Abstract
BackgroundIn 2017, the United States Comprehensive Addiction and Recovery Act (CARA) expanded authorization to prescribe buprenorphine for opioid use disorder (OUD) to nurse practitioners (NPs). Compared to physicians, NPs were required to complete 16 additional hours of training on controlled substance prescribing before a buprenorphine waiver application. As this differential additional education mandate was seen as a potential barrier, we evaluated the impact of this requirement on both NP waiver acquisition and prescribing of controlled substances, comparing NPs who obtained waivers to those who had not.MethodsThrough 2016–2018 Oregon Prescription Drug Monitoring Program and linked NP licensure data, we identified factors associated with waiver acquisition at baseline (2016) and evaluated changes in controlled substance prescribing before (2016) and after waiver acquisition (2018). Using chi-square and Mann-Whitney U testing, we calculated and described controlled substance prescribing types, rates, and patient level quantities including co-prescribing of benzodiazepines and opioids by NPs. Multivariable linear regression compared prescribing by waivered and non-waivered NPs for significant changes in non-buprenorphine controlled substance prescribing.ResultsWaivered NPs were more likely to have a psychiatric certification, have prior disciplinary action, and have generally higher levels of non-buprenorphine controlled substance prescribing than their non-waivered counterparts. While there was a significant increase in opioid prescriptions per patient among waivered NPs, following CARA implementation, co-prescribing of benzodiazepines and opioids significantly declined among waivered NPs relative to non-waivered NPs.ConclusionsAlthough educational requirements were rescinded in 2021 for most applicants, enhanced opioid prescribing training should be incorporated into professional educational offerings regardless of regulatory mandate. We recommended continued focus on education regarding avoidance of high risk prescribing such as co-prescribing of opioids and benzodiazepines. NPs who acquire waivers may take on higher risk patients already using opioids, and these findings may represent transitions in practice and patient setting.
Highlights
In 2017, the United States Comprehensive Addiction and Recovery Act (CARA) expanded authorization to prescribe buprenorphine for opioid use disorder (OUD) to nurse practitioners (NPs)
For each NP, we calculated the number of unique patients to whom they prescribed opioid analgesics, the average number of opioid prescriptions they prescribed to each patient, the number of patients to whom they prescribed long-term opioid therapy, and the number of patients who received at least one opioid prescription at or above 90 morphine milligram equivalents (MME) per day [15]
In this study we found waivered NPs to be more likely to have a psychiatric certification, have prior disciplinary action, and have generally higher levels of controlled substance prescribing than their non-waivered counterparts
Summary
In 2017, the United States Comprehensive Addiction and Recovery Act (CARA) expanded authorization to prescribe buprenorphine for opioid use disorder (OUD) to nurse practitioners (NPs). In 2016 Congress passed the Comprehensive Addiction and Recovery Act (CARA) which extended prescriptive authority for office-based treatment with buprenorphine to nurse practitioners (NPs) for up to 30 patients beginning in 2017 [1]. Prior studies demonstrate both a geographic maldistribution of providers and the potential contribution of NP prescribers to easing this disparity [2, 3]. An expanded understanding of additional facilitators and barriers to buprenorphine prescribing in states which provide little regulatory constraint is critical to continued assessment of federal law efficacy and success
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