Law Change Leads to Boom in Rural Medication-Assisted Treatment Access

Rural areas have seen an explosion in access to medication-assisted treatment since 2017, largely due to the passage of a law that allows nurse practitioners (NPs) and physician assistants (PAs) to prescribe buprenorphine-naloxone. The boom could have applications in other areas of behavioral health care, too.

That’s according to a recent study published in the December issue of Health Affairs.

Specifically, the number of clinicians with waivers to prescribe buprenorphine per 100,000 people in rural areas increased by 111% between 2016 to 2019. NPs and PAs accounted for more than half of that growth.


“Since the [Comprehensive Addiction and Recovery Act of 2017] (CARA) expanded buprenorphine waiver eligibility to nurse practitioners and physician assistants, we saw an explosion of adoption of these waivers, particularly in areas where it seems like they’re most needed,” lead author Michael Barnett told Behavioral Health Business. “Though, of course, there were exceptions to that.” 

Buprenorphine is a key medication used in medication-assisted treatment, which is often considered the most effective way to curb opioid use disorder (OUD) and other addictions. Before clinicians can prescribe the drug, they must complete dozens of hours of training and obtain a federal waiver, making the 111% spike even more impressive.

“This is not just some statistical noise, like that people just happened to get a waiver randomly,” Barnett said. “Every single NP and PA who got a waiver really was intending to do it and presumably plans to use it — or they wouldn’t have gone through half a week worth of training.”


Amid nationwide behavioral health workforce shortages, the study’s findings are especially promising. More than half of the counties in the U.S. lack a single practicing psychiatrist, with the worst shortages existing in rural areas.

Similar scarcities exist in the substance abuse world. But CARA seems to have helped improve access, according to the study. Researchers found that NPs and PAs who obtained waivers thanks to CARA brought MAT services to 285 rural counties that previously lacked a single waivered clinician.

“That means that 5.7 million rural residents had their first buprenorphine prescriber in their county because of an NP or PA,” Barnett said. “In terms of practicing at the top of the license, this shows just how critical and NPs and PAs are for the healthcare workforce in rural counties.”

However, CARA’s impact varied on a state-by-state basis. For example, states with more restrictive scope-of-practice regulations saw fewer MPs get buprenorphine waivers than states with broad scope-of-practice regulations. Scope-of-practice restrictions determine what tasks NPs and other healthcare workers may perform in caring for patients.

On top of that, CARA alone isn’t enough fix the shortage of substance abuse treatment options nationwide, the researchers said.

“Engaging people with OUD is a complex challenge that will require a suite of other efforts to accompany the increased availability of evidence-based treatment,” they wrote in the article.

But still, Barnett is hopeful the success of CARA will lead to similar law changes in other areas of behavioral health and allow more clinicians to operate at the top of their licenses.

“Any kind of behavioral health reform — or really healthcare delivery reform in general — that doesn’t … consider NPs and PAs as a key part of the workforce is going to have a limited impact,” Barnett said. “We can’t have an entirely physician-centric view of how we reform healthcare delivery. We need to include really the whole span of healthcare professionals.”

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