Advanced Practice Nurses: Increasing Access to Opioid Treatment by Expanding the Pool of Qualified Buprenorphine Prescribers

BACKGROUND

The high toll in human suffering and economic costs due to morbidity and mortality from opioid misuse and opioid use disorders is well documented. Well-known statistics have captured the nation's attention as communities reel from opioid overdoses.^1–5 Last summer, the White House blog aptly summarized the situation: “The opioid epidemic has already brought heartbreak to too many families across the country—but we're not powerless to stop it.”⁶ Although state monitoring initiatives and the White House's Office of National Drug Control Policy (ONDCP) seek to curb the opioid epidemic through various actions (including prescription drug monitoring programs), greater efforts are needed to identify and treat people with opioid use disorders.

The US government has advocated that improving access to quality medication-assisted treatment for patients with opioid use disorders is perhaps the best means to address the opioid misuse epidemic.⁷ Since 2002, US-approved buprenorphine and buprenorphine/naloxone (hereafter buprenorphine) have been used to treat persons with opioid use disorders outside of licensed substance abuse treatment programs. The medication was approved for use by physicians with a valid Drug Enforcement Agency (DEA) license who also meet other eligibility criteria, including participation in an 8-hour training course from an approved, credentialing organization. Yet, other practitioners who hold a DEA license, notably advanced practice nurses, cannot prescribe buprenorphine, even as the benefits and cost savings of buprenorphine treatment for opioid use disorders are clear.^8–11 This past August, a bipartisan group of 13 US senators sent a letter to the Secretary of Health and Human Services, urging increased access to buprenorphine treatment in the face of the opioid epidemic, and specifically requesting consideration for nurse practitioners and physician assistants to join physicians in prescribing buprenorphine.¹²

This editorial is an appeal for all advanced practice nurses with appropriate prescriptive privileges and DEA licenses to be allowed to join physicians in prescribing buprenorphine to increase access to opioid agonist treatment and to reduce the harms associated with the opioid epidemic. Constituting a large proportion of US health care providers, advanced practice nurses can help stop this epidemic.

PUBLIC HEALTH NEEDS HAVE OUTDISTANCED ACCESS TO TREATMENT

The Drug Addiction Treatment Act of 2000 (DATA 2000) provides waiver authority for physicians to dispense and prescribe certain narcotic drugs to treat opioid use disorders,¹³ but few physicians have opted to make use of that authority. Using publicly available and restricted-use information from the National Survey on Drug Use and Health (NSDUH), researchers have estimated that in 2012 there were 2.3 million Americans aged 12 and older with opioid use disorders.¹⁴ The authors noted that in 2012, there were 16,095 physicians with a DEA waiver to prescribe buprenorphine for up to 30 patients with opioid use disorder, and an additional 6103 DATA-waived physicians with a 100-patient limit, resulting in a national buprenorphine treatment capacity of 1,093,150 patients. However, the number of patients who actually received buprenorphine in 2012 was estimated at 709,000; thus, there are significant gaps between treatment need, buprenorphine capacity, and actual buprenorphine treatment. The authors also noted that only 44% to 66% of physicians with a DATA waiver truly prescribe buprenorphine, and most do not prescribe it to the patient limit. They detailed that 48 states plus the District of Columbia had greater rates of opioid use disorder than capacity to treat with buprenorphine, and that methadone did not fill the treatment gap. These numbers reveal that less than 2% of the approximately 916,264 physicians in the United States have chosen to treat opioid dependence with buprenorphine.¹⁵ This number is clearly insufficient, more so knowing that an estimated 120 US citizens are dying daily of opioid overdose.¹⁶ Meanwhile, traditions within the substance abuse treatment industry continue to hinder progress toward medication-assisted treatment.¹⁷

The pace of growth in the buprenorphine provider pool has slowed as the opioid epidemic has worsened. Between 2008 and 2011, for example, the number of counties in the United States that had at least 1 physician waivered to prescribe buprenorphine increased only slightly from 50% to 57%.¹⁸ Researchers have suggested enhancing efforts to target communities where there is a scarcity of providers,^18–22 and they also suggest that access to buprenorphine treatment can increase if the number of qualified providers increases.²³ Advanced practice registered nurses (APRNs) with prescriptive privileges, such as nurse practitioners (NPs), clinical nurse specialists (CNS), and others, are well positioned to expand the buprenorphine provider pool.

APRNs: PREPARED TO PROVIDE HIGH-QUALITY, SAFE CARE TO PERSONS WITH OPIOID USE DISORDERS

A 2010 report from the Institute on Medicine (IOM), The Future of Nursing, emphasizes that nurses should be legally able to practice to the full extent of their education and training²⁴ and cites restrictive collaboration requirements between physicians and nurse practitioners in most states as a barrier to health care. (For a current list of APRN scope of practice by state, see the Web site of the American Association of Nurse Practitioners.²⁵) The education and scope of practice for APRNs includes prescribing medications, including controlled substances if the APRN has an independent DEA license. Making buprenorphine waivers available to qualified APRNs could make a difference in the current opioid epidemic where treatment needs—including compassionate evidence-based care and improved outcomes—are too often unmet. An example of the unmet treatment need is illustrated by research showing the relative stability over time in the number of patients receiving opioid treatment with buprenorphine,²⁶ even as morbidity and mortality from opioid use disorders has escalated.

According to the American Association of Nurse Practitioners, in 2014 there were more than 205,000 NPs in the United States,²⁷ equipping them for key roles in treating opioid use disorders. Currently 49 states and the District of Columbia allow APRNs to prescribe schedule III controlled substances, with variation by state on prescriptive rights, which role classifications can prescribe controlled substances, and whether physician collaboration is required.²⁸ APRNs are known by many titles and classifications that vary according to state license and national certification, including Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), Certified Nurse-Midwife (CNM), Certified Registered Nurse Anesthetist (CRNA), and others. A systematic review of published literature (1990 to 2008) on care provided by APRNs concluded that they provide safe and effective quality care in numerous settings, and that, in partnership with physicians and other health providers, they contribute significantly to health promotion.²⁹ The scope and standards for addiction nursing further explicates best-practice guidelines for psychosocial as well as pharmacotherapeutic interventions.³⁰

The critical contributions of nurses in buprenorphine treatment spurred the publication of the Technical Assistance Protocol, Buprenorphine: A Guide for Nurses,³¹ and recently, nursing roles in buprenorphine treatment have been the focus of research³² and quality improvement projects.³³ As the United States moves toward models that integrate behavioral health with treatment of other medical problems, the roles of generalist and advanced practice nurses will be key in improving treatment outcomes.

APRNs working in human immunodeficiency virus (HIV) care, where the patient population has a high prevalence of opioid use disorders, are very interested in prescribing buprenorphine.³⁴ Similar interest by APRNs is likely in various health care settings, including primary care, urgent and emergency care, psychiatric and mental health care, and substance use treatment programs. Thus, although APRNs care for persons with opioid use disorders, they are not able to provide the full scope of treatment to this population because federal regulation restricts their ability to prescribe buprenorphine.

There would be no significant downside or harm to allow APRNs who are interested in prescribing buprenorphine for opioid use disorder if they have prescriptive ability and possess an independent DEA license. Having more providers who are interested in treating patients with opioid use disorder (and addiction) would certainly be welcome. Nurses have long been on the front lines in hospitals, clinics, institutions, and other settings, prescribing and monitoring patient responses to controlled substances, including opioids, and helping colleagues and patients make safe use of these often necessary medications. Many APRNs already engage in every aspect of care for patients with opioid use disorder, but are not able to prescribe the medication that they are managing (with waivered physicians). The IOM's The Future of Nursing report notes “the growing body of evidence that links nursing practice to improvements in the safety and quality of care.”²⁴ It seems particularly important to keep APRN quality-of-care measures in mind given recent research showing generally poor quality of care for Medicare patients receiving buprenorphine.³⁵ If APRN experience and quality of care are already in place, then why not allow this willing and able group to prescribe and manage—and hopefully improve quality for—this needed treatment?

THERE IS NATIONAL SUPPORT FOR EXPANDING THE NUMBERS OF PRESCRIBERS OF BUPRENORPHINE

In March 2015, the US Department of Health and Human Services called for “evidence-based, bipartisan effort” focused on “prescribing practices and treatment to reduce prescription opioid and heroin use disorders.”³⁶ Three priority areas were identified: (1) Providing training and educational resources, including updated prescriber guidelines, to assist health professionals in making informed prescribing decisions and in addressing overprescribing of opioids; (2) Increasing the use of naloxone, as well as continuing to support the development and distribution of this life-saving drug to help reduce the number of deaths associated with prescription opioid and heroin overdose; and (3) Expanding the use of medication-assisted treatment (MAT) combined with counseling and behavioral therapies to treat substance use disorders.

These priorities find support in position statements of the International Nurses Society on Addictions³⁷ and the American Psychiatric Nurses Association.³⁸ The priorities are also aligned with the mission of the Association of Medical Education and Research in Substance Abuse (AMERSA): to improve health and well-being through interdisciplinary leadership in substance use education, research, clinical care and policy.³⁹ As members of these nursing and interdisciplinary professional organizations, APRNs:

• Seek to practice to the full extent of their education and training

• Recognize the need to expand capacity to address the national health problems associated with opioid use

• Are prepared to provide comprehensive care, including MAT with buprenorphine, to reduce the morbidity and mortality of opioid use

In summary, appropriately credentialed APRNs should be permitted to prescribe life-saving medications and deliver counseling and behavioral therapies for persons with opioid use disorders. By joining physician colleagues, APRNs can increase access to medication-assisted treatment and enhance their significant roles in improving the health of the nation.

ACKNOWLEDGMENTS

The authors would like to thank the Board of Directors and members of the Nursing Special Interest group of the Association for Medical Education and Research in Substance Abuse (AMERSA), including Nursing Chair Kate Driscoll Malliarakis, PhD, ANP-BC, MAC, FAAN, for their support in producing this editorial.