Responding to Opioid Use Disorder: Identifying the Therapeutic Commitment of Maine Nurse Practitioners

3 Introduction and Background 6 Problem Statement 8 Purpose 9 Research Questions 9 Hypotheses 10 Rationale 10 Review of Evidence 11 Leveraging the NP Workforce 11 Contributions of the NP Early Adopters 12 NP Workforce Barriers 12 Facilitators of Effective Primary Care-Based Buprenorphine 13 The Theory of Therapeutic Commitment 16 Background 16 Overview 17 Stage 1: Role Security 17 Stage 2: Therapeutic Commitment 18 The Relationship Between Role Security and Therapeutic Commitment 18 The Outcomes of a Role Secure and Therapeutically Committed Provider 18 Application 19 Project Design 20 Overview 20 Population 21 Survey Instrumentation 21 Survey Methods 24 Strategies to Achieve Maximum Response Rate 25 Evaluation Strategies 27 Results 28 Demographic and Work Characteristics 28 Most Likely Clinical Response to Patients Screening Positive for Active OUD 28 Overall Therapeutic Commitment Scores 29 Overall Therapeutic Commitment Scores and Buprenorphine Waiver Status 29 Overall Therapeutic Commitment Scores and Practice Setting 30 NP Participants without a Buprenorphine Waiver 30 NP Participants with a Buprenorphine Waiver 31 SCHOLARLY PROJECT REPORT 3 Discussion 32 Maine NP Role Security 32 Maine NP Overall Therapeutic Commitment 34 Maine NPs without the Buprenorphine Waiver: Actionable Approaches to Increase Receipt of the Waiver 35 Maine NPs with the Buprenorphine Waiver: Actionable Approaches to Reach Full Treatment Capacity 37 Practice Implications 38 Strengths and Limitations 39 Future Directions 40 Conclusion 40 References 42 Table 1: Professional Characteristics of the Role Secure and Therapeutically Committed Provider 53 Table 2: Demographic and Work Characteristics 54 Table 3: Most Likely Clinical Response to Patients Screening Positive for Active Opioid Use Disorder 55 Table 4: Maine Nurse Practitioner Overall Therapeutic Commitment to Individuals with Opioid Use Disorder 56 Table 5: Overall Therapeutic Commitment Score and Buprenorphine Waiver Status 57 Table 6: Overall Therapeutic Commitment Scores and Practice Setting 58 Table 7: NP Participants without a Buprenorphine Waiver 60 Table 8: NP Participants with a Buprenorphine Waiver 61 Figure 1: The Theory of Therapeutic Commitment 62 Figure 2: Timeline of Survey Events 62 Figure 3: Strategies to Achieve a Maximum Response Rate 63 Appendix A: Survey 64 Appendix B: Initial Letter of Invitation 74 Appendix C: Email Reminder Scripts 75 SCHOLARLY PROJECT REPORT 4 Abstract Background: Buprenorphine, an underutilized pharmacotherapy, can play a key role in closing the substantial opioid use disorder (OUD) treatment gap in the United States. Although 2016 US legislation authorized trained nurse practitioners (NPs) to obtain the Drug Enforcement Agency waiver to prescribe buprenorphine for OUD, many NPs do not have the waiver, and a large proportion of waivered NPs do not prescribe to capacity. Purpose: To identify the therapeutic commitment of Maine NPs to OUD as well as understand why Maine NPs do not adopt and utilize buprenorphine for the treatment of OUD. Review of Evidence: Commitment to OUD andBackground: Buprenorphine, an underutilized pharmacotherapy, can play a key role in closing the substantial opioid use disorder (OUD) treatment gap in the United States. Although 2016 US legislation authorized trained nurse practitioners (NPs) to obtain the Drug Enforcement Agency waiver to prescribe buprenorphine for OUD, many NPs do not have the waiver, and a large proportion of waivered NPs do not prescribe to capacity. Purpose: To identify the therapeutic commitment of Maine NPs to OUD as well as understand why Maine NPs do not adopt and utilize buprenorphine for the treatment of OUD. Review of Evidence: Commitment to OUD and adoption of buprenorphine in clinical practice is influenced by factors such as professional support and education. Few studies have examined NP commitment to OUD and adoption of buprenorphine. Project Design: A cross-sectional, Web-based survey measured the therapeutic commitment of Maine NPs to OUD with the Drug and Drug Problems Perceptions Questionnaire. Resources were identified that would encourage those without the buprenorphine waiver to obtain it and those with the waiver to accept more patients. Methods: The online survey was delivered to a convenience sample of NPs in Maine (N=299) in fall 2018. Results: Maine NPs have a moderately high degree of overall therapeutic commitment to OUD. Maine NPs in rural (p=.018) and urban (p=.024) practice settings and those with the buprenorphine waiver (p<.001) had significantly higher overall therapeutic commitment scores than their suburban and non-waivered NP counterparts. Professional support and education were priority resources to increase buprenorphine adoption and utilization. Conclusion: To facilitate NP commitment to OUD as well as NP adoption and utilization of buprenorphine, a comprehensive approach with special emphasis on professional support and education is warranted. SCHOLARLY PROJECT REPORT 5