From 2017 to 2018, buprenorphine dispensing rates for the management of opioid use disorder (OUD) increased in the United States by 9.1%. The Comprehensive Addition and Recovery Act (CARA), which authorized nurse practitioners (NPs) and physician assistants (PAs) to prescribe buprenorphine, may have contributed to the increase, according to the results of a study published in Drug and Alcohol Dependence.1

Opioid misuse and overdose remain a significant public health care issue. The prescription of evidence-based medications (methadone, buprenorphine/naloxone, and naltrexone) for the treatment of OUD have been underused in the US.  It is estimated that only one-third of the 2 million American diagnosed with OUD each year receive substance use treatment.2

To see how the passage of CARA has impacted one treatment for OUD, the researchers utilized prescription audits to identify information on buprenorphine prescriptions dispensed from January 2017 to December 2018; this search yielded approximately 50,400 retail pharmacies in 2881 counties. The dispensing of buprenorphine prescriptions was first analyzed by patient age, sex, and location.

A further analysis of location included location of the dispensing pharmacy which were evaluated by counties that were broken down into 3 categories:  metropolitan (>50,000 residents), micropolitan (10,000 to <50,000 residents), and noncore/rural (<10,000 residents) areas.3


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To characterize where increases were seen among NPs and PAs, the researchers examined buprenorphine dispensing rates and potential buprenorphine treatment capacity in 2017 among counties experiencing an increase in prescribing by NPs and PAs. Prescribing changes were also examined among NPs/PAs by urban/rural status.

Nationally, buprenorphine dispensing increased by 9.1% from 2017 to 2018, from 40.7 to 44.4 per 1000 residents. Patients aged 60 to 84 years experienced the largest increase by age category (33%). The West had the largest increase by census region (18.2%). In 2018, dispensing rates were highest among men (53.2 per 1000), patients aged 20 to 39 years (95.2 per 1000), those who lived in micropolitan counties (71.9 per 1000), and those who lived in the Northeast (67.2 per 1000).

From 2017 to 2018, NPs and PAs had the largest percent increases in buprenorphine prescriptions (351.9% and 257.3%, respectively). In 2018, NPs and PAs accounted for 9.3% of all buprenorphine prescriptions dispensed compared with 2.4% in 2017, making up for 79.6% of the increase in prescriptions dispensed nationally between 2017 and 2018. After NPs and PAs, the next largest increase was seen among obstetricians and gynecologists (10.7%).

Across the country, buprenorphine dispensing rates increased in 67.8% counties; counties with micropolitan areas had the largest percent increase in dispensing (75.7%). Noncore/rural counties had the lowest percentage (59.5%). The states experiencing increases in buprenorphine dispensing were Delaware, Hawaii, Rhode Island, Washington, Oregon, and New York; Washington, DC also experienced an increase. At the county level, between 2017 and 2018, 66.3% of these counties experienced increases in part due to prescriptions filled by NPs and PAs; these increases were more likely to occur in counties with higher dispensing rates in 2017.

“The number of buprenorphine prescriptions dispensed from retail pharmacies in the United States increased by nearly 1.3 million prescriptions between 2017 and 2018, nearly all provider specialty groups contributed to this increase, and the majority of counties experienced an increase in buprenorphine dispensing,” concluded the researchers.

While the increase in the use of buprenorphine is encouraging, the authors noted that significant gaps remain in access to evidence-based treatment of OUD, including inadequate medical education on substance use disorders, low self-efficacy for treating patients with OUD, and concerns about buprenorphine diversion are reasons commonly cited by clinicians for not providing medication-based treatment.

“Particularly noteworthy is the finding that [NPs] and [PAs] were responsible for 79.6% of the total increase in dispensed buprenorphine prescriptions from 2017 to 2018, indicating the expansion of buprenorphine prescribing eligibility under CARA appears to be having its intended effect,” the researchers said.

References

1. Roehler DR, Guy Jr GP, Jones CM. Buprenorphine prescription dispensing rates and characteristics following federal changes in prescribing policy, 2017-2018: a cross-sectional study [published online May 25, 2020]. Drug Alcohol Depend. doi: 10.1016/j.drugalcdep.2020.108083

2. Jones CM, McCance‐Katz EF. Characteristics and prescribing practices of clinicians recently waivered to prescribe buprenorphine for the treatment of opioid usedisorder Addiction. 2019;114(3):471-482.

3. Health Resources and Services Administration. Defining rural populations.  https://www.hrsa.gov/rural-health/about-us/definition/index.html#:~:text=Office%20of%20Management%20and%20Budget%20Definition,but%20less%20than%2050%2C000)%20population. Accessed June 15, 2020.