The Impact of Advance Practice Provider Restrictions on Opioid Use Disorder

May 2019 Issue

  1. Heather J Jackson, MSN, RN, APRN-BC Assistant in Anesthesiology, Division of Pain Medicine, Vanderbilt University Medical Center Co-author
  2. Jenna Walters, MD Assistant Professor of Anesthesiology and Pain Medicine; Associate Director of Chronic Pain Fellowship; Director of Chronic Pain Resident and Medical Student Education, Vanderbilt University Medical Center Co-author


As pain specialists, we are well aware of the devastating effects from the current opioid crisis. The epidemic has numerous social and health-related implications, including substantial increases in the incidence of addiction, communicable disease, neonatal abstinence syndrome, violent crime, disruption of communities and families, and overdose-related deaths. Opioid misuse has created a nation in crisis, with more than 2 million cases of opioid use disorder (OUD) diagnosed in 2015 and subsequent rises in heroin use.[1],[2] More than 72,000 Americans died from opioid-related causes in 2017, with close to 16,000 of those deaths from heroin.[3]

In response to the growing number of opioid prescriptions and opioid-related deaths, the Centers for Disease Control and Prevention published prescribing guidelines and several states passed legislation successfully reducing the opioid supply. However, appropriate treatment options are lacking for those dependent on opioids, especially in rural areas of the United States.

Current evidence supports medication-assisted therapy (MAT) as the most effective treatment for OUD.[4],[5] MAT combines medications approved by the Food and Drug Administration (FDA) with psychological interventions, including counseling and behavioral therapies, to comprehensively treat OUD. Methadone, buprenorphine, and naltrexone are the only FDA-approved MAT medications. Buprenorphine MAT has been associated with fewer adverse effects as well as improved fetal outcomes when initiated during pregnancy.[5–8]

Unfortunately, access to MAT is limited, with the number of patients in need far exceeding that of qualified providers.[9],[10] In 2015, less than 50% of U.S. counties had a physician prescriber and most of the deficit in rural areas.[11] Based on current estimations, only 3% of all primary care providers have waivers to prescribe buprenorphine for OUD.[11] Additional barriers to MAT availability include geographic location, socioeconomic circumstances, and stigma regarding addiction.[11–17]


Because of current state restrictions on buprenorphine prescribing, advance practice providers who diagnose opioid dependence and OUD are unable to provide evidence-based treatment for their patients.


Prescribing buprenorphine maintenance treatment (BMT) requires specialty training with strict regulations on the number of patients each provider may treat. Currently, buprenorphine is a schedule III drug, and advanced practice providers are allowed to prescribe it for pain; however, many states have restrictions for addiction treatment.[18] Although section 303 of the federal Comprehensive Addiction and Recovery Act authorized physician assistants and nurse practitioners to prescribe BMT, many state laws restrict or even prohibit advanced practice providers from prescribing buprenorphine for addiction.[19]

The management of opioid dependence and OUD frequently defaults to primary care providers, especially in areas with limited access to addiction and chronic pain specialists. Advance practiced providers often serve rural areas to meet health care needs and, in certain states, practice independently.[20] Patients in rural regions may have limited financial and psychosocial resources, further restricting their ability to seek appropriate treatment for OUD. Health Resources and Services Administration projections estimate that physician assistants and nurse practitioners will provide up to 28% of primary care services by 2020.[21] But because of current state restrictions on buprenorphine prescribing, advance practice providers who diagnose opioid dependence and OUD are unable to provide evidence-based treatment for their patients.

Currently, three states (Oklahoma, Tennessee, and Wyoming) explicitly prohibit nurse practitioners from providing BMT, and 28 states place prescribing restrictions on the treatment.[22] Scientific evidence is lacking to support those practice restrictions, and analysis of state-level scope-of-practice restrictions displays no evidence of improved quality of care in those states.[23] In fact, states with reduced or restricted nurse practitioner scope of practice use more resources such as hospitalizations, readmissions, and emergency department admissions than full-practice states.[24] Prescribing limitations reduce the pool of qualified MAT providers and place patients at greater risk for misuse, overdose, and death. Equipping advance practice providers with BMT prescribing privileges could significantly increase the availability of OUD treatment specialists and improve access to care for those with OUD.[24]

References

  1. Han B, Compton WM, Blanco C, Crane E, Lee J, Jones CM. Prescription opioid use, misuse, and use disorders in U.S. adults: 2015 National Survey on Drug Use and Health. Ann Intern Med 2017;167:293–301.
  2. Kanouse AB, Compton P. The epidemic of prescription opioid abuse, the subsequent rising prevalence of heroin use, and the federal response. J Pain Palliat Care Pharmacother 2015;29:102–114.
  3. National Institute on Drug Abuse. Overdose death rates. Available at: https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Updated January 2019. Accessed March 4, 2019.
  4. Dematteis M, Auriacombe M, D’Agnone O, et al. Recommendations for buprenorphine and methadone therapy in opioid use disorder: a European consensus. Expert Opin Pharmacother 2017;18:1987–1999.
  5. Connery HS. Medication-assisted treatment of opioid use disorder: review of the evidence and future directions. Harv Rev Psychiatry. 2015;23:63–75.
  6. Coyle MG, Salisbury AL, Lester BM, et al. Neonatal neurobehavior effects following buprenorphine versus methadone exposure. Addiction 2012;107(suppl 1):63–73.
  7. Noormohammadi A, Forinash A, Yancey A, Crannage E, Campbell K, Shyken J. Buprenorphine versus methadone for opioid dependence in pregnancy. Ann Pharmacother 2016;50:666–672.
  8. Thomas CP, Fullerton CA, Kim M, et al. Medication-assisted treatment with buprenorphine: assessing the evidence. Psychiatr Serv 2014;65:158–170.
  9. Hutchinson E, Catlin M, Andrilla CH, Baldwin LM, Rosenblatt RA. Barriers to primary care physicians prescribing buprenorphine. Ann Fam Med 2014;12:128–133.
  10. Jenkinson J, Ravert P. Underutilization of primary care providers in treating opiate addiction. J Nurse Pract 2013;9:516–122.
  11. Rosenblatt RA, Andrilla CH, Catlin M, Larson EH. Geographic and specialty distribution of US physicians trained to treat opioid use disorder. Ann Fam Med 2015;13:23–26.
  12. Woods JS, Joseph H. Reducing stigma through education to enhance medication-assisted recovery. J Addict Dis 2012;31:226–235.
  13. Wielen LM, Gilchrist EC, Nowels MA, Petterson SM, Rust G, Miller BF. Not near enough: racial and ethnic disparities in access to nearby behavioral health care and primary care. J Health Care Poor Underserved 2015;26:1032–1047.
  14. Stein BD, Dick AW, Sorbero M, et al. A population-based examination of trends and disparities in medication treatment for opioid use disorders among medicaid enrollees. Subst Abus 2018;22:1–7.
  15. Scott A, Witt J, Humphreys J, et al. Getting doctors into the bush: general practitioners’ preferences for rural location. Soc Sci Med 2013;96:33–44.
  16. Salsitz E, Wiegand T. Pharmacotherapy of opioid addiction: “putting a real face on a false demon.” J Med Toxicol 2016;12:58–63. https://doi.org/10.1007/s13181-015-0517-5.
  17. Fagan EB, Gibbons C, Finnegan SC, et al. Family medicine graduate proximity to their site of training: policy options for improving the distribution of primary care access. Fam Med 2015;47:124–130.
  18. DEA Diversion Control Division. Mid level practitioners: controlled substance authority by discipline within state 2018. Available at: https://www.deadiversion.usdoj.gov/drugreg/practioners/mlp_by_state.pdf. Accessed March 4, 2019.
  19. St. Marie B, Arnstein P, Zimmer PA. Pain and opioids: call for policy action. J Nurse Pract 2018;14:40–44.
  20. O’Connor AB. Nurse practitioners’ inability to prescribe buprenorphine: limitations of the Drug Addiction Treatment Act of 2000. J Am Acad Nurse Prac 2011;23:542–545.
  21. HRSA Health Workforce. Projecting the supply and demand for primary care practitioners through 2020. Available at: https://bhw.hrsa.gov/health-workforceanalysis/primary-care-2020. Published November 2013. Accessed March 4, 2019.
  22. Jackson HJ, Lopez CM. Utilization of the nurse practitioner role to combat the opioid crisis. J Nurse Pract 2018;14:213–216.
  23. Perloff J, Clarke S, DesRoches CM, O’Reilly-Jacob M, Buerhaus P. Association of state-level restrictions in nurse practitioner scope of practice with the quality of primary care provided to Medicare beneficiaries. Med Care Res Rev 2017:1077558717732402.
  24. Buerhaus P. Nurse practitioners: a solution to America’s primary care crisis. Available at: http://www.aei.org/wp-content/uploads/2018/09/Nursepractitioners.pdf. Published September 2018.

Tags: opioids, opioid use disorder, buprenorphine

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