BARRIERS AND FACILITATORS TO BUPRENORPHINE PRESCRIBING AMONG NURSE PRACTITIONERS WORKING IN PRIMARY CARE SETTINGS IN EASTERN NORTH CAROLINA

Abstract

The opioid crisis has disproportionately impacted rural areas such as eastern North Carolina. Buprenorphine is an evidenced-based treatment for individuals experiencing opioid use disorder that is well suited for rural areas because it can be prescribed in primary care settings. Providers must have a specialized Drug Enforcement Agency prescribing waiver to prescribe buprenorphine. Nurse practitioners were granted the right to apply for these waivers in 2016. However, few NPs have obtained prescribing waivers. Literature to date has focused on barriers and facilitators to physician prescribing. Nurse practitioners are educated, regulated, and reimbursed differently than physicians, thus it was important to explore nurse practitioners’ potentially unique experiences. This qualitative, descriptive study used semi-structured interviews with nurse practitioners to address the research question: what are the barriers and facilitators to buprenorphine prescribing among nurse practitioners working in primary care settings in eastern North Carolina? The Theoretical Domains Framework, a comprehensive framework to address implementation problems among health care professionals, guided data collection and analysis. Analysis identified barriers and facilitators in eight domains: beliefs about capability, beliefs about consequences, emotion, environmental context and resources, reinforcement, skills, social influences, and social and professional role identity. This study is significant because it is the first qualitative study of nurse practitioner buprenorphine prescribing. Findings extend and clarify existing literature on buprenorphine prescribing. Analysis found that nurse practitioners face similar, though more pronounced, environmental barriers than physicians. Other striking barriers included those in the social influences domain: NPs expressed, had witnessed, or had experienced negative attitudes toward buprenorphine, individuals living with opioid use disorder, and providers who prescribe buprenorphine. Notable facilitators included developing skills to meet buprenorphine prescribing challenges and the sense of reward nurse practitioners experienced when patients were successful on buprenorphine therapy. Addressing the research question within the Theoretical Domains Framework laid groundwork for theory-informed intervention studies.This study also provides information for policymakers as they work to provide a regulatory environment amenable to buprenorphine prescribing and for educators as they prepare nurse practitioners to meet the treatment challenges presented by the opioid crises.