Full State Scope-of-Practice Laws

Research SummaryPublished Dec 21, 2023

Allow advanced-practice providers, such as nurse practitioners (NPs) and physician assistants (PAs), to prescribe medication treatment for opioid use disorder (OUD) independently (i.e., without a requirement for a collaborative agreement or post-licensure supervision).

A panel of experts rated how they expect this type of policy to affect four outcomes: OUD treatment engagement, OUD treatment retention, OUD remission, and opioid overdose mortality. Another panel of experts rated the policy on four decisionmaking criteria: acceptability to the public, feasibility of implementation, affordability from a societal perspective, and equitability in health effects.

Policy Recommendations According to Expert Ratings

Oppose Uncertain Support
No
No
Yes

Summary of Expert Ratings

Outcomes Effect Rating
Harmful Little-to-no Beneficial
OUD Treatment Engagement
No
No
Yes
OUD Treatment Retention
No
Yes
No
OUD Remission
No
Yes
No
Opioid Overdose Mortality
No
Yes
No
Criteria Implementation Rating
Low Moderate High
Acceptability
No
No
Yes
Feasibility
No
No
Yes
Affordability
No
No
Yes
Equitability
No
No
Yes

Summary of Expert Comments

  • Experts expect the policy to substantially improve OUD treatment engagement, as increasing the number of eligible prescribers would remove barriers and increase access to medication for OUD (MOUD).
  • Experts expect these improvements in turn to yield little-to-no improvements in OUD treatment retention, OUD remission, and overdose mortality.
  • Experts agree that this policy is highly implementable across all four criteria.
  • Experts believe the policy could significantly expand access to evidence-based MOUD (especially in rural and underserved areas). In addition, the public increasingly supports facilitating MOUD access to address the overdose epidemic.
  • Experts view the policy as relatively easy to implement once enacted and as cost-effective due to lower reimbursement rates for advanced-practice providers (APPs) and the effectiveness of MOUD.

Outcome Summaries

OUD Treatment Engagement

Percentage of people meeting the criteria for an OUD diagnosis who receive two or more OUD treatment services (including medication for OUD) within 34 days of initiating treatment.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial
(selected)
 Increasing the number of eligible prescribers should remove barriers and increase access to MOUD (especially in rural and underserved areas), which will help more people begin treatment. “There's a literature that allowing [APPs] to get waivered has increased buprenorphine prescribing, suggesting that it's building capacity of the treatment system. Full state scope of practice laws should make it even more feasible for more APPs to prescribe MOUD. The greater capacity should have positive benefits on treatment engagement”
Little-to-no Depends on the number of existing providers who can prescribe MOUD, although many who can often do not. “Lots of providers have their x-waivers to prescribe buprenorphine, but don't. I don't think the number of providers is a rate limiting step”
Harmful N/A N/A

OUD Treatment Retention

Percentage of people meeting the criteria for an OUD diagnosis who remain continuously enrolled in OUD treatment services for at least six months.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Increasing the number of eligible prescribers should remove barriers and increase access to MOUD (especially in rural and underserved areas). Having more prescribers would allow each provider to have more time with each patient. Particularly helpful when the APP is a trusted, preferred health care provider. “People are engaged when they receive care from a trusted provider. Patients remain in treatment longer when they trust their provider”
Little-to-no
(selected)
 Policy would impact engagement more directly than retention, which is based on several factors (e.g., quality of care). Many existing providers who can prescribe MOUD often do not. “Retention is based on other factors”
Harmful N/A N/A

OUD Remission

Percentage of people meeting the criteria for an OUD diagnosis who do not experience OUD symptoms (other than craving/desire/urge for opioid) for at least 12 months.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Increasing the number of eligible prescribers should remove barriers and increase access to MOUD (especially in rural and underserved areas). Particularly helpful when the APP is a trusted, preferred health care provider. “If an individual has easier access to one of these individuals, it may be easier for them to reach remission. This will help in rural areas”
Little-to-no
(selected)
 Policy would impact engagement more directly than remission, which is influenced by several factors. Many existing providers who can prescribe MOUD often do not. “I believe long-term remission is related to patient and environment factors more so than treatment factors”
Harmful N/A N/A

Opioid Overdose Mortality

Per capita rates of fatal overdose related to opioids, including opioid analgesics (e.g., oxycodone), illegal opioids (e.g., heroin), and synthetic opioids (e.g., fentanyl).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Increasing the number of eligible prescribers should remove barriers and increase access to MOUD (especially in rural and underserved areas). Particularly helpful when the APP is a trusted, preferred health care provider. “The more people with access to MOUD, the fewer people who will experience a fatal overdose related to opioids”
Little-to-no
(selected)
 Policy would impact engagement more directly than overdose mortality, which is influenced by several factors. Many existing providers who can prescribe MOUD often do not. “Mortality rates are affected by much more than a strategy to increase access to medications”
Harmful N/A N/A

Implementation Criteria Summaries

Acceptability

The extent to which the policy is acceptable to the general public in the state or community where the policy has been enacted.

Implementation Rating Summary of Expert Opinion Representative Quotations
High
(selected)
 Public supports policies perceived as effective in addressing the overdose epidemic. “Some of the public may not know or understand this policy, but once explained, I can't imagine objections, as long as, when implemented it reduces barriers, rather than creates new ones”
Moderate Varies by state and segments of the general public (e.g., those who stigmatize MOUD, those who are skeptical that APPs can provide the same care as doctors). Some medical professional associations may oppose scope creep. “The general public may not have high awareness of these types of nuances, but acceptability might be lower considering common views that medication treatment is substituting one drug for another”
Low Public may be concerned about APP qualifications to expand scope. Doctors may oppose scope creep. “Seems the general public is [wary] of expansion of scopes for APPs in general”

Feasibility

The extent to which it is feasible for a state or community to implement the policy as intended.

Implementation Rating Summary of Expert Opinion Representative Quotations
High
(selected)
 Easy to implement in existing programs with an available and willing provider population, especially as APPs have prescribing privileges for other medications. “Several states have already done this without any problems I am aware of and a resulting increase in care access”
Moderate Depends on (training available to improve) APP and supervisor competence. Faces barriers from opposing professional medical groups and from licensing board regulations. Stigmatization is also a barrier. “Considering the breadth of the audience, education, training, and advocacy can collectively be a high burden to overcome for implementation”
Low Difficulty getting policy enacted. “I do not see this getting through my statehouse”

Affordability

The extent to which the resources (costs) required to implement the policy are affordable from a societal perspective.

Implementation Rating Summary of Expert Opinion Representative Quotations
High
(selected)
 Cost-effective due to policy being inexpensive (e.g., lower reimbursement rates for APPs) and increased access to MOUD being impactful on important outcomes. “Would reduce costs since services provided by NPs and PAs are less costly than [doctors]”
Moderate Requires education, training, supervision, and ongoing monitoring and administrative oversight. “Need expanded training capacity and administrative oversight”
Low N/A N/A

Equitability

The extent to which the policy is equitable in its impact on health outcomes across populations of people who use opioids.

Implementation Rating Summary of Expert Opinion Representative Quotations
High
(selected)
 Significantly expands access to MOUD (especially in rural and underserved areas). APPs provide care that is more patient-centered and spend more time with patients compared with doctors. “If these laws increase the number of providers and thus increase access to care, they have the potential to help reduce existing disparities related to access”
Moderate Depends on whether policy implementation proactively aims to address disparities. Focus on increasing access to care through less-credentialed providers may exacerbate who receives care from doctors versus APPs and may engender further mistrust of the medical community. “Again, it depends—lots of policies out there, you have to proactively make them address inequities”
Low APP care is associated with worse outcomes, and societally disadvantaged groups are more likely to receive care from APPs. “Profit-seeking providers (e.g., hospitals) may hire NPs and PAs instead of physicians which could lead to lower quality care if the NPs and PAs did not have the same level of experience and training”
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Full State Scope-of-Practice Laws. Santa Monica, CA: RAND Corporation, 2023. https://www.rand.org/pubs/research_briefs/RBA3054-27.html.
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