Research & Policy

The Mainstreaming Addiction Treatment Act: Equipping all front-line providers.

Overview

  • Federal law discourages doctors, advanced practice registered nurses, and physicians from treating patients with opioid use disorder.

  • Some argue that the federal restrictions on prescribing buprenorphine should be removed, but only for doctors. Removing the federal restrictions for all providers with a standard controlled medication license, and not just doctors, is the only pathway to universal, equitable substance use disorder treatment.

  • The Mainstreaming Addiction Treatment Act equips healthcare providers, including advanced practice registered nurses and physician assistants, to provide lifesaving treatment for opioid use disorder.

Problem

Doctors, advanced practice registered nurses, and physician assistants are on the front-lines of multiple healthcare crises, including COVID-19 and the overdose epidemic. Four in ten doctors report burnout due to long work hours and bureaucratic requirements.
1
Assoc. of American Medical Colleges (“AAMC”), The Complexities of Physician Supply and Demand: Projections From 2018 to 2033, at 17 (2020), https://bit.ly/3chCUkG (noting “42% of physician respondents reported burnout due to long work-hours and excess bureaucratic tasks.”).
And, the workforce of primary care physicians is shrinking, particularly in rural areas.
2
Michael L. Barnett, MD, MS et al., “In Rural Areas, Buprenorphine Waiver Adoption Since 2017 Driven by Nurse Practitioners And Physician Assistants”, Health Affairs, at 2 (2019), https://bit.ly/3sk7Eay (“An additional challenge is a shrinking workforce of primary care physicians in rural areas. However, as primary care physicians have been leaving rural counties, primary care nurse practitioners (NPs) have been replacing them. The growth of NPs in the rural primary care workforce offers the potential to help improve access to buprenorphine treatment.”); Matthew A. Davis, MPH, PhD et al., Supply of Healthcare Providers in Relation to County Socioeconomic and Health Status, 33(4) J. General Internal Medicine 412-414 (2018), https://bit.ly/3tWvAkN (“Non-physician clinicians now constitute nearly one-quarter of the US primary care workforce, and as such are expected to play a significant role in offsetting projected physician shortfalls.”).
Equipping advanced practice registered nurses and physician assistants to treat opioid use disorder is critical to ending the overdose crisis.

But, federal law discourages doctors, advanced practice registered nurses, and physicians from treating patients with opioid use disorder. Medical providers must limit the number of patients they can treat at one time, obtain a special registration from the federal government, and undergo 8-24 hours of training on the medication (if they treat more than 30 patients at a time). It can take 2-3 months for medical providers to complete these bureaucratic requirements.

Providers have noted these restrictions, which do not apply to any other medical condition, are intimidating and discourage them from treating people with opioid use disorder.
3
Nat’l Acad. of Sciences, Engineering, and Medicine (“NASEM”), Consensus Study Report: Medications for Opioid Use Disorder Save Lives, Nat’l Acad. Press, at 120-21 (2019) https://bit.ly/2NJnNXQ (“Waivered providers have also reported that the DEA’s approach can be ‘threatening,’ and some buprenorphine-waivered providers feel that they are unfairly scrutinized by the DEA. More recent aggressive enforcement strategies by the DEA and several state attorneys general—including increases in raiding, auditing, and launching criminal investigations of waivered providers—perpetuate the fear of such surveillance that has been articulated by waivered and non-waivered providers.”); Letter from American Medical Assoc. (“AMA”) to Sec. Alex Azar (Jun. 2, 2019), https://bit.ly/3cgj9u8 (“Physicians are extremely reluctant to invite the scrutiny of the DEA by pursuing a waiver to treat OUD patients with buprenorphine. They fear that the DEA would take punitive action in response to innocent mistakes, and that DEA agents with weapons would enter their practices and frighten patients and staff. The DEA is a law enforcement agency, not a health care agency. Waivered physicians who have experienced DEA audits have expressed concerns that DEA auditors do not understand medical records and do not conduct audits appropriately. They have also described the DEA’s approach as ‘threatening.’ These concerns have been heightened by raids and criminal investigations of waivered physicians by the DEA and state attorneys general. Recently, to its credit, the DEA has conducted outreach to physicians in an effort to mitigate these fears, and the AMA has assisted DEA in this effort as part of a much larger effort by the AMA to remove stigma from OUD treatment. Removing the DEA requirements would help allay physicians’ concerns and, in our view, increase the number of physicians treating patients with OUD.”); Kevin Fiscella, MD, MPH, Sarah E. Wakeman, MD, Leo Beletsky, JD, MPH, Buprenorphine Deregulation and Mainstreaming Treatment for Opioid Use Disorder: X the X Waiver, 76(3) JAMA Psychiatry 229-30 (2018), https://bit.ly/3lNlDTU (“Buprenorphine training requirements, X-waiver applications, and DEA audits discourage prescribing buprenorphine.”).
As a result, only about 1 in 10 medical providers have federal approval to prescribe buprenorphine for opioid use disorder.
4
In February 2022, there were more than 116,600 medical providers who had federal approval to prescribe buprenorphine for opioid use disorder. This compares to 1,022,006 active physicans and more than 430,000 nurse practitioners and physician assistants. See U.S. Dep't Health and Human Svcs., Substance Abuse and Mental Health Svcs. Admin, Justifications of Estimates for Appropriations Committees, Fiscal Year 2023, p. 226 ("As of April 28, 2021, there were a total of 97,880 practitioners certified to prescribe buprenorphine. That number increased to a total of over 116,600 by February 1, 2022."); Kaiser Family Foundation, Professionally Active Physicians (Mar. 2020), https://bit.ly/31eSW8R (listing total physicians in U.S. at 1,022,006); Letter from American Assoc. of Nurse Practitioners (“AANP”) and American Academy of Physician Assistants (“AAPA”) to the Hon. Alex Azar (Jan. 15, 2021), https://bit.ly/2OUmdmO (“The American Association of Nurse Practitioners (AANP) and American Academy of PAs (AAPA), collectively, represent the interests of the more than 430,000 NPs and PAs practicing in the United States.”).


Some argue that the federal restrictions on prescribing buprenorphine should be removed, but only for doctors. Removing the federal restrictions for all licensed medical providers, and not just doctors, is important because:
  • Doctors rely on advanced practice registered nurses and physician assistants to treat patients and may be unwilling to take on patients with opioid use disorder if their team members cannot care for them. To manage their workloads, doctors rely heavily on advanced practice registered nurses and physician assistants to see patients and provide care.
    5
    Assoc. of American Medical Colleges (“AAMC”), The Complexities of Physician Supply and Demand: Projections From 2018 to 2033, at 23 (2020), https://bit.ly/3chCUkG (“Health care services are usually complex, requiring delivery by teams of people. Without the nurses, lab technicians, administrators, social workers, and many other types of workers who team with physicians to deliver care, the panel of patients each physician could manage would be relatively small...[P]rimary care physicians working alone had insufficient time to provide all recommended services and address the acute care needs of a panel of 2,500 patients”).
    Advanced practice registered nurses and physician assistants provide the same level of care as doctors and achieve good health outcomes for their patients.
    6
    Miranda Laurant et al., Nurses as substitutes for doctors in primary care, 7 Cochrane Database of Systematic Reviews (2018), https://bit.ly/399rwWa (“This review shows that for some ongoing and urgent physical complaints and for chronic conditions, trained nurses, such as nurse practitioners, practice nurses, and registered nurses, probably provide equal or possibly even better quality of care compared to primary care doctors, and probably achieve equal or better health outcomes for patients.”); Christine M. Everett, MPH, PA-C et al., Physician Assistants and Nurse Practitioners as a Usual Source of Care, 25(4) J. of Rural Health 407-14 (2009),https://bit.ly/3d0zhPv (“[T]here were few differences in utilization and no differences in difficulties/delays in care or outcomes. This suggests that PA/NPs are acting as primary care providers to underserved patients with a range of disease severity, findings which have important implications for policy, including clinician workforce and reimbursement issues.”).
    But, they face immense barriers to gaining federal approval to prescribe buprenorphine – including 24 hours of training (three full work days). As a result, fewer than 6 in 100 nurse practitioners and physician assistants have federal approval to provide this lifesaving medication.
    7
    Letter from AANP and AAPA to the Hon. Alex Azar (Jan. 15, 2021) (“The American Association of Nurse Practitioners (AANP) and American Academy of PAs (AAPA), collectively, represent the interests of the more than 430,000 NPs and PAs practicing in the United States.”); Lev Facher, “Trump administration will let nearly all doctors prescribe addiction medicine buprenorphine,” STAT News (Jan. 14, 2021), https://bit.ly/3d0AYMR (“As of now, only 66,000 physicians and another 25,000 prescribers like NPs or PAs have an X-waiver, Giroir said.”).
    Doctors, who already face significant workloads, may be unwilling to take on patients with opioid use disorder if their healthcare teams cannot care for those patients.
    8
    Nat’l Acad. of Sciences, Engineering, and Medicine (“NASEM”), Consensus Study Report: Medications for Opioid Use Disorder Save Lives, Nat’l Acad. Press, at 121 (2019) https://bit.ly/3vVOnOY (“Other reasons for not prescribing cited by non-waivered providers include concerns about managing the volume of patient requests for buprenorphine…”).
  • Advanced practice registered nurses are often the only line of care in rural and low-income communities. Rural communities make up three-quarters of the counties that have little or no access to a provider who can prescribe buprenorphine.
    9
    HHS, Geographic Disparities Affect Access to Buprenorphine Services for Opioid Use Disorder (2020), https://bit.ly/3rnaav7(“In total, 72 percent of counties with low-to-no patient capacity are in rural areas (for comparison purposes, 63 percent of counties nation-wide are rural). The lack of waivered providers in rural areas may reflect a wider problem with shortages and maldistribution of primary care and other providers.”).
    Advanced practice registered nurses are more likely to practice in rural and low-income communities and to be the sole provider.
    10
    Matthew A. Davis, MPH, PhD et al., Supply of Healthcare Providers in Relation to County Socioeconomic and Health Status, 33(4) J. General Internal Medicine 412-414 (2018), https://bit.ly/3tWvAkN (“It has long been recognized that the per capita availability of physicians varies substantially across regions, and that physicians tend to locate in more affluent locales rather than areas of greatest need… This study shows that nurse practitioners, who unlike physician assistants can practice independently in many states, are more likely to be located in areas of lower socioeconomic and health status than are physicians.”); Michael L. Barnett, MD, MS et al., “In Rural Areas, Buprenorphine Waiver Adoption Since 2017 Driven by Nurse Practitioners And Physician Assistants”, Health Affairs (2019), https://bit.ly/3sk7Eay (“Given that NPs are more likely to treat rural, Medicaid-covered, and other vulnerable patient populations than physicians are lowering barriers for NPs to prescribe buprenorphine could improve access to buprenorphine in ways that expanded physician waivers might not achieve.”).
    Lowering barriers for advanced practice registered nurses and physician assistants can improve access to buprenorphine in ways that expanding physician treatment alone may not achieve.
Medical providers see patients with opioid use disorder everyday, but federal law prevents them from providing effective treatment for these patients.

Solution

The Mainstreaming Addiction Treatment Act equips licensed medical providers - doctors, advanced practice registered nurses, and physician assistants - to provide lifesaving treatment for opioid use disorder. At a time when overdose deaths have reached record highs and are accelerating, we must remove all barriers that stand in the way of people participating in treatment.