APNA Position: APRNs Prescribing Buprenorphine & Buprenorphine/Naloxone & the Continuing Opioid Crisis
Introduction
With more than 205,000 lives lost each year to suicide (> 48,0001), drugs (> 67,0002) and alcohol (> 88,0003), psychiatric-mental health nurses are at the forefront of saving American lives. The American Psychiatric Nurses Association (APNA) calls for comprehensive support, education, and policy to help this essential workforce practice to the full extent of its education, training, and licensure in order to address the extreme rise in substance use disorders, and particularly the opioid crisis.
According to experts in addiction medicine, treatment of opiate addiction with FDA-approved medications including buprenorphine or buprenorphine/naloxone (BUP) can save lives and reduce the consequences of opiate addiction for individuals, their families, and society. However, there continues to be a shortage of providers who can provide this office-based treatment for persons who are diagnosed with opioid use disorder (OUD).
APNA takes the position that all nurses should practice to the full extent of their education and training4. Psychiatric-Mental Health Advanced Practice Nurse (PMH-APRNs), many of whom provide treatment to persons with OUDs, are educated to provide both psychotherapy and prescribe medications. Depending on each state’s Nurse Practice Act, APRNs’ level of prescriptive authority varies.
Discussion
The 2016 Comprehensive Addictions Recovery Act (CARA)5 and 2018 SUPPORT Act (Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities)6 expanded access to FDA-approved treatments by allowing Nurse Practitioners and physicians assistants (PAs) to prescribe buprenorphine (BUP) for opioid use disorders indefinitely and Clinical Nurse Specialists, Certified Nurse Midwives, and Certified Registered Nurse Anesthetists to prescribe (BUP) through October 2023. Under this legislation, APRNs with prescriptive authority must complete 24 hours of education in order to apply for a Drug Enforcement Agency waiver (DEA-X) to prescribe BUP. As of May 2019, more than 11,000 Nurse Practitioners had a waiver from the Drug Enforcement Agency to prescribe this treatment7.
There has been some improvement in access to BUP treatment since these national legislative advances. An analysis of pharmacy claims data for one year after the 2016 CARA Act passed showed that the number of NPs and PAs prescribing BUP increased rapidly and resulted in a 6% increase in patients receiving BUP prescriptions for OUD, with Medicare beneficiaries showing the highest increases in treatment.8 Rural areas have also seen a promising improvement in access to treatment for opiate addiction, though there is still a gap to fill9.
Restrictions to full nursing scope of practice at the state level continue to negatively impact access to care for a variety of populations, including those with opioid use disorders. APRNs who live in states where they are required by state law to be supervised by a physician or practice in collaboration with a physician are less likely to obtain waivers to prescribe BUP. Many of these states have high rates of opioid addiction and overdose, and the greatest need for more practitioners to prescribe medications for opioid use disorder (MAT)10.
Conclusion
The Opioid Epidemic in the United States continues. The American Psychiatric Nurses Association therefore applauds efforts made to date to increase access to evidence-based treatment for opioid use disorders. Considering the continued need for better access to this care, APNA calls for continued authority for advanced practice registered nurses to prescribe buprenorphine and buprenorphine/naloxone in the treatment of persons diagnosed with opioid use disorder.
APNA remains steadfast in all efforts to support nurses in practicing to the full extent of their education, training, and licensure. This will increase access to high quality and safe care for those with mental health and substance use disorders.
Approved by the APNA Board of Directors July 2, 2013.
Revised and approved June 10, 2020
References
1. Xu, J. Q., Murphy, S. L., Kochanek, K. D., & Arias, E. (2020). Mortality in the United States, 2018. NCHS Data Brief, no. 355. Retrieved from https://www.cdc.gov/nchs/data/databriefs/db355_tables-508.pdf
2. Hedegaard, H., Miniño, A. M., & Warner, M. (2020). Drug overdose deaths in the United States, 1999-2018. Retrieved from https://www.cdc.gov/nchs/products/databriefs/db356.htm
3. Centers for Disease Control and Prevention (CDC). Alcohol and Public Health: Alcohol-Related Disease Impact (ARDI). Average for United States 2006–2010 Alcohol-Attributable Deaths Due to Excessive Alcohol Use. Available at: https://nccd.cdc.gov/DPH_ARDI/Default/Report.aspx?T=AAM&P=f6d7eda7-036e-4553-9968-9b17ffad620e&R=d7a9b303-48e9-4440-bf47-070a4827e1fd&M=8E1C5233-5640-4EE8-9247-1ECA7DA325B9&F=&D=.
4. American Psychiatric Nurses Association (APNA). (2015). APNA position: The future of nursing: Leading change, advancing health. https://www.apna.org/i4a/pages/index.cfm?pageid=6235
5. Congress, U. S. (2016). Comprehensive Addiction and Recovery Act of 2016. In US Congress.
6. Congress, U.S. (2018). H.R.6 SUPPORT for Patients and Communities Act. Retrieved from: https://www.congress.gov/bill/115th-congress/house-bill/6/text#toc-HE7D6B79AFB0447CD9D2F6F189A1586FE.
7. American Association of Nurse Practitioners (August 2019). Nurse Practitioners: Improving Patient Outcomes for Opioid Use Disorder. Retrieved from https://www.aanp.org/advocacy/advocacy-resource/nurse-practitioners-improving-patient-outcomes-for-opioid-use-disorder
8. Johnson, K.E., Varghese, R., Feng, B., Liu, M., Sanford, A., Dowell, P., & Wedeles, J. (2019, November 6). The effects of the Comprehensive Addiction And Recovery Act Of 2016 on nurse practitioner and physician assistant buprenorphine prescribing in Medicaid. Health Affairs Blog. Retrieved from https://www.healthaffairs.org/do/10.1377/hblog20191105.242580/full/
9. Andrilla, C. H. A., Moore, T. E., Patterson, D. G., & Larson, E. H. (2019). Geographic Distribution of Providers With a DEA Waiver to Prescribe Buprenorphine for the Treatment of Opioid Use Disorder: A 5-Year Update. The Journal of Rural Health, 35(1), 108-112.
10. Spetz, J., Toretsky, C., Chapman, S., Phoenix, B., & Tierney, M. (2019). Nurse Practitioner and Physician Assistant Waivers to Prescribe Buprenorphine and State Scope of Practice Restrictions. JAMA: Journal of the American Medical Association, 321(14), 1407-1408.
11. Moore, D. J. (2019). Nurse practitioners’ pivotal role in ending the opioid epidemic. The Journal for Nurse Practitioners, 15(5), 323-327
