Barriers and Facilitators of Advanced Practice Registered Nurse Participation in Medication Treatment for Opioid Use Disorder: A Mixed Methods Study

Abstract

<h3>Background</h3> The misuse of opioids is a health crisis in the United States. Medication treatment for opioid use disorder reduces negative health outcomes, but there are widespread shortages of appropriately trained and credentialed providers. Advanced practice registered nurses (APRNs) have recently become eligible for Drug Enforcement Administration (DEA) waivers that allow them to prescribe the most common medication, buprenorphine, but many factors might constrain their full participation in opioid use disorder treatment. <h3>Purpose</h3> This study aimed to describe practice and regulatory barriers and facilitators to APRNs offering buprenorphine treatment. <h3>Methods</h3> This mixed methods study integrated quantitative data on whether states' APRN scope-of-practice regulations were correlated with obtaining DEA waivers and qualitative data from site visits to four states with high numbers of opioid overdose deaths. <h3>Results</h3> Quantitative analysis found that a higher percentage of APRNs were waivered in states in which APRNs could prescribe without physician oversight compared with states that require physician oversight. The average percentage of APRNs with a waiver was significantly greater in rural counties than in urban counties in states that do not require physician oversight of NPs (<i>p</i> = .006), as was the number of waivered APRNs per 100,000 population (<i>p</i> = .005). In contrast, the number of waivered APRNs per 100,000 population was lower in rural counties versus urban counties in states that required physician oversight (<i>p</i> = .005). Qualitative findings indicated that state regulations requiring physician supervision of APRNs, federal waiver restrictions on the number of patients treated, prior insurance authorization requirements for buprenorphine, insurance requirements of counseling services, and nurse attitudes toward addiction were barriers to buprenorphine prescribing. <h3>Conclusion</h3> Qualitative findings indicate that waivered APRNs may not use the waiver due to practice and regulatory barriers. Requirements that physicians oversee APRN prescribing of buprenorphine may have slowed the growth of the opioid treatment workforce. Other regulations, organizational culture, and community support of buprenorphine treatment also affect APRN engagement in offering buprenorphine treatment.