The ongoing opioid crisis in the United States began in the mid 1990s, when the American Pain Society, with the best of intentions, began advocating for adequate treatment of chronic noncancer pain.1 The result, buoyed by the misinterpretation of a five-sentence letter to the New England Journal of Medicine, was a tremendous increase in the number of prescriptions written for opioid analgesics.1 As a result, one-fifth of respondents to a 2017 Fortune magazine survey held physicians primarily responsible for the current crisis.1 Chen and colleagues used mathematical modeling to determine the effect that prevention efforts, primarily reducing opioid prescribing, would have on overdose deaths.2 They found that initiatives focused on reduced prescribing alone would have only a modest effect on overdose deaths.2 They concluded that changing the trajectory of the current crisis will require increased screening for opioid use disorder (OUD), improving access to medication treatment such as with buprenorphine and methadone, improving addiction training in healthcare education programs, providing increased access to harm reduction services, and reducing opioid prescribing.2
On page 30 of this issue, Radi and colleagues provide a broad overview of the use of buprenorphine to treat OUD.3 Medication treatment of OUD with buprenorphine provides several advantages over methadone, the only other available agonist medication.4 Buprenorphine, a partial agonist, has less effect on the respiratory centers and less likelihood of respiratory depression. The drug has fewer drug-drug interactions than methadone and does not affect the QT interval to any extent. The most advantageous aspect of buprenorphine for OUD treatment is the ability to prescribe it in the outpatient setting, rather than in the controlled environment of the opioid treatment program (methadone clinic).5
Radi and colleagues rightly note that regulatory constraints are a major impediment for physician assistants (PAs) seeking to prescribe buprenorphine to treat OUD.3 The original Drug Abuse and Treatment Act of 2000 (DATA 2000) provided physicians who were not addiction psychiatrists or certified in addiction medicine a path to prescribing buprenorphine in settings other than opioid treatment programs. Completing an 8-hour course qualified the physician to obtain a waiver from the federal Drug Enforcement Administration (DEA) to prescribe controlled substances such as buprenorphine for the treatment of OUD. The Comprehensive Addiction and Recovery Act of 2016 provided PAs and advanced practice nurses (APNs) a 5-year window, expiring in 2021, to qualify for the DATA 2000 waiver after completion of 24 hours of training.3 Subsequently, the SUPPORT for Patients and Communities Act of 2017 removed the time limit on waiver eligibility for PAs and certain APNs.6 However, language in the SUPPORT Act required PAs and NPs (in states where prescribing was delegated to PAs and NPs) to work with a collaborating or supervising physician who was a qualified prescriber of buprenorphine.6 Andrilla and colleagues used DEA and state-level demographics to estimate the effect of NP and PA eligibility to prescribe buprenorphine on access to treatment and concluded that NPs and PAs can substantially increase treatment capacity.7 Spetz and colleagues examined the effects that current scope-of-practice laws would have on the potential increase in the number of PAs and APNs obtaining waivers to prescribe buprenorphine.8 Both articles found that restrictive state regulation of NP and PA practice was a limiting factor in the number of NPs and PAs obtaining waivers to prescribe buprenorphine.
However, PAs and NPs gaining the ability to write a prescription will not improve patient access to treatment. PAs and NPs also face the same nonregulatory barriers that prevent physicians from prescribing buprenorphine to the limits of their waiver.7 Somewhere between 56% and 90% of waivered physicians are not prescribing to the limits of their waiver.9,10 The most common reasons physicians give for not prescribing to capacity include (in descending order of report)11:
- lack of psychosocial support
- time constraints
- lack of specialty backup
- lack of confidence
- resistance from practice partners
- lack of institutional support
- concerns about reimbursement
- lack of patient need.
In addition to these barriers, a number of myths persist about medications for treating OUD.12 The most pervasive of these are the myths that use of buprenorphine is just “exchanging one addiction for another,” that providing office-based OUD treatment is time-consuming, and that medication treatment of OUD is more dangerous than treating other chronic disease. To address these barriers to buprenorphine prescribing, Haffajee and colleagues present a number of policy recommendations.13 Key among their recommendations are incorporating waiver training into medical school and continuing education curricula to increase knowledge and confidence in the provision of treatment of OUD with buprenorphine and to reduce stigma. In addition, Haffajee and colleagues recommend using loan forgiveness programs and improved reimbursement to encourage clinicians to enter the practice of treating substance use disorders.13
Buprenorphine is a lifesaving treatment with an advantageous safety profile available outside the regulated environment of the opioid treatment program. Given the prevalence of substance use disorders, all PAs must become familiar with their diagnosis and management, even if they do not intend to treat these patients personally. Improving access to medication treatment of OUD will require a multifaceted approach of improved addiction education in healthcare professions education, improved practice environments and reimbursement, and regulatory changes to reduce barriers to practice. Both national and local initiatives will be required to increase the number of providers prescribing buprenorphine and improve access to care.
1. DeShazo RD, Johnson M, Eriator I, Rodenmeyer K. Backstories on the US opioid epidemic. Good intentions gone bad, an industry gone rogue, and watch dogs gone to sleep. Am J Med
2. Chen Q, Larochelle MR, Weaver DT, et al Prevention of prescription opioid misuse and projected overdose deaths in the United States. JAMA Netw Open
3. Radi JK, Fogarty KJ, Lagerwey MD. Using buprenorphine to treat patients with opioid use disorder. JAAPA
4. Connery HS. Medication-assisted treatment of opioid use disorder: review of the evidence and future directions. Harv Rev Psychiatry
5. Alderks CE. Trends in the use of methadone, buprenorphine, and extended-release naltrexone at substance abuse treatment facilities: 2003-2015 (update). The CBHSQ Report: August 22, 2017. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration.
7. Andrilla CHA, Patterson DG, Moore TE, et al Projected contributions of nurse practitioners and physician assistants to buprenorphine treatment services for opioid use disorder in rural areas. Med Care Res Rev
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8. Spetz J, Toretsky C, Chapman S, et al Nurse practitioner and physician assistant waivers to prescribe buprenorphine and state scope of practice restrictions. JAMA
9. Thomas CP, Doyle E, Kreiner PW, et al Prescribing patterns of buprenorphine waivered physicians. Drug Alcohol Depend
10. Huhn AS, Dunn KE. Why aren't physicians prescribing more buprenorphine. J Subst Abuse Treat
11. Hutchinson E, Catlin M, Andrilla CH, et al Barriers to primary care physicians prescribing buprenorphine. Ann Fam Med
12. Wakeman SE, Barnett ML. Primary care and the opioid-overdose crisis—buprenorphine myths and realities. N Engl J Med
13. Haffajee RL, Bohnert ASB, Lagisetty PA. Policy pathways to address provider workforce barriers to buprenorphine treatment. Am J Prev Med