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Buprenorphine Prescribing by Nurse Practitioners: Background, Barriers, Facilitators, & Future

Directions

Chandra Speight, PhD, RN, NP-C, CNEASPMN

January 20, 2021

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Target Audience

• The overarching goal of PCSS is to train a diverse range of healthcare professionals in the safe and effective prescribing of opioid medications for the treatment of pain, as well as the treatment of substance use disorders, particularly opioid use disorders, with medication-assisted treatments.

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Outline

• Opioid Use Disorder

• Medication Assisted Treatment and Rural Areas

• Buprenorphine Regulation

• Access Disparities

• Physician Barriers and Facilitators

• Nurse Practitioner Barriers and Facilitators

• Future Directions

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Educational Objectives

• At the conclusion of this activity participants should be able to:

Describe the role of buprenorphine-naloxone in treating individuals living with opioid use disorder in rural areas

Analyze policies that impact buprenorphine prescribing

Describe barriers and facilitators to buprenorphine prescribing

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Opioid Use Disorder in Rural Regions

• Public Health Crisis

• Geographic Disparities

• Rural South

https://time.com/magazine/us/5170229/march-5th-2018-vol-191-no-9-u-s/

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Medication Assisted Therapy

• Methadone

• Naltrexone

• Buprenorphine-Naloxone

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Buprenorphine Prescribing Policy

• DATA (2000) Drug Addiction Treatment Act

Included physicians not specialized in addiction medicine

DEA-X

8 hour education requirement

Buprenorphine-naloxone FDA approved (2002)

30 patients/practice

− Increased to 30/provider in 2005

Prohibited PA and NP prescribing

Estimated treatment gap >1.5 million (2006)

Issues: MDs not obtaining waivers, waivered MDs not prescribing, waivered MDs under-prescribing, increase NP/PA in primary care

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Buprenorphine Prescribing Policy

• CARA (2016) Comprehensive Addiction and Recovery Act

Extended prescribing to NPs and PAs

24 hour education requirement

30 pt limit for 1 year

Can apply for 100 pt waiver after 1 year

Was to expire October 1, 2021

• DATA (2016 amendment) Increased MD patient limit to 275

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Buprenorphine Prescribing Policy

• SUPPORT (2018) Substance Use-Disorder Prevention that Promotes Opioid

Recovery and Treatment for Patients and Communities Act

Overrode CARA (was to expire October 1, 2021)

Extended prescribing to CNSs, CNMs, CRNAs

Increased pt limit for Advanced Practice Providers (APPs)

Some APPs can immediately apply for 100 pt waivers

After 1 year with 100 year wavier, some MDs and APPs can apply for 275 pt waiver

Expires October 1, 2023

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Self-Check

Describe three qualities that

make buprenorphine-

naloxone therapy

particularly suitable for

those living in rural areas?

Photo credit: Chandra Speight. Image may not be used without permission.

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Self-Check

What legislation permitted

advanced practice providers

such as physician assistants

and nurse practitioners to

apply for buprenorphine

prescribing waivers?

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Access Disparities

• Rural areas disproportionally impacted by opioid crisis

• 1/3 rural Americans in county with no waivered prescriber

• Many waivered do not prescribe or under-prescribe

• Who delivers primary care in rural areas?

• Federal policy complicated by state restrictions NP practice

Photo credit: Chandra Speight. Image may not be used without permission.

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Case Study: Eastern North Carolina

Brunswick

Columbus

Robeson BladenPender

Scotland

HokeCumberland

SampsonDuplin

Onslow

Jones

Lenoir

Wayne

Johnston

Wilson

Harnett

Nash

Halifax

Edgecombe

Pitt

Greene

Northampton

Hertford

Gates

Martin

Bertie

Carteret

Craven

Pamlico

BeaufortHyde

DareTyrrell

Washington

NewHanover

Chow

an

Perquimans

Pasquotank

Cam

denCurrituck

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Self-Check

What is the maximum number of patients experiencing opioid use disorder a physician can treat with buprenorphine-naloxone therapy?

What is the maximum number of patientsexperiencing opioid use disorder an advanced practice provider can treat with buprenorphine-naloxone therapy?

Does federal law alone affect a nursepractitioner’s prescribing eligibility?

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What factors account for provider shortages

and access disparities?

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Physician Barriers

• Regulation

• Reimbursement & patient cost

• Perceived demand

• Organizational & external support

• Medication access

• Education & training

• Perceived intrusion

• Addiction stigma

Patient stigma Provider stigma

Medication stigma

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Physician Facilitators

• Mentorship

• Patient contracts

• Patient limits

• Organizational support

• Reward

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Advanced Practice Provider Barriers and Facilitators

• Limited inquiry into APP prescribing

• Regulation of APPs differs from physician regulation

• Regulation variation among APP providers

• Data from interviews with NPs practicing in primary care settings in eastern North Carolina

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Nurse Practitioner Barriers

• Environmental Context and Resources

− Resource poor environments

− Regulatory restrictions, education requirements

• Social Influences

− Stigma

– Medication Stigma

– Patient Stigma

– Provider to Provider Stigma

• Beliefs about Consequences

− Prescribing as a prescription?

• Beliefs about Capabilities

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Nurse Practitioner Facilitators

• Environmental Context and Resources

• Reward

• Professional Role Identity

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Future Directions

• Research

• Policy

• Practice and

Education

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Questions

•

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References

• Andraka-Christou, B., & Capone, M. J. (2018). A qualitative study comparing physician-reported barriers to treating addiction using buprenorphine and extended-release naltrexone in U.S. office-based practices. International Journal of Drug Policy, 54, 9-17. doi:10.1016/j.drugpo.2017.11.021

• Andrilla, C. H., Coulthard, C., & Larson, E. H. (2017). Barriers rural physicians face prescribing buprenorphine for opioid use disorder. Annals of Family Medicine, 15(4), 359-362. doi:10.1370/afm.2099

• Andrilla, C. H., Coulthard, C., & Patterson, D. G. (2018). Prescribing practices of rural physicians waivered to prescribe buprenorphine. American Journal of Preventive Medicine, 54(6), S208-S214. doi:10.1016/j.amepre.2018.02.006

• Andrilla, C. H., Moore, T. E., & Patterson, D. G. (2019). Overcoming barriers to prescribing buprenorphine for the treatment of opioid use disorder: Recommendations from rural physicians.The Journal of Rural Health, 35(1), 113-121. doi:10.1111/jrh.12328

• Andrilla, C. H., Moore, T. E., Patterson, D. G., & Larson, E. H. (2019). Geographic distribution of providers with a DEA waiver to prescribe buprenorphine for the treatment of opioid use disorder: A 5‐Year update. The Journal of Rural Health, 35(1), 108-112. doi:10.1111/jrh.12307

• Andrilla, C. H., Patterson, D. G., Moore, T. E., Coulthard, C., & Larson, E. H. (2018). Projected contributions of nurse practitioners and physicians [sic] assistants to buprenorphine treatment services for opioid use disorder in rural areas. Medical Care Research and Review,1-16. doi:10.1177/1077558718793070

• Arfken, C. L., Johanson, C., di Menza, S., & Schuster, C. R. (2010). Expanding treatment capacity for opioid dependence with office-based treatment with buprenorphine: National surveys of physicians. Journal of Substance Abuse Treatment, 39(2), 96-104. doi:10.1016/j.jsat.2010.05.004

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References

• Buerhaus, P. I., DesRoches, C. M., Dittus, R., & Donelan, K. (2015). Practice characteristics of primary care nurse practitioners and physicians. Nursing Outlook, 63(2), 144-153. doi:10.1016/j.outlook.2014.08.008

• Cohen, M. (2019, January). Vision for improving health in North Carolina. Paper presented at Rural Health Symposium, East Carolina Area Health Education Center, Greenville, NC.

• Fornili, K. S., & Burda, C. (2009). Buprenorphine prescribing: Why physicians aren't and nurse prescribers can't.Journal of Addictions Nursing, 20(4), 218-226. doi:10.3109/10884600903290424

• Fornili, K. S., & Fogger, S. A. (2017). Nurse practitioner prescriptive authority for buprenorphine: From DATA 2000 to CARA 2016. Journal of Addictions Nursing, 28(1), 43-48. doi:10.1097/JAN.0000000000000160

• Huhn, A. S., & Dunn, K. E. (2017). Why aren't physicians prescribing more buprenorphine? Journal of Substance Abuse Treatment, 78, 1-7. doi:10.1016/j.jsat.2017.04.005

• Hutchinson, E., Catlin, M., Andrilla, C. H., Baldwin, L., & Rosenblatt, R. A. (2014). Barriers to primary care physicians prescribing buprenorphine. Annals of Family Medicine, 12(2), 128-133. doi:10.1370/afm.1595

• Jones, C. M., Campopiano, M., Baldwin, G., & McCance-Katz, E. (2015). National and state treatment need and capacity for opioid agonist medication-assisted treatment. American Journal of Public Health, 105(8), e55-e63. doi:10.2105/AJPH.2015.302664

• Jones, C. M., & McCance-Katz, E. F. (2018). Characteristics and prescribing practices of clinicians recently waivered to prescribe buprenorphine for the treatment of opioid use disorder. Addiction, 114, 471-482. doi:10.1111/add.14436

• Jones, C. W., Christman, Z., Smith, C. M., Safferman, M. R., Salzman, M., Baston, K., & Haroz, R. (2018). Comparison between buprenorphine provider availability and opioid deaths among US counties. Journal of Substance Abuse Treatment, 93, 19-25. doi:10.1016/j.jsat.2018.07.008

• Jones, E. B. (2018). Medication‐assisted opioid treatment prescribers in federally qualified health centers: Capacity lags in rural areas. The Journal of Rural Health, 34(1), 14-22. doi:10.1111/jrh.12260

• Kermack, A., Flannery, M., Tofighi, B., McNeely, J., & Lee, J. D. (2017). Buprenorphine prescribing practice trends and attitudes among New York providers. Journal of Substance Abuse Treatment, 74, 1-6. doi:10.1016/j.jsat.2016.10.005

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References

• Knopf, T. (2017). Four North Carolina cities make top 25 list for opioid abuse. North Carolina Health News. Retrieved from https://www.northcarolinahealthnews.org/2017/07/27/four-north-carolina-cities-make-top-25-list-opioid-abuse/

• Knudsen, H. K., Havens, J. R., Lofwall, M. R., Studts, J. L., & Walsh, S. L. (2017). Buprenorphine

physician supply: Relationship with state-level prescription opioid mortality. Drug and Alcohol Dependence, 173(Suppl 1), S55-S64. doi:10.1016/j.drugalcdep.2016.08.642

• Lin, L., & Knudsen, H. K. (2019). Comparing buprenorphine-prescribing physicians across nonmetropolitan and metropolitan areas in the United States. Annals of Family Medicine, 17(3), 212-220. doi:10.1370/afm.2384

• McCarty, D., Rieckmann, T., Green, C., Gallon, S., & Knudsen, J. (2004). Training rural practitioners to

use buprenorphine. Journal of Substance Abuse Treatment, 26(3), 203-208. doi:10.1016/S0740-5472(03)00247-2

• Mendoza, S., Rivera-Cabrero, A. S., & Hansen, H. (2016). Shifting blame: buprenorphine prescribers, addiction treatment, and prescription monitoring in middle-class America. Transcultural Psychology 53(4), 465-487. doi:10.1177/1363461516660884

• Moore, D. J. (2019). Nurse practitioners’ pivotal role in ending the opioid epidemic. The Journal for

Nurse Practitioners, 15(5), 323-327. doi:10.1016/j.nurpra.2019.01.005• Oliva, E. M., Trafton, J. A., Harris, A. H., & Gordon, A. J. (2013). Trends in opioid agonist therapy in

the Veterans Health Administration: Is supply keeping up with demand? The American Journal of Drug and Alcohol Abuse, 39(2), 103-107. doi:10.3109/00952990.2012.741167

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References

• Rosenblatt, R. A., Andrilla, C. H., Catlin, M., & Larson, E. H. (2015). Geographic and specialty distribution of US physicians trained to treat opioid use disorder. Annals of Family Medicine, 13(1), 23-26. doi:10.1370/afm.1735

• Solberg, H., & Naden, D. (2020). It is just that people treat you like a human being: The meaning of

dignity for patients with substance use disorders. Journal of Clinical Nursing, 29, 480-491. doi:10.111/jocn.15108

• Spetz, J., Toretsky, C., Chapman, S., Phoenix, B., & Tierney, M. (2019). Nurse practitioner and physician assistant waivers to prescribe buprenorphine and state scope of practice restrictions. Journal of the American Medical Association, 321(14), 1407-1408. doi:10.1001/jama.2019.0834

• Stein, B. D., Pacula, R. L., Gordon, A. J., Burns, R. M., Leslie, D. L., Sorbero, M. J., . . . Dick, A. W.

(2015). 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. The Milbank Quarterly, 93(3), 561-583. doi:10.1111/1468-0009.12137

• Storholm, E. D., Ober, A. J., Hunter, S. B., Becker, K. M., Iyiewuare, P. O., Pham, C., & Watkins, K. E. (2017). Barriers to integrating the continuum of care for opioid and alcohol use disorders in primary care: A qualitative longitudinal study. Journal of Substance Abuse Treatment, 83, 45-54.

doi:10.1016/j.jsat.

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References

• Substance Abuse and Mental Health Services Administration. (n.d.-a). Buprenorphine practitioner locator. Retrieved from https://www.samhsa.gov/medication-assisted-treatment/practitioner-program-data/treatment-practitioner-locator

• Substance Abuse and Mental Health Services Administration. (n.d.-b). Understanding the final rule for

a patient limit of 275. Retrieved from https://www.samhsa.gov/sites/default/files/• programs_campaigns/medication_assisted/understanding-patient-limit275.pdf• Substance Abuse and Mental Health Services Administration. (2006). The SAMHSA evaluation of the

impact of the DATA waiver program. Summary report. Retrieved from https://www.samhsa.gov/sites/default/files/programs_campaigns/medication_assisted/evaluation-impact-data-waiver-program-summary.pdf

• Thomas, C. P., Doyle, E., Kreiner, P. W., Jones, C. M., Dubenitz, J., Horan, A., & Stein, B. D. (2017). Prescribing patterns of buprenorphine waivered physicians. Drug and Alcohol Dependence, 181, 213-218. doi:10.1016/j.drugalcdep.2017.10.002

• White, K. A. (2018). Exploring the perspectives and experiences of physicians in WV who prescribe medication-assisted treatment (MAT) to patients with opioid use disorder (OUD) (Doctoral dissertation). Retrieved from Proquest Dissertations and Theses Global (Order No. 13423444).

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PCSS Mentoring Program

PCSS Mentor Program is designed to offer general information to

clinicians about evidence-based clinical practices in prescribing

medications for opioid addiction.

PCSS Mentors are a national network of providers with expertise in addictions, pain, evidence-based treatment including medication-

assisted treatment.

• 3-tiered approach allows every mentor/mentee relationship to be unique and catered to the specific needs of the mentee.

• No cost.

For more information visit:

pcssnow.org/mentoring

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PCSS Discussion Forum

Have a clinical question?

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American Academy of Family Physicians American Psychiatric Association

American Academy of Neurology American Society of Addiction Medicine

Addiction Technology Transfer Center American Society of Pain Management Nursing

American Academy of Pain Medicine Association for Medical Education and Research in Substance Abuse

American Academy of Pediatrics International Nurses Society on Addictions

American College of Emergency Physicians American Psychiatric Nurses Association

American College of Physicians National Association of Community Health Centers

American Dental Association National Association of Drug Court Professionals

American Medical Association Southeastern Consortium for Substance Abuse Training

American Osteopathic Academy of Addiction Medicine

PCSS is a collaborative effort led by the American Academy of Addiction

Psychiatry (AAAP) in partnership with:

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Educate. Train. Mentor

www.pcssNOW.org

pcss@aaap.org

@PCSSProjects

www.facebook.com/pcssprojects/

Funding for this initiative was made possible (in part) by grant no. 1H79TI081968 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

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