Buprenorphine Prescribing by Nurse Practitioners and Physician Assistants

Carolyn Buppert, MSN, JD


December 18, 2017

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Restrictions on Buprenorphine Prescribing

Response from Carolyn Buppert, MSN, JD
Healthcare attorney

Here's a timely question. Why can nurse practitioners (NPs) and physician assistants (PAs) easily prescribe opioid pain medications but not, in many states, opioid antagonists (such as buprenorphine) to treat opioid addiction disorder?

First, some background. Federal law, until 2016, limited the prescribing of buprenorphine to physicians who had completed specified training and had a special Drug Enforcement Administration (DEA) number. The Comprehensive Addiction and Recovery Act (CARA), signed into law by President Obama in July 2016, created an opportunity for NPs and PAs to take a 24-hour training course, obtain a waiver, and then begin prescribing buprenorphine for up to 30 patients, if the NP or PA:

  • Is licensed under state law to prescribe schedule III, IV, or V medications for pain;

  • Has completed the not-less-than-24-hour education through a qualified provider;

  • Through other training or experience, has demonstrated the ability to treat and manage opioid use disorder;

  • If required by state law, is supervised or works in collaboration with a qualified physician to prescribe medications for the treatment of opioid use disorder; and

  • Practices in a state that allows an NP or PA to prescribe buprenorphine.

The states that do not allow an NP or PA to prescribe, specifically, buprenorphine are, as of the date of this article, Tennessee (for NPs and PAs) and Maine (for PAs). Several states have changed their rules recently in the direction of allowing more providers to prescribe buprenorphine. In states that require physician supervision or collaboration for NP or PA practice, NPs or PAs are hindered in that there are relatively few physicians who have the required special DEA number and are qualified to prescribe buprenorphine.

Why Discourage Buprenorphine Use?

This article won't get into the controversy about whether buprenorphine is a good idea from a public health perspective, from the perspective of any individual clinician or for any patient. But here is how the Washington Post summarized this controversy:

Suboxone is controversial. Even among those who strongly support the appropriate use of the drug, there are some who don't want to make it more widely available. The drug, after all, has street value. Patients can sell it to fund a heroin habit, although some experts say "subs" on the street are mainly used by people trying to fight off withdrawal symptoms, not get high. [1]

Suboxone® is the brand name for a drug that combines buprenorphine and naloxone. Buprenorphine is an opioid that has both agonist and antagonist properties. Naloxone is an opioid antagonist.

There is, for sure, a dissonance between laws that allow physicians, NPs, and PAs to prescribe opioids but that limit the ability of practitioners to prescribe drugs to treat opioid dependence. In the case of Tennessee, the 2015 law seems to be an attempt to control diversion fed by "Suboxone clinics" in East Tennessee rather than a move to limit the prescribing authority of NPs and PAs. That is, the legislature may have thought that limiting the numbers and types of providers who can prescribe buprenorphine may limit the amount of that drug being misused. Tennessee law says:

A physician...is the only healthcare provider authorized to prescribe any buprenorphine product for any federal Food and Drug Administration-approved use in recovery or medication-assisted treatment. [2]

Tennessee has enacted additional laws that limit the activities of clinics devoted to prescribing buprenorphine.

So my answer to the question, "Why can APRNs prescribe opioid pain medications but not, in many states, opioid antagonists?" is, in short: Laws authorizing prescribing of opioids have been on the books for years. The government's drive to decrease the prescribing of opioids is new in the past 5 years. Buprenorphine has street value. Its use to treat opioid dependency is fairly new. So, in a state where there is a reality or perception that buprenorphine is being misused, there are efforts to crack down on its misuse, and that includes restricting the authorized prescriber class to physicians.

In other states and federally, the trend is toward allowing more NPs and PAs to prescribe the medication.


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