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It’s Time to Question the Restrictions on Buprenorphine

June 25, 2019

By Andrew Penn, RN, MS, NP, CNS, APRN-BC
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The opinions expressed by Psychiatry & Behavioral Health Learning Network bloggers and those providing comments are theirs alone and are not meant to reflect the opinions of the publication.

I recently completed 24 hours of online training* to qualify for a buprenorphine “X” waiver and can now, in addition to the schedule II to V drugs that I was already permitted to prescribe as a nurse practitioner, provide this lifesaving medication to my patients with an opioid use disorder (OUD).

Increasingly, medication-assisted treatment (MAT) is a critical treatment for OUD, because it saves lives. Sordo and colleagues1 reported in The BMJ that all-cause mortality (including overdose death) was reduced by more than 50% in persons treated with buprenorphine, compared with those who were not receiving MAT.

Buprenorphine is a mu-opioid partial agonist**—commonly combined with naloxone (in a drug known as Suboxone)—that, unlike methadone, can be prescribed to a person with an opioid use disorder by a medical professional who has obtained a buprenorphine waiver (an “X” is added to ones Drug Enforcement Administration (DEA) number, denoting this qualification). Unlike methadone2, which must be dispensed by a federally licensed methadone clinic, or opioid treatment program (OTP), buprenorphine can be prescribed in an outpatient clinic by a provider with a “X” waiver and dispensed from a pharmacy, increasing patient access.

Buprenorphine is unusual in that, in addition to the standard qualifications one must have to prescribe a medication—an advanced practice nursing or medical license and a DEA number—one must undergo additional, specific training about the medication. Ironically, the problem of opioid use disorder in many patients often began with prescription opioids (such as hydrocodone and oxycodone) that are easier to prescribe than the medication that treats the dependency (buprenorphine). This makes no sense.

MORE: Are Benzodiazepines the Next Opioid Crisis?

You may be wondering why I had to have 3 times more training than my physician colleagues. Physicians are required to complete 8 hours of training, but nurse practitioners (NPs) and physician assistants (PAs) are required to complete 24 hours. The Comprehensive Addiction and Recovery Act (CARA),3 signed into law by President Barack Obama in 2016 to address the mounting opioid epidemic, allowed NPs and PAs to prescribe buprenorphine, but only with an additional 16 hours of training than physicians are required to complete. I can find no evidence that this additional training does anything other than create an additional barrier for patients seeking treatment and handicap NPs and PAs from being able to provide this critical service. When there are 70,000 overdose deathsin the United States each year (over 40,000 from opioids), shouldn’t we be making it less difficult, not more difficult, to obtain appropriate, lifesaving treatment?

Dr. Joanne Spetz and my colleagues at the University of California San Francisco School of Nursing5 recently published findings in JAMA6 noting that in states with physician restrictions on NP practice, NPs were half as likely to have buprenorphine waivers than their colleagues in states where NPs have independent practice. This trend was not present for physician assistants.

In many rural parts of the United States, nurse practitioners provide the lion’s share of health care services. Andrilla and colleagues7 reported that 61% of rural American counties do not have a physician with a buprenorphine waiver. Additionally, some states do not have even a single methadone clinic. One such state is Wyoming. In that state, 85 people died from opioid overdoses in 2017.8 In other, more populous states like California, where I live, methadone clinics are available in urban centers but in our rural northern and eastern counties, a methadone clinic may be a 8- to 10-hour round-trip drive, making daily visits to a clinic an impossibility. In these circumstances, access to buprenorphine is essential and many of the medical providers in these areas are nurse practitioners.

In 2010, the Institute of Medicine and the Robert Wood Johnson Foundation9 issued a clear decree: in order to get the care to the people who need it, all clinicians need to be empowered to work at the top of their license and training. Barriers that prevent this must be eliminated. Since that time, opioid-related deaths increased from 20,000 per year to 47,000 in 20174.

Addressing the opioid epidemic that has been sweeping the United States will require all hands on deck. It is time to question the utility of not only the additional 16 hours of training required for NPs to provide buprenorphine, but the entire buprenorphine waiver as a whole. Hutchinson and colleagues10 reported that despite a positive impression of buprenorphine, many providers are wary of doing so, citing the need for additional support and consultation to feel comfortable prescribing it. The Providers Clinical Support System11 already provides mentoring and support for those in need of buprenorphine treatment consultation. A system like this, scaled to the needs of all buprenorphine providers—NP, PA, and MD alike—would be a far better way than an arbitrary number of training hours to prepare clinicians to confidently provide this lifesaving treatment.

ADDENDUM

A bill has been proposed in Congress to do just this. HR 2482 would eliminate the requirement to obtain an additional waiver before prescribing buprenorphine. The supporters of the bill, Paul Tonko (D-NY), Antonio Delgado (D-NY), Ben Ray Lujan (D-NM), Tedd Budd (R-NC), Elise Stefanik (R-NY), and Mike Turner (R-OH), point out that when a similar law was passed in France, opioid overdose deaths dropped by 79% over 4 years.12 In addition, Fiscella, Wakeman, and Beletsky in a JAMA Psychiatry Viewpoint article13 urge the DEA and the Substance Abuse and Mental Health Services Administration to mainstream buprenorphine by requiring content on the drug in health care training programs and working with the Centers for Medicare & Medicaid Services to incentivize access to and integration of substance abuse services into primary care. These steps and the proposed law could markedly increase access to this lifesaving treatment for our patients who most desperately need it. 

* This training is available free to members of the American Psychiatric Nurses Center through Providers Clinical Support System.

** Buprenorphine, in addition to partial agonism on mu-opioid receptors, is also a kappa-opioid partial agonist and delta-opioid antagonist.

References

1. Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. The BMJ. 2017;357:j1550.

2. Methadone. Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/medication-assisted-treatment/treatment/methadone. Accessed June 13, 2019.

3. The Comprehensive Addiction and Recovery Act (CARA). Community Anti-Drug Coalitions of America. https://www.cadca.org/comprehensive-addiction-and-recovery-act-cara. Accessed June 13, 2019.

4. Overdose death rates. National Institute on Drug Abuse. https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Updated January 2019. Accessed June 13, 2019.

5. Maier S. Many nurse practitioners cannot provide medications to treat opioid addiction. University of California San Francisco. https://www.ucsf.edu/news/2019/04/413856/many-nurse-practitioners-cannot-provide-medications-treat-opioid-addiction. Published April 9, 2019. Accessed June 13, 2019.

6. Spetz J, Toretsky C, Chapman S, Phoenix B, Tierney M. Nurse practitioner and physician assistant waivers to prescribe buprenorphine and state scope of practice restrictions. JAMA. 2019;321(14):1407–1408.

7. Andrilla CHA, Coulthard C, Larson EH. Barriers rural physicians face prescribing buprenorphine for opioid use disorder. Annals of Family Medicine. 2017;15(4):359-362.

8. Wyoming opioid summary. National Institute on Drug Abuse. https://www.drugabuse.gov/opioid-summaries-by-state/wyoming-opioid-summary. Updated May 2019. Accessed June 13, 2019.

9. The future of nursing: leading change, advancing health. National Academy of Sciences. http://www.nationalacademies.org/hmd/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx. Published October 5, 2010. Accessed June 13, 2019.

10. Hutchinson E, Catlin M, Andrilla CH, Baldwin LM, Rosenblatt RA. Barriers to primary care physicians prescribing buprenorphine. Annals of Family Medicine. 2014;12(2):128–133.

11. Waiver training for NPs. Providers Clinical Support System. https://pcssnow.org/medication-assisted-treatment/waiver-training-for-nps/. Accessed June 13, 2019.

12. Fatseas M, Auriacombe M. Why buprenorphine is so successful in treating opiate addiction in France. Current Psychiatry Reports. 2007;9(5):358-364.

13. Fiscella K, Wakeman SE, Beletsky L. Buprenorphine deregulation and mainstreaming treatment for opioid use disorder. JAMA Psychiatry. 2019;76(3):229-230.


Andrew Penn was trained as an adult nurse practitioner and psychiatric clinical nurse specialist at the University of California, San Francisco. He is board certified as an adult nurse practitioner and psychiatric nurse practitioner by the American Nurses Credentialing Center. He has completed extensive training in Psychedelic Assisted Psychotherapy at the California Institute for Integral Studies and recently published a book chapter on this modality in The Casebook of Positive Psychiatry, published by American Psychiatric Association Press. Currently, he serves as an Associate Clinical Professor at the University of California-San Francisco School of Nursing, where he teaches psychopharmacology, and is an Attending Nurse Practitioner at the San Francisco Veterans Administration. He has expertise in psychopharmacological treatment for adult patients and specializes in the treatment of affective disorders and PTSD. As a steering committee member for Psych Congress, he has been invited to present internationally on improving medication adherence, cannabis pharmacology, psychedelic assisted psychotherapy, grief psychotherapy,  treatment-resistant depression, diagnosis and treatment of bipolar disorder, and the art and science of psychopharmacologic practice.

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