Nurse Practitioners’ Pivotal Role in Ending the Opioid Epidemic

What the X? Understanding changes in buprenorphine prescribing regulation

ABSTRACT

Opioid use disorder remains an epidemic in the United States. Buprenorphine is a Food and Drug Administration-approved medication for opioid use disorder that is associated with decreased opioid-related mortality and morbidity. Until recently, providers had to have a specialized wavier, a Drug Enforcement Agency (DEA) X, to prescribe buprenorphine for opioid use disorder. The 2023 Consolidated Appropriations Act, signed into law by President Biden, removed X waiver requirements and implements new training requirements for all new and renewing DEA registrants. This brief report outlines the history of buprenorphine prescribing regulation, reviews the recent regulatory changes and their implications for nurse practitioner buprenorphine prescribing, and concludes by considering the importance of promoting buprenorphine access.

Mobilizing nurses to address the opioid misuse epidemic

BACKGROUND

The opioid epidemic is a major health challenge in the United States.

PURPOSE

Members from the American Academy of Nursing joined to write a consensus paper about nurses' role in the opioid epidemic.

METHODS

The panel reviewed the history of the opioid epidemic and policies to care for patients with opioid use disorder (OUD) and how registered nurses (RNs) and advanced practice nurses (APRNs) could increase care for people with OUD.

DISCUSSION

Recommendations are presented to advance policies that empower RNs and APRNs to abate the opioid epidemic.

CONCLUSION

Recommendations include (a) advance legislation that supports RNs and APRNs full scope of practice and expands professional role in pain management and addiction prevention; (b) evaluate effective policies that promote RN and APRN care; support federal elimination of X-waiver with state law alignment; (c) sustain the use of nurses in telemedicine; (d) support nursing research on nurse involvement in all aspects of OUD.

Barriers and facilitators to nurse practitioner buprenorphine prescribing for opioid use disorder in primary care settings

BACKGROUND

Increasing access to opioid use disorder (OUD) treatment is critical to curbing the opioid epidemic, particularly for rural residents who experience numerous health and health care disparities, including higher overdose death rates and limited OUD treatment access compared with urban dwellers. Buprenorphine-naloxone is an evidence-based treatment for OUD that is well suited for rural areas. However, providers must have a specialized federal waiver to prescribe the medication. Despite the acceleration of the opioid epidemic in rural areas and the recent liberalization of federal buprenorphine-naloxone prescribing laws, few providers hold buprenorphine-naloxone prescribing waivers and even fewer prescribe the medication.

PURPOSE

This study explores barriers and facilitators to buprenorphine-naloxone prescribing among nurse practitioners (NPs) working in primary care settings in eastern North Carolina.

METHODOLOGY

Individual interviews were conducted with 13 NPs working in primary care settings in eastern North Carolina. Qualitative thematic analysis was used to identify perceived barriers and facilitators to buprenorphine-naloxone prescribing.

RESULTS

Analysis found prescribing barriers related to OUD stigma, perceived knowledge, federal and state regulation, and prescribing resources and found facilitators related to adopting a person-centered approach, developing prescriber skills, and access to prescribing resources.

CONCLUSIONS

The barriers and facilitators that NPs experience related to buprenorphine prescribing for OUD are similar to those faced by physicians, although the barriers arguably more profound. Future research should consider how to mitigate these prescribing barriers to facilitate NP buprenorphine prescribing for OUD.

IMPLICATIONS

To our knowledge, this is the first qualitative study of NP buprenorphine-naloxone prescribing in rural areas. Given the prominence of OUD in rural regions and the key role NPs play in primary care provision, this study lays import groundwork for developing interventions to support buprenorphine-naloxone prescribing by NPs practicing in rural regions.

State Policies and Buprenorphine Prescribing by Nurse Practitioners and Physician Assistants

Nurse practitioner (NP) and physician assistant (PA) prescribing can increase access to buprenorphine treatment for opioid use disorder. In this cross-sectional study, we used deidentified claims from approximately 90% of U.S. retail pharmacies (2017-2018) to examine the association of state policies with the odds of receiving buprenorphine treatment from an NP/PA versus a physician, overall and stratified by urban/rural status. From 2017 to 2018, the percentage of buprenorphine treatment episodes prescribed by NPs/PAs varied widely across states, from 0.4% in Alabama to 57.2% in Montana. Policies associated with greater odds of buprenorphine treatment from an NP/PA included full scope of practice (SOP) for NPs, full SOP for PAs, Medicaid pay parity for NPs (reimbursement at 100% of the fee-for-service physician rate), and Medicaid expansion. Although most findings with respect to policies were similar in urban and rural settings, the association of Medicaid expansion with NP/PA buprenorphine treatment was driven by rural counties.

Differences in buprenorphine treatment quality across physician provider specialties

BACKGROUND

The number and types of clinicians prescribing buprenorphine treatment for opioid use disorder (OUD) have increased over the past two decades, but there is little information on how potential indicators of quality of care to patients receiving buprenorphine vary by provider specialty.

METHODS

We used the Medicaid Analytic eXtract from 2009 to 2014 to identify buprenorphine treatment episodes. We assigned physician specialties to episodes based on whether an episode had at least one outpatient claim linked to specialists in addiction, behavioral health, opioid treatment program (OTP), pain, or primary care provider (PCP). We then used logistic regressions to estimate the association of linked physician specialty and achievement of the following process of care measures: at least 180-day duration, no co-occurring opioid analgesics, no co-occurring benzodiazepines, infectious disease screening, liver function test, drug and toxicology screenings, evaluation and management visits, and counseling.

RESULTS

Episodes linked to PCPs had significantly lower odds of achieving 180-day duration, an absence of opioid analgesics, an absence of benzodiazepines, drug and toxicology screenings, and counseling compared to addiction, behavioral health, and/or OTPs. Episodes linked to PCPs had significantly higher odds of undergoing infectious disease screenings, liver function tests, and evaluation and management visits compared to all specialty categories.

CONCLUSIONS

Episodes were more likely to achieve process of care measures related to the specialties of their physicians, but no specialty consistently demonstrated better performance compared to PCPs. Our findings highlight the need for models that can better integrate physical and behavioral health services for OUD treatment.

Expanding Opioid Use Disorder Treatment in Priority Areas: The Role of Certified Nurse-Midwives

INTRODUCTION

Perinatal opioid use disorder (OUD) is associated with maternal and neonatal morbidity, and treatment has been definitively shown to improve outcomes for both. As of 2018, certified nurse-midwives (CNMs) can prescribe buprenorphine for the treatment of OUD by obtaining a Drug Addiction Treatment Act waiver. This research aims to identify the number of CNMs who are waivered to prescribe buprenorphine for the treatment of OUD and who practice in priority areas for treatment expansion.

METHODS

Through a descriptive study design, authors collected and analyzed publicly available data from August 2020 to January 2021. Using the software GeoDa, authors identified priority counties in the United States and the number of waivered and nonwaivered CNMs in these areas. Counties were designated as priority if they had drug-poisoning mortality rates in the top 20th percentile of all US counties and no health care providers waivered to treat OUD or had a waivered health care provider per population rate in the bottom 20th percentile.

RESULTS

Analysis identified 141 priority counties in 23 states concentrated in rural areas throughout the Appalachian region of the United States. Tennessee had the most priority counties of any state. As of 2020, only 26 CNMs in the United States were waivered to prescribe buprenorphine, none of whom practiced in priority counties. Of the CNMs practicing in priority counties and without waivers, 59% (39 of 66) practiced in states where CNMs have independent practice authority.

DISCUSSION

CNMs are uniquely positioned to treat perinatal OUD given their scope of practice as primary and reproductive health care providers, especially in rural, underserved areas. To increase the number of midwives prescribing buprenorphine and expand treatment access, researchers, educators, practice leaders, and policy makers must address barriers to and experiences of treating OUD.

The Association Between Scope of Practice Regulations and Nurse Practitioner Prescribing of Buprenorphine After the 2016 Opioid Bill

This article examines the relationship between federal regulations, state scope-of-practice regulations on nurse practitioners (NPs), and buprenorphine prescribing patterns using pharmacy claims data from Optum's deidentified Clinformatics Data Mart between January 2015 and September 2018. The county-level proportion of patients filling prescriptions written by NPs was low even after the 2016 Comprehensive Addiction and Recovery Act (CARA), 2.7% in states that did not require physician oversight of NPs, and 1.1% in states that did. While analyses in rural counties showed higher rates of buprenorphine prescriptions written by NPs, rates were still considerably low: 3.7% in states with less restrictive regulations and 1.1% in other states. These results indicate that less restrictive scope-of-practice regulations are associated with greater NP prescribing following CARA. The small magnitude of the changes indicates that federal attempts to expand treatment access through CARA have been limited.

Outcomes from the medication assisted treatment pilot program for adults with opioid use disorders in rural Colorado

BACKGROUND

As Colorado ranked among the top nationally in non-medical use of opioids, a pilot medication for opioid use disorder (MOUD) program was developed to increase the number of NPs and PAs providing MOUD in order to bring this evidence- based treatment to 2 counties showing disproportionally high opioid overdose deaths. Over the first 18 months, the MOUD Pilot Program led to 15 new health care providers receiving MOUD waiver training and 1005 patients receiving MOUD from the 3 participating organizations. Here we evaluate patient centered clinical and functional outcomes of the pilot MOUD program implemented in 2 rural counties severely affected by the opioid crisis.

METHODS

Under state-funded law (Colorado Senate Bill 17-074), three rural agencies submitted de-identified patient-level data at baseline (N = 1005) and after 6 months of treatment (N = 190, 25%) between December 2017 and January 2020. The Addiction Severity Index, PhQ9 and GAD-7 with McNemar-Bowker, and Wilcoxon Signed Rank tests analysis were used to measure patient outcomes across after participation in the program. .

RESULTS

Patients in treatment reported using less heroin (52.1% vs 20.4%), opioids (22.3% vs 11.0%), and alcohol (28.6% vs 13.1%, all P < 0.01). Patients reported improved health (53.4% vs. 68.2%, P = 0.04), less frequency of disability (8.69 vs. 6.51, P = 0.02), symptoms (29.8% vs 21.3%), pain (67.5% to 53.6), worry (45.3% vs 62.3%), anxiety (49.7% vs 23.2%), depression (54.1% vs 23.3%, all P < 0.02) after treatment.

CONCLUSIONS

This study shows decreased substance use, improved physical and mental health, and reduced symptoms after 6 months of MOUD. Although more research on retention and long-term effects is needed, data shows improved health outcomes after 6 months of MOUD. Lessons learned from implementing this pilot program informed program expansion into other rural areas in need to address some of Colorado' major public health crises.

Opioid use disorder and COVID-19: Implications for policy and practice

ABSTRACT

Preliminary data suggest that opioid-related overdose deaths have increased subsequent to COVID-19. Despite national support for expanding the role of physician assistants (PAs) and NPs in serving patients with opioid use disorder, these clinicians are held to complex and stringent regulatory barriers. COVID-19 triggered significant changes from regulatory and federal agencies, yet disparate policies and regulations persist between physicians and PAs and NPs. The dual epidemics of COVID-19 and opioid use disorder highlight the inadequate infrastructure required to support patients, communities, and clinicians, and may serve as the catalyst for eliminating barriers to care.

Expanding access to nurse-managed medication for opioid use disorder

BACKGROUND

Advanced practice registered nurses (APRNs) are increasingly caring for individuals with opioid use disorder. Advances have been made to increase APRN education, outreach, and prescribing privileges, but as demand for medication for opioid use disorder (MOUD) grows, evidence suggests that policy and care barriers inhibit the ability of APRNs to support MOUD.

PURPOSE

This paper highlights the significant challenges of expanding access to buprenorphine prescribing by APRNs.

RESULTS

Barriers and recommendations were derived from the culmination of literature review, expert consensus discussions among a diverse stakeholder panel including patient representatives, and feedback from community webinars with care providers.

DISCUSSION

We provide an overview of existing care barriers, promising practices, and proposed recommendations to enhance the care of individuals and communities with opioid use disorder.

Revisiting the Fetal Assault Law in Tennessee: Implications and the Way Forward

The rising prevalence of opioid use disorder (OUD) among those living in the United States has demanded a collaborative response from health care and policy spheres. Addressing OUD among pregnant women is especially difficult, given the controversies surrounding the medical and ethical balance between meeting maternal versus fetal/newborn needs. Most medical organizations discourage the criminalization of drug use in pregnancy due to the adverse public health outcomes of such an approach. Despite this recommendation, many states continue to use punitive law to address drug use in pregnancy. In 2014, the Fetal Assault Law in Tennessee (TN) became the first law in the United States to directly allow women to be prosecuted for drug use in pregnancy. Since its expiration in 2016, this law has been re-introduced several times to the TN legislature in support of permanent implementation. This article outlines the impact of the initial Fetal Assault Law on maternal/newborn health in TN and provides alternative immediate, short-term, and long-term health policy strategies through which health care providers and legislators can better advocate for the well-being of both mothers with OUD and their infants.

In Rural Areas, Buprenorphine Waiver Adoption Since 2017 Driven By Nurse Practitioners And Physician Assistants

Few patients with opioid use disorder receive medication for addiction treatment. In 2017 the Comprehensive Addiction and Recovery Act enabled nurse practitioners (NPs) and physician assistants (PAs) to obtain federal waivers allowing them to prescribe buprenorphine, a key medication for opioid use disorder. The waiver expansion was intended to increase patients' access to opioid use treatment, which was particularly important for rural areas with few physicians. However, little is known about the adoption of these waivers by NPs or PAs in rural areas. Using federal data, we examined waiver adoption in rural areas and its association with scope-of-practice regulations, which set the extent to which NPs or PAs can prescribe medication. From 2016 to 2019 the number of waivered clinicians per 100,000 population in rural areas increased by 111 percent. NPs and PAs accounted for more than half of this increase and were the first waivered clinicians in 285 rural counties with 5.7 million residents. In rural areas, broad scope-of-practice regulations were associated with twice as many waivered NPs per 100,000 population as restricted scopes of practice were. The rapid growth in the numbers of NPs and PAs with buprenorphine waivers is a promising development in improving access to addiction treatment in rural areas.

"The Future of Nursing: Accelerating gains made to address the continuum of substance use"

PURPOSE

Guided by four key messages from the decade-old Institute of Medicine (IOM) report, "The Future of Nursing," this paper highlights the progress made by the nursing profession in addressing substance use and its related disorders and offers recommendations to sustain and advance efforts to enhance care for persons who use substances, one of the most stigmatized and vulnerable populations.

RESULTS

Patterns of substance use have shifted over the past 10 years, but the associated harms remain consequential. As awareness of the continuum of substance use has expanded, the care of persons with substance use has also expanded, from the domains of psychiatric-mental health and addictions nursing specialties to the mainstream of nursing. Now, greater efforts are being undertaken to identify and intervene with persons at risk for and experiencing substance use disorders. Nurses have advanced the knowledge and skills necessary for substance-related nursing care including education and training, leadership, care innovations, and workforce expansion and can drive efforts to increase public knowledge about the health risks associated with substance use. Recommendations aligned with each of the four IOM key messages are offered.

CONCLUSIONS

As a profession, nursing has a responsibility to expand the progress made in addressing substance use - from prevention and early intervention to tertiary care. Nurses at all levels of education and practice are in key positions to carry out the recommendations herein to accelerate the changes needed to provide high quality care for persons impacted by substance use.