Although the number of nurse practitioners (NPs) and physician assistants (PAs) who have obtained waivers to prescribe buprenorphine for the treatment of opioid use disorder (OUD) has increased, clinicians report many barriers to providing necessary care, according to research published in the Journal of Rural Health.
Using the October 2018 Drug Enforcement Administration (DEA) list of providers with a waiver to prescribe buprenorphine to treat OUD, researchers surveyed both rural-based NPs and PAs and a random sample of 500 urban-based NPs and PAs. Questionnaires asked clinicians about their history and current practice of treating patients with OUD with buprenorphine; the number of patients currently treated; the number and prescribing status of physician, NP, and PA coworkers with a DEA waiver; and whether certain groups of patients (eg, from another provider or clinic) and reimbursements (eg, Medicaid, private insurance) were accepted for buprenorphine treatment.
Responders were classified as never, former, or current buprenorphine prescribers. States were classified as less restrictive or restricted practice for NP buprenorphine prescribing authority based on state legislation. A total of 614 providers (498 NPs and 116 PAs) responded; the average age of NPs was 49.2 years and for PAs 47.3 years. A total of 81.2% of NPs and 53.9% of PAs were women. More than half self-reported practicing in primary care (54%).
There were significant differences in geographic distribution of respondents. More PAs than NPs practiced in the West (46.6% vs 34.7%, respectively); 31.8% of respondents worked in urban areas, 38.9% in large rural areas, 18.1% in small rural areas, and 11.2% in isolated rural areas. The percentage practicing in less-restrictive-practice states was 45.2% for NPs compared with 56.9% for PAs.
Approximately 80% of NPs and PAs indicated that they had prescribed buprenorphine to treat OUD and 71.1% indicated that they were accepting new patients with OUD. A total of 17.5% of NPs and PAs with the initial 30-patient waiver were approaching the patient limit, treating ≥27 patients. More NPs and PAs reported accepting private insurance for buprenorphine treatment (69.5%) and 65.4% accepted Medicare. More rural clinicians accepted Medicaid than urban clinicians (73.3% vs 63.6%, respectively). More rural clinicians accepted cash than urban clinicians (52.5% vs 39%, respectively).
The most commonly reported barrier was concern about diversion or misuse of the medication (50.9%). Lack of available mental health or psychosocial support services and insurance issues were reported by 44.1% and 41.8% of respondents, respectively. A higher proportion of rural providers reported these location-based barriers to prescribing buprenorphine: lack of specialty backup for complex patients, lack of available mental health or psychosocial support services, concerns about diversion or misuse of medication, and lack of conﬁdence in their ability to manage OUD. More rural respondents reported resistance to treating patients with OUD from their practice partners than urban respondents (24.5% vs 15.6%, respectively).
NPs and PAs who were not currently prescribing buprenorphine reported clinic barriers at higher rates than those who currently prescribed. Providers who had never prescribed buprenorphine reported concern about DEA intrusion on their practice and lack of confidence in their ability to manage OUD at about 3 times the rate that current prescribers did.
More NPs practicing in less-restrictive practice states identified lack of specialty backup as a barrier compared with those practicing in restricted-practice states (44.4% vs 32.0%, respectively). Female providers reported a lack of confidence in their ability to manage OUD almost twice as often as male providers (20.0% vs 10.9%).
“The newly waivered NPs and PAs are prescribing at higher rates than physicians have in past studies, but they still report many of the same barriers to providing care,” the researchers concluded. “Understanding how NPs and PAs overcome barriers is an area for further research.”
Andrilla CHA, Jones KC, Patterson DG. Prescribing practices of nurse practitioners and physician assistants waivered to prescribe buprenorphine and the barriers they experience prescribing buprenorphine [published online October 25, 2019]. J Rural Health. doi:10.1111/jrh.12404