Buprenorphine is associated with decreased mortality from opioid use disorder, but prescribing is limited in office-based settings to clinicians with federal waivers. To expand this workforce, on April 28, 2021, the US federal government eliminated educational requirements for waivers to prescribe buprenorphine to 30 or fewer patients. Modest growth in the nationwide number of clinicians with waivers was observed after this exemption; however, geographic variation in the net growth of this workforce is unknown. Characterization of counties with recent net growth in clinicians with waivers may help address geographically varying shortages of buprenorphine prescribers and opioid overdose deaths.

This cross-sectional study found that waiver growth during the first year after the federal education exemption was modest and concentrated among urban counties and counties with high baseline levels of clinicians with waivers. Although most growth occurred in urban areas, APN and PA waivers accounted for more than 70% of rural growth. Our results reinforce emerging evidence that APNs and PAs play an important role in buprenorphine treatment in rural areas.

Inability to examine effects of the exemption on waiver-seeking behavior and prescribing practices is a limitation of this study. Future qualitative research should explore why the removal of educational requirements did not significantly change clinicians’ waiver-seeking behavior and other barriers such as stigma, insufficient institutional and staff support, and limited access to counselors. Overall, our findings suggest that removing educational barriers is insufficient to address low waiver uptake among US clinicians in certain areas such as counties with preexisting low levels of uptake or rural counties.