The Association Between Scope of Practice Regulations and Nurse Practitioner Prescribing of Buprenorphine After the 2016 Opioid Bill

Nguyễn, Thủy; Muench, Ulrike; Andraka‐Christou, Barbara; Simon, Kosali; Bradford, W. David; Spetz, Joanne

doi:10.1177/10775587211004311

Cited by 22 publications

(18 citation statements)

References 25 publications

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“…However, our finding should be interpreted with caution as our study was cross-sectional in nature. Our finding that less restrictive SOP laws for NPs are associated with more NP buprenorphine treatment is consistent with Nguyen et al, who found that among a commercially insured and Medicare Advantage population, NPs wrote 2.7% of buprenorphine prescriptions in states with less restrictive SOP laws and 1.1% in states with more restrictive SOP laws between the third quarter of 2016 and the third quarter of 2018 (Nguyen et al, 2021). Given that commercial insurance covered only 20% of buprenorphine treatment episodes from 2017 to 2018, 40% of buprenorphine treatment episodes were covered by Medicaid, and many patients paid via cash, discount/voucher/coupon/rebate, or other sources such as Tricare or workers compensation, our work highlights the importance of examining patterns of buprenorphine treatment among multiple payers.…”

Section: Discussionsupporting

confidence: 92%

“…Consistent with previous findings, our results suggest that restrictive state SOP laws may be creating substantial barriers to prescribing buprenorphine (Auty et al, 2020; Barnett et al, 2019; Nguyen et al, 2021; Spetz et al, 2019, 2021). In several previous studies, less restrictive SOP laws have been associated with greater waiver uptake among NPs but not among PAs (Auty et al, 2020; Barnett et al, 2019; Spetz et al, 2019), potentially because laws in all states require PAs to work in collaboration with physicians, and fewer PAs than NPs practice in primary care or psychiatry (Barnett et al, 2019).…”

Section: Discussionsupporting

confidence: 91%

“…Scope of practice (SOP) laws in many states limit NPs' abilities to practice and prescribe medications without physician oversight or collaboration (American Association of Nurse Practitioners, 2021) or prevent PAs from performing one or more elements of practice (American Association of Physician Assistants, 2020). Less restrictive SOP laws have been associated with more waivered NPs but not PAs (Auty et al, 2020;Barnett et al, 2019;Spetz et al, 2019Spetz et al, , 2021 and higher rates of buprenorphine prescribing by NPs (Nguyen et al, 2021). State Medicaid policies also play an important role in states' response to the opioid crisis, as Medicaid is the largest payer for treatment of substance use disorders (Medicaid and CHIP Payment and Access Commission [MACPAC], 2017b; Orgera & Tolbert, 2019).…”

Section: Introductionmentioning

confidence: 99%

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State Policies and Buprenorphine Prescribing by Nurse Practitioners and Physician Assistants

et al. 2022

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Nurse practitioner (NP) and physician assistant (PA) prescribing can increase access to buprenorphine treatment for opioid use disorder. In this cross-sectional study, we used deidentified claims from approximately 90% of U.S. retail pharmacies (2017–2018) to examine the association of state policies with the odds of receiving buprenorphine treatment from an NP/PA versus a physician, overall and stratified by urban/rural status. From 2017 to 2018, the percentage of buprenorphine treatment episodes prescribed by NPs/PAs varied widely across states, from 0.4% in Alabama to 57.2% in Montana. Policies associated with greater odds of buprenorphine treatment from an NP/PA included full scope of practice (SOP) for NPs, full SOP for PAs, Medicaid pay parity for NPs (reimbursement at 100% of the fee-for-service physician rate), and Medicaid expansion. Although most findings with respect to policies were similar in urban and rural settings, the association of Medicaid expansion with NP/PA buprenorphine treatment was driven by rural counties.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionsupporting

confidence: 91%

Section: Introductionmentioning

confidence: 99%

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State Policies and Buprenorphine Prescribing by Nurse Practitioners and Physician Assistants

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“…41 Some individual states also passed versions of provisions found within the Comprehensive Addiction and Recovery Act at different times (eg, restricting nurse practitioners with waivers from prescribing medications for OUD treatment). 42 Such policy and/or law changes may have influenced the trend in buprenorphine prescribing during the study period but because this study was conducted using a control to account for such federal policy and/or law changes, the observed effect estimates may have not been influenced to some extent.…”

Section: Discussionmentioning

confidence: 99%

Buprenorphine Use Trends Following Removal of Prior Authorization Policies for the Treatment of Opioid Use Disorder in 2 State Medicaid Programs

et al. 2022

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IMPORTANCEState Medicaid programs have implemented initiatives to expand treatment coverage for opioid use disorder (OUD); however, some Medicaid programs still require prior authorizations (PAs) for filling buprenorphine prescriptions. OBJECTIVE To evaluate the changes in buprenorphine use for OUD among Medicaid enrollees in states that completely removed buprenorphine PA requirements. DESIGN, SETTING, AND PARTICIPANTS This retrospective cross-sectional study analyzed the immediate and trend changes on buprenorphine use during 2013 to 2020 associated with removal of PA requirements using a controlled interrupted time series analysis to account for autocorrelation. Data were collected from Medicaid State Drug Utilization Data for 2 states (California and Illinois) that completely removed a buprenorphine PA during the study period, and buprenorphine prescriptions for OUD treatment were identified among Medicaid enrollees. MAIN OUTCOMES AND MEASURESQuarterly total number of buprenorphine prescriptions for each state was calculated, and stratification analyses were conducted by dosage form (films and tablets). RESULTS Among the 2 state Medicaid programs (California and Illinois) that removed buprenorphine PAs, there was a total of 702 643 and 415 115 eligible buprenorphine prescription claims, respectively. After removing PA requirements for buprenorphine, there was an immediate increase that was not statistically significant (rate ratio [RR], 1.11; 95% CI, 0.76-1.61) in the number of all buprenorphine prescriptions in California and a statistically significant increase (RR, 6.99; 95% CI, in the number of all buprenorphine prescriptions in Illinois relative to the change in the control states (

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“…Our ability to draw inferences is limited by small effect sizes. Importantly, we did not examine the role of scope of practice laws as a barrier to BUP prescribing, even though previous research has found scope of practice laws impact waiver uptake [ 30 ] and prescribing behavior among NPs/PAs [ 31 ].…”

Section: Discussionmentioning

confidence: 99%

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

Andraka‐Christou

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Schoebel

et al. 2022

Addict Sci Clin Pract

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Background 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. Methods 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. Results 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. Conclusions 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.

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The Association Between Scope of Practice Regulations and Nurse Practitioner Prescribing of Buprenorphine After the 2016 Opioid Bill

Cited by 22 publications

References 25 publications

State Policies and Buprenorphine Prescribing by Nurse Practitioners and Physician Assistants

State Policies and Buprenorphine Prescribing by Nurse Practitioners and Physician Assistants

Buprenorphine Use Trends Following Removal of Prior Authorization Policies for the Treatment of Opioid Use Disorder in 2 State Medicaid Programs

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

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