Christopher L. Rowe, Jennifer Ahern, Alan Hubbard, Phillip O. Coffin
Post written by Irene Liu
In the midst of an ongoing opioid epidemic in the U.S., expanding access to effective treatment for opioid use disorder (OUD) is critical to the nation’s response. Medications like methadone and buprenorphine have been shown to be significantly effective in reducing opioid use and risk of related health encounters and mortality, but few individuals with OUD end up receiving any. Unlike methadone, buprenorphine is available in office-based settings and can be dispensed by pharmacies, potentially reducing patient burden and barriers to treatment retention. However, one constraint to buprenorphine access has historically been the federal waiver program, which limited the physicians able to administer, dispense, and prescribe buprenorphine and the number of patients they could prescribe to.
In 2016, there were two important policy changes made in an effort to expand buprenorphine prescribing capacity to meet treatment need:
 Increased prescribing capacity for existing buprenorphine providers:
The Substance Abuse and Mental Health Services Administration (SAHMSA) increased the patient limit from 100 to 275 for physicians who had prescribed buprenorphine to 100 patients for at least one year (MD/DO-275)
 Increased supply of buprenorphine providers:
The Comprehensive Addiction and Recovery Act (CARA) allowed nurse practitioners and physician assistants to start prescribing buprenorphine for OUD (NP/PA).
This recently-published article, authored by Christopher Rowe, examines the uptake of the new NP/PA and MD/DO-275 waivers and their associations with buprenorphine prescribing and opioid related health outcomes in California. The analysis was done on statewide administrative data between 2010 and 2018, namely: (1) counts of waivers by type, month, and county from SAMHSA, (2) individual-level buprenorphine prescription data from California’s controlled substance monitoring program (CURES 2.0), (3) individual-level opioid related mortality data, and (4) individual-level opioid-related emergency department visit and hospitalization data.
The authors found that the number of waivered providers and the overall buprenorphine prescribing capacity increased substantially in California after these policies were implemented. In metropolitan counties, each additional MD/DO-275 waiver was associated with a 2.8% increase in buprenorphine. In nonmetropolitan counties, each additional NP/PA and MD/DO-275 waiver was associated with a 2.6% and 5.8% increase in buprenorphine prescribing, respectively. Although these percentages may seem small, scaled to a median-sized county in California, they translate into an 4.1% increase in the buprenorphine patient rate and 5% increase in the total buprenorphine prescription rate for every new MD/DO waiver of up to 275 patients. Since by the end of 2018, there were 720 and 229 active NP/PA waivers and MD/DO-275 waivers, respectively, that’s a lot more buprenorphine out there being prescribed!
These results were especially encouraging for expanding treatment access in rural areas, complementing other studies that have shown that NP/PA waivers accounted for the majority of increases in the rate of waivered providers in rural areas from 2016 to 2019, and projected that NP/PA waivers will increase the number of rural patients treated with buprenorphine by 15%. That being said, state-level differences in existing supply of buprenorphine prescribers and scope of practice restrictions may temper NP/PA waiver uptake, warranting more targeted policy solutions to expand the workforce in persistently underserved areas.
No associations were found between the NP/PA and MD/DO-275 waivers and opioid-related health outcomes, likely due to the continuing underutilization of these novel waiver types. Researchers may need to wait a little longer- this study looked at health outcomes data spanning up to 2018, only 2 years after the first NP/PA and MD/DO-275 waivers were granted.
While the individual-level protective effects of buprenorphine are well established, more work can be done to translate these benefits meaningfully at the population-level. These new policies target the supply and prescribing capacity of prescribers, and while promising, do not specifically address other barriers to buprenorphine utilization like lack of training and support among providers, poor care coordination, inadequate reimbursement, and stigma among providers and patients. Even for clinicians who have successfully obtained a waiver, the results of a 2018 survey suggests that many are prescribing well below their patient limit, if at all.
Nevertheless, Rowe’s findings add to a growing body of evidence that expanding buprenorphine prescribing is an effective way to increase access to life-saving medications, and possibly moving towards getting rid of the waivers altogether. Most recently, the Department of Health and Human Services released new practice guidelines that have removed training requirements for providers treating up to 30 patients, in the effort to encourage more practitioners into the ranks of buprenorphine waiver holders.