Comprehensive Addiction And Recovery Act Research Articles

Federal Impacts on Buprenorphine Prescribing in Washington State, 2012 to 2022.

Objectives. To evaluate changes in monthly buprenorphine dispensation associated with federal prescribing policies in Washington State from 2012 to 2022. Methods. We conducted an interrupted time series analysis comparing monthly buprenorphine prescriptions dispensed per 1000 population after the Comprehensive Addiction and Recovery Act (CARA), Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT), and new prescribing rules during the COVID-19 pandemic. Buprenorphine formulated for opioid use disorder was included from the Washington State Prescription Monitoring Program. A log-linear autoregressive model measured linear trend changes. Results. Physician prescribing increased by 1.63% (95% confidence interval [CI] = 1.41%, 1.85%) per month after CARA with sustained declines after SUPPORT. Nurse practitioner (NP) prescribing increased by 19.48% (95% CI = 18.8%, 20.16%) per month after CARA with physician assistants (PAs) showing similar trends. Following the implementation of SUPPORT, NP and PA trends continued to increase at a reduced growth rate of 3.96% (95% CI = 2.01%, 5.94%) and 1.87% (95% CI = 0.56%, 3.19%), respectively. No prescribers experienced increases during the COVID-19 pandemic. Conclusions. CARA nearly tripled the buprenorphine prescribing rate. The SUPPORT Act initiated sustained declines for physician prescribing, and the COVID-19 period reversed gains for PAs and NPs. The current opioid crisis requires expanded efforts in Washington State. (Am J Public Health. 2024;114(7):696-704. https://doi.org/10.2105/AJPH.2024.307649).

The impact of CARA mandates on nurse practitioner controlled substance prescribing in Oregon: a cohort study

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.

Implementation of the North Carolina Plan of Safe Care in Wake County, North Carolina.

BACKGROUND The Comprehensive Addiction and Recovery Act (CARA) of 2016 amended the Child Abuse Prevention and Treatment Act (CAPTA), reinforcing and revising the requirement that states develop policies and procedures to address the needs of substance-affected infants and their caregivers. North Carolina's program, the North Carolina Plan of Safe Care (NC POSC), was implemented in August 2017 and involves coordination between multiple agencies.METHODS We conducted a quality improvement project to assess implementation of the North Carolina Plan of Safe Care in Wake County through interviews with key stakeholders involved in program delivery including health care providers (n = 7), child protective services social workers (CPS; n = 14), and care managers at Care Coordination for Children (CC4C; n = 10). We also analyzed data on Plan of Safe Care notifications to Wake County CPS from January 2018 to October 2019.RESULTS Several key themes emerged in stakeholder interviews, including 1) lack of awareness of the program among health care providers; 2) gaps in information sharing and communication between agencies; 3) concerns regarding CPS notifications for all substance exposure types, including prenatal exposure to medication for opioid use disorder (MOUD); 4) common family needs and service referrals; 5) challenges engaging with families; 6) lack of knowledge among health care providers and CPS social workers regarding CC4C; and 7) benefits of the program for infants and families. From January 2018 to October 2019, 91% of notifications for substance-affected infants received by Wake County CPS as part of the NC POSC were screened-in for a maltreatment assessment. Of those screened-in, more than two-thirds (70%) involved prenatal marijuana exposure only.LIMITATIONS This project was limited to one county.CONCLUSIONS As NC POSC implementation continues, further consideration of the infrastructure and guidance available to address the implementation challenges identified by stakeholders will be essential to meeting family needs and promoting infant safety and well-being.

Dispensing of medications used in MAT for Medicare Part D beneficiaries: Impact of 2016 CARA.

Objectives: (1) To describe dispensing of FDA-approved medications used in medication-assisted treatment (MAT) in Medicare Part D beneficiaries during 2013-2017; (2) to identify yearly dispensing associated with physician assistants (PAs) and nurse practitioners (NPs) during 2013-2017; and (3) to examine how Comprehensive Addiction and Recovery Act (CARA) of 2016 impacted dispensing of medications used in MAT in 2016-2017.Method: Retrospective secondary analysis of the Medicare Provider Utilization and Payment Data: Part D Prescriber datasets during the years 2013-2017. Generalized estimating equations (GEEs) were used to analyze the data.Participants: Providers whose national provider identifier is associated with at least one FDA-approved medication used in MAT during 2013-2017 and paid for by Medicare Part D.Main outcome measure: Per-prescriber population-adjusted number of claims for buprenorphine, buprenorphine/naloxone, and naltrexone.Results: There were 4,657,233 claims for medications used in MAT from 2013 to 2017 (mean = 2,374.48 per 100,000). PAs and NPs combined for 254,543 claims during 2013-2017 (mean = 127.58 per 100,000). In the first full year after CARA, prescriptions for medications used in MAT by PAs and NPs increased a population-adjusted 46.96 percent. In the GEE regression model, there were significantly fewer per-provider claims in the years 2013-2015 (pre-CARA) compared with 2017 (post-CARA) (all p < 0.05).Conclusion: The year after CARA was passed, claims for medications used in MAT from PAs and NPs increased.

CARA 3.0 introduced to increase access to treatment

Last month, U.S. Senators Rob Portman (R‐Ohio), Sheldon Whitehouse (D‐R.I.), Shelley Moore Capito (R‐W.Va.), Amy Klobuchar (D‐Minn.) and Jeanne Shaheen (D‐N.H.) introduced the Comprehensive Addiction and Recovery Act (CARA) 3.0 to increase the funding authorization levels for the CARA programs enacted in 2016 and put in place additional policy reforms to help combat the opioid epidemic that has worsened during the COVID‐19 pandemic. CARA was a bipartisan, national effort designed to ensure that federal resources were devoted to evidence‐based education, treatment and recovery programs that work. In FY 2021, CARA programs were funded at $782 million. Several key provisions of CARA 2.0 were enacted as part of the SUPPORT Act on Oct. 24, 2018. CARA 3.0 builds on these efforts by increasing the funding authorization levels and laying out new policy reforms to strengthen the federal government's response to this crisis.

The Association Between Scope of Practice Regulations and Nurse Practitioner Prescribing of Buprenorphine After the 2016 Opioid Bill.

This article examines the relationship between federal regulations, state scope-of-practice regulations on nurse practitioners (NPs), and buprenorphine prescribing patterns using pharmacy claims data from Optum's deidentified Clinformatics Data Mart between January 2015 and September 2018. The county-level proportion of patients filling prescriptions written by NPs was low even after the 2016 Comprehensive Addiction and Recovery Act (CARA), 2.7% in states that did not require physician oversight of NPs, and 1.1% in states that did. While analyses in rural counties showed higher rates of buprenorphine prescriptions written by NPs, rates were still considerably low: 3.7% in states with less restrictive regulations and 1.1% in other states. These results indicate that less restrictive scope-of-practice regulations are associated with greater NP prescribing following CARA. The small magnitude of the changes indicates that federal attempts to expand treatment access through CARA have been limited.

The Geographic Impact of Buprenorphine Expansion to Nurse Practitioner Prescribers in Oregon.

We examined the impact on geographic distribution of medications to treat opioid use disorder (MOUD) in Oregon after the Comprehensive Addiction and Recovery Act (CARA) was implemented in February 2017 to include nurse practitioner (NP) prescribers. We conducted interrupted time series analysis with linear regression on prescriptions dispensed for buprenorphine used for MOUD in the Oregon Prescription Drug Monitoring Database written by physician (MD/DO) and NP prescribers January 1, 2016, to December 31, 2018. We analyzed total prescriptions by prescriber type and pharmacy ZIP Code using STATA 16.1. From January 1, 2016, to December 31, 2018, 420,765 eligible prescriptions were written by waivered MD/DO and/or NP prescribers. Prior to CARA, buprenorphine use was increasing steadily at 140 prescriptions per month (95% CI: 78-201; P < .01). Following CARA, dispensing increased by 88 prescriptions per month (95% CI: 23-152; P = .01). The absolute number increased in rural areas immediately after CARA implementation (368 prescriptions; 95% CI: 124-613; P < .01). NP contribution to total buprenorphine prescribing increased significantly in both urban and rural areas (0.44% per month [95% CI: 0.30%-0.57%; P < .01] and 0.74% per month [95% CI: 0.62%-0.85%; P < .01]). The contribution of NPs had a particularly large impact for very rural (frontier) areas, where NPs provided 36% of all buprenorphine prescriptions by the end of 2018. Changes in federal law regarding MOUD had a positive impact on both supply and geographic distribution in Oregon, particularly in frontier areas comprising 10 of 36 counties (27%).

Innovations in Care: Complementary and Integrative Health in the Veterans Health Administration Whole Health System.

Innovations in Care: Complementary and Integrative Health in the Veterans Health Administration Whole Health System.

Accessing the Oregon Frontier: The Impact of Expanding Authority for Buprenorphine to Nurse Practitioners

Access to providers of treatment for opioid use disorder is a critical challenge to confronting the opioid epidemic. In 2017, the Comprehensive Addiction and Recovery Act (CARA) expanded buprenorphine prescribing privileges to nurse practitioners (NP). This research examined the effect of this regulatory change on buprenorphine prescribing in the state of Oregon.We performed an interrupted time‐series (ITS) analysis to examine the effect of CARA implementation (February 2017) on buprenorphine prescribing for medications to treat opioid disorders (MOUD) from January 1, 2016 to December 31, 2018. Specifically, we characterized changes in the trend and patterns of buprenorphine prescribing overall, by prescriber type (NPs vs MD/DO), and geographic designation. Our ITS regression models estimated prepolicy trends, immediate changes after CARA implementation, and changes in trend following implementation.We used Oregon Prescription Drug Monitoring Program data linked to a provider and dispensing characteristic files. Our study sample post‐CARA included 179 NPs with a total of 440 525 buprenorphine prescriptions statewide written by all prescribers.Prior to CARA implementation, the trend in total buprenorphine dispensing was increasing by 149 prescriptions per month (P &lt; .001). Following implementation, the trend in buprenorphine dispensing increased significantly by 75 prescriptions per month (P = .015). This increase was entirely driven by new NP prescribing of buprenorphine as the trend in MD/DO prescribing was unchanged (P = .65). By December 2018, 15% of buprenorphine prescriptions were prescribed by NPs. The proportion of buprenorphine prescribed by NPs increased in both urban (0.4% per month; P &lt; .001) and rural areas (0.6% per month; P &lt; .001). The increase was particularly large in counties classified as frontier (six or fewer people per square mile) where the proportion of buprenorphine prescribed by NPs increased from 1.2% to 23%.Buprenorphine dispensing rates in Oregon increased significantly following CARA implementation. The impact of adding NPs as authorized prescribers has enhanced access to buprenorphine prescriptions in rural and sparsely populated areas of the state where such patients were previously underserved.Expanding buprenorphine prescribing authority to NPs is a promising approach to improve access to MOUD, particularly in frontier counties where certified treatment centers do not exist. However, only 179 of the state’s 4946 licensed NPs prescribed buprenorphine demonstrating the need to for efforts to facilitate certification for these providers.WSU College of Nursing.

Buprenorphine prescription dispensing rates and characteristics following federal changes in prescribing policy, 2017-2018: A cross-sectional study

BackgroundExpansion of buprenorphine for opioid use disorder treatment is a core component of the opioid overdose epidemic response. The Comprehensive Addiction and Recovery Act (CARA) of 2016 authorized nurse practitioners (NPs) and physician assistants (PAs) to obtain a DATA-waiver to prescribe buprenorphine. The objectives of this study are to examine national- and county-level buprenorphine prescription dispensing, patterns by patient demographics and clinician specialty, and county-level characteristics associated with buprenorphine dispensing. MethodsRetrospective analysis of buprenorphine prescriptions dispensed from approximately 92% of all retail prescriptions in the US (2017–2018). Analyses include rates of buprenorphine prescriptions dispensed, by patient demographics and prescriber specialty, changes in buprenorphine prescriptions dispensed at the national- and county-level, and county-level characteristics associated with buprenorphine dispensing. ResultsBuprenorphine prescriptions dispensed increased by 9.1% nationally, from 40.7–44.4 per 1000 residents. From 2017 to 2018, NPs (351.9%) and PAs (257.3%) had the largest percent increases in dispensed buprenorphine prescriptions, accounting for 79.6% of the total increase. In 2018, county-level characteristics associated with high buprenorphine dispensing included. among others: greater potential buprenorphine treatment capacity, higher drug overdose death rates, and higher rates of Medicaid enrollment. Rural counties were associated with low buprenorphine dispensing. ConclusionBuprenorphine dispensing rates increased in the US from 2017 to 2018, suggesting the addition of NPs and PAs by CARA has contributed to an increase in dispensed buprenorphine prescriptions.

Tapering Recommendations for Benzodiazepines

Tapering Recommendations for Benzodiazepines

Lock-In Programs and the Opioid Epidemic: A Call for Evidence.

The authors discuss an opioid epidemic in America in relation to the U.S. Comprehensive Addiction and Recovery Act (CARA) which was passed in 2016 and contains a provision implementing drug management programs for at-risk beneficiaries (lock-in programs or LIPs) in Medicare Part D prescription drug plans beginning in January 2019. American public health interventions and drug overdose rates are examined, along with education and other services that are contained in LIPs.