Barriers and Facilitators of Advanced Practice Registered Nurse Participation in Medication Treatment for Opioid Use Disorder: A Mixed Methods Study

Buprenorphine and Opioid Use Disorder Training: Graduate Nursing Curricula Recommendations

Opioid use disorder (OUD) is a public health emergency, with a shortage of providers trained to prescribe buprenorphine for OUD treatment. We conducted a systematic review to examine advanced practice RN (APRN) and medical school programs that included OUD content or Drug Addiction Treatment Act waiver training and evaluate the outcomes of those curricular modifications. APRN and medical school programs that provided OUD content or waiver training saw improvements in students' knowledge and self-efficacy for managing buprenorphine treatment and reduced stigma toward individuals with OUD. Students' perceptions of training were largely positive, and the programs' results indicated improved practice outcomes related to the use of buprenorphine. Further inclusion of OUD content and training in APRN curricula will increase the number of capable buprenorphine prescribers, which will increase access to buprenorphine for individuals with OUD. [Journal of Psychosocial Nursing and Mental Health Services, 62(7), 17-24.].

Psychiatric Nursing Workforce Survey: Results and Implications

OBJECTIVE

The last national survey of psychiatric-mental health (PMH) nurses was conducted in 2016 and was limited to advanced practice registered nurses (APRNs). Data on the demographic and employment characteristics of the PMH workforce could inform how to optimize the PMH nursing workforce to address increasing demands for mental health services. The objective was to conduct a national survey of PMH registered nurses (RNs) and PMH-APRNs to gather data on their demographic, educational, and practice characteristics.

METHODS

An email survey was administered between October 2020 and February 2021 to all members of the American Psychiatric Nurses Association and to all PMH-APRNs certified by the American Nurses Credentialing Center. Separate surveys included 51 questions (RN) and 52 questions (APRN). Survey questions were informed by several sources including the Minimum Data Set for the Behavioral Health Workforce.

RESULTS

Surveys were completed by 4,088 PMH-RNs and 5,158 PMH-APRNs, with a combined response rate of 12.1%. Findings suggest that the workforce is aging but has increased slightly in diversity. In all, 62.4% of RNs reported a hospital as their primary employment setting, while the majority of APRNs (70.4%) practice in outpatient settings. Forty-four percent of the PMH-APRN respondents indicated that most of their patients receive federal insurance.

CONCLUSIONS

Nursing must plan for significant retirements in the PMH workforce in next 5 years. Hospital-based practice continues to dominate PMH-RN roles but might be expanded to community-based settings teaming with PMH-APRNs in outpatient sites. Increasing the diversity of the workforce should be prioritized.

Understanding Healthcare Providers' Care for Patients with Medications Treating Opioid Use Disorder in the Emergency Department: A Scoping Review

BACKGROUND

There is limited research exploring the changing clinical practices among healthcare providers (HPs) care for patients with Emergency Department (ED)-initiated Medication for Opioid Use Disorder (MOUD).

METHODS

This scoping review followed the methodological framework of Arksey and O'Malley to map relevant evidence and synthesize the findings. We searched PubMed, EMBASE, CINAHL, Web of Science, and Scopus for related studies from inception through October 12, 2022. Following the application of inclusion and exclusion criteria, 16 studies were included. Subsequently, they were charted and analyzed thematically based on ecological systems theory.

RESULTS

The main determinants in the four ecological systems were generated as follows: (1) microsystem: willingness and attitude, professional competence, readiness, and preference; (2) mesosystem: ED clinical practices, departmental factors; (3) exosystem: multidisciplinary approaches, discharge planning, and (4) macrosystem: stigma, health insurance, policy. The findings have implications for HPs and researchers, as insufficient adoption, implementation, and retention of MOUD in the ED affect clinical practices.

CONCLUSIONS

Across the four ecological systems, ED-initiated MOUD is shaped by multifaceted determinants. The microsystem underscores pivotal patient-HP trust dynamics, while the mesosystem emphasizes interdepartmental synergies. Exosystemically, resource allocation and standardized training remain paramount. The macrosystem reveals profound effects of stigma, insurance disparities, and evolving policies on treatment access and efficacy. Addressing these interconnected barriers is crucial for optimizing patient outcomes in the context of MOUD.

Perspectives on APRN prescribing of medications for opioid use disorder: Key barriers remain

INTRODUCTION

Deaths from drug overdoses are rising dramatically in the United States. Treatment for opioid use disorders may include behavioral treatments as well as medications for opioid use disorders (MOUD). Buprenorphine can be prescribed by physicians, nurse practitioners (NPs), other advanced practice registered nurses (APRNs), and physician assistants (PAs) and required a training and a federal waiver until recently. The number of NP MOUD prescribers grew steadily over the past decade, but research has identified state-level scope of practice regulations as a barrier to NP MOUD prescribing. This article explores the contributions of, and remaining barriers faced by NP and other APRN MOUD prescribers. We describe qualitative findings from a study of NPs and other key stakeholders involved in MOUD treatment in four states with two differing levels of regulatory structure.

METHODS

In this qualitative study, we conducted site visits and semi-structured interviews with NPs and other APRNs, physicians, clinic managers, and regulators in four states including New Mexico and West Virginia (full practice authority for NPs), and Ohio and Michigan (which require physician supervision). Interview notes were entered into a qualitative software package and coded and reviewed by two members of the research team. Data were grouped into key themes.

RESULTS

A total of 76 participants participated in individual or small group interviews in the four states. We found key themes and several subthemes that describe NP practice in MOUD. Participants described key contributions of NP engagement in MOUD, including increasing access, serving rural areas, the unique role of psychiatric NPs, and the value of the nursing model of care in working with people with substance use disorders (SUD). Participants also identified barriers including scope of practice regulations, other regulatory barriers, stigma, and lack of supportive services to address psychosocial needs.

CONCLUSIONS

The waiver requirements were eliminated at the end of 2022 in federal budget legislation. Other barriers for NP and other APRN prescribers remain and should be addressed in practice, and in state and federal regulations. Research needs to explore the impact of the waiver elimination on MOUD prescribing and access to services.

Nurse prescribing practices across the globe for medication-assisted treatment of the opioid use disorder (MOUD): a scoping review

BACKGROUND

Despite the dramatic increase in opioid-related deaths in recent years, global access to treatment remains poor. A major barrier to people accessing Medication-assisted treatment of the opioid use disorder (MOUD) is the lack of providers who can prescribe and monitor MOUD. According to the World Drug Report, more young people are using drugs compared with previous generations and people in need of treatment cannot get it, women most of all. Nurse prescribers have the potential to enhance both access and treatment outcomes. Nurse prescribing practices do, however, vary greatly internationally. The aim of this scoping review is to explore nurse prescribing practices for MOUD globally with a view to informing equitable access and policies for people seeking MOUD.

METHODS

This scoping review was informed by the preferred reporting items for systematic reviews and meta-analysis extension for scoping reviews (PRISMA-ScR). Electronic searches from 2010 to date were conducted on the following databases: PsycInfo, PubMed, Embase, and CINAHL. Only studies that met the eligibility criteria and described nurse prescribing policies and/or behaviours for MOUD were included.

RESULTS

A total of 22 articles were included in the review which found several barriers and enablers to nurse prescribing of MOUD. Barriers included legislation constraints, lack of professional education and training and the presence of stigmatizing attitudes. Enablers included the presence of existing supportive services, prosocial messaging, and nurse prescriber autonomy.

CONCLUSION

The safety and efficacy of nurse prescribing of MOUD is well established, and its expansion can provide a range of advantages to people who are dependent on opiates. This includes increasing access to treatment. Nurse prescribing of MOUD can increase the numbers of people in treatment from 'hard to reach' cohorts such as rural settings, or those with less financial means. It holds significant potential to reduce a wide range of harms and costs associated with high-risk opiate use. To reduce drug-related death and the global burden of harm to individuals, families, and communities, there is an urgent need to address the two key priorities of nurse prescriber legislation and education. Both of which are possible given political and educational commitment.

Influences on advance practice nursing education to prescribe medications for opioid use disorder

BACKGROUND

Opioid misuse is a major public health concern in the United States. Opioid agonist medications are evidence-based treatments for opioid use disorders (OUD) that can be prescribed by advance practice registered nurses (APRNs) with prescriptive authority and appropriate training.

PURPOSE

Article examines factors influencing preparation to provide medications for opioid use disorder (MOUD) in APRN education.

METHODS

Data from semi-structured interviews addressing the role of education in preparing APRNs to provide MOUD were grouped into key themes using thematic analysis. Data were collected in a mixed methods study in four states with high opioid overdose deaths whose main findings were previously published.

FINDINGS

Two overarching themes emerged: "addressing attitudes" and "curriculum change." Sub-themes include affective barriers to providing OUD treatment; motivation to respond to the OUD crisis; and attitude change through experience with MOUD.

DISCUSSION AND CONCLUSION

APRNs can play a key role in reducing the harms caused by OUD. Attention to attitudinal issues, such as stigma, toward people using opioids is important in educating APRNs about providing MOUD.

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.

Buprenorphine Treatment: Advanced Practice Nurses Add Capacity

During the COVID-19 pandemic, there was slower growth in the number of new waivers authorizing clinicians to provide buprenorphine treatment for opioid use disorder. However, treatment capacity grew at a stable rate as a result of already authorized clinicians obtaining waivers for larger patient panels. Advanced practice nurses accounted for the largest portion of capacity growth during the pandemic.

Organizational Leaders Perceptions of Barriers to Accessing Behavioral Health Services in a Low-Resource Community

Little is known about how to effectively implement behavioral health programs in low-resource communities. Leaders from 20 community-serving behavioral health organizations in Flint, MI, were asked about their organizations and the barriers that they, and the populations they serve, face in providing and accessing behavioral health services. Barriers are reported using a mixed-methods analysis, reporting the number and percentage of organizations that experienced the barrier along with example quotations from the organization leaders. The most frequently reported barrier to providing services was finding adequate funding (50%) while the most frequently reported barrier for accessing services was finding adequate and reliable transportation (30%). Comparisons of these findings with barriers reported by providers in different settings and those seeking services are discussed. These comparisons may provide an important next step in identifying areas where providers perceptions and the needs of the population are misaligned and for systemic improvements more broadly.

Results of a National Survey: Ongoing Barriers to APRN Practice in the United States

Limited information is available on the barriers to practice for advanced practice registered nurses (APRNs) among states with full, restricted, and reduced practice. The purpose of this study is to identify practice barriers in relationship to United States (U.S.) state practice authority, APRN type, area of practice (rural, suburban, urban), and nature of practice (outpatient, inpatient, and both). An electronic survey of a convenience sample of APRNs was conducted to assess barriers to practice. Identified barriers were examined based on state practice environment, APRN role, practice setting, and location. Data were analyzed using thematic analysis for qualitative data and descriptive analysis for quantitative data. Over 7,000 APRNs representing all 50 states participated. Themes that were identified and reported by respondents, included licensure and administrative barriers, therapy restrictions, physician signature requirements, a lack of collegiality, prescribing barriers, uneven reimbursement, physician only procedures, and telehealth issues. Barriers were identified in all states, regardless of the type of practice authority. All four APRN role types identified practice barriers, some of which were more frequent for some roles than others. Restrictions for home health approval and the requirement for a physician signature for durable medical supply orders were identified by over 40% of respondents practicing in rural areas. Barriers to APRN practice continue to restrict aspects of patient care and patient access to care, even in states with full practice authority. Continued efforts to reduce barriers to APRN practice are needed to ensure patient access to care, especially in rural areas.