Available online 5 January 2024, 102844

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We study the impact of scope-of-practice laws in a highly regulated and important policy setting, the provision of medication-assisted treatment for opioid use disorder. We consider two natural experiments generated by policy changes at the state and federal level that allow nurse practitioners more practice autonomy. Both experiments show that liberalizations of prescribing authority lead to large improvements in access to care. Further, we use rich address-level data to answer key policy questions. Expanding nurse practitioner prescribing authority reduces urban-rural disparities in health care access. Additionally, expanded autonomy increases access to care provided by physicians, driven by complementarities between providers.

Section snippetsThe opioid epidemic and regulations governing access to treatment

Unlike use disorders for some other drugs of abuse, opioid use disorder is effectively treatable for many patients with medications: methadone, buprenorphine or naltrexone. Medication-assisted treatment (MAT), which combines behavioral therapy with one of these medications when appropriate, is considered the gold standard of treatment for opioid use disorder (Office of the Surgeon General, 2018).

The United States’ approach to treating opioid use disorder with MAT is rooted in policies enacted

Access to treatment inside opioid treatment programs

Our data on usage of medication-assisted treatment in formal Opioid Treatment Programs comes from the Automated Reports and Consolidated Ordering System, which are yearly national reports on transactions of controlled substances collected by the Drug Enforcement Administration (U.S. Department of Justice Drug Enforcement Administration, 2016). For each state we extract the data on all grams dispensed of methadone and buprenorphine by OTPs using Report 5, which breaks down controlled substance

Phase I natural experiment: Access to medication-assisted treatment in opioid treatment programs

We first investigate the role of state-level laws governing independent prescriptive authority for nurse practitioners on treatment access until 2016. During this time, nurse practitioners could provide medication-assisted treatment only inside highly-regulated, non-office-based Opioid Treatment Programs (colloquially known as “methadone clinics”), as governed by state scope-of-practice laws. If more permissive regulations governing NPs prescriptive authority reduce the cost of running Opioid

Phase II natural experiment: Access to office-based buprenorphine treatment

We next investigate how the passage of the federal Comprehensive Addiction and Recovery Act (CARA) interacts with existing state-level licensing laws to impact access to treatment for opioid use disorder. CARA enabled nurse practitioners to obtain buprenorphine waivers and treat up to 30 patients in an office-based setting, bounded by pre-existing state scope-of-practice laws.

The difference-in-differences empirical model that we will employ is: Ycsqy=α+βIPAs+σPostCARAy+θ(IPAs×PostCARAy)+γs+λy+μX

Policy issue I: Access to medication-assisted treatment in underserved areas

Expanding scope of practice for nurse practitioners is often cited in policy debates as a way to close the primary care gap for geographically-underserved communities, because there are higher densities of nurse practitioners in rural areas than physicians (Graves et al., 2016). This point seems particularly salient in the context of the opioid epidemic, as a key concern has been the way it affects rural, underserved areas. Further, a historic emphasis on Opioid Treatment Programs has

Policy issue II: Physician crowd out

Finally, we consider whether the expansion of prescribing authority to nurse practitioners may have had unintended negative consequences by crowding out physician care, which may be of higher quality. A small literature suggests that increasing nurse practitioner practice authority or autonomy may crowd out physicians providing complementary services, due to their lower costs (Kleiner, 2016, Perry, 2009). However, two factors make our setting unusual. First, this market is characterized by

Conclusion

In this study we have considered the ways in which scope-of-practice occupational licensing decisions affect the provision of health care. Specifically, this study provides two experiments on the impact of reducing barriers to entry to medical practice, in a context – treatment for opioid use disorder – where supply is constrained, and demand persistently outstrips supply. Though many of our details are specific to the opioid use disorder setting, many aspects of medical care in the United

Uncited References

Goodman-Bacon (2019)

Declaration of competing interest

The author declares that they has no relevant or material financial interests that relate to the research described in this paper.

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