WEBVTT 00:00:00.760 --> 00:00:04.274 position:50% align:middle - [Moderator] Joanne Spetz is Director and Brenda and Jeffrey L. Kang 00:00:04.274 --> 00:00:08.534 position:50% align:middle Presidential Chair in Healthcare Finance at the Philip R. Lee 00:00:08.534 --> 00:00:14.440 position:50% align:middle Institute for Health Policy Studies at University of California, San Francisco. 00:00:14.440 --> 00:00:20.590 position:50% align:middle She is also Associate Director for research at Health for Center at UCSF. 00:00:20.590 --> 00:00:27.720 position:50% align:middle Her research focuses on the economics of the healthcare workforce, organization of healthcare services, 00:00:27.720 --> 00:00:32.010 position:50% align:middle and quality of healthcare, particularly of the nursing workforce 00:00:32.010 --> 00:00:33.565 position:50% align:middle and long-term care. 00:00:40.060 --> 00:00:41.860 position:50% align:middle - [Dr. Spetz] Hi, I'm Joanne Spetz. 00:00:41.860 --> 00:00:46.950 position:50% align:middle And, my presentation is on Nurse Practitioner Roles in Addressing the Opioid Crisis. 00:00:46.950 --> 00:00:52.490 position:50% align:middle In this study, we're focusing on the influence of state scope of practice regulations and the provision 00:00:52.490 --> 00:00:55.770 position:50% align:middle of medication treatment for opioid use disorder. 00:00:55.770 --> 00:00:59.910 position:50% align:middle My collaborators are Susan Chapman, Beth Phoenix, and Matthew Tierney, 00:00:59.910 --> 00:01:05.585 position:50% align:middle who are from the UCSF School of Nursing, and Laurie Hailer who is an independent data analyst. 00:01:07.170 --> 00:01:12.920 position:50% align:middle The study focuses on medication treatment for opioid use disorder, which is an evidence-based approach 00:01:12.920 --> 00:01:16.340 position:50% align:middle to treat people with opioid dependence or addiction. 00:01:16.340 --> 00:01:19.970 position:50% align:middle There are three medications now used for opioid treatment. 00:01:19.970 --> 00:01:24.600 position:50% align:middle Methadone has been around the longest and is a full opioid agonist. 00:01:24.600 --> 00:01:30.290 position:50% align:middle It's a Schedule II drug and can only be offered in a licensed narcotics treatment program. 00:01:30.290 --> 00:01:35.020 position:50% align:middle It's typically administered as a directly observed treatment, meaning that people must go to the program 00:01:35.020 --> 00:01:38.190 position:50% align:middle site for treatment on a regular basis. 00:01:38.190 --> 00:01:42.810 position:50% align:middle Buprenorphine is a semi-agonist and a Schedule III drug. 00:01:42.810 --> 00:01:49.110 position:50% align:middle Because it has what some call a ceiling effect, it has a relatively low risk for abuse or overdose. 00:01:49.110 --> 00:01:54.280 position:50% align:middle A common formulation has the brand name Suboxone, which includes Naloxone, 00:01:54.280 --> 00:01:57.070 position:50% align:middle the opioid overdose reversal drug. 00:01:57.070 --> 00:02:01.890 position:50% align:middle So, if a person tries to abuse this formulation, they get a large dose of Naloxone, 00:02:01.890 --> 00:02:08.440 position:50% align:middle which generates opioid withdrawal symptoms that are quite unpleasant and a deterrent to abuse. 00:02:08.440 --> 00:02:14.570 position:50% align:middle Naltrexone is the third medication and it's a full opioid agonist, meaning that it latches onto opioid 00:02:14.570 --> 00:02:19.690 position:50% align:middle receptors but does not have any analgesic or opioid-type effects. 00:02:19.690 --> 00:02:23.600 position:50% align:middle Because it is not an opioid it is not a scheduled medication. 00:02:23.600 --> 00:02:27.680 position:50% align:middle It is used for other substance use disorders including alcoholism. 00:02:27.680 --> 00:02:32.300 position:50% align:middle Vivitrol is an extended-release injection version of this medication. 00:02:32.300 --> 00:02:35.057 position:50% align:middle In this study, we're focusing on buprenorphine. 00:02:37.560 --> 00:02:43.770 position:50% align:middle The reason we're focusing on buprenorphine is that in 2000, the Drug Addiction Treatment Act authorized 00:02:43.770 --> 00:02:49.270 position:50% align:middle physicians to apply for a waiver from the requirement that opioid treatment occur in licensed 00:02:49.270 --> 00:02:51.268 position:50% align:middle narcotics treatment programs. 00:02:51.268 --> 00:02:58.380 position:50% align:middle So, these waivers are commonly known as the DEA-X waiver and allowed physicians to offer buprenorphine 00:02:58.380 --> 00:03:03.430 position:50% align:middle treatment in their offices or other non-treatment program settings. 00:03:03.430 --> 00:03:07.143 position:50% align:middle The first waivers were issued around 2002 and, to get a waiver, 00:03:07.143 --> 00:03:12.560 position:50% align:middle a physician must complete eight hours of training in the management of opioid use disorder. 00:03:12.560 --> 00:03:17.060 position:50% align:middle During the first year of the waiver, the physician is authorized to manage up to 30 patients 00:03:17.060 --> 00:03:17.938 position:50% align:middle at a time. 00:03:17.938 --> 00:03:22.430 position:50% align:middle And, after 1 year, the physician can apply to manage 100 patients. 00:03:22.430 --> 00:03:29.200 position:50% align:middle Starting in 2016, physicians can apply to manage up to 275 patients. 00:03:29.200 --> 00:03:34.870 position:50% align:middle The vast majority of physicians have a 30-patient waiver and other studies have found that many waivered 00:03:34.870 --> 00:03:39.532 position:50% align:middle physicians have never prescribed buprenorphine or have treated only a few people. 00:03:42.200 --> 00:03:48.260 position:50% align:middle The relatively small number of physicians with waivers and their low rates of prescribing buprenorphine has 00:03:48.260 --> 00:03:55.600 position:50% align:middle resulted in a nationwide shortage of buprenorphine providers, particularly as the opioid crisis emerged. 00:03:55.600 --> 00:04:01.870 position:50% align:middle This map shows the availability of physicians with DEA-X waivers, regardless of whether they are actually 00:04:01.870 --> 00:04:03.740 position:50% align:middle treating any patients. 00:04:03.740 --> 00:04:09.070 position:50% align:middle This is from a study conducted by Holly Andrilla and her colleagues at University of Washington. 00:04:09.070 --> 00:04:16.207 position:50% align:middle The blue-colored counties had at least one waivered physician in both 2002 and 2016. 00:04:16.207 --> 00:04:21.472 position:50% align:middle The yellow counties had a provider in 2016, but not in 2012. 00:04:21.472 --> 00:04:24.920 position:50% align:middle So, these are counties where they had an improvement. 00:04:24.920 --> 00:04:31.408 position:50% align:middle The red counties had a provider in 2012, but it lost that provider by 2016. 00:04:31.408 --> 00:04:34.530 position:50% align:middle And, the white counties never had a provider. 00:04:34.530 --> 00:04:39.790 position:50% align:middle Note that many of the areas that are white and red are places where the opioid epidemic has had the most 00:04:39.790 --> 00:04:46.828 position:50% align:middle impacts including Kentucky, West Virginia, Virginia, Illinois, Georgia, and the Great Plains states. 00:04:48.830 --> 00:04:54.160 position:50% align:middle In response to the worsening opioid crisis, Congress passed the Comprehensive Addiction and 00:04:54.160 --> 00:04:57.442 position:50% align:middle Recovery Act or CARA in 2016. 00:04:57.442 --> 00:05:02.550 position:50% align:middle This legislation allowed nurse practitioners some physician assistance to obtain waivers 00:05:02.550 --> 00:05:04.530 position:50% align:middle as a temporary provision. 00:05:04.530 --> 00:05:10.080 position:50% align:middle But note that other APRNs were not included in the 2016 CARA. 00:05:10.080 --> 00:05:13.660 position:50% align:middle These advanced practice clinicians must take 24 hours of training. 00:05:13.660 --> 00:05:18.270 position:50% align:middle Yes, that's three times the number of hours required for physicians. 00:05:18.270 --> 00:05:26.620 position:50% align:middle The 2018 opioid bill which was called the Support Act, made the NP and PA waivers permanent and added other 00:05:26.620 --> 00:05:29.390 position:50% align:middle advanced practice registered nurses. 00:05:29.390 --> 00:05:35.090 position:50% align:middle The regulations have no additional requirements on advanced practice clinicians if they are in a state 00:05:35.090 --> 00:05:37.860 position:50% align:middle that allows them full practice authority. 00:05:37.860 --> 00:05:43.050 position:50% align:middle But, if they're in a state that requires physician oversight, the physician also must be qualified 00:05:43.050 --> 00:05:46.590 position:50% align:middle to obtain an X waiver or meet other criteria. 00:05:46.590 --> 00:05:51.150 position:50% align:middle So, note that for physician assistants, they always have to have physician supervision. 00:05:51.150 --> 00:05:56.500 position:50% align:middle So, they always are going to have to have a physician supervisor that meets these criteria whereas for nurse 00:05:56.500 --> 00:06:00.486 position:50% align:middle practitioners and other APRNs it will vary state to state. 00:06:02.790 --> 00:06:06.170 position:50% align:middle State requirements for physician oversight are common. 00:06:06.170 --> 00:06:11.260 position:50% align:middle This map indicates whether nurse practitioners are allowed to prescribe Schedule III medications 00:06:11.260 --> 00:06:13.040 position:50% align:middle without physician oversight. 00:06:13.040 --> 00:06:16.630 position:50% align:middle Remember that buprenorphine is a Schedule III medication. 00:06:16.630 --> 00:06:20.930 position:50% align:middle The orange states never let a nurse practitioner prescribe a Schedule III drug 00:06:20.930 --> 00:06:22.800 position:50% align:middle without physician oversight. 00:06:22.800 --> 00:06:27.160 position:50% align:middle Although, I'll note that California is changing that rule thanks to a bill that was signed by our 00:06:27.160 --> 00:06:29.400 position:50% align:middle governor last year. 00:06:29.400 --> 00:06:36.030 position:50% align:middle The blue states allow NPs to prescribe Schedule III medications without physician oversight upon licensure. 00:06:36.030 --> 00:06:42.440 position:50% align:middle And, the purple states require physician oversight for a specific period of time ranging from six months 00:06:42.440 --> 00:06:47.210 position:50% align:middle to five years before the NP can prescribe without oversight. 00:06:47.210 --> 00:06:53.720 position:50% align:middle Note that these categorizations do not match the AANP categories as this map does not consider whether a 00:06:53.720 --> 00:06:59.720 position:50% align:middle physician board oversees NPs or any of the other regulatory attributes that the AANP considers 00:06:59.720 --> 00:07:01.430 position:50% align:middle in their map. 00:07:01.430 --> 00:07:07.470 position:50% align:middle We are caring only about Schedule III prescribing for this study and so for our analysis we lumped the blue 00:07:07.470 --> 00:07:09.177 position:50% align:middle and purple states together. 00:07:11.700 --> 00:07:17.140 position:50% align:middle Now, I want you to look at the map of availability of X-waivered physicians in 2016. 00:07:17.140 --> 00:07:22.290 position:50% align:middle Do you see a potential relationship between the areas with no waivered providers and the areas 00:07:22.290 --> 00:07:24.640 position:50% align:middle with physician oversight requirements? 00:07:24.640 --> 00:07:28.630 position:50% align:middle It sure looks like it when you put these maps side to side. 00:07:28.630 --> 00:07:31.220 position:50% align:middle This brings us to our research questions. 00:07:31.220 --> 00:07:37.430 position:50% align:middle First, we wanted to know if NPs are less likely to get waivers if physician oversight is required. 00:07:37.430 --> 00:07:40.950 position:50% align:middle This question can be answered with quantitative data. 00:07:40.950 --> 00:07:46.940 position:50% align:middle Second, we wanted to identify other barriers to NPs getting waivers and offering treatment. 00:07:46.940 --> 00:07:52.080 position:50% align:middle We know from the literature that other factors such as a lack of acceptance of buprenorphine treatment in the 00:07:52.080 --> 00:07:58.950 position:50% align:middle local healthcare community, stigma faced by patients, lack of mentoring, and reimbursement problems create 00:07:58.950 --> 00:08:02.560 position:50% align:middle barriers to clinicians offering buprenorphine. 00:08:02.560 --> 00:08:07.850 position:50% align:middle Third, we wanted to identify facilitators of NP engagement and medication treatment 00:08:07.850 --> 00:08:09.740 position:50% align:middle for opioid use disorder. 00:08:09.740 --> 00:08:15.430 position:50% align:middle The literature indicates that Medicaid coverage of buprenorphine, availability of education materials, 00:08:15.430 --> 00:08:21.440 position:50% align:middle and access to mentors are among the factors that support physician involvement in medication treatment 00:08:21.440 --> 00:08:25.465 position:50% align:middle and we wanted to see what factors might be specific to nurse practitioners. 00:08:27.960 --> 00:08:32.570 position:50% align:middle For the quantitative part of our study, we used two main data sources. 00:08:32.570 --> 00:08:36.420 position:50% align:middle First, we obtained state-level counts of waivered clinicians from SAMHSA, 00:08:36.420 --> 00:08:41.350 position:50% align:middle the Substance Abuse Mental Health Services Administration, through a Freedom 00:08:41.350 --> 00:08:43.600 position:50% align:middle of Information Act request. 00:08:43.600 --> 00:08:47.067 position:50% align:middle The file we received was dated September 2018. 00:08:47.067 --> 00:08:53.370 position:50% align:middle Second, we purchased full lists of all people and entities registered with the Drug Enforcement 00:08:53.370 --> 00:08:54.200 position:50% align:middle Agency, or DEA. 00:08:54.200 --> 00:09:02.050 position:50% align:middle These lists were accessed on a quarterly basis and include an indicator for X waivers and also indicate 00:09:02.050 --> 00:09:05.480 position:50% align:middle how many patients the clinician is allowed to treat. 00:09:05.480 --> 00:09:09.770 position:50% align:middle One frustrating thing with the data is that all APRNs are grouped together. 00:09:09.770 --> 00:09:15.520 position:50% align:middle So, we cannot identify nurse midwives or clinical nurse specialists separately from nurse practitioners, 00:09:15.520 --> 00:09:18.732 position:50% align:middle they're all coded in the same group. 00:09:20.206 --> 00:09:22.641 position:50% align:middle So, let's start with the state-level data that were 00:09:22.641 --> 00:09:30.860 position:50% align:middle from September 2018 at which time only NPs could get X waivers, other APRNs could not get them yet. 00:09:30.860 --> 00:09:35.460 position:50% align:middle This map shows the percent of NPs in the state with an X waiver. 00:09:35.460 --> 00:09:42.450 position:50% align:middle The darker shaded states had higher percentages which reached a maximum of 10.4% in Maine. 00:09:42.450 --> 00:09:49.470 position:50% align:middle The lighter states had lower percentages with the minimum being 2.4% in Tennessee. 00:09:49.470 --> 00:09:53.980 position:50% align:middle In fact, in Tennessee, NPs are not allowed to prescribe buprenorphine, 00:09:53.980 --> 00:10:00.090 position:50% align:middle so any waivered NPs in that state still were not allowed to provide medication treatment. 00:10:00.090 --> 00:10:08.128 position:50% align:middle So, let's go back to the physician oversight map, which was adjusted here to depict September 2018. 00:10:08.128 --> 00:10:12.860 position:50% align:middle After that year, Virginia and Florida had changed their regulations. 00:10:12.860 --> 00:10:18.720 position:50% align:middle You can see what might be a relationship between the percent of NPs with waivers and whether NPs must have 00:10:18.720 --> 00:10:21.160 position:50% align:middle physician oversight for Schedule III prescribing. 00:10:21.160 --> 00:10:29.070 position:50% align:middle And, in fact, when we estimated a regression, controlling for whether physician oversight is required 00:10:29.070 --> 00:10:33.760 position:50% align:middle and the percent of physicians with waivers, we found that there was a significantly lower 00:10:33.760 --> 00:10:38.460 position:50% align:middle percentage of NPs with waivers in states that required oversight. 00:10:38.460 --> 00:10:46.140 position:50% align:middle In fact, the percentage is about 1.75 times higher in states that do not require oversight for Schedule III 00:10:46.140 --> 00:10:50.250 position:50% align:middle prescribing compared to states that do require oversight. 00:10:50.250 --> 00:10:55.970 position:50% align:middle This result was published in the Journal of the American Medical Association in early 2019. 00:10:57.500 --> 00:10:59.630 position:50% align:middle Now, let's look at some newer data. 00:10:59.630 --> 00:11:04.640 position:50% align:middle This chart shows the number of clinicians with X waivers nationwide through the end of September 2020. 00:11:04.640 --> 00:11:11.947 position:50% align:middle You can see notable growth for all clinicians, but less so for PAs than for NPs and physicians. 00:11:13.410 --> 00:11:16.340 position:50% align:middle Let's take a look at the percentage of clinicians with waivers. 00:11:16.340 --> 00:11:18.270 position:50% align:middle Now, this is really striking. 00:11:18.270 --> 00:11:24.390 position:50% align:middle By early 2019, a greater percentage of NPs had waivers than did physicians. 00:11:24.390 --> 00:11:29.310 position:50% align:middle The only reason there are more physicians with waivers numerically is that there are just simply many more 00:11:29.310 --> 00:11:32.013 position:50% align:middle physicians in the United States than NPs. 00:11:33.880 --> 00:11:39.450 position:50% align:middle Another way to look at this is the total number of patients who could be treated if every clinician 00:11:39.450 --> 00:11:43.040 position:50% align:middle treated the maximum number allowed by their waiver. 00:11:43.040 --> 00:11:50.100 position:50% align:middle Here you can see the share of treatment capacity that is accounted for by NPs and that it's growing rapidly. 00:11:50.100 --> 00:11:56.879 position:50% align:middle This is due both to NPS getting waivers and due to them quickly advancing to 100-person treatment waivers. 00:11:58.970 --> 00:12:05.120 position:50% align:middle Finally, this chart shows the growth trajectories of the percent of NPs with waivers by whether physician 00:12:05.120 --> 00:12:08.790 position:50% align:middle oversight is required for Schedule III prescribing. 00:12:08.790 --> 00:12:14.840 position:50% align:middle What we saw in September 2018 has continued with greater proportions of nurse practitioners getting 00:12:14.840 --> 00:12:17.695 position:50% align:middle waivers when oversight is not required. 00:12:20.040 --> 00:12:25.500 position:50% align:middle Finally, this map shows the percent of treatment capacity provided by NPs. 00:12:25.500 --> 00:12:32.350 position:50% align:middle The highest state is North Dakota at 37% of their treatment capacity provided by NPs and New Mexico is 00:12:32.350 --> 00:12:34.680 position:50% align:middle not far behind at 33%. 00:12:34.680 --> 00:12:38.930 position:50% align:middle Tennessee is at the bottom, which is not surprising since they banned NPs 00:12:38.930 --> 00:12:40.407 position:50% align:middle from offering treatment. 00:12:43.090 --> 00:12:49.600 position:50% align:middle Finally, we explored whether NPS were more likely to obtain waivers in rural counties and whether this 00:12:49.600 --> 00:12:52.290 position:50% align:middle depends on whether physician oversight is required. 00:12:52.290 --> 00:12:57.690 position:50% align:middle As seen in the first column, there is a slightly higher percentage of NPs in rural 00:12:57.690 --> 00:13:03.940 position:50% align:middle counties with waivers than in urban counties, but this difference is not statistically significant. 00:13:03.940 --> 00:13:07.180 position:50% align:middle In the second column, we can see that there is a significantly higher 00:13:07.180 --> 00:13:14.110 position:50% align:middle percentage of NPs with waivers in rural areas when physician oversight is not required. 00:13:14.110 --> 00:13:18.470 position:50% align:middle And in the third column, there is a smaller percentage of NPS and waivers 00:13:18.470 --> 00:13:25.510 position:50% align:middle in rural areas when physician oversight is required, but this difference is not significant. 00:13:25.510 --> 00:13:32.050 position:50% align:middle So, not only do oversight requirements inhibit the total growth of the NP workforce for opioid treatment, 00:13:32.050 --> 00:13:36.190 position:50% align:middle but they have a larger negative impact on rural communities. 00:13:36.190 --> 00:13:41.460 position:50% align:middle Similar results were published by Michael Barnett and his colleagues from Harvard University in late 2019. 00:13:45.600 --> 00:13:52.150 position:50% align:middle In order to answer our last two research questions about barriers and facilitators to NPs obtaining X 00:13:52.150 --> 00:13:57.150 position:50% align:middle waivers and engaging in opioid treatment, we conducted in-depth qualitative research 00:13:57.150 --> 00:13:58.780 position:50% align:middle in four states. 00:13:58.780 --> 00:14:03.770 position:50% align:middle We first identified states with high rates of opioid overdose because these are the places where greater 00:14:03.770 --> 00:14:07.000 position:50% align:middle access to treatment is most desperately needed. 00:14:07.000 --> 00:14:11.960 position:50% align:middle We then identified states in each of our physician oversight categories. 00:14:11.960 --> 00:14:18.150 position:50% align:middle And finally, we picked one state in which a relatively high percentage of NPs had waivers and a state in which 00:14:18.150 --> 00:14:21.210 position:50% align:middle a relatively low percentage had waivers. 00:14:21.210 --> 00:14:26.470 position:50% align:middle Note that the high percentage for restrictive states was about equal to the low percentage for states that 00:14:26.470 --> 00:14:28.740 position:50% align:middle did not require oversight. 00:14:28.740 --> 00:14:32.880 position:50% align:middle Our states were West Virginia, New Mexico, Michigan, and Ohio. 00:14:34.530 --> 00:14:39.120 position:50% align:middle In each state, we had teams of two to four researchers conduct the site visits. 00:14:39.120 --> 00:14:43.380 position:50% align:middle We were lucky and we finished our site visit to New Mexico in February 2020. 00:14:43.380 --> 00:14:47.900 position:50% align:middle If we'd been a month later, we might not have been able to finish the work. 00:14:47.900 --> 00:14:54.230 position:50% align:middle We recruited potential interviewees by reaching out to known contacts including APRN practitioners, 00:14:54.230 --> 00:14:59.280 position:50% align:middle behavioral health clinics, opioid treatment clinics, nursing leadership organizations, 00:14:59.280 --> 00:15:01.620 position:50% align:middle and nursing program faculty. 00:15:01.620 --> 00:15:06.630 position:50% align:middle We used snowball sampling to identify additional potential interview subjects. 00:15:06.630 --> 00:15:13.400 position:50% align:middle We wanted to be sure to interview APRNs with X waivers or an interest in getting a waiver, clinic managers, 00:15:13.400 --> 00:15:19.130 position:50% align:middle physicians, state regulatory leaders, and other state nursing and policy leaders. 00:15:19.130 --> 00:15:24.120 position:50% align:middle As you can see, more than half of the interviews we did were with APRNs. 00:15:24.120 --> 00:15:27.800 position:50% align:middle Interviews were either with individuals or small groups. 00:15:27.800 --> 00:15:31.610 position:50% align:middle One interviewer would lead the interview while the other took notes. 00:15:31.610 --> 00:15:36.140 position:50% align:middle We did not record the interviews because they often took place in non-work public settings such 00:15:36.140 --> 00:15:38.330 position:50% align:middle as coffee shops. 00:15:38.330 --> 00:15:44.880 position:50% align:middle Interview notes were reviewed by each of the 14 members who participated in the site visit research. 00:15:44.880 --> 00:15:48.510 position:50% align:middle We then met to develop consensus on key themes. 00:15:48.510 --> 00:15:53.810 position:50% align:middle We then coded the interviews within those initial themes and we reviewed the themes and codings 00:15:53.810 --> 00:15:57.600 position:50% align:middle iteratively to ensure that no new themes were emerging. 00:15:57.600 --> 00:16:02.760 position:50% align:middle We identified four key thematic areas that I'll talk about today. 00:16:02.760 --> 00:16:07.110 position:50% align:middle Not surprisingly, scope of practice barriers were the first thing. 00:16:07.110 --> 00:16:12.600 position:50% align:middle Physician oversight requirements are a barrier in and of themselves but there are some more subtle barriers. 00:16:12.600 --> 00:16:19.920 position:50% align:middle The inconsistency of regulations creates challenges for NP engagement in medication treatment much 00:16:19.920 --> 00:16:23.120 position:50% align:middle as for general APRN practice. 00:16:23.120 --> 00:16:29.510 position:50% align:middle NPs who practiced in the border areas of Ohio and Kentucky, for example, found the differences in scope 00:16:29.510 --> 00:16:32.010 position:50% align:middle of practice regulations frustrating. 00:16:32.010 --> 00:16:37.080 position:50% align:middle Some states also have additional specific requirements that add confusion. 00:16:37.080 --> 00:16:42.390 position:50% align:middle For example, West Virginia had granted NPs the ability to practice and prescribe without physician 00:16:42.390 --> 00:16:44.627 position:50% align:middle oversight in 2017. 00:16:44.627 --> 00:16:50.380 position:50% align:middle But, they also passed a bill requiring that all buprenorphine treatment programs have a medical 00:16:50.380 --> 00:16:53.100 position:50% align:middle director who must be a physician. 00:16:53.100 --> 00:16:59.860 position:50% align:middle So, this legislation may have been intended to reduce the risk of pill mills but it also forced NPs to find a 00:16:59.860 --> 00:17:05.560 position:50% align:middle physician medical director to engage in buprenorphine treatment, so it was a barrier. 00:17:05.560 --> 00:17:11.150 position:50% align:middle In contrast, New Mexico has a history of more than 20 years of full practice authority. 00:17:11.150 --> 00:17:15.538 position:50% align:middle And in that state, NP engagement and medication treatment was fully embraced. 00:17:17.800 --> 00:17:24.350 position:50% align:middle Other regulatory and organizational factors create barriers to NPs offering buprenorphine treatment. 00:17:24.350 --> 00:17:28.120 position:50% align:middle Medicaid regulations came up in many of our interviews. 00:17:28.120 --> 00:17:34.150 position:50% align:middle All state Medicaid plans cover buprenorphine treatment but some have specific requirements. 00:17:34.150 --> 00:17:38.340 position:50% align:middle For example, in West Virginia, those in treatment must have four hours of therapy 00:17:38.340 --> 00:17:41.880 position:50% align:middle per month, one of which must be one on one. 00:17:41.880 --> 00:17:45.100 position:50% align:middle The state has a significant shortage of therapists. 00:17:45.100 --> 00:17:50.900 position:50% align:middle Some NPs expressed frustration that they couldn't offer medication treatment in some parts of the state because 00:17:50.900 --> 00:17:54.992 position:50% align:middle there were no therapists to fulfill the therapy requirement. 00:17:54.992 --> 00:18:01.070 position:50% align:middle Prior authorization requirements exist for some Medicaid plans and commercial insurance as well 00:18:01.070 --> 00:18:03.500 position:50% align:middle in various states around the country. 00:18:03.500 --> 00:18:09.071 position:50% align:middle This also creates a barrier to NP interest in offering treatment and patients accessing treatment. 00:18:10.120 --> 00:18:15.790 position:50% align:middle We encountered a number of reports that some clinics, hospitals, and other providers placed restrictions 00:18:15.790 --> 00:18:18.990 position:50% align:middle on APRN provision of buprenorphine treatment. 00:18:18.990 --> 00:18:24.950 position:50% align:middle These restrictions varied ranging from requiring the first visit to be with a physician to requiring greater 00:18:24.950 --> 00:18:29.160 position:50% align:middle oversight of NP's buprenorphine prescribing. 00:18:29.160 --> 00:18:33.850 position:50% align:middle We also heard that there's a lot of stigma both against people with opioid use disorder and 00:18:33.850 --> 00:18:37.125 position:50% align:middle against buprenorphine or other medication treatment. 00:18:37.125 --> 00:18:42.830 position:50% align:middle This exists both within practices and in the larger substance abuse treatment community. 00:18:42.830 --> 00:18:46.218 position:50% align:middle This was a notable barrier to NP engagement and treatment. 00:18:46.218 --> 00:18:52.706 position:50% align:middle It should be noted that some organizations had policies in place that 00:18:52.706 --> 00:18:59.460 position:50% align:middle explicitly supported all clinicians, including APRNs, in offering buprenorphine treatment. 00:18:59.460 --> 00:19:04.370 position:50% align:middle And, some practices and communities were very supportive of buprenorphine treatment. 00:19:04.370 --> 00:19:09.570 position:50% align:middle For example in West Virginia, we heard concern that although APRNs wanted to expand 00:19:09.570 --> 00:19:14.940 position:50% align:middle medication treatment access, the 12-step programs often discouraged it. 00:19:14.940 --> 00:19:20.300 position:50% align:middle In contrast, we did not hear nearly as much about stigma in New Mexico. 00:19:20.300 --> 00:19:25.250 position:50% align:middle There were other important facilitators of APRNs offering medication treatment. 00:19:25.250 --> 00:19:31.740 position:50% align:middle Both APRNs and physicians commented that the holistic nature of nursing education and practice was a very 00:19:31.740 --> 00:19:35.120 position:50% align:middle positive benefit of their ability to get waivers. 00:19:35.120 --> 00:19:41.110 position:50% align:middle It was recognized that APRNs were not just more prescribers, but that they bring a holistic perspective 00:19:41.110 --> 00:19:46.232 position:50% align:middle of patient care that is particularly powerful for opioid use disorder treatment. 00:19:47.135 --> 00:19:52.900 position:50% align:middle The extent to which state government leaders and nursing champions advocated for expanded treatment, 00:19:52.900 --> 00:19:58.620 position:50% align:middle coordinated their efforts, and encouraged APRNs to get involved also were important. 00:19:58.620 --> 00:20:04.240 position:50% align:middle For example, even though Ohio requires physician oversight of NPs, government leaders have focused 00:20:04.240 --> 00:20:09.270 position:50% align:middle on expanding treatment, and in their eyes, this includes APRNs. 00:20:09.270 --> 00:20:15.180 position:50% align:middle This may explain why Ohio has one of the largest percentages of NPs with waivers among the states that 00:20:15.180 --> 00:20:17.890 position:50% align:middle require physician oversight. 00:20:17.890 --> 00:20:22.026 position:50% align:middle Local nursing culture was also noted as a facilitator. 00:20:22.160 --> 00:20:26.770 position:50% align:middle The more that APRNs are networked with each other and the more they learn from each other, 00:20:26.770 --> 00:20:30.930 position:50% align:middle the more they are supportive of going into buprenorphine treatment. 00:20:30.930 --> 00:20:37.536 position:50% align:middle And access to free training to fulfill those 24 hours of training requirement was also important. 00:20:39.740 --> 00:20:46.310 position:50% align:middle Growing numbers of APRN education programs are including addiction training in their curriculum and 00:20:46.310 --> 00:20:51.370 position:50% align:middle some are even providing the full 24 hours of training so all graduates are qualified to apply 00:20:51.370 --> 00:20:53.480 position:50% align:middle for an X waiver. 00:20:53.480 --> 00:20:57.750 position:50% align:middle Some are also offering education on substance use disorder treatment in their 00:20:57.750 --> 00:21:00.100 position:50% align:middle pre-licensure nursing programs. 00:21:00.100 --> 00:21:06.130 position:50% align:middle This can be important because RNs who work in hospitals often encounter patients with opioid use disorder and 00:21:06.130 --> 00:21:10.770 position:50% align:middle they can play a positive role in facilitating medication treatment. 00:21:10.770 --> 00:21:15.470 position:50% align:middle Some APRN education programs are also partnering with psychology, social work, 00:21:15.470 --> 00:21:19.810 position:50% align:middle and other professional schools to develop interprofessional training. 00:21:19.810 --> 00:21:26.210 position:50% align:middle At New Mexico State University, for example, the APRN education program is playing a leadership role 00:21:26.210 --> 00:21:31.830 position:50% align:middle in a training program that includes social work and criminal justice students. 00:21:31.830 --> 00:21:38.000 position:50% align:middle Many faculty also are engaged in buprenorphine treatment in their community-based clinical practices 00:21:38.000 --> 00:21:44.380 position:50% align:middle which can offer APRN students real-world exposure to care of this population. 00:21:44.380 --> 00:21:46.720 position:50% align:middle I'll close with three points. 00:21:46.720 --> 00:21:52.940 position:50% align:middle First, full practice authority could increase the ability of APRNs to provide medication treatment, 00:21:52.940 --> 00:21:57.570 position:50% align:middle and we strongly encourage that all states seriously consider this. 00:21:57.570 --> 00:22:02.150 position:50% align:middle This could have an even bigger impact in rural areas. 00:22:02.150 --> 00:22:07.410 position:50% align:middle Second, other health care regulations and organizational cultures are important to increasing 00:22:07.410 --> 00:22:12.540 position:50% align:middle uptake of X waivers by APRNs and also by physicians. 00:22:12.540 --> 00:22:18.860 position:50% align:middle Finally, as more education programs include waiver training, additional research should examine the extent 00:22:18.860 --> 00:22:23.060 position:50% align:middle to which graduates actually provide treatment services. 00:22:23.060 --> 00:22:27.530 position:50% align:middle Thank you very much for your listening to my presentation and feel free to contact me if you 00:22:27.530 --> 00:22:29.260 position:50% align:middle have any questions. 00:22:50.300 --> 00:22:53.940 position:50% align:middle Hi, I'm Joanne Spetz and I am ready for questions and answers. 00:22:53.940 --> 00:22:59.350 position:50% align:middle I know there's a little bit of a delay for questions coming into the queue. 00:22:59.350 --> 00:23:07.260 position:50% align:middle I'll note that after I did that recording, there have been some press articles about the 00:23:07.260 --> 00:23:15.060 position:50% align:middle possibility of eliminating the so-called X waivers for some proportion of clinicians, 00:23:15.060 --> 00:23:20.950 position:50% align:middle perhaps focusing the initial proposal that the Trump administration had put out was to reduce it or 00:23:20.950 --> 00:23:25.970 position:50% align:middle eliminate it for physicians caring for 30 or fewer patients. 00:23:25.970 --> 00:23:31.310 position:50% align:middle Those regulation changes have been put on hold by the Biden administration. 00:23:31.310 --> 00:23:36.890 position:50% align:middle Those of us who believe that APRNs have an important role in opioid care were a little dismayed that they 00:23:36.890 --> 00:23:40.750 position:50% align:middle were not included in a potential X waiver elimination. 00:23:40.750 --> 00:23:43.370 position:50% align:middle So, we'll see what happens next. 00:23:43.370 --> 00:23:52.270 position:50% align:middle So, we have a question in around whether completion of the educational requirement for obtaining the x waiver 00:23:52.270 --> 00:23:59.030 position:50% align:middle was a barrier and whether the eight-hour requirement is a barrier for physicians. 00:23:59.030 --> 00:24:03.290 position:50% align:middle And of course, for advanced practice nurses, the requirement is 24 hours. 00:24:03.290 --> 00:24:08.410 position:50% align:middle We definitely heard from the people that we interviewed that this was a barrier, 00:24:08.410 --> 00:24:12.310 position:50% align:middle the whole training process in general, or the training requirement. 00:24:12.310 --> 00:24:19.450 position:50% align:middle In addition, there was no rationale that was ever provided for APRNs being required to do 24 hours 00:24:19.450 --> 00:24:23.490 position:50% align:middle of training versus the physician eight hour of training. 00:24:23.490 --> 00:24:28.380 position:50% align:middle Some of the nurse practitioners we spoke with quipped that they thought that it was the same 00:24:28.380 --> 00:24:29.490 position:50% align:middle as the physician training. 00:24:29.490 --> 00:24:31.920 position:50% align:middle They just said everything three times. 00:24:31.920 --> 00:24:38.380 position:50% align:middle So, in terms of that being a barrier, seemed absolutely like it probably was. 00:24:38.380 --> 00:24:45.180 position:50% align:middle What was interesting and also maybe a barrier is the mentoring question. 00:24:45.180 --> 00:24:47.430 position:50% align:middle You know, a lot of the training is available online. 00:24:47.430 --> 00:24:52.110 position:50% align:middle It is often available free. It's good quality. 00:24:52.110 --> 00:24:57.930 position:50% align:middle But, when you're taking care of your first patient, we heard from people that we interviewed, 00:24:57.930 --> 00:25:03.300 position:50% align:middle just kind of that fear of taking care of a first patient with buprenorphine, 00:25:03.300 --> 00:25:09.180 position:50% align:middle especially if a person is in a relatively smaller solo practice or is the first one in their practice to be 00:25:09.180 --> 00:25:11.520 position:50% align:middle offering buprenorphine treatment. 00:25:11.520 --> 00:25:16.930 position:50% align:middle So, that need for mentorship and networks is very important. 00:25:16.930 --> 00:25:26.820 position:50% align:middle And, that may be something worth considering and true for both physicians and for advanced practice nurses. 00:25:26.820 --> 00:25:28.800 position:50% align:middle So, thank you for that question, Tracy. 00:25:28.800 --> 00:25:38.620 position:50% align:middle I'm taking a quick look to see if anything came into the chat as a question and I don't see anything there. 00:25:38.620 --> 00:25:44.012 position:50% align:middle So, please use the Q&A section to ask any questions. 00:25:53.500 --> 00:25:57.230 position:50% align:middle We are continuing the research project. 00:25:57.230 --> 00:26:00.820 position:50% align:middle We now have funding from the federal government. 00:26:00.820 --> 00:26:07.330 position:50% align:middle So, we will be continuing mostly the data analysis components to look at the roles of advanced practice 00:26:07.330 --> 00:26:12.360 position:50% align:middle nurses in expanding access to medication treatment. 00:26:12.360 --> 00:26:19.670 position:50% align:middle And, we're interested in the colocation of providers and the degree to which advanced practice clinicians 00:26:19.670 --> 00:26:24.420 position:50% align:middle are moving from their 30-person waiver up to the higher numbers of waivers. 00:26:24.420 --> 00:26:28.720 position:50% align:middle So, Michelle Buck asked, "Are there any outcomes data in states with higher 00:26:28.720 --> 00:26:34.600 position:50% align:middle levels of APRNs providing buprenorphine treatment in terms of relapses or overdoses or such?" 00:26:34.600 --> 00:26:38.360 position:50% align:middle The short answer to that is, not yet. 00:26:38.360 --> 00:26:42.430 position:50% align:middle The overdose question, I have spoken with a couple of graduate students who 00:26:42.430 --> 00:26:44.830 position:50% align:middle are interested in trying to look at that. 00:26:44.830 --> 00:26:52.480 position:50% align:middle And using the idea that you have different states that regulate APRNs differently, 00:26:52.480 --> 00:26:58.820 position:50% align:middle provides an external source of variation in the rates at which people are taking up waivers. 00:26:58.820 --> 00:27:06.080 position:50% align:middle And, that is an opportunity to essentially do a natural experiment, where in some states, 00:27:06.080 --> 00:27:09.600 position:50% align:middle the APRN workforce is growing more rapidly in other states. 00:27:09.600 --> 00:27:17.520 position:50% align:middle And, that natural experiment then might help you better assess whether any changes in overdoses or negative 00:27:17.520 --> 00:27:19.470 position:50% align:middle outcomes is causal. 00:27:20.550 --> 00:27:26.150 position:50% align:middle We also know that there are a number of people who've been interested in studying advanced practice 00:27:26.150 --> 00:27:32.620 position:50% align:middle engagement and buprenorphine treatment using insurance claims data or Medicare claims data. 00:27:32.620 --> 00:27:37.930 position:50% align:middle And, that's an area where it's very difficult to measure what the "quality of care" would be 00:27:37.930 --> 00:27:40.330 position:50% align:middle for those populations. 00:27:40.330 --> 00:27:43.210 position:50% align:middle But, we do have interest in that. 00:27:43.210 --> 00:27:50.130 position:50% align:middle We were really struck with the qualitative comments that people made, both physicians and nurses, 00:27:50.130 --> 00:27:56.750 position:50% align:middle about how they perceived the APRNs not only just added more, you know, more people to battle the 00:27:56.750 --> 00:28:04.160 position:50% align:middle opioid epidemic, but also that the nursing training and perspective was really valuable and that holistic 00:28:04.160 --> 00:28:06.223 position:50% align:middle approach to care was really important. 00:28:10.084 --> 00:28:17.480 position:50% align:middle So, I have time for one last question I have been told and so I'm looking to see if any other questions come 00:28:17.480 --> 00:28:19.322 position:50% align:middle in before we close. 00:28:37.130 --> 00:28:43.540 position:50% align:middle All right, I'm happy to share my slides and any of the papers that we've put together. 00:28:43.540 --> 00:28:50.290 position:50% align:middle We are hoping to have some more publications coming out soon and we are continuing to do work on this, 00:28:50.290 --> 00:28:53.470 position:50% align:middle thanks to a grant from the National Institute for Drug Abuse. 00:28:53.470 --> 00:29:00.290 position:50% align:middle But the original funding from National Council of State Boards of Nursing absolutely got our work off the 00:29:00.290 --> 00:29:06.950 position:50% align:middle ground and was cited in our reviews from NYDA as having really provided a strong basis 00:29:06.950 --> 00:29:08.260 position:50% align:middle for our overall proposal. 00:29:08.260 --> 00:29:13.671 position:50% align:middle So, we are really excited and grateful for the support from NCSBN in this work. 00:29:21.460 --> 00:29:23.520 position:50% align:middle Well, I see no other questions. 00:29:23.520 --> 00:29:27.080 position:50% align:middle So, I'm available to answer questions offline. 00:29:27.080 --> 00:29:28.140 position:50% align:middle Feel free to email me. 00:29:28.140 --> 00:29:31.960 position:50% align:middle I'm easy to find online and I'm happy to share my slides. 00:29:31.960 --> 00:29:32.834 position:50% align:middle Thank you.