronously. This has been shown to enhance access to specialists, improve quality of care, and boost clinician productivity.20,21 In one large institution, the use of an eConsult program for chronic pain management resulted in significantly reduced other opioid use.22
Our institution has implemented eConsults since the late 2000s; these have proven to be valuable among primary care clinicians (PCCs).23 We see a role to offer a similar eConsult service for PCCs unfamiliar with buprenorphine. These eConsults will be conducted by other PCCs working (some working in rural settings) with experience treating patients with buprenorphine (Figure 1 outlines workflow). Since those performing eConsults also work in rural settings, they will understand the constraints rural PCCs and patients face and are able to tailor patient-centered recommendations based on these challenges.
Process workflow for buprenorphine eConsult.
Our study aims to assess our institution’s PCCs' knowledge, attitudes, and prescribing practices regarding buprenorphine for chronic pain and OUD. In addition, we explore their interest in using eConsult to increase buprenorphine adoption in primary care. This serves as part of a larger quality improvement initiative to expand buprenorphine access for OUD and to enhance safety in managing patients on chronic opioids.
Methods
Survey Development
The survey, developed based on existing literature on PCC’s attitudes on buprenorphine prescribing,7,9,10 included 6 multiple-choice and 1 open-ended question regarding prescribing practices, familiarity with guideline recommending buprenorphine for chronic pain, and perceived barriers to its use, Figure 2.
Anonymized survey to family medicine clinicians on buprenorphine prescribing and attitudes on a buprenorphine eConsult platform.
Key areas of focus included current buprenorphine prescribing for OUD and chronic pain, factors influencing its use, and the potential role of eConsult for prescribing guidance and dosage adjustments.
Our survey was not validated. It was reviewed by our leadership and deemed to align with practice priorities and appropriate for dissemination. The survey was created on Qualtrics to enable users to complete on desktop, laptop and smart phones.
Setting
Our institution has 53 primary care clinics in rural southern Minnesota and western Wisconsin comprising of 461 clinicians (physicians, nurse practitioners and physician assistants) in the departments of family medicine and internal medicine. Counties served range in urbanicity with Rural-Urban Continuum Codes (RUCC) of 3 to 9; RUCC ranges from 1 being most urban to 9 being most remote.24
Survey Deployment
Our survey was distributed electronically over a 2-week period (September 9 to 20, 2024, inclusive), with 2 reminder e-mails on September 13 and September 19, 2024. Responses were anonymous.
This study was reviewed by our Institutional Review Board; it was determined to be exempt under 45 CFR 46.101, item 2.
Data Analysis
Data collected from multiple choice questions were descriptive; as such, no statistical analysis was conducted.
Responses to open-ended questions were categorized into the following themes: (1) Perceived challenges to prescribing buprenorphine and (2) Attitudes toward a buprenorphine eConsult platform.
Results
A total of 146 PCCs responded to the survey (31.7% response rate). Most respondents (61%) were from Southeast Minnesota, followed by 19% from Southwest Minnesota, 13% from Northwest Wisconsin, and 8% from Southwest Wisconsin.
Regarding buprenorphine prescribing, 37% of respondents reported prescribing buprenorphine. Of those, 19% prescribed buprenorphine for both OUD and chronic pain, 14% for OUD only, and 5% for chronic pain alone. When asked about future intentions, 72% expressed interest in prescribing buprenorphine, while 28% indicated they would not.
Key barriers to prescribing buprenorphine included lack of knowledge (76%) and lack of confidence (78%). Other obstacles cited were perceived lack of patient need (15%), time constraints (30%), and lack of institutional support (27%), Table 1.
Practice Regions of Survey Respondents and Survey Responses
Open-ended responses highlighted concerns related to medication cost and insurance coverage, patient resistance, complexity of buprenorphine induction, stigma/provider resistance, and inadequate training and education, Table 2.
Themes from Open-Ended Primary Care Clinician Responses Related to Barriers to Buprenorphine Prescribing
Regarding the potential use of eConsult, 89% of respondents expressed interest in using the platform for advice on buprenorphine initiation, dosage adjustments, and opioid transition. Many respondents requested educational resources, such as free materials and continuing medical education (CME) focused on buprenorphine use and monitoring.
Discussion
Our survey results underscore the significant potential for expanding buprenorphine use in primary care for chronic pain and OUD. Although most respondents (63%) do not currently prescribe buprenorphine, 72% expressed interest in doing so, indicating a willingness to integrate buprenorphine into practice with the appropriate support and education.
The most cited barriers—lack of knowledge and confidence (76% and 78%, respectively)—align with previous studies highlighting insufficient training and unfamiliarity with buprenorphine as major hurdles to its adoption in primary care.7–10 These barriers could be addressed through targeted education. There is emerging evidence suggesting that longitudinal tele-education and tele-mentoring models with PCCs may lead to increased buprenorphine prescribing.25,26
Other barriers, including time constraints and lack of institutional support (30% and 27%, respectively), reflect the realities of primary care, where clinicians are often pressed for time and resources. A recently implemented Massachusetts model of nurse care management in primary care for patients with OUD noted increased number of patients receiving OUD treatment.27 In addition, based on our survey responses, we contend that an eConsult platform to provide actionable steps for managing OUD and pain with buprenorphine can meet the needs of PCCs who desire guidance and reassurance, thereby reducing hesitation in prescribing. Prior studies suggest improved attitudes toward buprenorphine after PCCs start prescribing;28,29 we hope the proposed eConsult service will positively affect attitudes, knowledge, and willingness to prescribe buprenorphine to the appropriate patients.
Within one of our institution’s regions, a Controlled Substance Advisory Group comprising primary care and pain medicine physicians, psychiatrists, psychologists, nurses, and pharmacists providing real-time review with input from the referring PCCs, has positively impacted care for patients on chronic opioids.30 Unfortunately, such multidisciplinary teams are not available at all our sites and can be challenging to scale up due resource constraints, particularly in more rural areas. Our eConsult model can serve as an accessible and effective tool to empower more PCCs to prescribe buprenorphine.
Notably, the overwhelming interest (89%) in an eConsult platform for buprenorphine prescribing suggests that PCCs recognize the need for ongoing support. eConsults have been successfully implemented across multiple institutions in a variety of specialties and has demonstrated effectiveness in enhancing clinician and patient satisfaction while improving patient care.21,22,31 Our institution has had eConsult services for nearly 2 decades involving specialties ranging from neurology, ophthalmology, dermatology to infectious diseases,31–35 demonstrating effectiveness in improving access to specialists’ expertise and improving patient outcomes. We contend that our institution has adequate experience and infrastructure to facilitate addition of the proposed buprenorphine eConsult service.
Concerns about the cost of buprenorphine and insurance coverage highlight broader systemic issues. Financial barriers can limit access to treatment.8 Addressing these financial challenges through insurance reform and patient assistance programs could expand access to buprenorphine.
The request for additional educational resources highlights the demand for accessible, evidence-based education to support buprenorphine prescribing in primary care.
Our study has several key limitations. The low response rate (31.7%) and the fact that we surveyed clinicians working for one health care institution in the upper Midwest may limit the generalizability of our findings. Self-selection bias may also play a role given the low response rate, and since participants were not given any incentives to participate in the survey. Attitudes of nonresponders may differ from those who responded to our survey. Future efforts to increase response rates, such as extending the survey period and increased advertisement of our survey, as well as expanding our survey to other health care institutions could improve generalizability. Work is under way to conduct focus groups with PCCs, which could help gain more nuanced insights on challenges associated with buprenorphine prescribing.
Finally, given lack of survey validation before deployment, respondents may have misinterpreted some of the survey items. We also acknowledge the limitations of conducting qualitative analysis on a single open-ended survey question. Future efforts to conduct focus groups with PCCs could help provide more clarity.
Conclusion
Buprenorphine has the potential to revolutionize the management of chronic pain and OUD in primary care, and there is significant interest among PCCs in prescribing it. However, barriers related to knowledge gaps, confidence, and systemic challenges hinder its broader adoption. An eConsult platform presents a promising solution to support PCCs in adopting buprenorphine into their practice. Future research should evaluate the effectiveness of eConsults and other initiatives in improving buprenorphine prescribing in primary care.
Notes
This article was externally peer reviewed.
Funding: Benjamin Lai, MB BCh BAO, FAAFP receives financial support for research through Mayo Clinic’s Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery.
Conflict of interest: None.
- Received for publication January 27, 2025.
- Revision received April 14, 2025.
- Accepted for publication April 28, 2025.
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