Buprenorphine waiver uptake among nurse practitioners and physician assistants: The role of existing waivered prescriber supply.

Buprenorphine is an effective pharmacotherapy for the treatment of opioid use disorder (OUD), but recent increases in the rate of OUD in the U.S. have outpaced the supply of clinicians waivered to prescribe buprenorphine. To increase the supply of buprenorphine prescribers, the Comprehensive Addiction and Recovery Act expanded buprenorphine prescribing waiver eligibility beyond physicians to nurse practitioners (NP) and physician assistants (PA) in 2017. Little is known about patterns of waiver uptake among NPs and PAs. This study examined associations between the existing supply of waivered prescribers and waiver uptake among NPs and PAs in U.S. states. NP and PA waiver uptake was evaluated as the number of NPs or PAs obtaining an initial buprenorphine prescribing waiver per 10,000 state residents from January 2017 to December 2018 using data from the Buprenorphine Waiver Notification System. NP and PA waiver uptake was estimated as a function of existing waivered prescriber supply, OUD treatment capacity, and other state characteristics using generalized least squares (GLS) regression. 28,010 NPs and PAs have become waivered to prescribe buprenorphine since January 2017. GLS regressions indicated that waivered prescriber supply was significantly, positively associated with both NP (b = 0.101 p < 0.001) and PA (b = 0.030, p < 0.001) waiver uptake. Results suggest an addition of ten waivered prescribers to existing supply was associated with an increase of one waivered NP, and an addition of thirty-three waivered prescribers to existing supply was associated with an increase of one waivered PA. NP and PA waiver uptake is strongly associated with the existing supply of waivered prescribers in a state, suggesting NPs and PAs may be more likely to acquire waivers in states with a high existing supply of buprenorphine prescribers. Additional policy solutions are needed to scale up the supply of buprenorphine prescribers in underserved states.

Auty SG ，Stein MD ，Walley AY ，Drainoni ML ... -  《-》

Perceptions of buprenorphine barriers and efficacy among nurse practitioners and physician assistants.

Medications for opioid use disorder (MOUDs), including methadone, buprenorphine, and naltrexone, decrease mortality and morbidity for people with opioid use disorder (OUD). Buprenorphine and methadone have the strongest evidence base among MOUDs. Unlike methadone, buprenorphine may be prescribed in office-based settings in the U.S., including by nurse practitioners (NPs) and physician assistants (PAs) who have a federal waiver and adhere to federal patient limits. Buprenorphine is underutilized nationally, particularly in rural areas, and NPs/PAs could help address this gap. Therefore, we sought to identify perceptions of buprenorphine efficacy and perceptions of prescribing barriers among NPs/PAs. We also sought to compare perceived buprenorphine efficacy and perceived prescribing barriers between waivered and non-waivered NPs/PAs, as well as to compare perceived buprenorphine efficacy to perceived naltrexone and methadone efficacy. We disseminated an online survey to a random national sample of NPs/PAs. We used Mann-Whitney U tests to compare between waivered and non-waivered respondents. We used non-parametric Friedman tests and post-hoc Wilcoxon signed-rank tests to compare perceptions of medication types. 240 respondents participated (6.5% response rate). Most respondents agreed buprenorphine is efficacious and believed counseling and peer support should complement buprenorphine. Buprenorphine was generally perceived as more efficacious than both naltrexone and methadone. Perceived buprenorphine efficacy and prescribing barriers differed by waiver status. Non-waivered practitioners were more likely than waivered practitioners to have concerns about buprenorphine affecting patient mix. Among waivered NPs/PAs, key buprenorphine prescribing barriers were insurance prior authorization and detoxification access. Our results suggest that different policies should target perceived barriers affecting waivered versus non-waivered NPs/PAs. Concerns about patient mix suggest stigmatization of patients with OUD. NP/PA education is needed about comparative medication efficaciousness, particularly regarding methadone. Even though many buprenorphine treatment patients benefits from counseling and/or peer support groups, NPs/PAs should be informed that such psychosocial treatment methods are not necessary for all buprenorphine patients.

Andraka-Christou B ，Page C ，Schoebel V ，Buche J ，Haffajee RL ... -  《-》

Prescribing Practices of Nurse Practitioners and Physician Assistants Waivered to Prescribe Buprenorphine and the Barriers They Experience Prescribing Buprenorphine.

In 2016, the Comprehensive Addiction Recovery Act permitted nurse practitioners (NPs) and physician assistants (PAs) to obtain a waiver to prescribe buprenorphine to treat opioid use disorder (OUD), with the goal of increasing access to this treatment. This study's purpose was to describe the buprenorphine prescribing practices of NPs and PAs and compare the barriers rural and urban providers face delivering treatment. From the October 2018 Drug Enforcement Administration list of providers with the waiver to prescribe buprenorphine, all rural NPs and PAs (1,057) and a random sample of 500 urban NPs and PAs were surveyed. The questionnaire queried respondents about demographics, prescribing practices, practice characteristics, reimbursement policies, and barriers to prescribing buprenorphine to treat OUD. Of the waivered NPs and PAs, 80.3% reported having prescribed buprenorphine and 71.1% said they were currently accepting new patients with OUD. Providers with the 30-patient waiver were treating, on average, 13.2 patients; 37.0% were not treating any patients. The most common barrier, cited by half of providers, was concerns about diversion/medication misuse. More rural providers indicated lack of specialty backup and mental health providers as a barrier than urban providers. Never-prescribers and former-prescribers reported 6 barriers at significantly higher rates than did current prescribers. More rural providers accepted Medicaid and cash reimbursement than urban providers. NPs and PAs face many of the same barriers to providing buprenorphine as physicians have reported. Interventions to address these barriers have the potential to benefit all providers with the waiver to prescribe buprenorphine.

Andrilla CHA ，Jones KC ，Patterson DG 《-》

Beyond state scope of practice laws for advanced practitioners: Additional supervision requirements for buprenorphine prescribing.

Buprenorphine is a life-saving medication for people with opioid use disorder (OUD). U.S. federal law allows advanced practice clinicians (APCs), such as nurse practitioners (NPs) and physician assistants (PAs), to obtain a federal waiver to prescribe buprenorphine in office-based practices. However, states regulate APCs' scope of practice (SOP) variously, including requirements for physician supervision. States may also have laws entirely banning NP/PA buprenorphine prescribing or requiring that supervising physicians have a federal waiver to prescribe buprenorphine. We sought to identify prevalence of state laws other than SOP laws that either 1) prohibit NP/PA buprenorphine prescribing entirely, or 2) require supervision by a federally waivered physician. We searched for state statutes and regulations in all 50 states and Washington D.C. regulating prescribing of buprenorphine for OUD by APCs during summer 2021. We excluded general scope of practice laws, laws only applicable to Medicaid-funded clinicians, laws not applicable to substance use disorder (SUD) treatment, and laws only applicable to NPs/PAs serving licensed SUD treatment facilities. We then conducted content analysis. One state prohibits all APCs from prescribing buprenorphine for OUD, even though the state's general SOP laws permit APC buprenorphine prescribing. Five states require PA supervision by a federally waivered physician. Three states require NP supervision by a federally waivered physician. Aside from general scope of practice laws, several states have created laws explicitly regulating buprenorphine prescribing by APCs outside of licensed state SUD facilities.

Andraka-Christou B ，Gordon AJ ，Spetz J ，Totaram R ，Golan M ，Randall-Kosich O ，Harrison J ，Calder S ，Kertesz SG ，Stein BD ... -  《-》

In Rural Areas, Buprenorphine Waiver Adoption Since 2017 Driven By Nurse Practitioners And Physician Assistants.

Barnett ML ，Lee D ，Frank RG 《-》