Responding to NC’s Opioid Epidemic:

Background

Opioid overdoses, already high (>5 deaths/day in NC), rose dramatically in 2020 and there is no sign that’s leveling off, particularly given the behavioral health stressors due to COVID-19. Expanding access to pharmacotherapy for opioid use disorder is a key strategy of NC’s Opioid Action Plan 2.0.

NC lacks sufficient buprenorphine treatment capacity.

• • • 30 NC counties are designated by the US DHHS Office of the Inspector General as counties that are both “high-need” and have “low-to-no capacity” to provide buprenorphine services to patients
    • 14 NC counties do not have any waivered providers
    • 6 NC counties have at least 1 waivered NP or PA, yet 0 waivered physicians
    • There is evidence that only half of waivered clinicians actually prescribe buprenorphine

In rural and other underserved communities, there is not adequate coverage of practitioners who are able to prescribe buprenorphine. This is problematic as we know that medication assisted treatment with buprenorphine is the gold standard treatment for opioid use disorder. We also know that Advanced Practice Providers (APPs) are more likely to practice in rural and underserved areas than are physicians.

In 2016, legislation was passed to allow APPs to obtain a waiver to prescribe buprenorphine, and since then, NC’s NP and PA programs have been graduating students with their DATA 2000 waivers from SAMHSA, enabling them to prescribe. These individuals are well trained: receiving 24 hours of training instead of the 8 hours required of doctors. However, there are barriers to them being able to offer this treatment in NC.

Barriers/Opportunities

Many waivered APPs go to work in clinical settings where their supervising physicians do not have DATA 2000 waivers. This is a problem because the NC Medical Board currently interprets its supervision rules to require that an APP’s supervising physician must have the waiver in order for the APP to be able to prescribe buprenorphine for OUD. However, many of these supervising physicians do not have the waiver to prescribe. On the flip side, there are many NC physicians with expertise in buprenorphine treatment who are willing to serve as mentors to APPs, but who are not able to sign on as supervising physicians of record due to restrictions of the health systems in which they work.

With this pilot program, we are able to dramatically increase access to lifesaving OUD treatment, while also taking care that treatment is delivered effectively and, most importantly, safely.

How the Pilot Works  

The pilot program will enable waivered PAs (*NP participation will be brought before the Board at the March 2021 Board meeting) to prescribe buprenorphine even if the APP’s supervising physician is not waivered, provided the criteria below are met. The Governor’s Institute and the NC Society of Addiction Medicine will connect participants with resources and experienced buprenorphine mentors at no cost to participants.

Waivered APPs and their supervising non-waivered physicians may join this pilot if:

1. 1. The physician has authority to prescribe Schedule III controlled substances
   2. The physician has taken an 8-hour training on medication-assisted treatment (MAT), i.e., the physician must be eligible to apply for a waiver even if the physician does not actually apply
   3. The PA or NP has completed training and has a DATA waiver

An optional mentoring program will be administered by the Governor’s Institute.

• • • The NC Society of Addiction Medicine, which the Governor’s Institute supports, will solicit physician mentors from its membership to serve as mentors. Mentors from the same vicinity of the state will be assigned when possible.
    • The GI will facilitate registration with the PCSS.
    • The mentors will volunteer their services at no charge to the supervising physician or APP.
    • The mentors will agree to be available by phone when a supervising physician or APP has a question.
    • Responsibility and liability for the APPs work will remain with the supervising physician and the APP, as it does for all areas of practice.