June 2, 2020
PAs Report Barriers to Obtaining Buprenorphine Waiver
Knowledge Gaps Exist Related to Opioid and Substance Use Disorders
April 13, 2020
By AAPA Research Department
Substance and opioid use disorders (SUD and OUD) affect all patient groups in the United States: from affluent to poor, urban to rural, and across racial, ethnic, religious, gender, and age groups. Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that 10.3 million persons aged 12 and older misused opioids in 2018, including 9.9 million who misused prescription pills.1 Adolescents and adults that abuse non-medical prescription opioids have a higher incidence of mood disorders, such as major depressive disorder, bipolar, and any generalized anxiety disorder.2 Injection drug users are at higher risk for contracting HIV, hepatitis B, and hepatitis C1; the CDC reports that 9% of HIV diagnoses in 2017 were related to injection-related opioid abuse.3 Given the widespread nature of opioid use disorder (OUD) and addiction, and the widespread effects of opioid abuse in other areas of health, PAs should be prepared to address OUD in their scope of practice.
Medication-assisted treatments (MAT) approved to potentially combat OUD and SUD include the usage of medication in conjunction with counseling and/or behavioral therapies to treat substance use disorder. The goal of MAT is to regulate brain chemistry, block and alleviate cravings, and return the neurochemistry to pre-drug use levels. Three FDA-approved drugs can be used for opioid dependence: buprenorphine, methadone and naltrexone.4 In November 2016, U.S. Department of Health and Human Services (HHS) announced that PAs and NPs could apply for buprenorphine waivers to prescribe buprenorphine for the treatment of opioid addiction. As a condition to be waived, outlined in Section 303 of the Comprehensive Addiction and Recovery Act (CARA), PAs and NPs must complete 24 hours of required educational training.5
Multiple criteria must be met to qualify as a MAT prescriber, according to SAMHSA:
- Be licensed under state law to prescribe Schedule III, IV, or V medications for pain
- Complete not less than 24 hours of appropriate education through a qualified provider
- Through other training or experience, demonstrate the ability to treat and manage OUD
- If required by state law, be supervised or work in collaboration with a qualifying physician to prescribe medications for the treatment of OUD 6
The waiver allows PAs to treat up to 30, 100, or 275 patients for OUD.
Few PAs have buprenorphine waivers
In November 2019 AAPA asked PAs whether they hold a buprenorphine waiver, what barriers they may face to obtain a waiver, and more broadly, what level of competency they have related to diagnosing, treating, and managing SUD. Within this randomly selected group of PAs, 7.5% responded that they were waivered and able to prescribe buprenorphine. This is slightly higher than the number of PAs reported by SAMHSA in the United States: as of March 9, 2020, 5,083 PAs hold waivers for 30, 100, or 275 patients, for a total of 3.6% of PAs.7
Barriers to obtain waivers include confidence in managing OUD
Of the large percentage of PAs not waivered for buprenorphine, PAs report lack of training (65.6%), lack of available mental health or psychosocial services (55.1%), and time constraints (54.0%), as the top three barriers to obtaining their buprenorphine waiver. This is consistent with past research from Huhn & Dunn that found lack of training, lack of support services in the community, and time spent providing treatment to be the top three concerns to PAs and MDs.7 Lack of confidence in their ability to manage OUD was reported by more than half of respondents (51.8%), possibly speaking to gaps in current versus desired skills and abilities among PAs.
PAs have skills gaps in SUD and OUD
To understand more about how education, skills, and confidence to manage and treat SUD and OUD play a part in a PA’s decision for or against a buprenorphine waiver, PAs self-reported their current versus desired skills and abilities on five-point scales (1: None to 5: High) for a series of 12 competencies related to managing, treating, and diagnosing patients with SUD and OUD (Figure 1).
Averaged across 12 separate SUD and OUD skills and abilities that were averaged together, PAs without a buprenorphine waiver indicated that their current skills and abilities were lower than their desired skills and abilities. This was true across specialties, but for PAs in addiction medicine, pain management, and psychiatry, their current versus desired skills were not statistically significantly different. PAs without a buprenorphine waiver reported low current skills and abilities, and their desired skills and abilities were moderately low as well. For more information on these data, including a breakdown of the current and desired skills and abilities on all 12 competencies, please see the full report.
Education and reduction of barriers important
Substance and opioid use disorders do not discriminate. PAs in every setting and specialty are likely to encounter a patient who may potentially be struggling with SUD or OUD. Having a well-trained healthcare workforce that can comfortably treat and manage OUD patients is paramount to successful eradication of the opioid epidemic. In addition to more PAs becoming buprenorphine waivered, it is incumbent on the profession to provide training that prepares PAs to handle this crisis, and for prescriptive barriers to treating these patients to be removed.
AAPA and Physician Assistant Education Association (PAEA) are actively assisting PAs to combat this epidemic. OUD is one of AAPA’s national health priorities. AAPA is also a collaborative member on National Academy of Medicine’s Action Collaborative on Countering the U.S. Opioid Epidemic. In addition to AAPA’s work, PAEA is actively promoting buprenorphine waiver training within all PA programs.
AAPA, in conjunction with other organizations, continues to look for ways to help PAs combat OUD. By understanding the needs of PAs trying to obtain MAT waivers and their resistance to them, AAPA, PAEA, and other community partners can strengthen their OUD education, support, and lobbying. With opioid use disorders affecting large portions of the population, it is imperative that more PAs be able to recognize and treat this disorder. For more information, reference the full report.
- Substance Abuse and Mental Health Services Administration. (2019). Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health (HHS Publication No. PEP 19-5068, NSDUH Series H-54). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data.
- Martins, SS, Fenton, MC, Keyes, KM, Blanco, C, Zhu, H, Storr, CL. Mood and anxiety disorders and their association with non-medical prescription opioid use and prescription opioid-use disorder: longitudinal evidence from the National Epidemiologic Study on Alcohol and Related Conditions. Psychological Medicine, 2012; 42: 6 1262-1272.
- HIV: People Who Inject Drugs. https://www.cdc.gov/hiv/group/hiv-idu.html. Accessed February 6, 2020.
- Medication and Counseling Treatment: SAMHSA . https://www.samhsa.gov/medication-assisted-treatment/treatment#medications-used-in-mat. Updated 2020. Accessed March 15, 2020.
- Summary of the Comprehensive Addiction and Recovery Act. https://www.asam.org/advocacy/issues/opioids/summary-of-the-comprehensive-addiction-and-recovery-act. Accessed March 2020.
- 24-Hour Waiver Training: AAPA. https://elearning.asam.org/products/24-hour-waiver-training-aapa. Accessed March 19, 2020.
- National Waiver Totals. Substance Abuse and Mental Health Services Administration website. https://www.samhsa.gov/medication-assisted-treatment/practitioner-program-data/certified-practitioners. March 9, 2020. Accessed March 19, 2020.
- Huhn AS, Dunn KE. Why aren’t physicians prescribing more buprenorphine. J Substance Abuse Treatment, 2017; 78: 1-7.
AAPA Responding to the Opioid Epidemic (A National Health Priority of AAPA)
CME Waiver Training (AAPA and American Society of Addiction Medicine)
SAMSHA Waiver Resources
Authors of this article are Kristina Medlock, BA, research intern, and Tim McCall, PhD, associate director, surveys & analysis at AAPA. Contact them at [email protected]. Data included in this article are part of a larger report that is accessible here.