The opioid epidemic has devastated communities across the United States, particularly in rural areas where access to healthcare services has long been limited. For many living in these regions, seeking treatment for opioid use disorder (OUD) has often been an uphill battle, complicated by geographic isolation, insufficient healthcare resources, and a shortage of healthcare providers specializing in addiction treatment. However, in recent years, a significant shift has occurred, thanks to the expansion of who can prescribe life-saving medications like buprenorphine.
A recent study published in Health Affairs sheds light on how the Comprehensive Addiction and Recovery Act (CARA) of 2017 has dramatically improved access to medication-assisted treatment (MAT) in rural communities by allowing nurse practitioners (NPs) and physician assistants (PAs) to prescribe buprenorphine. This change has been credited with significantly increasing the number of clinicians authorized to provide MAT in rural areas, addressing a critical gap in treatment availability for opioid use disorder and other substance abuse conditions.
The Role of Buprenorphine in Combatting Opioid Use Disorder
Buprenorphine is a key medication used in MAT, a widely regarded and evidence-based approach for treating opioid use disorder (OUD). MAT combines medication with counseling and behavioral therapies to treat substance use disorders. Buprenorphine, specifically, helps manage withdrawal symptoms and cravings without producing the “high” that is characteristic of opioids like heroin or prescription painkillers. This medication is seen as a critical tool in reducing opioid overdose deaths and improving the chances of long-term recovery.
Before clinicians can prescribe buprenorphine, they must undergo specialized training and obtain a federal waiver, which ensures that they have the necessary knowledge and expertise to safely prescribe and manage MAT. The process of getting this waiver was historically restricted to physicians, but the passage of CARA in 2017 made a significant change: the law expanded eligibility for buprenorphine waivers to include nurse practitioners and physician assistants.
This shift has proven to be a game-changer, especially in rural areas where healthcare providers are scarce. The Health Affairs study highlighted this development, showing that the number of clinicians with waivers to prescribe buprenorphine per 100,000 people in rural areas increased by 111% from 2016 to 2019. What’s more, NPs and PAs accounted for more than half of that growth. This means that in just a few years, thousands of rural residents gained access to a clinician who could prescribe the critical medication that had previously been out of reach.
The Impact of Nurse Practitioners and Physician Assistants
The expansion of buprenorphine prescribing authority to NPs and PAs has been instrumental in filling a critical gap in rural healthcare. According to lead author Michael Barnett, “Since CARA expanded buprenorphine waiver eligibility to nurse practitioners and physician assistants, we saw an explosion of adoption of these waivers, particularly in areas where it seems like they’re most needed.”
NPs and PAs have long been a vital part of the healthcare workforce, particularly in underserved areas. By enabling these professionals to prescribe buprenorphine, CARA effectively increased the capacity of rural healthcare systems to address the opioid crisis. The Health Affairs study found that NPs and PAs who obtained waivers under CARA brought MAT services to 285 rural counties that previously lacked a single waivered clinician. As Barnett notes, “That means that 5.7 million rural residents had their first buprenorphine prescriber in their county because of an NP or PA.”
This expansion of the healthcare workforce is particularly important in the context of the broader shortage of behavioral health professionals in rural areas. More than half of the counties in the U.S. lack a practicing psychiatrist, and the situation is equally dire in substance abuse treatment services. The involvement of NPs and PAs in buprenorphine prescribing not only alleviates some of the burden on physicians but also provides much-needed access to medication for individuals struggling with OUD.
Variability in CARA’s Impact Across States
While the success of CARA in increasing access to MAT in rural areas is clear, the study also points to variability in how the law’s impact has played out in different states. The expansion of buprenorphine waivers has been more pronounced in states with less restrictive scope-of-practice regulations, which govern what tasks healthcare providers such as NPs and PAs are allowed to perform. In states with broad scope-of-practice laws, NPs and PAs have been more likely to receive buprenorphine waivers, thereby increasing the number of clinicians available to prescribe MAT.
On the other hand, in states with stricter scope-of-practice regulations, the expansion of buprenorphine prescribing has been slower. This disparity highlights the importance of addressing state-level regulations in efforts to improve access to addiction treatment. States with more restrictive regulations may still face challenges in fully leveraging the potential of NPs and PAs to address the opioid crisis.
The Promise of CARA Beyond MAT
The success of CARA in expanding access to buprenorphine waivers also raises questions about the potential for similar reforms in other areas of behavioral health care. As the Health Affairs study demonstrates, increasing the number of clinicians who can provide essential services like MAT has tangible benefits, particularly in rural areas. These findings suggest that expanding the roles of NPs and PAs in other aspects of behavioral health could be an effective way to address the behavioral health workforce shortage and improve access to care.
Barnett, the lead author of the study, emphasizes the importance of including NPs and PAs in broader healthcare delivery reforms: “Any kind of behavioral health reform — or really healthcare delivery reform in general — that doesn’t consider NPs and PAs as a key part of the workforce is going to have a limited impact.”
This could mean expanding the scope of practice for NPs and PAs to include the ability to prescribe medications for other behavioral health conditions, such as antidepressants or antipsychotics, or to provide therapy services. The potential for NPs and PAs to work at the top of their licenses and take on a larger role in mental health care could help address the growing demand for behavioral health services, particularly in underserved areas.
The Road Ahead
While the expansion of buprenorphine prescribing authority to NPs and PAs has had a positive impact in rural areas, it is important to recognize that CARA is not a silver bullet for the opioid crisis. As the study points out, engaging individuals with OUD requires a multifaceted approach that includes not only medication-assisted treatment but also counseling, therapy, and community-based support. The increase in access to MAT services is a crucial first step, but it must be accompanied by efforts to reduce stigma, improve social support systems, and ensure that individuals have access to a full continuum of care.
Furthermore, addressing the broader shortage of behavioral health professionals will require continued investment in the workforce and policies that support the development of a diverse and well-trained healthcare workforce. Expanding the roles of NPs and PAs is a promising step, but it must be part of a larger effort to build a sustainable and equitable healthcare system.
The success of CARA in expanding access to buprenorphine waivers highlights the importance of leveraging the full potential of the healthcare workforce to address pressing public health issues. If these reforms are expanded to other areas of behavioral health, they could play a key role in improving access to care and ultimately improving the lives of individuals in underserved communities. As Barnett aptly puts it, “We can’t have an entirely physician-centric view of how we reform healthcare delivery. We need to include really the whole span of healthcare professionals.”Attach
Search
Reason
