Allowing more NPs and PAs to prescribe buprenorphine has been a boon for rural health, boosting patient access to care and opioid care.
New laws regarding nurse practitioners (NPs) and physician assistants (PAs) prescribing buprenorphine have increased the number of clinicians authorized to administer the drug by nearly twofold in rural areas, a key step forward in improving patient access to care for opioid use disorder (OUD), according to data published in Health Affairs.
Buprenorphine is a drug used in medication-assisted treatment (MAT), seen as the gold standard in OUD treatment across the country. In contrast to other medications included in MAT, buprenorphine can be prescribed on an outpatient basis, making it easier for individuals with OUD to access care while still participating in their daily lives.
But despite the promise of these drugs, very few patients can actually access MAT. A June 2019 study published in the Annals of Internal Medicine showed that fewer than half of all OUD patients could access buprenorphine.
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The Health Affairs researchers said somewhere between 10 and 25 percent of OUD patients receive some sort of treatment, and of those patients, only 34 percent receive evidence-based treatment, or MAT.
This is largely because of a scarcity of providers who are authorized to prescribe buprenorphine, a key drug in MAT. Until 2017, physicians were the only clinicians who were allowed to prescribe buprenorphine, a limitation that was especially challenging in rural areas. In 2017, more than half of all rural regions did not have a provider who was authorized to prescribe buprenorphine.
“Barriers to accessing buprenorphine are magnified in rural areas, whose burden of opioid-related mortality is similar to that of more populous areas but that have a smaller health care workforce and fewer clinical resources,” the researchers wrote.
“An additional challenge is a shrinking workforce of primary care physicians in rural areas,” they added. “However, as these physicians have been leaving rural counties, primary care nurse practitioners (NPs) have been replacing them. The growth of NPs in the rural primary care workforce could help improve access to buprenorphine treatment, but until recently, all advanced practice providers such as NPs and physician assistants (PAs) were barred from obtaining buprenorphine waivers.”
In 2017, lawmakers sought to address physician scarcity and buprenorphine access by authorizing more providers to administer the drug. The Comprehensive Addiction and Recovery Act (CARA) created a waiver system that would allow NPs and PAs to prescribe and administer buprenorphine as a part of a MAT regimen.
This provision aimed to increase the number of clinicians prescribing the drug, ultimately making it easier for patients to actually gain access to the drug.
An assessment of federal data revealed that expanded waivers were a good step forward. Between 2016 and 2019, the number of clinicians authorized to prescribe MAT in rural areas increased by 111 percent, and NPs and PAs account for over half of that increase.
All said, nearly 12,000 NPs and PAs across the country received a buprenorphine waiver, with especially positive impacts on rural regions. NPs and PAs were the first waivered clinicians in 285 rural regions, ultimately serving 5.7 million patients.
“Though the spread of buprenorphine waivers among NPs and PAs was a national phenomenon, rural counties experienced the largest change in their workforce,” the researchers reported. “The majority of new waivered providers in rural areas in the period 2017–19 were NPs or PAs, and rural areas had by far the largest population gaining access to a clinician with a buprenorphine waiver.”
The bump in approved NP and PA prescribers may be the result of more than just the CARA. The researchers also observed a link between this influx of waivered NPs and broad scope of practice laws, or laws that outline the extent to which NPs and PAs have autonomy over their prescribing and practice.
Rural areas with broad scope of practice laws saw twice as many waivered NPs than areas with narrow laws.
The researchers did not observe the same association with PAs, likely a sign of either clinician group’s preferred specialties. While most NPs specialize in primary care and psychiatry, two areas in which clinicians usually prescribe buprenorphine, less than a quarter of PAs do the same.
More data is necessary to understand the full impact of an expanded clinician workforce authorized to prescribe buprenorphine, the researchers pointed out.
“Because our analysis did not assess prescribing, we were unable to examine the association between the change in the NP and PA workforce and prescribing of buprenorphine,” they said. “However, our results suggest that the Comprehensive Addiction and Recovery Act is having its intended effect, particularly in rural areas that had few or no clinicians with buprenorphine waivers before 2017.”
Future research may look at how many patients were actually able to access buprenorphine and MAT as a result of the CARA.
Nonetheless, these current results indicate a positive path forward for policymakers looking to address the opioid crisis.
“Patterns of waiver adoption after implementation of CARA show that the NP—and, to a more limited extent, the PA— workforce is a significant and rapidly growing resource for potentially expanding access to treatment for OUD,” the researchers concluded. “Given that NPs are more likely than physicians to treat rural, Medicaid-covered, and other vulnerable patient populations, lowering barriers for NPs to prescribe buprenorphine could improve access to buprenorphine in ways that expanded physician waivers might not achieve.”
Source: Patient Engagement Hit