by jessica lippa ms, fnp-c, rn a capstone project ... · evidence-based practice to successfully...

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Barriers for Prescribing Buprenorphine for Advanced Practice Registered Nurses

By

Jessica Lippa MS, FNP-C, RN

A capstone project submitted to the

School of Nursing

The State University of New York

In partial fulfillment of the requirements for the degree of Doctor of Nursing Practice

May 2019

BARRIERS TO PRESCRIBING BUPRENORPHINE 2


Table of Contents Table of Contents .................................................................................................................................. 3

Abstract ................................................................................................................................................. 4

Acknowledgements ............................................................................................................................... 5

Introduction ........................................................................................................................................... 6

Theoretical Framework ....................................................................................................................... 11

Purpose ................................................................................................................................................ 11

Methods............................................................................................................................................... 11

Results ................................................................................................................................................. 14

Discussion ........................................................................................................................................... 16

Limitations .......................................................................................................................................... 22

Conclusion and Implications ............................................................................................................... 23

References ........................................................................................................................................... 24

Appendix A: Tables ............................................................................................................................ 27

Appendix B: NP PA Survey................................................................................................................ 32

Appendix C: ........................................................................................................................................ 36

Appendix D: Poster ............................................................................................................................. 38


Abstract Background: In response to the nation’s opioid crisis, the legislation allowed Advanced Practice Registered Nurses (APRNs) to prescribe medication assisted treatment (MAT) such as buprenorphine. Current literature provides evidence regarding physician’s barriers in prescribing buprenorphine. However, there were no prior studies investigating the barriers among APRNs. APRNs are a great resource to combat the opioid epidemic by providing treatment. Therefore, it is important to understand what is holding APRNs back from prescribing buprenorphine. This study aims to identify barriers in prescribing buprenorphine for opioid use disorder (OUD) in APRNs. Theoretical Framework: Change theory was used to guide the study, understanding perception of barriers is critical to lead change in APRNs prescribing behaviors. Methods: This study used a web-based survey sent via e-mail was distributed to APRNs to collect information about barriers to prescribing MAT and stigma associated with OUD. The survey was developed by researchers and clinicians through literature review and clinical experiences. Descriptive and correlational statistics were used for data analysis. Results: Results show that APRN’s greatest barriers include knowledge to prescribing buprenorphine, access to mental health and addiction resources, and adequate support from a consultant with expertise in buprenorphine treatment. The lowest barriers included growing the practice beyond the waiver cap and allocating more office space. Conclusions & Implications: Our findings provide information regarding APRN prescribing barriers and identify factors associated with those barriers. Moving forward, appropriate strategies can be developed to overcome those barriers and provide support to APRNs to improve access to MAT.

Keywords: buprenorphine, opioid use disorder, APRNs, barriers, prescribing behavior


Acknowledgements My utmost gratitude goes toward my husband, Geoff, for his undying support during the

completion of my doctorate and especially during the final days, weeks, and months working on

my final project. I also want to acknowledge my sister, Mary Ellen, who has been my personal

cheerleader to reach my highest potential and my parents, Rich and Mary, who have always

supported me in my endeavors.

I also want to acknowledge the support and guidance of my advisor Dr. Yu-Ping Chang.

Without her knowledge and positive energy, I would not have been able to complete my project.

Thank you for supporting young professionals to reach their potential! You are changing lives. I

am grateful that we were able to work together, because you have changed my life for the better!

Thank you to my friends and colleagues at Alfred State College who have supported me

and encouraged me to continue my education!

Lastly, I want to thank the multiple people who made my project possible, Christopher

Barrick Ph.D., Elizabeth Dick MS, Brian Quigley Ph.D., Kenneth Leonard Ph.D., and Amy

Hequembourg Ph.D. Thank you for the work that you all put into this project. Without you all, I

could not have completed my project!


Introduction

Drug overdoses have become an epidemic in the United States of America (USA). In

2016, drug overdoses in the USA increased 21.4% from 2015 with synthetic opioids driving this

increase (Scholl, Seth, Kariisa, Wilson, & Baldwin, 2018). It has been determined that more

than 42,000 opioid related deaths occurred in 2016 (SAMHSA Opioid overdose prevention

toolkit, 2018). The opioid epidemic continues to grow with higher rates of drug overdose every

year (Scholl et al., 2018). Medications considered opioids include hydrocodone, codeine,

oxycodone, fentanyl, morphine, hydromorphone, morphine, and illicit drugs such as heroin

(SAMHSA Opioid overdose prevention toolkit, 2018). Opioids affect the receptors of the brain

to decrease the amount of pain perceived by the person, which also decreases the respiratory rate

and gives the person a euphoric feeling of being high (SAMHSA Opioid overdose prevention

toolkit, 2018). Overdoses can occur when a person takes any of the above opioids in excess or

when combined with other drugs such as alcohol or benzodiazepines (SAMHSA Opioid

overdose prevention toolkit, 2018).

The rates of opioid related overdoses between 2000 and 2014 went up 200% involving

opioid pain relievers and heroin (Rudd, Aleshire, & Gladden, 2016). Many states within the

United States are showing increasing trends of opioid use disorder (OUD) and opioid overdose

deaths (Opioid summaries by state, 2018). The rate of opioid related deaths in the year 2000 was

6.2 per 100,000 persons and went up to 14.7 per 100,000 in the year 2014 (Rudd et al., 2016).

With the introduction of carfentanil, which is more potent and increases the respiratory

depression effects of the opioid, the risks of overdose will continue to rise (Rudd et al., 2016).

The Opioid Epidemic

The availability of naloxone, an antidote for opiate related respiratory depression, has

been growing and there are five essential steps for first responders that has been helping to


reduce the time of administration of naloxone for patients suspected of opioid overdose

(SAMHSA Opioid overdose prevention toolkit, 2018). The Food and Drug Administration

(FDA) have been working in response to the epidemic with proactive pharmacovigilance

(Throckmorton, Gottlieb, & Woodcock, 2018). The FDA uses a systematic approach to review

and monitor trends related to the opioid epidemic and they have identified that the use of

gabapentin, an analgesic adjunct, for neuropathic pain has tripled from 2002 to 2015

(Throckmorton et al., 2018). Pregabalin, a nonopioid analgesic, was ranked among the top 10

best-selling drugs in 2017 (Throckmorton et al., 2018). The FDA has also pushed to limit the

amount of opioid prescriptions in the USA, which may account for the increases in these longer

chronic alternatives (Throckmorton et al., 2018). The FDA will continue to analyze trends to

investigate patterns related to OUD (Throckmorton et al., 2018).

Medication Assisted Treatment

Medication assisted treatment (MAT) includes both methadone and buprenorphine as

evidence-based practice to successfully treat OUD (Li, Shorter, & Kosten, 2014).

Buprenorphine has a better safety profile and a decreased chance of abuse (Li, Shorter, &

Kosten, 2014). Buprenorphine is a partial agonist with high-affinity mu-opioid receptors

reducing the risk of overdose (Li, Shorter, & Kosten, 2014). Buprenorphine is an effective

treatment for OUD with reduced respiratory depression, which prevents unintentional overdose

deaths (Li, Shorter, & Kosten, 2014).

The use of MAT is patient specific and the treatment may change based on the

disorder(s) being treated. The problem with treating people with OUD is that they typically have

multiple psychosocial needs that are not getting met. Knudsen, Lofwall, Walsh, Havens, and

Studts (2018) provided physicians with 20 case studies and asked each provider to score on a 0

to 10 scale on the willingness of the provider to provide MAT. The study examined different


backgrounds of patients including financial, insurance, risky substance abuse, and partner

relationship (Knudsen et al., 2018). The study found that physicians were less likely to prescribe

MAT to patients who had confounding alcohol and benzodiazepine use, were using Medicaid

insurance, and if their partner was not involved with the treatment (Knudsen et al., 2018).

Guidelines suggest being cautious when prescribing to individuals who use illicit drugs and with

individuals with partners who are also using illicit drugs (Knudsen et al., 2018).

The Substance Abuse and Mental Health Services Administration (SAMHSA) has

collaborated with the National Institute of Drug Abuse to deliver education to support healthcare

providers to use evidence-based practice (EBP) (Knudsen et al., 2011). There has been an

increase of the MAT facilities, however more work needs to be done to look at the barriers to the

adoption of MAT centers based on regulatory factors (Knudsen et al., 2011).

Legislation

The Drug Addiction Treatment Act of 2000 (DATA) allowed physicians to apply for a

waiver to prescribe buprenorphine in the year 2000. The Comprehensive Addiction Treatment

and Recovery Act (CARA) legislation allowed Advanced Practice Registered Nurses (APRNs)

and Physician Assistants (PAs) to prescribe buprenorphine in 2016. There has been a large push

for APRNs to lead the fight against OUD. Advanced Practice Registered Nurses represent a

large portion of practicing healthcare providers and work in a variety of settings.

Nurse Practitioners Role

The ANA identified the impact that nurses could have on the opioid epidemic and

assisted in the legislation that allowed APRNs to prescribe MAT (Nursing's role in addressing

nation's opioid crisis, n.d.). The ANA supports education and training to prescribers, they work

to create deterrent formulations, increase the utilization of prescription drug monitoring


programs (PDMP), and lastly increase the access for naloxone for family, friends, and first

responders to prevent overdoses (Nursing's role in addressing nation's opioid crisis, n.d.).

Barriers to Prescribing Buprenorphine

Cunningham, Kunins, Roose, Elam, and Sohler (2007) sought out to examine physicians’

barriers to obtaining waivers to prescribe buprenorphine. This study, although slightly outdated,

gives a good understanding of research after buprenorphine was allowed to be prescribed by

physicians in 2002 (Cunningham et al., 2007). Survey questions addressed the physician

demographics, barriers to prescribing buprenorphine, and how confident the physicians felt

addressing drug problems (Cunningham et al., 2007). Out of the responses, only 22 (6%)

physicians at the time of the survey had prescribed buprenorphine (Cunningham et al., 2007).

The barriers that were indicated included: knowledge deficit about opioid addiction (54.9%),

lack of addiction expert support (42.9%), inability to send patients to a substance abuse treatment

program (41.3%), concerns about diversion (40.3%), and concerns about the complexity of

opioid-addicted patients (40.3%) (Cunningham et al., 2007). The results also found that

physicians who had completed the 8-hour training were less concerned about the lack of

knowledge (p < .01), lack of addiction expert support (p < .05), and inability to send patients to a

substance abuse treatment program (p < .05) (Cunningham et al., 2007).

Web-based surveys can yield significant results about barriers to prescribing

buprenorphine. Kermack, Flannery, Tofighi, McNeely, and Lee (2017) used a cross-sectional

web-based survey study with buprenorphine prescribers in the New York City (NYC) area

(Kermack et al., 2017). The focus was on provider attitudes and common practice to the

Medicaid and uninsured populations in New York City (Kermack et al., 2017). The study used a

25-question instrument that identified demographics, induction approaches, and attitudes related


to, “buprenorphine diversion, prescriber patient limits, insurance issues, and ancillary

treatments” (Kermack et al., 2017, p. 2).

Rural counties continue to be without a physician capable of prescribing buprenorphine

(Andrilla, Coulthard, & Larson, 2017). Currently, only 60.1% of rural communities across the

USA have access to a physician who can prescribe buprenorphine for OUD (Andrilla et al.,

2017).

Stigma

Stigma toward people with mental health disorders is a barrier to providing OUD MAT

within the healthcare profession (Modgill, Knaak, Kassam, & Szeto, 2014). There is

overwhelming data to show that the opioid epidemic is getting increasingly worse. The first step

to tackle a problem like an epidemic is to identify needs. This project will help to identify

healthcare providers’ needs by identifying barriers regarding prescribing buprenorphine. The

findings of this project will provide important information regarding strategies to support

healthcare providers in their clinical practice.

The first year after the CARA legislation was passed, 3,534 nurse practitioners (NP) had

obtained the DEA waiver, which is equivalent to 1.7% of eligible NPs given state laws (Andrilla

et al., 2018). Even though the number of NP waivers has increased, there are still approximately

42.3% of counties within the USA without a physician, APRN, or PA to prescribe buprenorphine

(Andrilla et al., 2018). There is also a disparity between rural and urban areas with healthcare

provider presence missing in 69.3% of rural counties (Andrilla et al., 2018).

There have been multiple studies done to investigate the barriers for physicians who

prescribe buprenorphine. There were no studies found that investigate the barriers for APRNs,

revealing a gap in the research.


Theoretical Framework

This study was guided by Change Theory, as described by Kurt Lewin in 1951 (Kritsonis,

2005). Change Theory attempts to describe a process that is complex by breaking down the

complex steps into phases (Kritsonis, 2005). This study focused on Phase 1: diagnosing the

problem (Kritsonis, 2005). The information obtained about barriers to prescribing

buprenorphine will guide future initiatives to overcome the barriers. Advanced Practice

Registered Nurses have the ability to prescribe buprenorphine after completing a 24-hour

prescriber education program that is free for individuals seeking to prescribe buprenorphine

(LaBelle, n.d.).

Purpose

The purpose of this project was to describe barriers in prescribing buprenorphine and

identify factors (demographic and practice) associated with reported barriers and stigma in

APRNs who have completed the MAT waiver program and have a DEA number in New York

State.

Methods Design, Sample and Setting

This study used a cross-sectional online survey distributed to APRNs in New York State

(NYS). The copy of the survey is in Appendix A. The Institutional Review Board (IRB) at The

University at Buffalo (UB) approved this study.

Procedure

The Clinical and Research Institute on Addictions (CRIA) collected information from a

variety of resources to distribute the online survey. The CRIA disclosed to recipients the

statement, “The study aims to gather information to better understand knowledge, attitudes, and

perceived barriers regarding Nurse Practitioners’ use of buprenorphine as a medication assisted


treatment.” The survey was designed to collect information regardless of the practitioner’s

ability to prescribe buprenorphine. The e-mail survey was anonymous and the CRIA, through a

secured location and computer, collected the results. To ensure there is anonymity with the

survey, a password-protected computer stored the data. The data was de-identified and

aggregated (Social & behavioral research investigators, n.d.).

Measures

The online survey was developed by a group of researchers and clinicians. These

researchers developed the survey through an extensive review of research evidence and relevant

questionnaires in the context of OUD and MAT, as well as clinical expertise in the content area.

Survey content validity was established through the incorporation of content experts. The Survey

includes three parts: demographic and practice characteristics, barriers, and stigma.

Demographic and practice data including gender, age, degree, number of years of

practice, practice setting, practice location, patient insurance accepted, low income patient

percentage, and whether the practitioner was prescribing buprenorphine (with the waiver cap).

Additional information that was included in the survey was related to the number of patients

treated with buprenorphine, the participant’s education related to MAT within the past 90 days,

and additional resources provided to patients receiving MAT. The second part of the survey was

related to barriers to prescribing MAT. Participants were asked barrier associated questions using

a Likert scale for 20 items from very unhelpful to very helpful to identify items that would help

the practitioner better provide buprenorphine treatment. The last part of the survey was related

to Sigma. The Opening Minds Scale for Health Care Providers (OMS-HC) identifies stigma in

healthcare providers. (Modgill et al., 2014). The 15-item OMS-HC showed good internal

consistency (Modgill et al., 2014). Each of the questions had varying degrees of stigma toward

individuals with OUD using a Likert scale from strongly disagree to strongly agree. Some


questions were directional, so each question was evaluated to identify that the highly stigma

related questions obtained five points and the questions related to low stigma received one point.

• Demographic Characteristics: Age, Education, Gender, Years in Practice

• Practice Characteristics: Practice Setting, Practice Location, Specialty, Insurance

Accepted

• Prescribing Barrier Scale (23 items):

• Factor One: Knowledge and Skills

• Factor Two: Practice Growth

• Factor Three: Practice Support – Staff/Office

• Factor Four: Practice Support – General

• Factor Five: Behavioral Health Support

• Factor Six: Complexity of Prescribing

• Stigma Scale (15 items)

Data Analysis

Descriptive statistics were used to describe the participants and practice characteristics

including the mean, standard deviation, and percentages of the survey questions. T-test,

ANOVA, and Pearson’s correlations were used to examine the associations between

demographic characteristics, barriers and stigma.

ANOVA was used to show the variance, avoid Type II error, and helped to draw

inferences about the differences using three or more groups. This test is a little more

complicated than the prior two due to the one-way and two-way abilities with respect to

independent and dependent variables. This test allows us to use two independent measures and

compare them to other factors. There are multiple independent and dependent variables on the

survey, so this test will allow for analysis based on all of the items on the survey compared to the


demographic data. The concern about the ANOVA is the Power Analysis. Using 0.80 for the

Power and alpha at a level of .05 and medium Cohen’s d of .50-.40 would provide a sample size

of approximately 64-99 subjects in each of the groups.

A factor analysis was conducted to identify potential factors of the prescribing barrier

scale, six factors were identified including Factor 1: Knowledge and Skills; Factor 2: Practice

Growth; Factor 3: Practice Support – Staff/Office; Factor 4: Practice Support – General; Factor

5: Behavioral Health Support; Factor 6: Complexity of Prescribing. These factors were

correlated with multiple other variables.

Results A total of 49 participants completed the online survey. The demographic data from the

sample is described in Table 1, Appendix A. The participants consisted of 16 individuals who

were between 56-65 years of age (36.4%) and 14 from 46-55 (31.8%). Of the participants there

were 36 females (81.8%) and eight males (18.2%). There were 14 participants with >20 years of

practice (31.8%), 12 with 0-5 years (27.3%), and nine with 6-10 years (20.4%). For practice

location there were 21 participants who indicated practicing in a suburban location, 18 indicated

rural, and 14 identified urban location, no percentages were used, because participants could

choose more than one option. For specialty there were 16 participants who identified they work

in a Family Practice (36.4%), 10 identified an Other specialty (22.7%) and 7 identified Internal

Medicine (15.9%). Most participants, between 32-36, accepted multiple insurances, with the

options including Commercial, Medicaid, Medicaid managed, Medicare, and Self-Pay

Insurances.

The top five barrier questions were summarized in Table 2, Appendix A. The question

identified as the highest barrier was, “If I could obtain greater knowledge of prescribing

buprenorphine,” had a mean of 4.29 out of 5 with standard deviation of ± 0.739. The next


questions, “If I had access to sufficient mental health and behavioral addiction treatment

resources,” had a mean of 4.16 out of 5 with standard deviation of ±1.036. The third highest

question, “If I had adequate support from a consultant with expertise in buprenorphine

treatment,” had a mean of 4.13 out of 5 with standard deviation of ±0.885. The fourth highest

question identified, “If buprenorphine treatment could be more easily integrated into the norms

of our existing practice,” had a mean of 4.03 out of 5 and a standard deviation of ±0.795. The

fifth highest question, “If I had access to a streamlined referral plan to manage those patients

who are noncompliant or require additional support,” had a mean of 4.00 out of 5 and a standard

deviation of ±0.931.

In Table 3, Appendix A, the results of Pearson’s Correlation show significant differences

in barriers to participants between who had the 30 cap waiver and those who had the 250 cap

waiver. Participants with the 250 cap waiver had significantly higher barrier for Total Barrier

(p<.001), Factor One: Knowledge and Skills (p<.01), and Factor Six: Complexity of Prescribing

(p<.01). Participants identified lower barriers in the group with the 250 waiver cap than the 30

waiver cap (p<.01) to Factor Three: Practice Support – Staff/Office.

In Table 4, Appendix A, a significant difference was found between prescribing barriers

and the insurance group of Medicaid Managed that our study participants accepted. There was a

significantly higher level of total barrier for our APRN participants who did not accept Medicaid

Managed Insurance (p<.01).

In Table 5, Appendix A, a correlation was analyzed between the Barrier subscales and

other related factors. Significance was determined between Total Barrier Score and the Number

of patients (p<.01), Factor 1 with Number of patients (p<.05), Factor 3 with Stigma (p<.05),

Factor 4 with Number of patients (p<.01), Factor 5 with Gender (p<.05) and Rural Location

(p<.05), and Factor 6 with Number of patients (p<.05).


Discussion

Our study was among the first to report on APRNs’ barriers in prescribing buprenorphine

to patients with OUD. We identified the most reported barriers including Factor One: Knowledge

and Skills; Factor Five: Behavioral Health Support, Factor Six: Complexity of Prescribing, and

Factor Four: Practice Support – General. These findings are similar to the study by Cunningham

et al., 2007 who found that the top five barriers for physicians prescribing buprenorphine

included: knowledge deficit about opioid addiction (54.9%); lack of addiction expert support

(42.9%); inability to send patients to a substance abuse treatment program (41.3%); concerns

about diversion (40.3%); and concerns about the complexity of opioid-addicted patients (40.3%)

(Cunningham et al., 2007). These top five barriers align with the top five barriers that were

found with APRNs. Cunningham et al., 2007 also found that physicians who had completed the

8-hour training were less concerned about the lack of knowledge (p < .01), lack of addiction

expert support (p < .05), and inability to send patients to a substance abuse treatment program (p

< .05) (Cunningham et al., 2007). This indicates that the barriers that APRNs have indicated on

the survey may be reduced with an educational program.

Advanced Practice Registered Nurses who have the higher waiver cap of 250-waiver cap

versus 30-waiver cap, have a significantly higher level of barrier related to Total Barriers, Factor

One: Knowledge and Support and Factor Six: Complexity of Prescribing. There is significantly

lower level of barrier for participants who have the 250-waiver cap versus the 30-cap waiver.

The APRNs who accept Medicaid Managed Insurance have significantly lower levels of total

barriers. This may be due to the lower cost to patients, and the healthcare providers receive

appropriate payment for services. Other significant factors include stigma and number of

patients treated.


A significant correlation was identified related to Factor Five: Behavioral Health Support

and Gender (p<.05). A correlation was identified between Factor Five: Behavioral Health

Support with a rural location (p<.05). A significant correlation was identified with Total Barrier

(p<.01), Factor One: Knowledge and Skills (p<.05), Factor Four: Practice Support – General

(p<.01), and Factor Six: Complexity of Prescribing (p<.05) with number of patients who are

prescribed buprenorphine. A significant correlation was identified with Factor Three: Practice

Support – Staff/Office and Stigma (p<.05). A lack of a behavioral health referral system is a

critical factor in APRNs who practice in rural areas, indicating a disparity issue in combating

opioid crisis in rural areas.

Factor One

The barrier questions related to Factor One: Knowledge and Skills are

• If I could obtain greater knowledge of prescribing buprenorphine.

• If I could feel more comfortable prescribing buprenorphine.

• If prescribing was simpler / more straightforward.

• If I could obtain better assessment tools.

• If I had higher patient compliance or less concern about diversion.

• If the induction logistics were less difficult.

These barriers relate to knowledge deficit and indicate reasons why APRNs may not seek

to prescribe buprenorphine. The top barrier was the question, “If I could obtain greater

knowledge of prescribing buprenorphine.” This indicates that APRNs do not feel they have the

knowledge to prescribe buprenorphine. Since this barrier has been identified, the next step

would be to provide the appropriate educational opportunities to support APRNs. A pre and post


assessment could be provided before and after the education to evaluate if there was greater

knowledge obtained.

Factor Two

The barrier questions related to Factor Two: Practice Growth are

• If my interest in treating patients with addictions was piqued.

• If I could grow my practice beyond the prescribing patient limit (waiver cap).

• If I had greater patient need / demand.

• If I had help recruiting my initial patients to start buprenorphine treatment.

• If I was confident providing treatment was financially sustainable.

• If paperwork was streamlined and/or there was less documentation required.

These barriers relate to practice growth within the APRNs current practice. This list of

barriers relates to interest in treating addicted patients, concerns about growing the practice,

recruitment, financial concerns, and documentation requirements. These can all relate to how the

APRN current practice structure would need to change. If the APRN is at capacity in regards to

patient numbers, they will not be looking to bring on more patients. In addition, if the APRN is

not interested in treating patients with buprenorphine, then they would not be concerned about

recruiting new patients into their practice. The end concerns relate to finances and the amount of

increased paperwork and documents that would be required.

These are valid concerns, however when looking at the uses of buprenorphine the APRN

may need to prescribe the medication for one of their current patients. The patients within their

current practice may need to transition to buprenorphine, especially if they are diagnosed with

OUD. The idea that the APRN would need to recruit new patients or be interested in treating

patients with OUD needs to be modified, and hopefully providing education can change the


provider’s mindset to look at OUD as any other chronic health condition that a patient may

encounter.

In addition, education should be provided that the APRNs current patients may go to an

acute addiction center to be initiated on buprenorphine. After discharge from an acute hospital

visit, the APRN may need to continue those medications in the primary care office. Once this

education is provided, the APRN may see that many of these barriers are not valid, because the

patient may be one of their current patients and maintenance of the buprenorphine would be

required to continue treatment.

Factor Three

The barrier questions related to Factor Three: Practice Support – Staff/Office are

• If I could increase the number of ancillary staff.

• If I could increase the training of my ancillary staff.

• If I could allocate more dedicated office space.

These barriers relate to the staff and office space. None of these questions were in the top

five barriers. These barriers correlate with the Factor Two questions in that the barriers relate

more to APRNs who are going to be prescribing to large amounts of patients in need of

buprenorphine. If the patients were already patients within the APRN’s current practice, there

would not need to be an increase in ancillary staff or office space. Training and education would

help support the practice and patients with OUD.

Factor Four

The barrier questions related to Factor Four: Practice Support – General are

• If I had access to a streamlined referral plan to manage those patients who are

noncompliant or require additional support.


• If the practice I work with was more supportive of it.

These barriers related to practice support in general. In this case, the APRNs are

indicating a concern about patient compliance and correct referral processes and whether the

practice will support the decision. Having a streamlined referral plan is the fifth highest barrier

identified. Buprenorphine is an evidence-based medication to treat OUD. Many patients are

noncompliant with their chronic health medications such as hypertension and diabetes. Patients

with OUD are treated the same as other patients with chronic health conditions. For instance, if

a patient does not take their hypertension or diabetic medications, the provider would not stop

prescribing the patient’s medication. Using Change Theory, the APRN would need to change

their views of patients with OUD to see that some patients will be noncompliant, but that does

not mean they should stop prescribing to the patients. With a change in viewpoint of prescribing

to patients with OUD, the practice may be more supportive with additional education related to

MAT.

Factor Five

The barrier questions related to Factor Five: Behavioral Health Support are

• If I had fewer competing activities / time constraints.

• If I had access to sufficient mental health and behavioral addiction treatment resources.

• If I had adequate support from a consultant with expertise in buprenorphine treatment.

These barriers related to behavioral health support such as mental health addiction

resources and consultants with expertise in buprenorphine treatment. The second and third

bullets are the second and third highest barriers indicated by APRNs. This Factor also includes

time constraints related to prescribing buprenorphine. These barriers are very important to future

initiatives to provide support to APRNs who care for patients with OUD. If appropriate


resources and consultants are provided, APRNs may feel more comfortable prescribing

buprenorphine to their patients.

Factor Six

The barrier questions related to Factor Six: Complexity of Prescribing

• If buprenorphine treatment could be more easily integrated into the norms of our existing

practice.

• If I was able to prescribe buprenorphine but not required to manage patients other health

problems.

These barriers relate to the complexity of prescribing. The first bullet was identified as

the fourth highest barrier for APRNs. This item identifies that APRNs do not see prescribing

buprenorphine as a normal chronic health medication. With education and support, the APRN

may determine prescribing buprenorphine can become a norm of practice within their healthcare

practice. Future initiatives could provide more education to support the complexities of patient

situations. A safe environment for APRNs to bring patient case studies to a group of experts, to

gather expertise, may support the APRN to prescribe the appropriate treatment. Collaboration

with other health professionals will also allow for a dialog about best practices when initiating

treatment and maintenance. In addition, changing the idea that buprenorphine is not able to be

incorporated into the APRN current practice may also be adjusted with additional education and

knowledge.

Stigma

Interestingly, many people did not complete the stigma survey. It is unclear why

participants did not complete the stigma survey. It may be related to the length of the survey and

participants were fatigued by the end. Incompletion could also be related to the participant

feeling uncomfortable answering the questions related to stigma. The relationship found


between stigma and Factor Three: Practice Support – Staff/Office was significant (p<.05). This

may be related the thought that an APRN needs to have designated ancillary staff and practice

space to prescribe buprenorphine. With a modification of perception, APRNs could change their

perspective to understand that they do not require more staff or office space to prescribe

buprenorphine. The ethical issues for this project are limited with no obvious ethical issues.

Participants may feel burdened by taking the survey, but the survey is quite short, approximately

10-15 minutes.

Other data that was on the survey related to the percentage of underserved/low income

individuals, current buprenorphine practice status, educational activities within the past 90 days,

kinds of buprenorphine treatments provided, counseling recommendations for patients,

monitoring practices, and therapeutic goals of treatment. These items did not disclose any

significance with barriers or stigma scores. With a larger sample size, these survey questions

may also show significance related to barriers, stigma, or other factors within the survey.

Limitations

One of the limitations to this study was the sample size. It was difficult to use e-mail to

request participants to answer questions. Another limitation is that the survey questions related

to barriers have not been tested to include reliability data.

Another limitation is related to the lack of qualitative data with regards to the survey

questions. Some of the information is being interpreted related to the data, however, when

collecting qualitative data, some of this interpretation may become clearer. It would be

important to include qualitative data in the future to be able to implement support services to

better education and support the APRNs to increase the comfort level for prescribing

buprenorphine.


Many of the questions on the survey allowed for participants to answer more than one

option. This made some of the data difficult to report. In the future, it may be better to structure

the survey slightly different to allow for only one response for each option. For answers that

may require more than one answer, a focus group may be more beneficial to collect that

information.

Conclusion and Implications

The study findings provide timely and critical information regarding APRN’s prescribing

barriers and identify factors associated with those barriers. Now that data has been collected

based on APRN barriers, educational programs can be developed to support the APRN in

prescribing buprenorphine to patients with OUD. Continued growth for APRNs to improve

patient care is also needed. Obtaining the buprenorphine waiver would provide the APRN

another medication to prescribe to help their patients. It is important to change the viewpoints of

APRNs towards OUD to treat patients as if they had any other chronic health condition.

Training for APRNs should include information related to stigma to allow APRNs to identify

their own stigma or bias related to patients with OUD.

Appropriate strategies can be developed to overcome barriers and provide support to

APRNs to improve access to MAT. Future studies with a larger sample size will better identify

APRNs’ barriers. Qualitative methods will provide a different perspective to treating OUD.


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Appendix A: Tables Table 1. Demographic Characteristics of Study Participants (N = 49)

Variable N % Age (years)

25-35 36-45 46-55 56-65 >65

3 9 14 16 2

6.8% 20.5% 31.8% 36.4% 4.5%

Gender Female 36 81.1% Male 8 18.2% Number of years in practice (years) 0-5

6-10 11-15 16-20 >20

12 9 4 5 14

27.3% 20.4% 9.1% 11.4% 31.8

Practice location (Select all that apply) Urban 14 NA Suburban

Rural 21 18

NA NA

Specialty Family practice 16 36.4% Internal medicine 7 15.9% Psychiatry

Addiction medicine Pediatrics

6 1 10

13.6% 2.3% 22.7%

Which of the following kinds of insurance do you accept? (Select all that apply)

Commercial Medicaid Medicaid managed Medicare Self-pay/no insurance Unsure

36 36 36 32 33 6

NA NA NA NA NA NA


Table 2. Top Five Barriers Questions (N=49)

M ± SD or % If I could obtain greater knowledge of prescribing buprenorphine

4.29 ± 0.739

If I had access to sufficient mental health and behavioral addiction treatment resources If I had adequate support from a consultant with expertise in buprenorphine treatment If buprenorphine treatment could be more easily integrated into the norms of our existing practice

4.16 ± 1.036 4.13 ± 0.885 4.03 ± 0.795

If I had access to a streamlined referral plan to manage those patients who are noncompliant or require additional support

4.00 ± 0.931


Table 3. Relationships Between Buprenorphine Waiver Cap and Barriers (N=49) Variables 30 Cap 250 Cap t df Barrier Total 71.67 84.76 -3.701*** 21 Factor 1 18.83 24.22 -2.674** 22 Factor 2 18.17 18.83 -1.436 23 Factor 3 10.00 8.10 2.267* 24 Factor 4 6.83 8.11 -1.596 23 Factor 5 10.67 12.16 -1.974 23 Factor 6 6.33 8.06 -3.478** 22

Note: * p < .05; ** p < .01; *** p < .001; Factor One: Knowledge and Support; Factor Two: Practice Growth; Factor Three: Practice Support – Staff/Office; Factor Four: Practice Support – General; Factor Five: Behavioral Health Support; Factor Six: Complexity of Prescribing


Table 4. Relationships Between Buprenorphine Waiver Cap and Total Barriers (N=49) Yes (n=27) No (n=4) t df Medicaid Managed 79.32 93.25 -2.971** 27

Note: * p < .05; ** p < .01; *** p < .001


Table 5. Relationship Between Barriers and Related Factors (N = 49) Variables Gender Rural Number of

Patients Stigma

Barrier Total 1.452 -1.549 -0.574** 0.211 Factor 1 0.923 -0.751 -0.510* 0.268 Factor 2 0.339 -1.197 -0.105 0.079 Factor 3 -1.224 0.223 -0.301 -0.428* Factor 4 0.551 -1.835 -0.531**[ 0.97 Factor 5 2.485* -2.664* -0.318 -0.064 Factor 6 -0.377 -0.426 -0.480* 0.065

Note: * p < .05; ** p < .01; *** p < .001; Factor One: Knowledge and Support; Factor Two: Practice Growth; Factor Three: Practice Support – Staff/Office; Factor Four: Practice Support – General; Factor Five: Behavioral Health Support; Factor Six: Complexity of Prescribing


Appendix B: NP PA Survey General Information (Please completely fill in the circle, where appropriate)

Sex � Male � Female � Other __________

Age � <25 � 25-35 � 36-45 � 46-55 � 56-65 � >65 Degree (Please check all that apply) � MS � Ph.D. � CNM � APRN

� DNP � PA � Other __________

Number of years in practice � 0-5 � 6-10 � 11-15 � 16-20 � >20 Practice setting � Hospital

� Private Practice � Group Practice � Community Health Center/Clinic

� OASAS certified OUD � Addiction treatment program � Other __________

Practice location(s) (Please check all that apply) � Urban � Suburban

� Rural � Reservation

Specialty � Family Practice � Internal Medicine � Psychiatry

� Addiction Medicine � Pediatrics � Other __________

Is your name on SAMHSA’s register of buprenorphine providers?

� Yes � No

Which of the following kinds of insurance do you accept? (Please check all that apply)

� Commercial � Medicaid � Medicaid Managed Care

� Medicare � Self-pay/no insurance � Unsure

Approximately what percentage of your patients are underserved/low income individuals?

___________ %

What is your current buprenorphine practice status

� Currently prescribing � Planning to prescribe � Discontinued prescribing with no plans to restart � Never prescribed and no plans to start � Never prescribed and unsure what is required for prescribing

Do you have a buprenorphine waiver? � Yes (30 cap) � Yes (100 cap) � Yes (250 cap) � No


If no, why not? � Do not have time for additional patients � Do not know how to get the waiver � No interest in waiver � Other ____________________

Treatment Practices (if currently prescribing buprenorphine)

Approximately how many buprenorphine patients do you manage?

____________________

Any buprenorphine-related educational activities within the past 90 days? (check all that apply)

� Continuing Medical Education (CME) activity � Conference where buprenorphine was discussed � Read buprenorphine article � Consulted with a mentor � Other ___________________

Treatment Practices (if currently prescribing buprenorphine)

What kinds of buprenorphine treatment do you provide? (Please check all that apply)

� Detox � Maintenance

� Induction � Tapering

What kind(s) of substance abuse counseling do you recommend for patients? (check all that apply)

� Mandatory counseling � Individual counseling offered in practice � Group counseling offered in practice � Offer referral to counseling

What kind(s) of monitoring practices do you use with your buprenorphine patients? (check all that apply)

� Pill counts � Observed drug screens

� Unobserved drug screens � Observed dose administration

What do you see as the therapeutic goal of buprenorphine treatment?

� Brief taper and outpatient detox � Limited maintenance, then taper � Indefinite maintenance � Duration of therapy on a case-by-case basis � Other ________________


What things would help you provide buprenorphine treatment?

Very Unhelpful

Unhelpful

Neither Helpful

nor Unhelpful

Helpful

Very Helpful

If I had fewer competing activities / time constraints � � � � � If I could obtain greater knowledge of prescribing buprenorphine � � � � � If I could feel more comfortable prescribing buprenorphine � � � � � If prescribing was simpler / more straightforward � � � � � If my interest in treating patients with addictions was piqued � � � � � If I could obtain better assessment tools � � � � � If I could increase the number of ancillary staff � � � � � If I could increase the training of my ancillary staff � � � � � If buprenorphine treatment could be more easily integrated into the norms of our existing practice

� � � � �

If I could allocate more dedicated office space � � � � � If I could grow my practice beyond the prescribing patient limit (waiver cap)

� � � � �

If I had access to sufficient mental health and behavioral addiction treatment resources

� � � � �

If I had adequate support from a consultant with expertise in buprenorphine treatment

� � � � �

If I had greater patient need / demand � � � � � If I had higher patient compliance or less concern about diversion � � � � � If the induction logistics were less difficult � � � � � If I had help recruiting my initial patients to start buprenorphine treatment

� � � � �

If I was confident providing treatment was financially sustainable � � � � � If paperwork was streamlined and/or there was less documentation required

� � � � �

If I was able to prescribe buprenorphine but not required to manage patient’s other health problems

� � � � �

If I had access to a streamlined referral plan to manage those patients who are noncompliant or require additional support

� � � � �

If the practice I work with was more supportive of it. � � � � �

How likely are you to begin (or increase) prescribing buprenorphine?

� � � � �

very unlikely unlikely possiblylikely very likely


What single factor would you find most useful in encouraging you to begin (or increase) buprenorphine prescribing? ____________________________________________________

Please indicate how strongly you agree or disagree with each statement below.

Strongly Disagree

Disagree

Neither Agree

nor Disagree

Agree

Strongly Agree

I am more comfortable helping a person who has a physical illness than I am helping a person who has opioid use disorder.

� � � � �

If a colleague with whom I work told me they had a managed opioid use disorder, I would be just as willing to work with him/her.

� � � � �

If I were under treatment for an opioid use disorder I would not disclose this to any of my colleagues.

� � � � �

I would see myself as weak if I had an opioid use disorder and could not fix it myself.

� � � � �

I would be reluctant to seek help if I had opioid use disorder. � � � � � Employers should hire a person with a managed opioid use disorder if he/she is the best person for the job.

� � � � �

I would still go to a physician if I knew that the physician had been treated for opioid use disorder.

� � � � �

If I had opioid use disorder, I would tell my friends. � � � � � Despite my professional beliefs, I have negative reactions towards people who have opioid use disorder.

� � � � �

There is little I can do to help people with opioid use disorder. � � � � � More than half of people with opioid use disorder don’t try hard enough to get better.

� � � � �

I would not want a person with opioid use disorder, even if it were appropriately managed, to work with children.

� � � � �

Health care providers do not need to be advocates for people with opioid use disorder.

� � � � �

I would not mind if a person with opioid use disorder lived next door to me.

� � � � �

I struggle to feel compassion for a person with opioid use disorder. � � � � �

Have you ever treated a person with opioid use disorder for any reason?

� � �

yes no don’t know


Appendix C:

Running head: BARRIERS TO PRESCRIBING BUPRENORPHINE 38

Appendix D: Poster

by jessica lippa ms, fnp-c, rn a capstone project ... · evidence-based practice to successfully...

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