As the opioid epidemic rages on and the number of deaths continues to climb, the use of medications to treat opioid use disorder (OUD) has drawn increasing attention. Often referred to as “Medication-Assisted Treatment,” drugs including methadone, buprenorphine, and naltrexone are used to help treat heroin addiction, as well as other forms of opioid addiction.

Although methadone and buprenorphine are considered the gold standard for the treatment of OUD, numerous restrictions limit the use of these medications by physician assistants (PAs), nurse practitioners (NPs), and other advanced practice providers.1 Methadone can be prescribed for pain by any provider with DEA Schedule II authority, including PAs and NPs; however, the Federal Narcotic Treatment Act of 1974 prohibits any clinician from prescribing methadone for the treatment of addiction. Instead, the Act mandates that methadone can only be ordered and dispensed at federally licensed opioid treatment programs, often referred to as “methadone clinics.” 

This restriction poses a significant barrier to the effective management of patients with OUD. At the American Academy of Family Physicians (AAFP) National Conference of Family Medicine Residents and Medical Students, resolutions to increase patient access to therapies for OUD were presented. One such resolution asked that the AAFP advocate for primary care providers to prescribe methadone for treating OUD without restrictions or the need for licensing.

Another point discussed at the conference was the urgent need to expand care for OUD into rural settings. As noted by one of the resolution authors, “I come from a largely rural state, and more than half our population lives in rural areas. 92% of methadone clinics are in urban areas, and so this is also about promoting rural care.”2

An additional obstacle to the access of methadone for patients with OUD is the historic “physician only” regulation in the federal Substance Abuse and Mental Health Services Administration (SAMHSA) guidelines that govern the use of methadone for OUD. An effort to change this limitation in 2015 failed and led to the reaffirmation of the “physician only” stance.3 The resulting outcry from members of the opioid treatment program community resulted in the creation of a poorly understood and cumbersome exemption process in which PAs, NPs, and the opioid treatment program agencies where they practice can be permitted to practice fully within the restrictive guidelines.  

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Along with the restrictions on methadone, restrictions also exist on the use of buprenorphine/naloxone for the treatment of OUD. Currently, physicians, PAs, and NPs are required to receive a waiver from the Drug Enforcement Agency in order to be able to prescribe buprenorphine/naloxone. Physicians are currently required to complete 8 hours of training while PAs and NPs must complete 24 hours of training. This lack of parity is likely to change soon, putting NPs and PAs on equal footing with physicians regarding the ability to obtain the waiver. There are also restrictions on the number of patients providers can see, with the tightest restrictions imposed on PAs and physicians.

The good news is that there is increasing support for the removal of the buprenorphine waiver requirement, which would also do away with the special training and patient limits.

The bottom line is that people continue to suffer and die as a result of opioid misuse at an alarming rate, with 47,000 Americans dying from opioid overdoses in 2017.4  Although there is an increased urgency across the nation to search for ways to address this emergency, it is difficult to understand the hesitancy in changing and eliminating dated, nonmedical, stigma-driven, and “anti-addict” processes and rules that keep clinicians from providing effective treatments to patients who struggle with the ravages of addiction. It’s time for all PAs and NPs to work with their professional associations, state medical boards, and local, regional, and national legislators to address these prescribing restrictions.  

References

  1. Mittal ML, Vashishtha D, Sun S, et al. History of medication-assisted treatment and its association with initiating others into injection drug use in San Diego, CA. Subst Abuse Treat Prev Policy. 2017;12:42.
  2. Porter S. Residents focus discussions on training, patient care. American Academy of Family Physicians website. https://www.aafp.org/news/education-professional-development/20190731nc-rescongress.html. Published July 31, 2019. Accessed September 3, 2019.
  3. Opioid treatment program accreditation guidelines will not allow mid-levels; SAMHSA will work with states on exemptions. Addiction Treatment Forum website. http://atforum.com/2015/04/new-otp-accreditation-guidelines-will-not-allow-mid-levels/. Published April 21, 2015. Accessed September 3, 2019.
  4. Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and opioid-involved overdose deaths – United States, 2013-2017. MMWR Morb Mortal Wkly Rep. 2019;67(5152):1419-1427.