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Nurse practitioners and physician assistants, rather than physicians, are the clinicians who have boosted capacity for buprenorphine prescribing in rural America, according to a study in a rural health–focused issue of the journal Health Affairs.
In the face of an ongoing crisis of opioid use disorder, and associated overdoses and deaths that have spared no sector of the U.S. population, the federal government expanded its waiver program for buprenorphine prescribing in 2017. The waiver expansion allows nurse practitioners (NPs) and physician assistants (PAs) – along with clinical nurse specialists, certified registered nurse anesthetists, and certified nurse-midwives – to use the drug for medication-assisted treatment (MAT) for opioid use disorder after completing 24 hours of mandated training; physicians are required to complete 8 hours of training to receive their waiver.
From 2016 to 2019, capacity for MAT in rural areas increased, with the number of clinicians with buprenorphine waivers more than doubling. Of the newly waivered prescribers accounting for this 111% increase, more than half were NPs and PAs.
In many areas, NPs and PAs led the way forward, wrote the study’s lead author Michael L. Barnett, MD, and coauthors, noting in the abstract accompanying the paper that “NPs and PAs accounted for more than half of this increase and were the first waivered clinicians in 285 rural counties with 5.7 million residents.” Overall, the proportion of people living in a county without a waivered clinician has decreased by 36% since NPs and PAs were permitted to obtain waivers.
SAMHSA data identifies trends
In an in-depth interview, Dr. Barnett, an internal medicine physician and health services researcher at the Harvard School of Public Health, Boston, said the issue today is “not so much continuing to dissect the risks and benefits of opioids as a treatment for pain, but more trying to address the current overdose crisis, and the fact that our patient treatment infrastructure is woefully inadequate for the magnitude of the problem that we face.”
Dr. Barnett’s chief intention for this study, he said, was to generate information that will drive policy to implement effective opioid treatment. He’d always been interested in models of care delivery that move beyond seeing just the physician-patient dyad.
“There are a whole range of nonphysician providers that are probably better at providing many different types of care – things that physicians aren’t necessarily that well trained to do,” he said.
Expansion of buprenorphine waivers to NPs and PAs, said Dr. Barnett, presented “a very interesting opportunity to see: How does a nonphysician workforce respond to a new practice opportunity, to really be engaged in areas that many physicians really were neglecting?”
The researchers used information drawn from what Dr. Barnett characterized as a “gold-standard” dataset maintained by the federal Substance Abuse and Mental Health Services Administration. They found that, by March 2019, 52% of U.S. rural residents lived in counties with at least one NP or PA holding a buprenorphine waiver, though there was wide geographic variation: Every county in Maine and New Hampshire had waivered NPs or PAs, but in Tennessee, just 3 of 95 counties had an NP or PA with a waiver.
Scope-of-practice regulations matter
The scope of practice permitted NPs and PAs varies by state, and Dr. Barnett and coauthors also looked to see whether broader scope of practice meant that more advanced practice clinicians were getting buprenorphine waivers. This did appear to be the case: In an analysis that dichotomized scope of practice into “broad” and “restricted,” states with broader practice scope saw twice as many waivered NPs per 100,000 rural residents as those with restrictive practice scope. This association was not seen for PAs, but Dr. Barnett pointed out that PAs are less likely overall to work in primary care.
This, he added, is where scope of practice starts to matter. “A lot of states are still bickering about scope of practice. We show in our paper the clear relationship between scope of practice and the degree to which providers are able to take up these waivers. We can’t prove causality, but I think it’s not a big stretch to think that these policies are playing a big role. I hope we’re working to try to advance that conversation.”
Helping address the unmet need for evidence-based treatment of opioid use disorder, he said, “is one of the more important examples, because doctors have been leaving rural areas in droves. We are lucky that there is a workforce of NPs that still seem to recognize the market opportunity; rural areas still need providers, and they have been willing to fill the gap.”
Waivered NPs or PAs can apply for an expanded waiver, permitting expansion of the buprenorphine panel from 30 to 100 patients after 1 year of holding their initial waiver. Physicians may apply for a waiver to treat up to 275 patients.
Effect on quality of care
The evidence doesn’t support big worries about quality of care, he said. “We don’t have any data on this in the clinical context of addiction, but all of the data that are out there in terms of evaluating the quality of care and level of care being offered by NPs and PAs versus primary care doctors – the types of things that we think of as within the scope of NP and PA practice typically – have shown that they are the same.” Dr. Barnett acknowledged that “there are a little bit of mixed results here and there in one direction or another, but largely, the care being delivered is much more the same than different.”
In addressing the opioid crisis as in the rest of medicine, it’s a mistake not to include this sector of the health care workforce when policies are being crafted, said Dr. Barnett. “People who are making policy and aren’t familiar with the workforce in rural areas could miss the boat. ... NPs aren’t just an asterisk to the workforce – they are an essential part of delivering medicine, just as much as physicians are.”
Dr. Barnett said that, in his estimation, “a lot of protectionist myths get physicians worked up around increased scope of practice for NPs.” However, “The truth is that there’s enough health care spending to go around for everybody and there’s plenty of work to go around.”
Dr. Barnett acknowledged that the current study captured only prescribing capacity, and not actual prescription volume. But, based on some preliminary data, “my sense is that NPs and PAs who acquire waivers are more likely to be prescribing to a larger number of patients proportionately than MDs.” He wasn’t surprised to see this, since the many more hours of training required for NPs and PAs to acquire a waiver means they’re likely to be committed to using the waiver in practice.
Stepping back to look at the bigger picture, Dr. Barnett remarked that, “taking a look at the waiver requirement, a part of me feels that it’s a bit of an anachronistic regulation, anyway – it’s really hard to justify clinically or ethically versus other things that we do.” The waiver program he said, is “a regulation barrier whose time should be limited. ... I’m hoping that the waiver disappears soon.”
Prescribing issues will linger beyond any future abolition of the waiver program, since many clinicians will still not be comfortable prescribing medication for MAT of opioid use disorder, said Dr. Barnett. “It’ll be a lot of the same stigma and structural barriers that were in place prior to the waiver.”
Dr. Barnett reported that he has been retained as an expert witness for plaintiffs in lawsuits against opioid manufacturers. The study was partly funded by the National Institutes of Health.
SOURCE: Barnett ML et al. Health Aff. 2019 Jan;38(12):2048-56.
Nurse practitioners and physician assistants, rather than physicians, are the clinicians who have boosted capacity for buprenorphine prescribing in rural America, according to a study in a rural health–focused issue of the journal Health Affairs.
In the face of an ongoing crisis of opioid use disorder, and associated overdoses and deaths that have spared no sector of the U.S. population, the federal government expanded its waiver program for buprenorphine prescribing in 2017. The waiver expansion allows nurse practitioners (NPs) and physician assistants (PAs) – along with clinical nurse specialists, certified registered nurse anesthetists, and certified nurse-midwives – to use the drug for medication-assisted treatment (MAT) for opioid use disorder after completing 24 hours of mandated training; physicians are required to complete 8 hours of training to receive their waiver.
From 2016 to 2019, capacity for MAT in rural areas increased, with the number of clinicians with buprenorphine waivers more than doubling. Of the newly waivered prescribers accounting for this 111% increase, more than half were NPs and PAs.
In many areas, NPs and PAs led the way forward, wrote the study’s lead author Michael L. Barnett, MD, and coauthors, noting in the abstract accompanying the paper that “NPs and PAs accounted for more than half of this increase and were the first waivered clinicians in 285 rural counties with 5.7 million residents.” Overall, the proportion of people living in a county without a waivered clinician has decreased by 36% since NPs and PAs were permitted to obtain waivers.
SAMHSA data identifies trends
In an in-depth interview, Dr. Barnett, an internal medicine physician and health services researcher at the Harvard School of Public Health, Boston, said the issue today is “not so much continuing to dissect the risks and benefits of opioids as a treatment for pain, but more trying to address the current overdose crisis, and the fact that our patient treatment infrastructure is woefully inadequate for the magnitude of the problem that we face.”
Dr. Barnett’s chief intention for this study, he said, was to generate information that will drive policy to implement effective opioid treatment. He’d always been interested in models of care delivery that move beyond seeing just the physician-patient dyad.
“There are a whole range of nonphysician providers that are probably better at providing many different types of care – things that physicians aren’t necessarily that well trained to do,” he said.
Expansion of buprenorphine waivers to NPs and PAs, said Dr. Barnett, presented “a very interesting opportunity to see: How does a nonphysician workforce respond to a new practice opportunity, to really be engaged in areas that many physicians really were neglecting?”
The researchers used information drawn from what Dr. Barnett characterized as a “gold-standard” dataset maintained by the federal Substance Abuse and Mental Health Services Administration. They found that, by March 2019, 52% of U.S. rural residents lived in counties with at least one NP or PA holding a buprenorphine waiver, though there was wide geographic variation: Every county in Maine and New Hampshire had waivered NPs or PAs, but in Tennessee, just 3 of 95 counties had an NP or PA with a waiver.
Scope-of-practice regulations matter
The scope of practice permitted NPs and PAs varies by state, and Dr. Barnett and coauthors also looked to see whether broader scope of practice meant that more advanced practice clinicians were getting buprenorphine waivers. This did appear to be the case: In an analysis that dichotomized scope of practice into “broad” and “restricted,” states with broader practice scope saw twice as many waivered NPs per 100,000 rural residents as those with restrictive practice scope. This association was not seen for PAs, but Dr. Barnett pointed out that PAs are less likely overall to work in primary care.
This, he added, is where scope of practice starts to matter. “A lot of states are still bickering about scope of practice. We show in our paper the clear relationship between scope of practice and the degree to which providers are able to take up these waivers. We can’t prove causality, but I think it’s not a big stretch to think that these policies are playing a big role. I hope we’re working to try to advance that conversation.”
Helping address the unmet need for evidence-based treatment of opioid use disorder, he said, “is one of the more important examples, because doctors have been leaving rural areas in droves. We are lucky that there is a workforce of NPs that still seem to recognize the market opportunity; rural areas still need providers, and they have been willing to fill the gap.”
Waivered NPs or PAs can apply for an expanded waiver, permitting expansion of the buprenorphine panel from 30 to 100 patients after 1 year of holding their initial waiver. Physicians may apply for a waiver to treat up to 275 patients.
Effect on quality of care
The evidence doesn’t support big worries about quality of care, he said. “We don’t have any data on this in the clinical context of addiction, but all of the data that are out there in terms of evaluating the quality of care and level of care being offered by NPs and PAs versus primary care doctors – the types of things that we think of as within the scope of NP and PA practice typically – have shown that they are the same.” Dr. Barnett acknowledged that “there are a little bit of mixed results here and there in one direction or another, but largely, the care being delivered is much more the same than different.”
In addressing the opioid crisis as in the rest of medicine, it’s a mistake not to include this sector of the health care workforce when policies are being crafted, said Dr. Barnett. “People who are making policy and aren’t familiar with the workforce in rural areas could miss the boat. ... NPs aren’t just an asterisk to the workforce – they are an essential part of delivering medicine, just as much as physicians are.”
Dr. Barnett said that, in his estimation, “a lot of protectionist myths get physicians worked up around increased scope of practice for NPs.” However, “The truth is that there’s enough health care spending to go around for everybody and there’s plenty of work to go around.”
Dr. Barnett acknowledged that the current study captured only prescribing capacity, and not actual prescription volume. But, based on some preliminary data, “my sense is that NPs and PAs who acquire waivers are more likely to be prescribing to a larger number of patients proportionately than MDs.” He wasn’t surprised to see this, since the many more hours of training required for NPs and PAs to acquire a waiver means they’re likely to be committed to using the waiver in practice.
Stepping back to look at the bigger picture, Dr. Barnett remarked that, “taking a look at the waiver requirement, a part of me feels that it’s a bit of an anachronistic regulation, anyway – it’s really hard to justify clinically or ethically versus other things that we do.” The waiver program he said, is “a regulation barrier whose time should be limited. ... I’m hoping that the waiver disappears soon.”
Prescribing issues will linger beyond any future abolition of the waiver program, since many clinicians will still not be comfortable prescribing medication for MAT of opioid use disorder, said Dr. Barnett. “It’ll be a lot of the same stigma and structural barriers that were in place prior to the waiver.”
Dr. Barnett reported that he has been retained as an expert witness for plaintiffs in lawsuits against opioid manufacturers. The study was partly funded by the National Institutes of Health.
SOURCE: Barnett ML et al. Health Aff. 2019 Jan;38(12):2048-56.
Nurse practitioners and physician assistants, rather than physicians, are the clinicians who have boosted capacity for buprenorphine prescribing in rural America, according to a study in a rural health–focused issue of the journal Health Affairs.
In the face of an ongoing crisis of opioid use disorder, and associated overdoses and deaths that have spared no sector of the U.S. population, the federal government expanded its waiver program for buprenorphine prescribing in 2017. The waiver expansion allows nurse practitioners (NPs) and physician assistants (PAs) – along with clinical nurse specialists, certified registered nurse anesthetists, and certified nurse-midwives – to use the drug for medication-assisted treatment (MAT) for opioid use disorder after completing 24 hours of mandated training; physicians are required to complete 8 hours of training to receive their waiver.
From 2016 to 2019, capacity for MAT in rural areas increased, with the number of clinicians with buprenorphine waivers more than doubling. Of the newly waivered prescribers accounting for this 111% increase, more than half were NPs and PAs.
In many areas, NPs and PAs led the way forward, wrote the study’s lead author Michael L. Barnett, MD, and coauthors, noting in the abstract accompanying the paper that “NPs and PAs accounted for more than half of this increase and were the first waivered clinicians in 285 rural counties with 5.7 million residents.” Overall, the proportion of people living in a county without a waivered clinician has decreased by 36% since NPs and PAs were permitted to obtain waivers.
SAMHSA data identifies trends
In an in-depth interview, Dr. Barnett, an internal medicine physician and health services researcher at the Harvard School of Public Health, Boston, said the issue today is “not so much continuing to dissect the risks and benefits of opioids as a treatment for pain, but more trying to address the current overdose crisis, and the fact that our patient treatment infrastructure is woefully inadequate for the magnitude of the problem that we face.”
Dr. Barnett’s chief intention for this study, he said, was to generate information that will drive policy to implement effective opioid treatment. He’d always been interested in models of care delivery that move beyond seeing just the physician-patient dyad.
“There are a whole range of nonphysician providers that are probably better at providing many different types of care – things that physicians aren’t necessarily that well trained to do,” he said.
Expansion of buprenorphine waivers to NPs and PAs, said Dr. Barnett, presented “a very interesting opportunity to see: How does a nonphysician workforce respond to a new practice opportunity, to really be engaged in areas that many physicians really were neglecting?”
The researchers used information drawn from what Dr. Barnett characterized as a “gold-standard” dataset maintained by the federal Substance Abuse and Mental Health Services Administration. They found that, by March 2019, 52% of U.S. rural residents lived in counties with at least one NP or PA holding a buprenorphine waiver, though there was wide geographic variation: Every county in Maine and New Hampshire had waivered NPs or PAs, but in Tennessee, just 3 of 95 counties had an NP or PA with a waiver.
Scope-of-practice regulations matter
The scope of practice permitted NPs and PAs varies by state, and Dr. Barnett and coauthors also looked to see whether broader scope of practice meant that more advanced practice clinicians were getting buprenorphine waivers. This did appear to be the case: In an analysis that dichotomized scope of practice into “broad” and “restricted,” states with broader practice scope saw twice as many waivered NPs per 100,000 rural residents as those with restrictive practice scope. This association was not seen for PAs, but Dr. Barnett pointed out that PAs are less likely overall to work in primary care.
This, he added, is where scope of practice starts to matter. “A lot of states are still bickering about scope of practice. We show in our paper the clear relationship between scope of practice and the degree to which providers are able to take up these waivers. We can’t prove causality, but I think it’s not a big stretch to think that these policies are playing a big role. I hope we’re working to try to advance that conversation.”
Helping address the unmet need for evidence-based treatment of opioid use disorder, he said, “is one of the more important examples, because doctors have been leaving rural areas in droves. We are lucky that there is a workforce of NPs that still seem to recognize the market opportunity; rural areas still need providers, and they have been willing to fill the gap.”
Waivered NPs or PAs can apply for an expanded waiver, permitting expansion of the buprenorphine panel from 30 to 100 patients after 1 year of holding their initial waiver. Physicians may apply for a waiver to treat up to 275 patients.
Effect on quality of care
The evidence doesn’t support big worries about quality of care, he said. “We don’t have any data on this in the clinical context of addiction, but all of the data that are out there in terms of evaluating the quality of care and level of care being offered by NPs and PAs versus primary care doctors – the types of things that we think of as within the scope of NP and PA practice typically – have shown that they are the same.” Dr. Barnett acknowledged that “there are a little bit of mixed results here and there in one direction or another, but largely, the care being delivered is much more the same than different.”
In addressing the opioid crisis as in the rest of medicine, it’s a mistake not to include this sector of the health care workforce when policies are being crafted, said Dr. Barnett. “People who are making policy and aren’t familiar with the workforce in rural areas could miss the boat. ... NPs aren’t just an asterisk to the workforce – they are an essential part of delivering medicine, just as much as physicians are.”
Dr. Barnett said that, in his estimation, “a lot of protectionist myths get physicians worked up around increased scope of practice for NPs.” However, “The truth is that there’s enough health care spending to go around for everybody and there’s plenty of work to go around.”
Dr. Barnett acknowledged that the current study captured only prescribing capacity, and not actual prescription volume. But, based on some preliminary data, “my sense is that NPs and PAs who acquire waivers are more likely to be prescribing to a larger number of patients proportionately than MDs.” He wasn’t surprised to see this, since the many more hours of training required for NPs and PAs to acquire a waiver means they’re likely to be committed to using the waiver in practice.
Stepping back to look at the bigger picture, Dr. Barnett remarked that, “taking a look at the waiver requirement, a part of me feels that it’s a bit of an anachronistic regulation, anyway – it’s really hard to justify clinically or ethically versus other things that we do.” The waiver program he said, is “a regulation barrier whose time should be limited. ... I’m hoping that the waiver disappears soon.”
Prescribing issues will linger beyond any future abolition of the waiver program, since many clinicians will still not be comfortable prescribing medication for MAT of opioid use disorder, said Dr. Barnett. “It’ll be a lot of the same stigma and structural barriers that were in place prior to the waiver.”
Dr. Barnett reported that he has been retained as an expert witness for plaintiffs in lawsuits against opioid manufacturers. The study was partly funded by the National Institutes of Health.
SOURCE: Barnett ML et al. Health Aff. 2019 Jan;38(12):2048-56.
FROM HEALTH AFFAIRS