Medication-assisted treatment (MAT), is an important treatment regimen that decreases:
- opioid use
- opioid-related deaths
- criminal activity
- infectious disease transmission
With the passage of the Comprehensive Addiction and Recovery Act of 2016 (CARA), nurse practitioners (NP) and physician assistants (PA) were authorized to prescribed MAT to treat opioid use disorder (OUD) after obtaining a DEA waiver. Since CARA passed, the Substance Abuse and Mental Health Services Administration (SAMHSA) reported that over 14,000 NPs have obtained a waiver and over 3,000 are waived to treat up to 100 patients. This demonstrates their commitment to their patients and that the waivers are an effective tactic to tackle OUD.
Additionally, the Medicaid and CHIP Payment and Access Commission (MACPAC) recently found that the number of waiver prescribers and the number of patients treated with MAT increased substantially in the first year that NPs were authorized to obtain their waiver.
To learn more about how important these advancements are to Americans, The Modern Medicaid Alliance sat down for a Q&A with Sophia Thomas, President of the American Association of Nurse Practitioners (AANP).
Modern Medicaid Alliance: How critical is improving access to treatment to address the opioid epidemic?
Sophia Thomas: The opioid epidemic is estimated to have cost the United States over $2.5 trillion, but the personal impact on the lives of families across the country is incalculable. Despite concerted efforts to address this epidemic, the majority of patients with OUD still do not receive treatment for OUD. While there are several reasons for not receiving treatment, including stigma, one of the primary reasons is the lack of access to a health care provider who can provide the patient with the necessary treatment. Since 2016 when NPs were authorized to obtain waivers they have created over 500,000 potential treatment access points for their patients. As the data notes, we continue to see NPs answering this call and increasing access to this medically necessary treatment.
Modern Medicaid Alliance: How has the opioid epidemic specifically impacted the Medicaid beneficiary population?
ST: The opioid epidemic impacts patients in all age groups and backgrounds, but it has been more pronounced in the Medicaid population which has higher rates of mental health and substance use disorders. For the Medicaid population, it is extremely important to increase access to treatment for OUDs and co-occurring mental and behavioral health disorders. NPs are essential to providing treatment to Medicaid patients, and over 80% of NPs are seeing new Medicaid patients. As noted in MACPAC’s report, the population with the greatest increase in access due to authorizing NPs to prescribe buprenorphine for the treatment of OUD is the Medicaid population.
Modern Medicaid Alliance: What is medication-assisted treatment (MAT)?
ST: MAT is the use of medications, along with counseling and behavioral health therapy, for the treatment of substance use disorders. For the treatment of OUD, the FDA-approved medications include naltrexone, methadone and buprenorphine products. Naltrexone can be prescribed by any provider licensed to prescribe medications, methadone is only authorized to be dispensed in SAMHSA-approved Opioid Treatment Programs, and clinicians prescribing buprenorphine for the treatment of OUD must receive a waiver from the DEA. NPs and PAs were first authorized to obtain a waiver with the passage of CARA in 2016.
Modern Medicaid Alliance: How important is it to treating individuals with OUD?
ST: MAT is considered the “gold standard” in treating OUD and methadone and buprenorphine are considered to be “essential medicines” by the World Health Organization. Studies have shown that MAT increases retention to treatment and reduces opioid use, opioid overdose and diseases associated with OUD. We do want to highlight counseling, behavioral therapy, peer support and other wrap-around services as integral components of the treatment of patients receiving MAT.
Modern Medicaid Alliance: What has the impact of CARA been on improving access to treatment?
ST: CARA was landmark legislation that took critical steps to help address the opioid epidemic, including granting NPs and PAs a five year authorization to prescribe buprenorphine to their patients suffering from OUD. It was later buttressed by the passage of the SUPPORT Act of 2018 which made this original authorization permanent for NPs and PAs. Studies, including the recent MACPAC report, have found that the passage of CARA has increased access to MAT for patients in rural and underserved communities. For example, a recent study published in Health Affairs found that NPs and PAs were the first clinicians to receive waivers in 285 rural counties covering 5.7 million residents.
Modern Medicaid Alliance: How critical are NPs and PAs to addressing the opioid epidemic?
ST: NPs and PAs are essential providers in addressing the opioid epidemic, particularly for rural and underserved populations. There are currently more than 270,000 NPs practicing in the United States today and NPs comprise over a quarter of the primary care workforce with that percentage growing annually. The data from the MACPAC report shows the substantial impact NPs are having on this epidemic. Within just a single year of receiving the authority to obtain waivers, NPs and PAs accounted for 18% of all Medicaid prescribers, with that percentage higher in rural counties. Since the completion of the study, the number of waived NPs and PAs has continued to grow substantially and is now more than double the number of prescribers during the study period.
Modern Medicaid Alliance: What role does the clinician shortage play in limiting access to treatment for individuals with OUD?
ST: Nationwide we have a shortage of primary care and behavioral health clinicians who are needed on the front lines of combatting this epidemic. This is exacerbated in rural and underserved areas.NPs and their patients also face additional challenges due to certain state laws that restrict acccess to their services. As MACPAC found, states with restrictive practice environments had a lower percentage of NPs obtaining waivers, hampering access to treatment. We strive to achieve full practice authority for all NPs, which would ultimately improve patient access to MAT and the other services NPs are educated and clinically trained to provide.
Modern Medicaid Alliance: What additional legislative or regulatory solutions would increase access to treatment for OUD?
ST: We would urge state and federal legislatures to ensure laws and regulations are crafted to increase access to care and remove artificial barriers that restrict providers from practicing to the full extent of their education and clinical training.
Modern Medicaid Alliance: What else would do you think is important to mention on this topic?
ST: As a Louisiana citizen, I am pleased that one of twelve HRSA awards for expansion of MAT services was recently awarded to an NP-owned rural health clinic, Louisiana Health Care Practitioners (LHCP), which operates 5 sites serving over 60,000 patients in two underserved Louisiana parishes. LHCP is partnering with Access Behavioral Health, another NP-owned practice, to implement opioid prevention, treatment, and recovery services as well as to provide the integration of psychiatric care and individual and group behavioral health counseling to comprehensively address addiction as well as psychological precursors and sequelae. By addressing the addiction and the continued mental health needs of patients through this collaborative approach, these NPs will be providing the continuity of care through a 360-degree approach to meet the needs of the patients in rural Louisiana.
Sophia L. Thomas, DNP, APRN, FNP-BC, PPCNP-BC, FNAP, FAANP, is president of the American Association of Nurse Practitioners® (AANP). A family and pediatric nurse practitioner (NP) at the Daughters of Charity Health System in Kenner (New Orleans), Louisiana, Dr. Thomas’ clinical practice has focused on providing care to the medically underserved families. Dr. Thomas is active within several professional organizations, including the Louisiana Association of Nurse Practitioners (LANP). She has served in elected and appointed leadership and committee positions, including as president of LANP, and previously in AANP as Region 6 Director. Dr. Thomas was inducted as a Fellow in both the AANP in 2012 and the National Academy of Practice in Nursing in 2013. In addition to her advocacy, Dr. Thomas impacts NP education as clinical faculty for Georgetown University’s FNP program as well as through publications and presentations on multiple clinical topics. As AANP President and spokesperson, her multimedia reach includes print, radio and television. She also speaks extensively throughout the U.S. and internationally, advocating for NP scope of practice legislation and for improving patient access to quality, affordable health care.
Sophia L. Thomas, DNP, APRN, FNP-BC, PPCNP-BC, FNAP, FAANP, President
The American Association of Nurse Practitioners® (AANP)