NPs and PAs join the fight

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In the early 2000s DATA 2000 was passed and gave physicians the opportunity to undergo 8 hours of training in order to become certified to administer buprenorphine to patients who were seeking treatment. This act also gave physicians the ability to provide medication outside of large hospitals, such as correction facilities, private offices, and other places where patients did not feel they had to be publicly shamed in order to get help. An unfortunate aspect of this opportunity was that physician assistants and nurse practitioners were not included in this new law. As a matter of fact, PAs, and NPs were prohibited from providing treatment even in cases where patients were presenting for help. 

 

In 2002, there were only a mere 1,119 physicians that were certified to prescribe buprenorphine. The number of opioid related deaths however continued to climb in the U.S., and the situation only became worse as not enough physicians were receiving training to prescribe and treat opioid addiction. In 2015, only about half of US counties had a physician who was certified to treat opioid addiction with buprenorphine. States with the highest rates of mortality were the ones who were found to have the least DATA 2000 certified physicians. 

 

To counteract this, President Obama signed CARA in 2016, which aimed to decriminalize first- time and non-violent drug offenses, and instead offered more treatment facilities to those who were suffering with addiction. It ensured that paramedics and police had access to naloxone, and also gave NPs and PAs the opportunity to undergo MAT training. This legislative move gave these mid-level providers the opportunity to treat OUD patients. Once these NPs and PAs acquired the necessary training and certification they could begin with treatment of up to 30 patients in the first year. The following year an appeal to Substance Abuse and Mental Health Services Administration (SAMHSA) can be made to increase this number to 100 patients.

 

In 2018 the SUPPORT Act gave NPs who had received MAT certified had the opportunity to prescribe buprenorphine to 100 in the first year. More specifics on regulations concerning the CARA, and NP practice is available in Section 3201 in the SUPPORT Act. CARA guidelines varies from state to state. In certain states, even if an NP were to be certified and eligible to prescribe buprenorphine, the supervising physician would also need to be waivered so that the order for the medication can be made. Because of the CARA Act, since 2018 around 6,843 NPs have now become certified to prescribe buprenorphine

 

Overview: The Waiver Process

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The Drug and Treatment Act of 2002 (DATA 2000) gives physicians the permission to prescribe buprenorphine and buprenorphine/naloxone for treatment purposes, once the physician has completed the required training and has received necessary certification by the Drug Enforcement Agency (DEA). Buprenorphine products can be prescribed by a certified, and qualified physician in any facility that medical practice is permitted.

Under DATA 2000 a DEA certified physician is someone who is licensed by the state to practice medicine, and has trained under DEA to administer narcotics. In the first year this physician is permitted to treat no more than 30 patients per year, and must be able to refer the patient to another facility for further treatment. 

 

The training from ASAM is excellent. It can be done for free by clicking on this link.

 

A DEA-X notification is then given to the physician after Substance Abuse and Mental Health Services Administration (SAMHSA) verifies that the background of the physician is correct and valid. When an order of buprenorphine is made two different numbers are entered into the order- the physician’s DEA registration number, and another ID number that shows the physician is DATA 2000 certified.

 

 Am I eligible to obtain a waiver?

 

Residents who want to be DATA 2000 certified

DATA 2000 does not exclude physicians who are still in residency training, so there are residents who are certified to administer buprenorphine.There are, however, certain states that have more strict guidelines than others, for example, some states do not permit residents to prescribe Schedule III medications even if it is for treatment purposes. 

 

Physicians working in Correctional Facilities

Providers who work with detained patients may obtain a waiver, to prescribe medication to those who those who need treatment. The rules pertaining to this however may vary by state. Methadone treatment has varying treatment regimens, and this is very likely the case for buprenorphine. Under DATA 2000 providers in these settings are also restricted to treating a certain amount of patients per year.

 

Government employed physicians

DEA training and the DATA 2000 waiver is also open to physicians that work for the government. Basic guidelines remain the same: physicians must obtain DEA training, and an identification number, he or she must be licensed to practice in the state, and must be able to pass a background check from SAMHSA. If the physician did not previously acquire any registration number, the state offers one free of cost. This is offered even for physicians who are not licensed to practice in that particular state, but are licenced to practice elsewhere in the United States, including Puerto Rico, the District of Columbia, and the Virgin Islands. In order to acquire this registration number the physician will need to fill out an application that contains the physicians address and the name and contact information of a reference. This newly acquired waiver from the DEA can only be used while working for the government, and cannot be used in other facilities such as private practices. Physicians who work under a contract cannot apply under this category.

 

DEA-X waiver the basics

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In 2002, the Drug and Treatment Act (DATA 2000), and the Comprehensive Addiction and Recovery Act of 2016 (CARA) allowed providers to acquire a waiver to permit the prescription of buprenorphine and buprenorphine/naloxone to patients suffering from withdrawal symptoms. This law is still valid as of today, and gives physicians the authorization to prescribe buprenorphine outside of a rehabilitation clinic.1

In order to obtain this waiver, physicians must first enroll and fulfill an 8 hour course in a DATA2000 accredited facility. Physician assistants and nurse practitioners can also participate in acquiring this waiver, and instead enroll in a 24 hour course. After the provider completes the training on opioid use disorder (OUD) treatment he or she must then contact the Drug Enforcement Agency (DEA) to request this waiver. After the waiver is acquired there are still restrictions on how many patients the physician can prescribe the medication to. In the first year the provider can only prescribe the medication to 30 patients and if all requirements are met, the number of patients can then increase to 100 patients, and in the following year 275 patients. Prescriptions can continue to be made as long as the provider has had DEA certification.

Buprenorphine Home Induction Instructions for Patients: MGH

By | Implementation

Home Induction:

For patients who are not in withdrawal but are still looking for help in beginning or continuing their recovery journey, home induction with buprenorphine offers an effective, safe, and time efficient alternative to in ED induction when waiting for the patient to enter withdrawal during a busy ED shift is not feasible. 

Clinicians who do have a DEA X waiver can write patients for a short course of buprenorphine after brief patient education on when to administer the medication at home. In this model, clinicians write for no more than 2-3 days of SL buprenorphine(no more than a total of 32-48mg) and send patients home with a step by step guide outlining symptom assessment and dosage information. More information and a clear guideline on home induction for patients here. All patients should have a clear follow up plan in place upon discharge for maintenance treatment. 

 

Departments interested in this approach may consider establishing a waivering program to compel physicians to obtain their DEA X waiver. One example of this is the Get Waivered program which may provide a useful model – overview here.