Nurse practitioner roles and clinical competencies

¶ … Drug Addiction Treatment Act of 2000 certainly had noble intentions and safeguards. Indeed, there is a definitive reason why physicians are allowed a certain set of rights and responsibilities and why nurse practitioners are just a little further down the ladder in terms of rights and options. To be sure, anything related to opiates is something that should be regulated very highly as the ability and opportunity to abuse the rights to prescribe these drugs is prevalent and hard to miss. However, also hard to miss is the rampant amount of abuse and addiction that has been rendered and this problem is aggravated by the fact that drugs containing buprenorphine are restricted to physicians only despite the immeasurable benefit that could be rendered to addicted persons. While restricting such drugs is not a terrible idea, it is not the best idea with buprenorphine because of the amount of addicted and untreated people in question and this report will shall use scholarly and peer-reviewed research to make the point as to why this needs to change.

Literature Review

The author of this report found four articles that specifically address and assail the restriction of nurse practitioners. To put a fine point on the problem, the nurse practitioners that see the need to prescribe buprenorphine cannot do so and many of the physicians that can actually dispense the medication seem to choose not to do so. This is especially vexing as buprenorphine-laden drugs were specifically approved and designed for out-patient use which is something that is a bit rare with people saddled with an opioid addiction. The reason physicians are not prescribing is likely related to the fact that it is indeed done on an outpatient basis and perhaps they feel that such an approach is not wise or effective for opiate addiction. In addition, physicians that monitor nurse practitioners that have the right to prescribe medication are specifically prohibited from delegating the prescribing of buprenorphine-laden drugs. This combination is no doubt aggravating the fact that so many people, about 1.2 million in 2005, are addicted to opiates but only about a fifth of those people are getting treatment. This means that nearly a million people, and this was in 2005, are not getting drug treatment they could get much easier if physicians would actually use the drugs or at least be given the option to delegate the ability to nurse practitioners. Perhaps there is some valid concern in treating opiate addiction on an outpatient basis. Indeed, some people simply cannot or will not get clean unless they enter a full-fledged rehabilitation program. However, if more people could get treatment, even if in-patient is the better course, then the choice to allow for more prescription of buprenorphine would seem to be the better course regardless of how it comes about. Unfortunately, the DATA law is very explicit in that it says that any person that prescribes buprenorphine has to be a "physician that is licensed under state law" (Fornili & Burda, 2009).

One solution to perhaps making a change to the DATA restriction relative to buprenorphine without being careless is using the Geelhoed-Schouwstra Framework (GSF). It is a rational problem-solving schematic which allows for a policy evaluation process to be undertaken and completed before any rash or major changes are made. Part of such a framework would be information collection and exactly that has been attempted on many occasions. Indeed, many of the physicians who were contacted about their use (or non-use) of buprenorphine said that they either don't use it or "don't treat addicts" in general. However, a very telling and damning statistic is that nearly nine out of ten physicians assailed the reimbursement rates as the (or at least one of the) main reasons why they did not prescribe the drug more often. This is despite the fact that the same number of physicians were given the purview and option to use the buprenorphine drugs as they wished. At the same time, only about ten percent actually did so. The head-scratching part is that while the DATA specifically forbids delegation to nurse practitioners (the "what"), there is no "why" given as to why buprenorphine is restricted from use for nurse practitioners and/or the doctors that want to give their nurse practitioners supervisees the ability to do so. It begs the question why the legislation levies these requirements but does not explain or justify why nurse practitioners can prescribe other drugs under the supervision of a physician but not drugs like buprenorphine, especially without a valid reason being given. Again, it is understandable to very gun-shy about non-doctors prescribing opiates or anything related to the same. However, the amount of people addicted to opiates is mushrooming and it would make a ton of sense to allow nurse practitioners to have buprenorphine in their toolbox and for physicians to actually use it themselves. Perhaps the cost reimbursements for the drug should be evaluated (Fornili & Burda, 2009).

To further clarify why a recalibration of policy relating to buprenorphine is called for, it has come to a point where the abuse of prescription opiates like Oxycontin now far exceeds that of the illicit forms of opiates like heroin. Even the International Nurses Society is now on board with the change to allow for APRN's and such to prescribe buprenorphine when it's called for or prudent. The same agency states that they are completely on board with the same controls and training requirements being levied against nurse practitioners before they can prescribe buprenorphine but they insist it is something that should be allowed for under the law at the discretion of a supervising physician and not banned outright by DATA or any other legislation. The problem with nurse practitioners not being able to prescribe the drug and doctors being simply unwilling to do the same is creating access issues relating to drug addiction treatment. Again, in-patient rehabilitation and detoxification is obviously superior and more effective. However, not all addicts can or need that level of treatment and can indeed pull of becoming unhooked from opiates without being inside rehab. At the very least, it can be a thing to try that makes it clear to the addict that an out-patient solution simply isn't going to work. At the same thing, it is not something that should be used like a rubber stamp whereby anyone with an addiction, even a severe one, is given buprenorphine or something similar. Some people are heavily addicted and/or need to be detoxified in a controlled environment lest they die from the comedown. However, just as there are varying levels and types of pain killers such opiates, acetaminophen, NSAID's and so forth, there should be different ways to address differing levels of addiction as well. Some people just need a little nudge, for example, to get out of an alcohol drinking habit while others are perpetually intoxicated and could die if they quit cold turkey. For the latter, the equivalent with opiates could not and should not be treated with buprenorphine but for those where the addiction is present but relatively minor, then the ability and willingness to prescribe buprenorphine needs to be there (Strobbe & Hobbins, 2012).

As was mentioned before, the number of prescription opiate-addicted people was 1.2 million in 2005. However, that number rose by nearly fifty percent in just three years as that same figure in 2008 was 1.7 million people. While there was a rise in the proportion of people being treated, it only rose from a fifth to about a third. In other words, while the amount of people being treated (including as a matter or proportion) is going up, the amount of people (in terms of absolute numbers) is also going up. It was mentioned before that the untreated amount was a shade under a million in 2005 but that same number rose to 1.105 million in 2008. This is a rise of ten percent. It is assuring that the amount of people becoming treated is going up but this rise is not enough to cancel out the number of new addicts. Another tool in the toolbox is methadone. However, many of the challenges with methadone are at least partially shared with buprenorphine. Methadone is only prescribed from specialized clinics and the amount of prescriptions for methadone, at least through 2010, was steady even with the sharp spike in new addicts. Further aggravating the availability of methadone is that the clinics that actually make use of it are spread out fairly widely and unevenly in many areas (O'Connor, 2010).

Another wrinkle with buprenorphine, at least from 2000 to 2006, was that even physicians were limited in their use of buprenorphine from a statutory standpoint. Indeed, doctors could only treat up to twenty patients at a time. However, an amendment to the Controlled Substances Act of 2006 allowed for physicians to prescribe the drug to up to one hundred patients so long as they were prescribing the drug for at least a year and they filed a letter of intent to up their limit. However, given the apparent general preference of doctors to not prescribe the drug even if they can, that is not of much benefit in the long run (O'Connor, 2010).

The National Institute of Drug Abuse weighed in on the subject of prescribing buprenorphine and noted that drug addiction is a chronic condition on par with diabetes and cardiovascular disease. While some may scoff at the idea of drug addiction being the same as diabetes or heart issues, the parallels are quite easy to see. All three of the conditions are often (if not entirely) due to personal behavior and lifestyle choices, all three have an onset and all three are affected by the patient's ongoing behavior, choices and reactions to the condition. Indeed, a diabetic's future would be determined in large part by whether they become more active, eat healthier and so forth. Also important are the familial and cultural influences that feed the same. Much the same thing can be said of drug addicts. For example, one of the major things that drug addicts are implored to do as part of their treatment plan is to avoid people, situations and areas that could lead to relapse. For example, prior alcohol addicts should avoid bars and people addicted to opiates should avoid taking opiates, even for valid reasons, at all costs and they should also avoid situations where this could happen in a social or private situation such as sharing pills with a friend or family member. Indeed, they are also similar in that not all people hooked on pills or subject to heart disease/diabetes got into their situation entirely of their own doing. Many people that get hooked on Oxycontin and the like do so while taking the drug for valid reasons such as back surgery or general chronic pain of any sort. As such, to be mocking or incendiary when medical professionals lump diabetes and drug addiction treatment into the same discssuion should really be less ignorant and understanding. They should understand that while some people actively and intentionally abuse heroin and the prescription variants, many people simply are weak due to pain or mental illness and/or they do not think there is a way out of their dilemma. One major way to address this dynamic is to allow nurse practitioners to help assist with the problem rather than box them out of being able to provide a solution (O'Connor, 2010).

Indeed, the cost to train nurse practitioners to prescribe and discuss buprenorphine is about the same as it would be for physicians. Further, it was found with patients in the United States, the United Kingdom and Canada that health outcomes were not noticeably different for patients treated by fully licensed physicians as compared to nurse practitioners executing and performing the same tasks. However, between the unwillingness of physicians to use buprenorphine and the fact that the amount of doctors seems to veering into dangerous territory, it is important to mitigate such conditions as much as possible so long as patients and the public are not endangered. The research clearly shows that no such thing would happen if nurse practitioners are able to prescribe buprenorphine drugs. Disallowing nurse practitioners to use the drug effectively denies the access of patients to life-sustaining and life-improvement treatments and there does not seem to be a common-sense reason or motive behind the rules that are currently on record. It is suggest by many that industry professional groups that are comprised in whole or in part by nurse practitioners should issue position statements and urge the licensing boards as well as the United States government to reconsider its stance or at least find a way to justify why the restriction remains as the current laws on the books do little to nothing to address that concern. Major steps have been taken in recent years that are along the same lines and of similar in benefit to what this would do such as needle exchange program funding and so forth. Visting this subject under the same auspices might yield similar results sooner rather than later and this would be a wonderful thing for the addiction treatment sector of medicine and its patients (O'Connor, 2010).