There are still several details to be worked out, and 18 months to do so, but nurse practitioners (NPs) and physician assistants (PAs) are now able to prescribe buprenorphine for the treatment of opioid use disorders. The change was made possible by the Comprehensive Addiction and Recovery Act (CARA) signed into law this summer and given $7 million by Congress last month.
On Oct. 1 (a Saturday), the Substance Abuse and Mental Health Services Administration (SAMHSA), which administers CARA funding and also the buprenorphine waiver process, held a meeting on the NP and PA waiver training.
Yngvild K. Olsen, M.D., medical director of the Institutes for Behavior Resources in Baltimore and board member, director-at-large and chair of the Public Policy Committee with the American Society of Addiction Medicine (ASAM), was at the SAMHSA meeting, which focused on training. “SAMHSA is looking for input from the field” on how to do the training, she told ADAW last week. CARA calls for specific items to be included in the training.
The legislation requires 24 hours of training for NPs and PAs, while physicians only need eight. (ASAM had asked for even more than 40 hours for midlevels, and some people still think that the eight hours required for physicians is inadequate.) The issue of training in buprenorphine prescribing revolves around whether the provider already has some training in addiction. “My sense is that there may be NPs or PAs who have no training at all in [addiction], and the 24 hours may be a way of getting them training,” said Olsen.
The waiver training must be done by the same organizations SAMHSA has certified to train physicians. (The term “waiver” applies to the waiver from the law that bans treating addiction with controlled substances; opioid treatment programs, which use methadone, are allowed to exist because they are so strictly regulated.) These are the American Academy of Addiction Psychiatry, American College of Emergency Physicians, American College of Physicians, American Psychiatric Association, American Osteopathic Academy of Addiction Medicine, American Society of Addiction Medicine, Association for Medical Education and Research in Substance Abuse and National Association of Drug Court Professionals. Now two additional organizations have been added for the NP and PA waiver training — the American Association of Nurse Practitioners (AANP) and the American Academy of PAs (AAPA).
Accounting for experience
Many NPs and PAs have already taken the training, said Olsen. “There was a strong suggestion made to SAMHSA that this be allowed to count towards the 24 hours,” she said. In addition, many already have experience in the area of addiction medicine. But CARA did not spell out how SAMHSA should account for that experience. Much of the discussion on Oct. 1 concerned how to validate and confirm the training “in a timely fashion because there is a sense of urgency,” said Olsen. “So many people’s lives are dependent on being able to access buprenorphine.”
The fact that NPs and PAs are allowed to prescribe full agonists such as morphine and Oxycontin also argues for their ability to prescribe buprenorphine safely, said Olsen.
Another message to SAMHSA was “don’t re-create the wheel,” said Olsen. “We have these waiver organizations, and different NP and PA subspecialty organizations, and a wealth of curricula out there,” she said. “We do need guidance on what they are going to count as meeting the requirements, but there is already a certification process.”
We asked Olsen how expanding the buprenorphine waivers to NPs and PAs will help expand access to the medication, considering that the majority of physicians with the waiver are not prescribing. She responded that NPs, based on her experience, “come out of a nursing background” and are concerned with “healing, recovery, and nurturing.” This culture lends itself to treating addiction — not just writing a prescription — she said. In addition, in many community health centers, NPs and PAs are the main providers, because they are less expensive than physicians. Finally, there are more NPs and PAs in rural areas of the country.
Jeffrey Quamme, executive director of the Connecticut Certification Board, which certifies addiction counselors, wants to make sure that wraparound services such as counseling are provided. “We want the spirit, not just the letter, of DATA 2000 to be followed,” he told ADAW, referring to the Drug Addiction Treatment Act of 2000, which made buprenorphine treatment for addiction a reality. It will be up to the respective medical boards to conduct the training, he said, but he wants to make sure that the NPs and PAs — as well as physicians — know that recovery support services exist.
“It’s difficult to build knowledge of recovery support into the competencies” for prescribers, he said.
And Quamme doesn’t think it’s all bad for practices to have only a few patients on buprenorphine, and not the maximum. “I know the numbers — they may have a DATA 2000 waiver but only three patients on buprenorphine,” he said. “But those are the practices that have a great laboratory to work with a recovery support team,” he said. For example, he knows of one program that has a “medication group” every week. “To get your prescription, you have to go to the group,” he said. “This is a very safe way to do it.”
Response from PAs and NPs
While CARA requires 24 hours of training, the law also provides for the Department of Health and Human Services, SAMHSA’s parent agency, to adjust this for midlevels with experience, said Jennifer L. Dorn, CEO of the AAPA. “AAPA hopes this will be the case and believes that many PAs are already qualified to provide this much-needed care,” she told ADAW last week.
“As one of the eight organizations authorized to provide the 24-hour educational requirement for the waiver, AAPA is currently working with the American Association of Nurse Practitioners and ASAM to develop a program that will meet the 24-hour educational requirement,” she said. “As a group, AAPA, AANP and ASAM have even applied for an educational grant to develop this program.” AAPA recently sent a survey to 10,000 PAs in pain management, addiction medicine and primary care to get their input on the waiver.
“PAs frequently work with patients who struggle with opioid dependency,” said Dorn. “While many PAs specialize specifically in addiction medicine, there are approximately 30,000 PAs practicing as primary care providers on the front lines of patient care in hospitals, private practices, community health centers, rural health clinics, non-federally qualified public or community health clinics, prisons, behavioral health care facilities and free clinics,” she said, noting that they commonly see patients in these settings who present with or are at risk of opioid use disorders. “This care is especially critical in rural and medically underserved areas, where PAs may serve as the only primary care clinician or in areas where PAs own and serve their own medical practices.”
Likewise, the AANP will be seeking input from members via a survey to help with determining who is interested in a waiver, said Nancy McMurrey, vice president for communications from the AANP. “AANP plans to work in collaboration with ASAM, AAPA and the International Nurses Society on Addictions “to provide the 24 hours of education for our respective members,” she told ADAW.
Training for NPs and PAs should not cost a lot, considering that there are already programs available. The existing eight-hour course for physicians has everything that CARA requires, and there is additional training available covering other addiction-related topics. For example, ASAM launched its “Fundamentals of Addiction” course last year, geared toward primary care, including midlevels.
It is likely that at least some of the $7 million for CARA has already been spent on this, and more will go toward training grants, although SAMHSA has not determined what its plans are for allocating that money.
But expanding access to buprenorphine has been a linchpin of the federal government’s response to the opioid epidemic.
Still, why does buprenorphine prescribing take so much training? “My personal belief is that we are still struggling with the issue of whether addiction is a disease or a moral failing, a choice,” said Olsen. “Even for individuals who believe it is a disease, there is worry about diversion,” she said. “We want to open the door to better access, but not open it so quickly or so broadly that a perceived issue of diversion gets worse. I don’t know that there’s anyone who has any models or studies that clearly identify this.”
However, diverted buprenorphine may be being used for its intended purpose — treating opioid use disorders — said Olsen. “There is good data to suggest that people who use diverted buprenorphine tried to access treatment and can’t, or are self-treating a disease for which the quality and the access are limited,” she said.
For CARA, go to https://www.congress.gov/bill/114th-congress/senate-bill/524.
Midlevel providers are now in the process of becoming buprenorphine prescribers, thanks to CARA.