Literature Collection

OBJECTIVE: Effective treatments for opioid use disorder exist, but rural areas of the United States have a shortage of services offering such treatments. Physician bias toward patients with opioid use disorder can also limit care access, but no studies have assessed whether physician bias is a more acute barrier in rural compared with urban communities. METHODS: In total, 408 board-certified physicians in Ohio, a state with a high rate of opioid overdoses, completed an online survey examining perspectives on clinical care for patients who misuse opioids. Respondents with missing county-level data were excluded, leaving a total sample of 274. The authors used t tests to determine rural-urban differences in bias, key predictors of bias, and availability of opioid services. Multivariable regression modeling was used to estimate rural-urban differences in bias independent of key bias predictors. RESULTS: Physicians in rural areas (N=37) reported higher levels of bias toward patients with opioid use disorder than did their urban counterparts (N=237). This difference remained statistically significant even after accounting for known bias predictors and physician specialty. Physicians specializing in addiction medicine reported lower bias than did physicians not working in this specialty. CONCLUSIONS: Given existing disparities in harm reduction and addiction treatment services in rural areas, increased physician bias in counties lacking these services suggests that rural patients with opioid use disorder face numerous challenges to finding effective treatment. Bias reduction interventions should target health care professionals in rural communities where such efforts may have the most pronounced impact on improving health care access.

The prevalence of opioid use among pregnant people has been increasing over the past few decades, with a parallel increase in the rate of neonatal abstinence syndrome. Opioid agonist treatment (OAT) including methadone and buprenorphine is the recommended management method for opioid use disorders during pregnancy. Methadone has been extensively studied during pregnancy; however, buprenorphine was introduced in the early 2000s with limited data on the use of different preparations during pregnancy. Buprenorphine-naloxone has been incorporated into routine practice; however, only a few studies have investigated the use of this medication during pregnancy. To determine the safety and efficacy of this medication, we conducted a systematic review of maternal and neonatal outcomes among buprenorphine-naloxone-exposed pregnancies. The primary outcomes of interest were birth parameters, congenital anomalies, and severity of neonatal abstinence syndrome. Secondary maternal outcomes included the OAT dose and substance use at delivery. Seven studies met the inclusion criteria. Buprenorphine-naloxone doses ranged between 8 and 20 mg, and there was an associated reduction of opioid use during pregnancy. There were no significant differences in gestational age at delivery, birth parameters, or prevalence of congenital anomalies between buprenorphine-naloxone-exposed neonates and those exposed to methadone, buprenorphine monotherapy, illicit opioids, or no opioids. In studies comparing buprenorphine-naloxone to methadone, there were reduced rates of neonatal abstinence syndrome requiring pharmacotherapy. These studies demonstrate that buprenorphine-naloxone is a safe and effective opioid agonist treatment for pregnant people with OUD. Further large-scale, prospective data collection is required to confirm these findings. Patients and clinicians may be reassured about the use of buprenorphine-naloxone during pregnancy.