Abstract
The U.S. epidemic of opioid use and deaths continues to be a public health crisis. The Consolidated Appropriations Act (CAA), a 2023 U.S. federal law, takes another step toward medication-assisted treatment (MAT) for those with opioid use disorder (OUD). It ends longstanding federal waiver requirements for advanced practice registered nurses (APRNs) and physician assistants (PAs) MAT-prescribing. Although a step in the right direction, incremental legislation and has been eclipsed by the escalating crisis, which has implications for nursing practice. The evolution of MAT policies illustrates ongoing barriers that impede nurses’ capacity to provide needed services.
Historically, treatment for OUD was limited to federally approved clinics that could dispense medication (e.g., methadone). The 2000 passage of the Drug Addiction Treatment Act (DATA) allowed for use of other FDA-approved opioid medications, such as buprenorphine, to now be prescribed by physicians if they first received a federal waiver (Manlandro, 2005). 1 Waived physicians could treat up to 30 people in Year-1 and up to 275 people subsequently. DATA included no similar provisions for APRNs.
The next milestone in OUD treatment was the passage of The Comprehensive Addiction and Recovery Act of 2016 (CARA, P.L. 114-198). DEA-registered APRNs and PAs could apply for a waiver after completing 24 hours of education; waived APRNs/PAs could then treat up to 30 patients/year. APRNs were also regulated by state scope-of-practice (SOP) laws. SOP varied from no barriers beyond the 30-cap, to physician oversight and, in a few states, APRN-prescribed buprenorphine was prohibited (Vestal, 2017). The 2018 Substance Use-Disorder Prevention Promotes Opioid Recovery and Treatment (SUPPORT) Act allowed APRNs to treat up to 100 patients/year one and up to 275 subsequently (AANP, n.d.), again modulated by state SOP.
As the opioid epidemic accelerated, the U.S. Surgeon General defined the standard treatment for OUD as MAT, supported by psychosocial/community-based interventions (Donelson, 2020; HHS, 2018). Primary care is also emphasized as essential in this treatment modality, but the U.S. shortage of primary care providers represents a substantial and systemic obstacle (Numerof, 2023).
CAA 2023, Section 1262, lifted the federal requirement that providers obtain a waiver to prescribe MAT for OUD; patient limits, criteria around prescribing disciplines, and counseling requirements have also been removed. Providers must have a DEA license. CAA Section 1263 lists requirements for DEA license. The following relate to U.S. APRNs:
“… eight hours of training from certain organizations on opioid or other substance use disorders for practitioners renewing or newly applying for a registration from the DEA to prescribe any Schedule II-V controlled medications;… Graduation within five years and status in good standing from medical, advanced practice nursing, or physician assistant school in the United States that included successful completion of an opioid or other substance use disorder curriculum of at least eight hours” (SAMSHA, n.d., para 6).
Elimination of the waiver requirement for MAT is valuable but doesn’t address systemic barriers affecting OUD treatment. Notably, only 16% of Medicare beneficiaries
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with SUD received treatment in 2020 (U.S Office of the Inspector General, 2021). Two-thirds of those covered by Medicaid received treatment, and there were discrepancies by race, age, and disability (U.S. Office of the Inspector General, 2023). Although stigma represents an access barrier for many (National Academies of Sciences, Engineering, and Medicine, 2019), the shortage of primary care providers is also problematic. APRNs can fill this gap, but educational capacity is limited by clinical preceptor and faculty availability. Porat-Dahlerbruch et al. (2022) detail a successful Medicare-funded Graduate Nurse Education (GNE) Demonstration that provided financial support for the clinical education of APRNs at a fraction of the cost of medical residencies, $47,000 versus $157,000. GNE must become permanent if the primary care needs of vulnerable populations are to be addressed.
State prescribing laws also impact access to MAT. Now, with federal barriers lifted to allow DEA-registered APRNs to treat without waivers or patient caps, avenues to explore include:
Funding for pilot programs in states with restrictive APRN SOP to expand state-specific effectiveness evidence. Funding to support APRN SUD-focused education to expand workforce preparedness. Expanded APRN compact licensure to support virtual MAT access, particularly in underserved areas.
MAT illustrates the manner in which federal and state legislation can enhance or impede the ability of nurses to provide valuable services to people in need. Nurses are willing and able to serve those with SUD. Now is the time to better align policies and funding streams with societal need.