(30) Barriers Persist: MOUD Knowledge, Attitudes, & Prescribing in North Carolina Family Medicine

Background & Introduction: Primary care clinicians are essential to expanding access to medications for opioid use disorder (MOUD), yet outpatient buprenorphine care remains challenging in the fentanyl era. (1) Clinician-level barriers, including limited training and low confidence with initiation, may constrain both MOUD prescribing and faculty ability to precept trainees. (2, 3) Residency training is critical to equipping future physicians with the necessary experience and knowledge to deliver MOUD care effectively. Prescribing opportunities during residency increased after elimination of the DEA Drug Addiction Treatment Act waiver requirement. However, buprenorphine prescribing in primary care has not increased substantially in recent years. (4) To better understand the current primary care training environment for OUD care, this study sought to describe MOUD prescribing patterns, attitudes, and knowledge among North Carolina family medicine clinicians and explore differences between faculty and residents.

Methods: An electronic survey was developed and distributed in Fall 2025 to faculty and residents affiliated with all 19 North Carolina family medicine residency programs via program contacts. Survey items included demographic and practice characteristics, self-reported buprenorphine prescribing behaviors, attitudes toward MOUD treatment, and knowledge of MOUD best practices. Knowledge was assessed with 7 items covering MOUD initiation, dosing, and continuation during ongoing use (score 0–7). Continuity clinic ZIP codes were used to assign 2020 Rural–Urban Commuting Area (RUCA) codes; RUCA >4 was classified as rural. Bivariate statistics (chi-square, t-test) compared outcomes between residents and faculty, rural versus non-rural clinic sites, and resident year of training.

Results: One hundred and thirty family medicine physicians completed the survey (72 faculty, 56 residents, 2 fellows). Faculty mean age was 45 years (SD=11), 53% were female, and mean years in practice was 15 (SD=11). Resident/fellow mean age was 30 years (SD=3), 76% were female, and training distribution was 35% Post-Graduate Year (PGY) 1, 28% PGY2, and 34% PGY3. Fourteen percent reported a rural continuity clinic location, with no significant differences between faculty and residents in rural and non-rural settings.

Faculty reported greater buprenorphine prescribing than residents: 10% of faculty versus 29% of residents reported caring for zero patients on buprenorphine; 43% of residents reported prescribing buprenorphine to 1–5 patients. Residents were less likely than faculty to report having initiated buprenorphine for a patient not currently taking it (29% vs. 58%, p < .01). Residents were less likely to report off-label buprenorphine prescribing for chronic pain than faculty (29% vs 65%, p < .01). More than 70% of residents intended to prescribe MOUD after graduation.

Attitudes toward tapering/discontinuing buprenorphine did not differ between faculty and residents. While greater than 90% reported they would not taper/discontinue buprenorphine for cannabis use, 39% agreed/strongly agreed they would taper/discontinue for benzodiazepine use, 32% for methamphetamine use, and 33% for cocaine use.

MOUD knowledge scores were modest and not significantly different between faculty and residents (faculty mean 3.8/7 [SD=2.0] vs residents 3.3/7 [SD=1.5]); resident mean scores improved across training years. Comparisons by rural and non-rural continuity clinic site were not statistically significant (p > .05).

Conclusion & Discussion: Family medicine faculty and residents reported similar attitudes about continuing buprenorphine in the setting of ongoing substance use, yet prescribing experiences differed: residents were less likely to report initiating buprenorphine for patients not already receiving it. MOUD knowledge was not significantly different between groups. We identified gaps in best practices suggesting continued training needs for both residents and faculty.

Survey distribution methods likely varied by program, which may have influenced who completed the survey. We could not calculate a response rate, and the sample may overrepresent clinicians with stronger interest in MOUD, higher prescribing confidence, or existing buprenorphine panels. This may bias results toward more favorable attitudes and greater reported prescribing than would be observed in a representative family medicine sample. While we aimed to examine differences based on rurality, response rates were insufficient for meaningful comparisons. Future research may target rural residency programs to ensure adequate responses from rural sites.

These findings suggest training may need to include supervised buprenorphine initiation experiences and faculty development. Strengthening resident opportunities to initiate buprenorphine alongside targeted education addressing identified knowledge gaps may increase confidence, normalize evidence-based low-threshold care for patients with ongoing use, and expand MOUD capacity in primary care.

References: 1. Suen LW, Chiang AY, Jones BLH, et al. Outpatient Low-Dose Initiation of Buprenorphine for People Using Fentanyl. JAMA Netw Open. 2025;8(1):e2456253.

2. Lai B, Good J, O’Grady J, Rushlow D. Buprenorphine prescribing comfort level among family medicine providers post MAT and MATE Acts. J Opioid Manag. 2025;21(5):373–376.

3. Ukaoma SC, Kedia SK, Regmi S, et al. Barriers and facilitators to medications for opioid use prescribing in primary care: a scoping review. Drugs: Education, Prevention and Policy. 2025;32(6):507–519.

4. Chua KP, Bicket MC, Bohnert ASB, et al. Buprenorphine Dispensing after Elimination of the Waiver Requirement. N Engl J Med. 2024;390(16):1530–1532.