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The medications for opioid use disorder, methadone and buprenorphine, are lifesaving and support recovery from opioid use disorder (OUD). Although federal and state policy in the United States has made it difficult for practitioners to prescribe these medications, some recent policy changes have begun to remedy this and make buprenorphine more accessible. In an article in this issue o^AJPH, Xiong et al. (p. 696) demonstrate this. Their findings show that federal policies to make buprenorphine accessible to people with OUD-in particular, the Comprehensive Addiction and Recovery Act (CARA) and the Substance Use Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act-did increase prescribing overall. However, their findings highlight other trends. Although nurse practitioners (NPs) and physician associates (PAs; also called physician assistants) increased their prescribing per month following the passage of CARA and SUPPORT, rates of prescribing among physicians declined.
Although we agree with many of the findings of Xiong et al. and their implications, including that federal policy alone cannot solve issues with buprenorphine access and reaching saturation for this medication, we also believe that other contextual factors help explain why physician rates of prescribing have declined and why more robust policy solutions are needed to address the ongoing overdose crisis. We address implications from several perspectives: clinical, training, implementation supports, care models, and settings.
Firstly, NP and PA prescribers are willing to prescribe buprenorphine for opioid use disorder; given the potentially greater accessibility of these prescribers, this is most welcome. The decline in physician prescribing is concerning because the overall treatment gap between diagnosed and treated OUD remains very large and the scale of morbidity and mortality requires all hands on deck to contribute. As Xiong et al. note, the decrease in physician prescribing can be associated with role shifting. This could be the case in practices where, before the passage of CARA, physicians prescribed buprenorphine for patients whose care was otherwise managed by an NP or PA, who then filled that role after the passage of CARA.1 However, role shifting likely only explains part of the associated physician decreases in buprenorphine prescribing and points to a larger access problem. For example, one study found that in rural areas, NPs and PAs accounted for over half of the...