By Joanne Spetz, PhD
Three of every four pharmaceutical overdose deaths in 2010 involved opioids, according to the CDC. This sobering statistic focused attention on the rapid acceleration and devastating impact of the epidemic of opioid use disorder in the United States. Throughout the country, individuals and families faced challenges stemming from the overprescribing of opioids, easy access to heroin and other illicit drugs, and a shortage of treatment for opioid dependence and addiction. In 2018, 128 people died per day in the United States after overdosing on opioids, and the challenges of obtaining treatment for opioid use disorder have been exacerbated by the COVID-19 pandemic.
In the field of opioid treatment, there has been a concerted effort to increase availability of medications to treat opioid use disorder. Buprenorphine is the most widely used medication used to help those with opioid use disorder both due to the well-established evidence of its effectiveness and its availability in physician offices, clinics, and other venues outside licensed narcotics treatment programs. In order to prescribe buprenorphine outside of a licensed narcotics treatment program, a clinician must complete training and apply for a waiver (the “X waiver”) from the Drug Enforcement Agency.
The waiver process is a barrier in and of itself. Until 2016, only physicians were allowed to obtain waivers, creating an additional obstacle. Nurse practitioners (NPs) and physician assistants (PAs) were authorized to prescribe opioid medications in the Comprehensive Addiction and Recovery Act (CARA) of 2016. The SUPPORT Act of 2018 extended waivers to other advanced practice nurses.
However, advanced practice nurses and physician assistants continue to face barriers in obtaining waivers. The largest barrier is that nearly half of states require a nurse practitioner to have formal physician oversight in order to prescribe medications, and all PAs nationwide must have physician oversight. To obtain a waiver, the physician who oversees an NP or PA also must be waivered or meet other stringent requirements. Our team’s analysis demonstrated that oversight requirements have resulted in significantly smaller percentages of NPs obtaining waivers as compared with states that do not require formal physician supervision. A separate study from researchers at Harvard found that this negative effect was particularly pronounced in rural communities.
Amidst shelter-in-place strategies to mitigate the COVID-19 pandemic, people who suffer from addiction are facing even greater social isolation along with physical barriers to obtaining support through personal contacts and groups. Moreover, social isolation increases the risk of developing substance use disorders and may compound existing addictions. Fortunately, under the national emergency declared in March 2020, the government suspended the requirement that patients have an in-person visit in order to be prescribed buprenorphine. Some clinicians had been advocating for this change for years, and anecdotal reports suggest that telehealth treatment has allowed more people to obtain treatment than anticipated. States can engage in a number of other activities to leverage federally-authorized flexibility to support those seeking treatment.
These changes to support ongoing expansion of opioid treatment amidst the COVID-19 pandemic have helped countless people but may not be enough to continue progress fighting the opioid epidemic. Fundamental barriers in access to care persist and the flexibility available now is not a permanent change.
What else can we do to fight the opioid epidemic while we are fighting the COVID-19 pandemic? Several measures can be considered:
- Eliminate the requirement for waivers to prescribe buprenorphine. A growing number of clinicians and patients are advocating to “X the X waiver”. When the process for obtaining waivers to prescribe buprenorphine outside narcotics treatment programs was established in 2000, it was viewed as a substantial liberalization of access to medication treatment. At the time, methadone and buprenorphine were offered only in fixed treatment sites; expansion of access to low-risk buprenorphine was a notable advance. However, with nearly 20 years of experience in buprenorphine treatment and a raging opioid epidemic, advocates have questioned whether buprenorphine should continue to be regulated differently from other opioid medications. Clinicians are not required to obtain special authorization or training to prescribe OxyContin or other medications that are notably riskier than buprenorphine. Bipartisan legislation introduced in Congress in 2019 to eliminate buprenorphine waivers, which would mark an important advancement in access to treatment.
- End requirements that nurse practitioners and other advanced practice nurses have formal oversight by physicians. NPs and other advanced practice nurses are educated to independently provide patient care in collaborative professional teams. Restrictions on their practice do not have any beneficial effect on patient safety or the quality of care and have reduced access to care. Physician oversight requirements both create a barrier to obtaining buprenorphine waivers and reduce advanced practice nurses’ ability to practice in communities where their services are most needed.
- Rigorously evaluate the benefits and unintended consequences of federal waivers that allow telehealth consultations to initiate buprenorphine treatment, and base permanent policies on the results. At present, the suspension of required in-person consultations for buprenorphine prescribing will end when or if the national emergency is ended. This may be a step backward in efforts to expand treatment access. However, in-person consultations can have benefits in facilitating referrals to therapy and other supportive treatment, and in monitoring patients to reduce diversion to illicit markets.
Careful analyses of these benefits and risks can and should be conducted to guide federal and state policymaking, with a focus on approaches to best help those suffering from addiction.
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