DEA Expands Access to Opioid Addiction Treatment via NPs, PAs

Alicia Ault

January 29, 2018

The US Drug Enforcement Administration (DEA) has cleared the way for nurse practitioners (NPs) and physician assistants (PAs) to become prescribers and dispensers of US Food and Drug Administration (FDA)–approved opioid addiction medications containing buprenorphine for opioid use disorders.

The agency had been required to include these practitioners as authorized providers by the 2016 Comprehensive Addiction and Recovery Act (CARA).

The law mandated a 3-year pilot that allowed advanced NPs and PAs who had received training to prescribe buprenorphine. A final DEA rule makes that permanent.

This helps create a certain level of predictability for hospitals, health systems, and clinicians who want to provide addiction treatment services, Corey Waller, MD, chair of the American Society of Addiction Medicine's (ASAM's) Legislative Advocacy Committee, told Medscape Medical News.

Some 5000 NPs and PAs have already been treating patients, according to the DEA. Dr Waller said he believes at least 25,000 more would be interested. In all, 43,000 physicians have been certified to prescribe and dispense buprenorphine, said the DEA.

Under CARA, NPs and PAs are eligible provided they are licensed under state law to prescribe schedule III, IV, or V medications for the treatment of pain and that they receive at least 24 hours of initial training. State laws requiring supervision by physicians will continue to apply.

According to the ASAM, the American Academy of Physician Assistants, and the American Association of Nurse Practitioners, the Substance Abuse and Mental Health Services Administration (SAMHSA) "has indicated that if collaboration or supervision is required by state law, [SAMHSA] will interpret CARA in such a way that NPs and PAs will not be required to collaborate with or be supervised by a waivered physician as a condition of their own waiver, as long as they and their associated physician otherwise meet the requirements of the program."

The three organizations wrote to state medical boards in October 2017, urging them to adopt the SAMHSA approach to help expand the number of prescribers.

NPs and PAs "are a solution to expanding access to care for all of medicine, not just addiction," said Dr Waller, who is also senior medical director for education and policy at the National Center for Complex Health and Social Needs/Camden Coalition of Healthcare Providers, New Jersey.

He notes that many NPs and PAs are often the first-line providers for patients with substance use disorders in clinics and emergency departments. Giving them the ability to treat "gives them the capability to do something about it," he said.

Expanding access to addiction care is important, said Ajay D. Wasan, MD, professor of anesthesiology and psychiatry and vice chair for pain medicine, University of Pittsburgh Medical Center, in Pennsylvania.

Giving advanced practice providers the ability to prescribe buprenorphine is fine, as long as they have the appropriate training, Dr Wasan told Medscape. Maintenance addiction treatment has to be combined with a psychosocial intervention to be effective, he said.

Both he and Dr Waller said that increasing the number of prescribers does slightly heighten concern about inappropriate use.

"Most likely, the majority of providers prescribing medication-assisted therapy are doing it responsibly," said Dr Wasan. But he said some clinics begin prescribing after brief meetings and do not follow up with behavioral interventions.

"No one wants to see more of these Suboxone pill mills rising up," said Dr Wasan. "People want to see that good, comprehensive addiction treatment is being done."

Dr Waller agreed, noting that "expansion of access has to be equal with expansion of quality of access." But he added that the DEA seems to be cracking down on those prescribers who act criminally. And there is still an access crisis, he said.

"We have only 14% or 15% of the access required to treat these patients, so we have a long way to go before we saturate the market with availability of treatment."

The DEA said that its policy change should help more people with opioid use disorders who reside in rural areas. A 2017 National Rural Health Association report found that 90% of physicians who have been approved to prescribe medication-assisted therapy were in urban counties. Half of rural counties did not have any prescribing physician, and 30 million people lived in counties where treatment was unavailable.

The majority — 92% — of substance use treatment facilities were in urban areas.

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