Eliminate the buprenorphine DEA X waiver: Justification using a policy analysis approach

Examining the Impact of Eliminating the X Waiver on Buprenorphine Dispensation in 63 Counties in Pennsylvania

BACKGROUND

Opioid overdose rates continue to rise in the United States while access to treatment options remains limited. The X waiver, which allowed clinicians to prescribe buprenorphine, a medication for opioid use disorder (MOUD), in an outpatient setting, was eliminated in December 2022 with hopes of increasing buprenorphine access. We used a quasi-experimental approach to evaluate how eliminating the X waiver affected buprenorphine prescribing in Pennsylvania.

METHODS

Drawing on Pennsylvania Prescription Drug Monitoring Program data from July 1, 2016, to December 31, 2023, we used a difference-in-differences (DD) approach to assess changes in buprenorphine prescribing between Pennsylvania counties with the proportion of X-waivered providers per county population above the median versus counties with the proportion below the median, before and after the elimination of the X waiver. We also tested whether areas most affected by the opioid epidemic with the highest rates of opioid overdose were more impacted by the X-waiver elimination, using opioid overdose death rates from a pretreatment baseline period (2016-2018) for each county.

RESULTS

Thirty-one counties were categorized as above the median and 32 as below the median. We did not observe a significant difference in the effects of eliminating the X waiver on buprenorphine dispensation (DD estimate: -0.6%, 95% CI: -7.5%-6.2%) between above versus below-the-median counties in Pennsylvania. We also did not find a significant effect of the X-waiver elimination on buprenorphine dispensation in counties most affected by the opioid epidemic (difference-in-difference-in-differences estimate 1.6%, 95% CI: -10.2%-13.4%).

CONCLUSIONS

We found no evidence that eliminating the X waiver had a significant impact on buprenorphine dispensing in Pennsylvania in counties with fewer waivered prescribers or higher fatal overdose rates. Additional efforts to increase buprenorphine use will likely need to address systemic barriers and stigma limiting MOUD access.

Analysis of Ohio Advanced Practice Registered Nurses' Rate of Prescribing Naltrexone for Patients With Alcohol Use Disorder Since Elimination of the X-Waiver

BACKGROUND

Alcohol use disorder (AUD) is common and deadly. Naltrexone is a treatment for AUD. Previous research examined factors that predict Ohio Advanced Practice Registered Nurses' (APRNs) utilization of naltrexone to treat AUD. Inclusion criteria included APRNs' endorsing receipt of the X-waiver, a designation indicating providers' receipt of substance use disorder education. In 2023, the X-waiver was eliminated. The purpose of this study was to replicate the previous research design in respondents without an X-waiver and compare findings.

AIMS

The aims of this study were three-fold: (1) assess whether race, age, practice setting, years in practice, or work experience with an addiction specialist physician predicted prescription of naltrexone for AUD, (2) assess whether the goal of abstinence or reduced alcohol use as desired treatment affected the likelihood of naltrexone prescription for AUD, and (3) compare differences between the answers in the current respondent group without X-waiver and the previous study's X-waivered respondents.

METHOD

All Ohio APRNs were sent surveys. Eighty-eight responses were included in analysis. Descriptive statistics, logistic regression, and chi-square results were reported.

RESULTS

Work experience with an addiction specialist physician was negatively associated with prescribing naltrexone for AUD. Respondents from the previous study of X-waivered APRNs were significantly more likely to prescribe naltrexone for reduced alcohol consumption as a treatment outcome than the respondents in this study.

CONCLUSION

The recent policy change eliminating the X-waiver provides important context for research, adding to the substance use disorder literature.

Concurrent Treatment of Opioid and Tobacco Use Disorder in a Telemedicine Clinic: Case Report of Breaking Through Barriers

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1177/20552076241258400.

Community coalitions' navigation of policies to address the opioid epidemic: insights from qualitative interviews in four states

Introduction

The opioid epidemic in the USA presents a multifaceted challenge regulated by a patchwork of federal, state and local policies. In some communities, cross-sector coalitions navigate this complex policy environment to address the epidemic. However, limited research has explored these public health-oriented community coalitions and their interactions with the policy landscape. This study explores how cross-sector public health-oriented community coalition members perceive and navigate the multidimensional policy landscapes to address the opioid epidemic.

Methods

Using data from 304 semistructured HEALing Communities Study coalition member interviews conducted April-June 2021 in 67 communities in Kentucky, New York, Massachusetts and Ohio, we inductively analysed participants' discussions of opioid-related policies to characterise themes and subthemes.

Results

We describe two themes where coalitions and policy intersect: policy landscape barriers and navigation and mitigation strategies to address policy barriers. Participants revealed community misunderstandings and lack of knowledge of opioid-related policies. Furthermore, participants shared how these policies often hindered coalitions' initiatives to address substance use. Nevertheless, community coalitions functioned despite these policy challenges through knowledge sharing, innovation and policy advocacy.

Conclusions

Cross-sector public health-oriented community coalitions serve a vital role in navigating the complexities of the multidimensional policy landscape regulating substance use services. Insights from these findings may encourage policy-makers to support community coalitions in pursuing solutions to the opioid crisis and other public health crises.

Trial registration number

NCT04111939.

Empowering Primary Care Nurse Practitioners: A Multilevel Approach to Combating the Opioid Crisis

AIMS

We offer a literature-driven, empirically informed, and highly warranted recommendation for a multilevel approach tailored to nurse practitioners. This approach aimed to drive change at the individual level (nurse practitioner), dyadic level (nurse-patient therapeutic relationship), and systems level (organisational culture, education, and policy) to strengthen nurse practitioners' capacity to deliver optimal opioid use disorder care.

BACKGROUND

The opioid overdose epidemic is a global public health crisis, with the United States facing the most severe impact. Access to evidence-based treatment for opioid use disorder remains a significant barrier. Primary care nurse practitioners can play a crucial role in expanding access and bridging the treatment gap. Addressing factors influencing access to, quality of, and effectiveness of treatment requires urgent and careful consideration.

DESIGN

This position paper highlights the multilevel barriers that inhibit nurse practitioners in managing opioid use disorder, negatively impacting treatment access and opioid use disorder-related outcomes.

METHOD

The Advanced Practice Provider conceptual model was adapted to guide this paper. This adapted model illustrates the interconnected layers among nurse practitioners, clinical care, education, professional development, and organisational culture and policy in caring for patients with opioid use disorder.

CONCLUSIONS

Equipping primary care nurse practitioners with the necessary tools to both understand opioid addiction and empower patients experiencing it can have a profound impact. This impact benefits the provider and patient and extends to addressing the opioid crisis at multiple levels. Future research should explore nurse practitioners' experiences when working with individuals with opioid use disorder, identify barriers that hinder positive interactions with patients seeking treatment, and pragmatically test and implement multilevel interventions designed to holistically benefit providers and patient outcomes.

IMPACT TO NURSING

This American-based reflection offers valuable insights to nurse practitioners worldwide as they consider effective strategies for addressing opioid use disorder in primary care settings.

Ensuring Advanced Practice Nursing Students Meet the 2023 Drug Enforcement Agency Requirements

BACKGROUND

All advanced practice nursing students in the doctor of nursing practice program at Johns Hopkins School of Nursing are required to complete 3 core courses (pathophysiology, pharmacology, and physical assessment). As of June 2023, the Drug Enforcement Agency (DEA) required all prescribers of controlled medications to attest to at least 8 hours of substance use training.

PURPOSE

To quantify the amount of time advanced practice nursing students learn substance use-related content and engage in teaching/learning activities across the 3 courses as a basis for meeting the DEA requirement.

METHODS

Lead course faculty teaching identified content related to substance use disorders, including reading assignments and skill-building activities, and the minimum amount of time that students spend in those teaching/learning experiences.

RESULTS

Advanced practice nursing students complete a total of 14 hours of substance use-related content in the 3 core courses.

CONCLUSIONS

This article describes substance use-related content and strategies that can be integrated in advanced practice nursing programs for students to meet the new DEA requirement.

Perspectives on APRN prescribing of medications for opioid use disorder: Key barriers remain

INTRODUCTION

Deaths from drug overdoses are rising dramatically in the United States. Treatment for opioid use disorders may include behavioral treatments as well as medications for opioid use disorders (MOUD). Buprenorphine can be prescribed by physicians, nurse practitioners (NPs), other advanced practice registered nurses (APRNs), and physician assistants (PAs) and required a training and a federal waiver until recently. The number of NP MOUD prescribers grew steadily over the past decade, but research has identified state-level scope of practice regulations as a barrier to NP MOUD prescribing. This article explores the contributions of, and remaining barriers faced by NP and other APRN MOUD prescribers. We describe qualitative findings from a study of NPs and other key stakeholders involved in MOUD treatment in four states with two differing levels of regulatory structure.

METHODS

In this qualitative study, we conducted site visits and semi-structured interviews with NPs and other APRNs, physicians, clinic managers, and regulators in four states including New Mexico and West Virginia (full practice authority for NPs), and Ohio and Michigan (which require physician supervision). Interview notes were entered into a qualitative software package and coded and reviewed by two members of the research team. Data were grouped into key themes.

RESULTS

A total of 76 participants participated in individual or small group interviews in the four states. We found key themes and several subthemes that describe NP practice in MOUD. Participants described key contributions of NP engagement in MOUD, including increasing access, serving rural areas, the unique role of psychiatric NPs, and the value of the nursing model of care in working with people with substance use disorders (SUD). Participants also identified barriers including scope of practice regulations, other regulatory barriers, stigma, and lack of supportive services to address psychosocial needs.

CONCLUSIONS

The waiver requirements were eliminated at the end of 2022 in federal budget legislation. Other barriers for NP and other APRN prescribers remain and should be addressed in practice, and in state and federal regulations. Research needs to explore the impact of the waiver elimination on MOUD prescribing and access to services.