ASRA Pain Medicine Update

As pain specialists, we are well aware of the devastating effects from the current opioid crisis. The epidemic has numerous social and health-related implications, including substantial increases in the incidence of addiction, communicable disease, neonatal abstinence syndrome, violent crime, disruption of communities and families, and overdose-related deaths. Opioid misuse has created a nation in crisis, with more than 2 million cases of opioid use disorder (OUD) diagnosed in 2015 and subsequent rises in heroin use.^[1],[2] More than 72,000 Americans died from opioid-related causes in 2017, with close to 16,000 of those deaths from heroin.^[3]

In response to the growing number of opioid prescriptions and opioid-related deaths, the Centers for Disease Control and Prevention published prescribing guidelines and several states passed legislation successfully reducing the opioid supply. However, appropriate treatment options are lacking for those dependent on opioids, especially in rural areas of the United States.

Current evidence supports medication-assisted therapy (MAT) as the most effective treatment for OUD.^[4],[5] MAT combines medications approved by the Food and Drug Administration (FDA) with psychological interventions, including counseling and behavioral therapies, to comprehensively treat OUD. Methadone, buprenorphine, and naltrexone are the only FDA-approved MAT medications. Buprenorphine MAT has been associated with fewer adverse effects as well as improved fetal outcomes when initiated during pregnancy.^[5–8]

Unfortunately, access to MAT is limited, with the number of patients in need far exceeding that of qualified providers.^[9],[10] In 2015, less than 50% of U.S. counties had a physician prescriber and most of the deficit in rural areas.^[11] Based on current estimations, only 3% of all primary care providers have waivers to prescribe buprenorphine for OUD.^[11] Additional barriers to MAT availability include geographic location, socioeconomic circumstances, and stigma regarding addiction.^[11–17]

Because of current state restrictions on buprenorphine prescribing, advance practice providers who diagnose opioid dependence and OUD are unable to provide evidence-based treatment for their patients.

Prescribing buprenorphine maintenance treatment (BMT) requires specialty training with strict regulations on the number of patients each provider may treat. Currently, buprenorphine is a schedule III drug, and advanced practice providers are allowed to prescribe it for pain; however, many states have restrictions for addiction treatment.^[18] Although section 303 of the federal Comprehensive Addiction and Recovery Act authorized physician assistants and nurse practitioners to prescribe BMT, many state laws restrict or even prohibit advanced practice providers from prescribing buprenorphine for addiction.^[19]

The management of opioid dependence and OUD frequently defaults to primary care providers, especially in areas with limited access to addiction and chronic pain specialists. Advance practiced providers often serve rural areas to meet health care needs and, in certain states, practice independently.^[20] Patients in rural regions may have limited financial and psychosocial resources, further restricting their ability to seek appropriate treatment for OUD. Health Resources and Services Administration projections estimate that physician assistants and nurse practitioners will provide up to 28% of primary care services by 2020.^[21] But because of current state restrictions on buprenorphine prescribing, advance practice providers who diagnose opioid dependence and OUD are unable to provide evidence-based treatment for their patients.

Currently, three states (Oklahoma, Tennessee, and Wyoming) explicitly prohibit nurse practitioners from providing BMT, and 28 states place prescribing restrictions on the treatment.^[22] Scientific evidence is lacking to support those practice restrictions, and analysis of state-level scope-of-practice restrictions displays no evidence of improved quality of care in those states.^[23] In fact, states with reduced or restricted nurse practitioner scope of practice use more resources such as hospitalizations, readmissions, and emergency department admissions than full-practice states.^[24] Prescribing limitations reduce the pool of qualified MAT providers and place patients at greater risk for misuse, overdose, and death. Equipping advance practice providers with BMT prescribing privileges could significantly increase the availability of OUD treatment specialists and improve access to care for those with OUD.^[24]

References

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3. National Institute on Drug Abuse. Overdose death rates. Available at: https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Updated January 2019. Accessed March 4, 2019.
4. Dematteis M, Auriacombe M, D’Agnone O, et al. Recommendations for buprenorphine and methadone therapy in opioid use disorder: a European consensus. Expert Opin Pharmacother 2017;18:1987–1999.
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18. DEA Diversion Control Division. Mid level practitioners: controlled substance authority by discipline within state 2018. Available at: https://www.deadiversion.usdoj.gov/drugreg/practioners/mlp_by_state.pdf. Accessed March 4, 2019.
19. St. Marie B, Arnstein P, Zimmer PA. Pain and opioids: call for policy action. J Nurse Pract 2018;14:40–44.
20. O’Connor AB. Nurse practitioners’ inability to prescribe buprenorphine: limitations of the Drug Addiction Treatment Act of 2000. J Am Acad Nurse Prac 2011;23:542–545.
21. HRSA Health Workforce. Projecting the supply and demand for primary care practitioners through 2020. Available at: https://bhw.hrsa.gov/health-workforceanalysis/primary-care-2020. Published November 2013. Accessed March 4, 2019.
22. Jackson HJ, Lopez CM. Utilization of the nurse practitioner role to combat the opioid crisis. J Nurse Pract 2018;14:213–216.
23. Perloff J, Clarke S, DesRoches CM, O’Reilly-Jacob M, Buerhaus P. Association of state-level restrictions in nurse practitioner scope of practice with the quality of primary care provided to Medicare beneficiaries. Med Care Res Rev 2017:1077558717732402.
24. Buerhaus P. Nurse practitioners: a solution to America’s primary care crisis. Available at: http://www.aei.org/wp-content/uploads/2018/09/Nursepractitioners.pdf. Published September 2018.