April 14, 2021 - Podcast

Episode 116—Medication Assisted Treatment, and depression

Since 2016, a federal regulation has allowed nurse practitioners and physician assistants to obtain a waiver to prescribe buprenorphine, a medication used to treat opioid use disorder as a medication assisted treatment. But a recent study by Indiana University researchers found the bill, called the Comprehensive Addiction and Recovery Act, or CARA, has not greatly increased the amount of nurse practitioners prescribing buprenorphine, especially in states that have further restrictions. IU researcher Kosali Simon says nurse practitioners and physician assistants are an important workforce with capacity to expand treatment access for those with substance use disorders. But she says they have found that efforts like CARA have been limited in actually utilizing this group, with nurse practitioners accounting for a relatively small proportion of buprenorphine prescriptions made. Buprenorphine is the only agonist medication for opioid addiction that can be prescribed by a qualified physician or nonphysician practitioner in an office-based setting. Simon said research has shown it is associated with significant decreases in relapse and overdose. However, the U.S. has a shortage of providers who have a waiver from the Drug Enforcement Administration to prescribe buprenorphine outside of opioid treatment programs. According to the study, at the county level, the proportion of patients filling prescriptions written by nurse practitioners was low even after CARA: 2.7% in states that did not require physician oversight of nurse practitioners and 1.1% in states that did. While rural counties showed higher rates of buprenorphine prescriptions written by nurse practitioners, the study found the rates were still considerably low – 3.7% in states with less restrictive regulations and 1.1% in other states. Simon says since relatively few physicians have a waiver to prescribe, it can be difficult for nurse practitioners who must have physician oversight to find a waivered physician to oversee them. Some nurse practitioners also face supervising physicians who are unsupportive of buprenorphine treatment. While state restrictions don’t help, Kosali says there are more deterrents to buprenorphine treatment, including insufficient training and education about opioid use disorder treatment, burdensome training time, lack of institutional and clinician peer support, poor care coordination and inadequate insurance reimbursement. Kosali recommends relaxing state scope-of-practice requirements for nurse practitioners and addressing other practice-level and educational barriers that impede treatment access. Additionally, Simon says eliminating the need for a waiver for all practitioners should be further considered to help address gaps in opioid use disorder care, especially in primary care settings and rural areas.

In other news, worldwide, 1 in 4 people will suffer from a depressive episode in their lifetime. While current diagnosis and treatment approaches are largely trial and error, a breakthrough study by the IU School of Medicine researchers sheds new light on the biological basis of mood disorders and offers a promising blood test that may yield a precision-medicine approach to depression treatment. IU’s Dr. Alexander B. Niculescu says the study brings psychiatry from the 19th century into the 21st century, to help it become like other contemporary fields such as oncology. The study describes how researchers developed a blood test, composed of RNA biomarkers, that can distinguish how severe a patient's depression is, their risk of severe depression in the future and their risk of future bipolar disorder, or manic-depressive illness. The test also informs medication choices tailored for patients. This comprehensive study took place over four years, with over 300 participants. The participants were followed over time, with researchers observing them in both high and low mood states. With each state, the researchers recorded how biomarkers in their blood changed between the highs and lows. Next, Niculescu's team used large databases developed from previous studies in the field to cross-validate and prioritize their findings. They validated the top 26 candidate biomarkers in people with clinically severe depression or mania. Finally, the biomarkers were further tested to determine how strong they were at predicting who is depressed, and who will become depressed in the future. Researchers were able to demonstrate how to match patients with medications -- even finding a new potential medication to treat depression. In addition to the diagnostic and therapeutic advances discovered in their latest study, Niculescu's team found that mood disorders are affected by circadian clock genes -- the genes that regulate seasonal, day-night and sleep-wake cycles—which helps to explain why some patients get worse with seasonal changes as well as the sleep alterations that occur in mood disorders. According to Niculescu, the work done by his team has opened the door for their findings to be translated into clinical practice, as well as help with new drug development. Focusing on collaboration with pharmaceutical companies and other doctors in a push to start applying some of their tools and discoveries in real-world scenarios, Niculescu says he believes the work being done by his team will improve the quality of life for countless patients.