Nurse practitioners (NPs) and physician assistants (PAs) are now eligible to prescribe buprenorphine for the treatment of opioid use disorder (OUD) to up to 30 patients without requiring a Drug Addiction Treatment Act of 2000 (DATA) waiver, according to practice guidelines from the US Department of Health and Human Services (HHS).1

On January 14, 2021 in the final days of the Trump Administration, the HHS announced a plan to issue practice guidelines on buprenorphine for OUD that included an exemption to the DATA waiver that only applied to physicians. The guidelines were never issued and were rescinded in early February 2021 under the Biden Administration, which said that the announcement of the guidelines was “premature.” When the final guideline was published, it allowed physicians as well as NPs, PAs, and other practitioners to apply for the exemption to the DATA waiver. The guidance took effect on April 28, 2021.  

“The American Association of Nurse Practitioners [AANP] is pleased that the [Biden] Administration recognizes the important role of NPs in combating the opioid epidemic,” the organization said in a statement to the press.2 “These guidelines remove barriers for NPs and other eligible practitioners to provide medication-assisted treatment to patients in need, and we applaud the Administration for these important changes.”


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Chin Hwa (Gina) Dahlem, PhD,
FNP-C, FAANP

“This updated guidance is a huge win for all NPs and providers who treat patients with OUD,” said Chin Hwa (Gina) Dahlem, PhD, FNP-C, FAANP, Clinical Associate Professor at the University of Michigan School of Nursing in Ann Arbor. “Particularly, this guidance lifts the cumbersome 24-hour waiver training requirements for advance practice nurses.”

“Despite this extensive training requirement, NPs and PAs have already made a significant impact particularly in rural counties and areas where there has been a severe shortage of waivered providers,” Dr. Dahlem said in an interview. “A study published in Health Affairs showed that States with full NP scope of practice regulations had twice as many waivered NPs per 100,000 population compared with those in states with restricted scope of practice. NPs and PAs have once again risen to the needs in delivering care to the most vulnerable and low-resourced communities where the opioid epidemic has devastated the lives of patients and their families. Imagine how much more impact we can have if all states gave NPs full scope of practice.” 

Updates to the OUD Guidance

The updated guidance allows practitioners (including NPs, PAs, clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives) who have a valid DEA registration to be exempt from training, counseling, and ancillary services certification requirement if they submit a notice of intent in which they select a patient limit of 30 for buprenorphine treatment of OUD. The exemption applies to the prescription of Schedule III to V drugs but does not apply to Schedule II medications such as methadone for the treatment of opioid use disorders.

Practitioners using this exception must treat patients located in the same state as their licensure unless the practitioner is an employee or contractor of a US department or agency or is using the registration of a hospital or clinic operated by a US department or agency of the United States.

Practitioners who do not wish to practice under the exemption and its attendant 30 patient limit may seek a waiver per established protocols.

“Allowing NPs to treat up to 30 patients with buprenorphine without requiring drug waiver documentation will serve to increase the availability of much needed providers for these patients with OUD,” said Marlene Glashen, NP/BC, PhD, who is adjunct faculty in nursing at Mercy College, Bronx Campus, NY.

Opioid Overdoses Increased During the COVID-19 Pandemic

“The updated HHS guidelines for NPs prescribing buprenorphine to treat patients with OUD are timely because of the increased numbers of reported drug overdose deaths in 2020, seemingly related to COVID-19 stressors,” said Dr. Glashen, who has experience working in a pain management treatment program that included use of narcotic agents. 

The COVID-19 pandemic exacerbated the already increasing rates of opioid overdoses in the US with a 26.8% increase in the 12 months leading up to August 2020 compared with the previous 12 months.

“This guideline change is monumental as we have seen increases in opioid overdose deaths nationally during the COVID-19 pandemic,” Dr Dahlem said. “People were not calling emergency response system, not going to the emergency room until it was too late, and had delayed access to medical, social, and treatment services. The pandemic also increased social isolation, worsened mental health, and limited access to critical recovery support and treatment services. Underneath the pandemic, we still have an opioid epidemic and, in fact, worsening drug epidemic. We are now seeing not just opioid overdoses, but polysubstance overdoses particularly involving stimulants.”

Education on Buprenorphine Prescription Still Needed

Despite the updated guidelines, Dr. Dahlem noted that most NPs intending to prescribe buprenorphine for OUD may still need to receive additional prescribing education around medications for OUDs. 

“The 24-hr waiver training was too extensive, but I feel we would still need education on medications for OUD.  More NP schools are incorporating a substance use disorder curriculum into their programs, but many practicing NPs may not have received education on medications for OUDs. NPs can still access the free waiver training courses through the Providers Clinical Support System and AANP/American Society of Addiction Medicine. Many states provide free 4- to 8-hour waiver training as well,” Dr. Dahlem said.

References

1. Practice guidelines for the administration of buprenorphine for treating opioid use disorder. Fed Regist. 2021;86(80):22439-22440.

2. American Association of Nurse Practitioners. AANP applauds updated guidelines to treat opioid use disorder. News Release. April 28, 2021. Accessed May 5, 2021. https://www.aanp.org/news-feed/aanp-applauds-updated-guidelines-to-treat-opioid-use-disorder