Prescribing psychologists: Forgotten providers in the battle against opioid use disorder

The opioid overdose crisis has claimed the lives of nearly 1million people in the United States since 1999, including almost 100 000 in 2020 [1], a problem that worsened during the COVID-19 pandemic [2]. Buprenorphine, a partial opioid agonist, is one of several medications recognized as a life-saving treatment for opioid use disorder (OUD) [3]. Access to buprenorphine in the United States has long been hindered by extensive regulatory barriers, with health-care providers being required to complete several hours of additional training and seek a Drug Enforcement Administration (DEA) waiver in order to prescribe buprenorphine for OUD. As part of the bipartisan 2023 omnibus bill, President Joe Biden signed the Mainstreaming Addiction Treatment (MAT) Act, which eliminated these arduous requirements for providers seeking to prescribe buprenorphine for OUD [4]. However, not all providers receive the benefits of the MAT Act, due to scope-of-practice regulations at the state level. From 3 March 2023, six states now currently allow qualified psychologists seek prescriptive authority (RxP; Table 1), and there were nearly 250 prescribing psychologists in the United States from early 2023 (Dr. Derek Phillips, personal communication) [5, 6]. Furthermore, several states have RxP bills under consideration [7-9]. While RxP is currently limited to the United States, interest is growing in other countries, with professional psychological associations in Canada and England exploring such policies [10, 11]. Additional interest has been expressed by individuals in Brazil, Norway, the Netherlands, Croatia, Taiwan and South Africa [12, 13]. Although additional specific requirements vary between states, all prescribing psychologists complete a 2-year post-doctoral Master of Science in clinical psychopharmacology (MSCP) degree and pass a national psychopharmacology qualifying examination [5]. The MSCP is designed to equip psychologists with the technical knowledge necessary to prescribe psychotropic medications and provides extensive training in pharmacology, psychopharmacology, physiology, neuroscience and clinical pharmacotherapeutics. Training on opioids at both the receptor and drug levels is included in the program. Despite this extensive training, the RxP laws in every state except New Mexico explicitly prohibit prescribing psychologists from prescribing opioids, including buprenorphine. As a result, prescribing psychologists are legally restricted from the use of evidence-based pharmacotherapy for OUD. Importantly, there is a substantial need for additional providers to treat OUD in the states with RxP laws, with age-adjusted opioid overdose rates ranging from 14.3 to 42.7 per 100 000 people [1]. While the restriction on opioid prescribing was originally intended as a safety precaution against a growing crisis, buprenorphine is a partial opioid agonist and therefore significantly safer than other opioids. Opioid overdose deaths rarely involve buprenorphine (and almost never as the only drug) [14], and buprenorphine misuse is primarily performed to self-treat withdrawal symptoms, rather than to induce euphoric effects [15]. In addition to the relative safety of buprenorphine, it is important to consider that OUD is highly comorbid with myriad mental health conditions, such as depression and anxiety [16]. Prescribing psychologists are therefore well equipped to make an impact in reducing opioid overdose deaths, as they have done with mental health-related mortality [17]. As such, states with RxP laws have a unique, highly trained work-force at their disposal that is ready-made to address the surging opioid crisis. Those states should work to enact an exception to their current RxP laws for buprenorphine, and future RxP bills in the United States and internationally should include a similar exception, to allow these forgotten providers to do what they do best: save lives. Phillip M. Hughes: Conceptualization; writing—original draft; writing—review and editing. Derek C. Phillips: Writing—review and editing. E. Blake Fagan: Writing—review and editing. The authors declare no conflicts of interest.

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