Opioids

The Feds Are Willing to Let More Medical Workers Treat Opioid Addicts. Now the States Need to Step Up and Allow It.

It's time we unleashed non-physicians to help opioid addicts.

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Pharmacist Jim Pearce fills a Suboxone prescription at Boston Healthcare for the Homeless Program in Boston, Massachusetts. Photo credit: BRIAN SNYDER/REUTERS/Newscom

The Drug Enforcement Administration (DEA) announced today that it will begin granting waivers making it easier for nurse practitioners and physician assistants to administer a drug designed to wean people off prescription painkillers and heroin without inducing withdrawal. Under the new rule, they'll be able to give patients the drug—buprenorphine—in outpatient settings without requiring that care providers register as narcotics treatment programs. If the state where they practice allows it, nurse practitioners will also be allowed to administer the drug without a physician on the premises.

The Food and Drug Administration approved buprenorphine in 2002. That same year, the Department of Health and Human Services created a waiver program that would allow physicians to administer the drug in a primary care setting.

The waiver system was designed to provide an alternative to the regulatory obstacles physicians must navigate to set up a treatment center. Establishing a federally approved treatment program requires you to submit an application to both the DEA and the Food and Drug Administration, plus a state regulatory agency. Applicants must then be interviewed and have their facilities inspected by all three agencies. The waiver provision—which also involves a fair amount of paperwork—was intended to expand treatment access to Americans in rural areas. But nurse practitioners and physician assistants weren't allowed to apply for the waivers.

In 2016, the Comprehensive Addiction and Recovery Act changed the waiver eligibility language from "qualifying physician" to "qualifying practitioner." The DEA's notice states that the definition of "qualifying practitioner" will include physicians, physician assistants, and nurse practitioners until October 2021, at which point the language will have to be reauthorized.

Under the new regulations, any nurse practitioner or physicians assistant who is licensed to administer a schedule III drug can now apply for a waiver. (Schedule III drugs have moderate potential for abuse and can be mildly habit forming.) They will be required to undergo 24 hours of training, and they will need a physician's authorization if their state requires them to work under a doctor's supervision. All physician assistants require such supervision, but 22* states and the District of Columbia allow nurse practitioners "full practice" status, meaning they can prescribe drugs independently of a medical doctor.

Unfortunately, many of the states hit hardest by opioids do not allow nurse practitioners this independence. Pennsylvania, New Hampshire, Kentucky, West Virginia, and Ohio had the highest overdose death rates in 2016. Of those five, only New Hampshire allows nurse practitioners to prescribe independently.

That blunts the impact of today's announcement. According to the DEA, "rural providers of buprenorphine report a demand far beyond their capacity and say they lack the resources to adequately support themselves and patients in treatment." A 2017 report from the National Rural Health Association revealed that only 39 percent of rural counties have a waivered physician.

Meanwhile, a 2016 survey found that 36 percent of waivered physicians who are not treating the maximum number of patients allowed by Health and Human Services say it's because they lack the time to treat additional patients. A 2015 research review by the Kaiser Family Foundation found that nurse practitioners "can manage 80–90% of care provided by primary care physicians" and that primary care outcomes between nurse practitioners and physicians are roughly identical.

The DEA took a step in the right direction today. Now states need to make it easier for non-physicians to keep their patients alive.

*Correction: This post erroneously stated that nurse practitioners have full practice authority in 21 states; they currently have full practice authority in 22 states.

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  1. Meh, People should be able to be on dope if they want to.

    1. Sorta.

      Your ability to swing your fist ends at my nose. I’ve got no problem with you swinging your fist nowhere near my nose. We’ve got “no problem” when you swing your fist and knowingly hit my nose. When you swing your fist and your senses are so dulled and/or your fist so numb that you aren’t aware of hitting my nose, that creates some problems. When your numbness and dulled senses detract from the services I pay for, that’s a problem.

      I’ve got no problem with functional dope users and even non-functional but self-contained dope users. Unfortunately, that still leaves thousands if not millions of dope users who routinely call the fire department after ODing, show up in hospitals with conditions that they’ve induced as well as insurance that I’ve subsidized, and, last but not least, adults around them who insist that I/we ‘do something’ about their issue.

      1. mad.casual’s nose is like the immanent god: in and of all things. He who swings his fist in any direction is bound to hit mad.casual’s nose.

      2. The law does not distinguish between functional and nonfunctional. And YOUR right to swing your fist ends the second it interferes with MY right to make my own lifestyle and/or medical decisions. the right to be left alone is the cornerstone of freedom. If I harm or endanger another human being, abuse or neglect a child or animal in my care, if I take or destroy another person’s private property, then by all means, send in the troops. But what I do to or with my body, in the privacy of my home, alone or in the presence of other consenting adults, is no one’s business but my own.

        1. It’s worth noting, for the record, that harming or endangering people, abusing children and pets, and taking or destroying private property is part and parcel of what the government is “doing” about drug use. And you know what? Even if you think certain drugs (but not the most dangerous or addictive ones) should be illegal, you should know that after 45 years, over a trillion dollars spent, millions imprisoned, countless lives destroyed, Mexico literally bleeding to death on our doorstep, the percentage of Americans who use illegal drugs, and the number of people who die from using them, has only risen. Explain, if you can, the rationale of continuing the same tactics and policies.

    2. While Suboxone and Subutex may have been “designed to wean people off prescription painkillers and heroin without inducing withdrawal” that is not how they are generally employed by treatment centers.

      They are maintenance programs, where the majority of patients never get opiate free.

      So, at least in that sense, they are able to ‘be on dope if they want to.’

      Although I’m not sure what is remotely libertarian about adding alternate members to the cartel.

      1. The more members in the cartel, the less cartel-like it is. If everyone were in the cartel, it wouldn’t be a cartel at all, would it? Therefore every increase in the # is a step toward “everyone”.

  2. Facts: US GWOT Vets Opiods increase ONLY Until 2010; “Opiod Crisis Vets” cases 0.87% in 2000. 1.76%. in 2010. GWOT Vets returned, when Nam Vets died.

    Real #’s: 1% of 100 is 1%. 1.86% of 600? 0.3% Real Opiod Crisis? Nope! Real INJURIES Crisis, maybe.

    98% of Vets receiving Opiods needed them & used correctly. So, no real treatment – 8 yrs? Since 2010 the VA CUT Scripts. While receiving MORE Vets. 36% cut in scripts : more than 2ce the Disabled Vets = less than 2/3 Opiod Scripts!

    Gen Practice MD playing at Psych? Primary Care playing at Pain Anesthesia? Was regular. Caused the less than 2% issue. So, put non-MDs into mix? People who cannot legally prescribe?

    By-the-way, same 2010 to 2018 cutting of 70% of actual care REAL result?! 44% increase in ALL Veteran Deaths! Increase! BUT people who cannot legally prescribe are “Reason’s” and this author’s answer?!

    VA Chiropractor claims HE treats ‘mental health’ @ Minneapolis Region VA Hospital – not adjustment of the spine? Nope! Opioid Crisis!! “Mental Health”!!!

    If I disagree shows I “need of Mental Health”, when a 17 dvd Navy & VA Record shows the nerves are impinged & adjustment helps mechanically correct & is a part of Navy, US [but not Minneapolis Region] VA?!

    That’s the Bullshit this article calls for?

    The New Editor in Chief is the last of Reason I respect. Malpractice is an issue that kills! Every 20 some minutes, another Vet kills themselves! Try some Editorial Oversight, Ma’am!!

  3. Btw:

    According to the Opiod Crisis LIE- by folks like this idiot & Chris Christie,

    The VA ‘started the Crisis’ in 2007 & “corrected” by driving up almost half again more suicides as treatment, starting in 2010.

    Also, my demonstrable experience & education in this matter is pretty much assumed expert by the US Courts, so…

  4. Imagine if all Americans (Land of the Free! Yay!) could purchase their drug(s) of choice from any grocery store, the way users of alcohol (in most states, at least) and tobacco can. Imagine if quality and purity of the drugs was assured, the way they are with alcohol and tobacco. Imagine if unbiased testing was ongoing, and information about potential dangers, possible benefits, and contraindications for use was freely available. The way it is with alcohol and tobacco. Imagine users having access to medical advice about minimizing the risks of their drug use, and safe, judgement-free access to emergency medical aid should they become sick, and being arrested not being a prerequisite for treatment. You know, like alcohol and tobacco. (Either one of which, by the way, kill more Americans than all illegal drugs combined.) In other words, imagine minding your own business for a change.

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