Background
The misuse of opioids is a health crisis in the United States. Medication treatment
for opioid use disorder reduces negative health outcomes, but there are widespread
shortages of appropriately trained and credentialed providers. Advanced practice registered
nurses (APRNs) have recently become eligible for Drug Enforcement Administration (DEA)
waivers that allow them to prescribe the most common medication, buprenorphine, but
many factors might constrain their full participation in opioid use disorder treatment.
Purpose
This study aimed to describe practice and regulatory barriers and facilitators to
APRNs offering buprenorphine treatment.
Methods
This mixed methods study integrated quantitative data on whether states’ APRN scope-of-practice
regulations were correlated with obtaining DEA waivers and qualitative data from site
visits to four states with high numbers of opioid overdose deaths.
Results
Quantitative analysis found that a higher percentage of APRNs were waivered in states
in which APRNs could prescribe without physician oversight compared with states that
require physician oversight. The average percentage of APRNs with a waiver was significantly
greater in rural counties than in urban counties in states that do not require physician
oversight of NPs (p = .006), as was the number of waivered APRNs per 100,000 population (p = .005). In contrast, the number of waivered APRNs per 100,000 population was lower
in rural counties versus urban counties in states that required physician oversight
(p = .005). Qualitative findings indicated that state regulations requiring physician
supervision of APRNs, federal waiver restrictions on the number of patients treated,
prior insurance authorization requirements for buprenorphine, insurance requirements
of counseling services, and nurse attitudes toward addiction were barriers to buprenorphine
prescribing.
Conclusion
Qualitative findings indicate that waivered APRNs may not use the waiver due to practice
and regulatory barriers. Requirements that physicians oversee APRN prescribing of
buprenorphine may have slowed the growth of the opioid treatment workforce. Other
regulations, organizational culture, and community support of buprenorphine treatment
also affect APRN engagement in offering buprenorphine treatment.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Nursing RegulationAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Extended-release naltrexone: A qualitative analysis of barriers to routine use.Journal of Substance Abuse Treatment. 2016; 62 (https://doi.org/10.1016/j.jsat.2015.10.003): 68-73
- Transforming mental health and addiction services.Health Affairs. 2021; 40 (https://doi.org/10.1377/hlthaff.2020.01472)
- State practice environment.(Retrieved July 15, 2018, from)
- State practice environment: States categorized by Type.(Retrieved July 15, 2018, from)
- State practice environment.(Retrieved May 26, 2021, from)https://www.aanp.org/advocacy/state/state-practice-environmentDate: 2021, January 1
American Society of Addiction Medicine. (n.d.). State Medicaid reports. Retrieved May 26, 2021, from https://www.asam.org/advocacy/aaam/smr
- Opioid & Health Indicators database.(Retrieved May 26, 2021, from)https://opioid.amfar.org/aboutDate: 2019
- Barriers rural physicians face prescribing buprenorphine for opioid use disorder.Annals of Family Medicine. 2017; 15 (https://doi.org/10.1370/afm.2099): 359-362
- Changes in the supply of physicians with a DEA DATA waiver to prescribe buprenorphine for opioid use disorder.WWAMI Rural Health Research Center, 2017
- Prescribing practices of rural physicians waivered to prescribe buprenorphine.American Journal of Preventive Medicine. 2018; 54 (https://doi.org/10.1016/j.amepre.2018.02.006): S208-S214
- Prescribing practices of nurse practitioners and physician assistants waivered to prescribe buprenorphine and the barriers they experience prescribing buprenorphine.Journal of Rural Health. 2020; 36 (https://doi.org/10.1111/jrh.12404): 187-195
- Projected contributions of nurse practitioners and physician assistant to buprenorphine treatment services of opioid use disorder in rural areas.Medical Care Research and Review. 2020; 77 (https://doi.org/10.1177/1077558718793070): 208-216
- Buprenorphine waiver uptake among nurse practitioners and physician assistants: The role of existing waivered prescriber supply.Journal of Substance Abuse Treatment. 2020; 115 (Article 108032. https://doi.org/10.1016/j.jsat.2020.108032)
- In rural areas, buprenorphine waiver adoption since 2017 driven by nurse practitioners and physician assistants.Health Affairs. 2019; 38 (https://doi.org/10.1377/hlthaff.2019.00859): 2048-2056
- Payment source and provider type in the U.S. healthcare system.Journal of the American Academy of Physician Assistants. 2015; 28: 46-53
- Affordable Care Act expands mental health and substance use disorder benefits and federal parity protections for 62 million Americans.(Office of the Assistant Secretary for Planning and Evaluation)
- Remedy for the Rural Opioid Epidemic: Leaders Discuss Medication-Assisted Addiction Treatment in Primary Care.(Author)
- Provisional counts of drug overdose deaths, as of 8/6/2017.(Author)
- FDA approved medications for the treatment of opiate dependence: Literature reviews on effectiveness & cost-effectiveness.in: Advancing Access to Addiction Medications: Implications for Opioid Addiction. American Society of Addiction Medicine, 2013
- Enhancing psychiatric mental health nurse practitioner practice: Impact of state scope of practice regulations.Journal of Nursing Regulation. 2019; 10 (https://doi.org/10.1016/S2155-8256(19)30081-X): 35-43
- Qualitative inquiry & research design: Choosing among five approaches.2nd ed. Sage Publications, 2007
- Growth in buprenorphine waivers for physicians increased potential access to opioid agonist treatment, 2002-11.Health Affairs (Millwood). 2015; 34 (https://doi.org/10.1377/hlthaff.2014.1205): 1028-1034
- Physician assistants and nurse practitioners as a usual source of care.The Journal of Rural Health. 2009; 25 (https://doi.org/10.1111/j.1748-0361.2009.00252.x): 407-414
- Methadone maintenance at different dosages for opioid dependence.Cochrane Database of Systematic Reviews. 2003; 3 (Article CD002208. https://doi.org/10.1002/14651858.CD002208)
- Overdose-related cardiac arrests observed by emergency medical services during the US COVID-19 epidemic.JAMA Psychiatry. 2021; 78 (https://doi.org/10.1001/jamapsychiatry.2020.4218): 562-564
- Trends in state regulation of nurse practitioners and physician assistants, 2001 to 2010.Medical Care Research and Review. 2015; 72 (https://doi.org/10.1177/1077558714563763): 200-219
- States should remove barriers to advanced practice registered nurse prescriptive authority to increase access to treatment for opioid use disorder.Policy Politics and Nursing Practice. 2020; 22 (https://doi.org/10.1177/1527154420978720): 85-92
- Who is caring for the underserved? A comparison of primary care physicians and nonphysician clinicians in California and Washington.Annals of Family Medicine. 2003; 1: 97-104
- Employment of advanced-practice psychiatric nurses to stem rural mental health workforce shortages.Psychiatric Services. 2008; 59 (https://doi.org/10.1176/ps.2008.59.1.109): 109-111
- Nurse-managed health centers.American Journal of Nursing. 2010; 110 (https://doi.org/10.1097/01.NAJ.0000388257.41804.41): 23-26
- Assessing differences in the availability of opioid addiction therapy options: Rural versus urban and American Indian reservation versus nonreservation.The Journal of Rural Health. 2016; 33 (https://doi.org/10.1111/jrh.12178): 102-109
- Trends in the supply of physician assistants and nurse practitioners in the United States.Health Affairs. 2002; 21 (https://doi.org/10.1377/hlthaff.21.5.174): 174-181
- Characteristics of nurse practitioners and physician assistants in the United States.Journal of the American Association of Nurse Practitioners. 2016; 28: 39-46
- Treatment of opioid use disorder among commercially insured patients in the context of the COVID-19 pandemic.JAMA. 2020; 324 (https://doi.org/10.1001/jama.2020.21512): 2440-2442
- Barriers to primary care physicians prescribing buprenorphine.Annals of Family Medicine. 2014; 12 (https://doi.org/10.1370/afm.1595): 128-133
- The future of nursing: Leading change, advancing health.National Academies Press, 2011 (https://doi.org/10.17226/12956)
- National and state treatment need and capacity for opioid agonist medication-assisted treatment.American Journal of Public Health. 2015; 105 (https://doi.org/10.2105/AJPH.2015.302664): e55-e63
- Medication-assisted opioid treatment prescribers in federally qualified health centers: Capacity lags in rural areas.The Journal of Rural Health. 2018; 34 (https://doi.org/10.1111/jrh.12260): 14-22
- Opioid overdose death rates and all drug overdose death rates per 100,000 population (age-adjusted).
- Understanding APRN distribution in the United States using NPI data.The Journal for Nurse Practitioners. 2012; 8: 626-635
- The geographic impact of buprenorphine expansion to nurse practitioner prescribers in Oregon.The Journal of Rural Health. Advance online publication. 2020; (https://doi.org/10.1111/jrh.12538)
- The supply of physicians waivered to prescribe buprenorphine for opioid use disorders in the United States: A state-level analysis.Journal of Studies on Alcohol and Drugs. 2015; 76: 644-654
- Buprenorphine physician supply: Relationship with state-level prescription opioid mortality.Drug and Alcohol Dependence. 2017; 173 (https://doi.org/10.1016/j.drugalcdep.2016.08.642): S55-S64
- The geographic distribution of nurse practitioners in the United States.Applied Geographic Studies. 1997; 1: 287-301
- Alcohol and opioid dependence medications: prescription trends, overall and by physician specialty.Drug and Alcohol Dependence. 2009; 99 (https://doi.org/10.1016/j.drugalcdep.2008.07.018): 345-349
- How collaborative practice agreements impede the provision of vital behavioral health services.Nursing Outlook. 2020; 68 (https://doi.org/10.1016/j.outlook.2020.04.002): 581-590
- Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence.Cochrane Database of Systematic Reviews. 2009; 3 (https://doi.org/10.1002/14651858.CD002209.pub2)CD002209
- Medications for opioid use disorder save lives.The National Academies Press, 2019 (https://doi.org/10.17226/25310)
- The future of nursing 2020-2030: Charting a path to achieve health equity.The National Academies Press, 2021 (https://doi.org/10.17226/25982)
- The 2010 report to the secretary: Rural health and human services.(Author)
- America’s Health Centers: 2020 Snapshot.(Retrieved May 27, 2021, from)
- Major components of the consensus model by state.(Retrieved [January 31, 2018], from)
- The role of nurse practitioners in reinventing primary care.Health Aff (Millwood). 2010; 29 (https://doi.org/10.1377/hlthaff.2010.0440): 893-899
- Assessment of filled buprenorphine prescriptions for opioid use disorder during the coronavirus disease 2019 pandemic.JAMA Internal Medicine. 2021; 181 (https://doi.org/10.1001/jamainternmed.2020.7497): 562-565
- Nurse practitioners’ inability to prescribe buprenorphine: Limitations of the Drug Addiction Treatment Act of 2000.Journal of the American Academy of Nurse Practitioners. 2011; 23: 542-545
- Modeling health benefits and harms of policy responses to the US opioid epidemic.American Journal of Public Health. 2018; 108: 1394-1400
- Pope C. Mays N. Qualitative Research in Health Care. 3rd ed. BMJ Books, Blackwell Publishing, 2006
- Availability without accessibility? State Medicaid coverage and authorization requirements for opioid dependence medications.American Society of Addiction Medicine, 2013
- Using medication-assisted treatment for substance use disorders: Evidence of barriers and facilitators of implementation.Addict Behav. 2011; 36 (https://doi.org/10.1016/j.addbeh.2011.01.032): 584-589
- Geographic and specialty distribution of US physicians trained to treat opioid use disorder.Annals of Family Medicine. 2015; 13 (https://doi.org/10.1370/afm.1735): 23-26
- Timing of buprenorphine adoption by privately funded substance abuse treatment programs: the role of institutional and resource-based interorganizational linkages.Journal of Substance Abuse Treatment. 2012; 42 (https://doi.org/10.1016/j.jsat.2011.06.009): 16-24
- Health costs and financing: Challenges and strategies for a new administration.Health Affairs. 2021; 40 (https://doi.org/10.1377/hlthaff.2020.01560): 235-242
- Washington State primary care provider survey, 2011-2012: Summary of findings.WWAMI Center for Health Workforce Studies, 2012
- California’s nurse practitioners: How scope of practice laws impact care.California Health Care Foundation, 2019
- Nurse practitioner and physician assistant waivers to prescribe buprenorphine and state scope of practice restrictions.JAMA. 2019; 321 (https://doi.org/10.1001/jama.2019.0834): 1407-1408
- Supply of buprenorphine waivered physicians: The influence of state policies.J Subst Abuse Treat. 2015; 48 (https://doi.org/10.1016/j.jsat.2014.07.010): 104-111
- The impact of buprenorphine on treatment of opioid dependence in a Medicaid population: recent service utilization trends in the use of buprenorphine and methadone.Drug and Alcohol Dependence. 2012; 123 (https://doi.org/10.1016/j.drugalcdep.2011.10.016): 72-78
- Where is buprenorphine dispensed to treat opioid use disorders? The role of private offices, opioid treatment programs, and substance abuse treatment facilities in urban and rural counties.Milbank Quarterly. 2015; 93 (https://doi.org/10.1111/1468-0009.12137): 561-583
- The prescribing of buprenorphine by advanced practice addictions nurses.Journal of Addictions Nursing. 2012; 23 (https://doi.org/10.3109/10884602.2011.649026): 82-83
- Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 18-5068, NSDUH Series H-53).Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, 2018
The Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, H.R. 6, 115th Cong. (2018).
- Use of buprenorphine for addiction treatment: Perspectives of addiction specialists and general psychiatrists.Psychiatric Services. 2008; 59: 909-916
- Advanced practice nurses: Increasing access to opioid treatment by expanding the pool of qualified buprenorphine prescribers.Substance Abuse. 2015; 36 (https://doi.org/10.1080/08897077.2015.1101733): 389-392
- Mid-level practitioners authorization by state.
- Area Health Resources File.http://ahrf.hrsa.gov/download.htmDate: 2016
- In fighting an opioid epidemic, medication-assisted treatment is effective but underused.Health Affairs (Millwood). 2016; 35 (https://doi.org/10.1377/hlthaff.2016.0504): 1052-1057
- Nonfatal drug overdoses treated in emergency departments—United States, 2016–2017.MMWR Morbidity and Mortality Weekly Report. 2020; 69: 371-376
- Medication-assisted therapies—Tackling the opioid-overdose epidemic.New England Journal of Medicine. 2014; 370 (https://doi.org/10.1056/NEJMp1402780): 2063-2066
- Office-based management of opioid dependence with buprenorphine: Clinical practices and barriers.Journal of General Internal Medicine. 2008; 23 (https://doi.org/10.1007/s11606-008-0686-x): 1393-1398
- Lawmakers are finally sobering up to the reality of opioid addiction.in: Washington Post. 2016, March 17
Biography
Joanne Spetz, PhD, is the Director, Philip R. Lee Institute for Health Policy Studies, and a Professor, Departments of Family & Community Medicine, Social and Behavioral Sciences, & Community Health Systems, University of California, San Francisco.
Biography
Susan Chapman, PhD, RN, is a Professor, Department of Social and Behavioral Sciences & Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco.
Biography
Matthew Tierney, MS, RN, is a Professor, Department of Community Health Systems, University of California, San Francisco.
Biography
Bethany Phoenix, PhD, RN, is a a Professor, Department of Community Health Systems, University of California, San Francisco.
Biography
Laurie Hailer, MA, MS, is an Independent Consultant, Fairfax, California.
Article info
Footnotes
This research was supported by the National Council of State Boards of Nursing (grant R101026) and the National Institute on Drug Abuse, US National Institutes for Health, grant R01DA047379. Dr. Spetz reports receiving consulting fees from the Center to Champion Nursing in America (American Association of Retired Persons) and Dennehy and Associates, LLC. Dr. Tierney reports receiving honoraria from Contemporary Forums, the American Society of Addiction Medicine, the California Society of Addiction Medicine, Cabezon Group, the Association for Multidisciplinary Education and Research in Substance Use and Addiction, the American Psychiatric Nurses Association, and Johnson & Johnson.
Identification
Copyright
© 2021 National Council of State Boards of Nursing. Published by Elsevier Inc. All rights reserved.
