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Workforce Considerations for Rural MOUD Programs

Many considerations regarding workforce for rural programs providing medication for opioid use disorder (MOUD) are closely related to policies guiding the use and distribution of medication to treat opioid use disorder (OUD).

State Laws and Regulations

In addition to federal requirements, all medication-assisted treatment (MAT) and MOUD programs must comply with applicable state laws and regulations regarding the types and number of providers a program can hire. Many of these laws and regulations pertain to opioid treatment programs (OTPs). Each state has a State Opioid Treatment Authority to help regulate MOUD programs and serve as a resource for understanding state-specific guidance regarding program staff.

The Waiver Process

To prescribe buprenorphine and other medication for OUD outside of an OTP, the typical process is for eligible providers to obtain a DATA (Drug Addiction Treatment Act) 2000 waiver. This waiver is also sometimes called an X-waiver, MAT waiver, buprenorphine waiver, or DEA waiver. Under the typical waiver process, providers can apply for a waiver by submitting a Notice of Intent (NOI), after completing required training and certification. Eligible providers who obtain the waiver are authorized to prescribe buprenorphine to no more than 30 patients in the first year and 100 patients in following years. The SUPPORT Act expands the maximum number of patients eligible providers may treat, provided the practitioner meets certain conditions.

Recent U.S. Department of Health & Human Services Practice Guidelines have exempted eligible providers from the typical DATA-waiver certification requirements, allowing them to treat up to 30 patients at one time without undergoing training. Practitioners under this exemption cannot treat more than the 30-patient limit. To treat more than 30 patients, providers must apply for a waiver by submitting a new NOI, and they must demonstrate that they have met the existing DATA-2000 requirements related to training.

Qualified MOUD Prescribers

Currently, the Substance Abuse and Mental Health Services Administration (SAMHSA) identifies the following provider types as eligible to pursue waivers, complete required training, and apply for a waiver to become qualified MOUD prescribers:

  • Physicians (MDs and DOs)
  • Nurse practitioners (NPs)
  • Physician assistants (PAs)
  • Clinical nurse specialists (CNSs)
  • Certified registered nurse anesthetists (CRNAs)
  • Certified nurse midwives (CNMs)

SAMHSA provides details on buprenorphine training for physicians, advanced practice registered nurses (NPs, CNSs, CRNAs, CNMs), and physician assistants through their Providers' Clinical Support System.

Depending on the program model used, rural MOUD programs may seek to have more than one DATA-2000 waivered provider, including physicians, nurse practitioners, physician assistants, and others. Each waivered provider may provide a different level of prescribing. Some may treat only their current patients, thus prescribing under the patient limit, and some may be full-time MOUD providers.

Additional Program Staff

To best support patients, programs will need a team of medical and administrative staff that understand the aspects of MOUD prescribing and treatment. In addition to having waivered providers who are eligible to prescribe medication, MOUD programs may seek to engage other types of staff for:

  • Program intake
  • Care coordination
  • Case management
  • Psychosocial services
  • Clinical services beyond MOUD

MOUD programs may choose to fill these roles using different types of staff, depending on program structure, workforce availability, and more. Many of these roles can be filled by individuals in a variety of occupations and with different backgrounds, education, and training. For example, one program may rely on administrative staff to conduct patient intake, while another may rely on nurses (such as registered nurses or nurse care managers) or behavioral health staff (such as social workers or counselors). Some staff may have multiple roles, such as both conducting program intake and coordinating care. The flexibility to use different types of staff in different roles may be particularly helpful for rural MOUD programs where workforce can be limited. Additionally, programs may choose to hire staff directly or partner with other organizations to increase program capacity.

For MAT and MOUD programs that provide mental health services, it is important to have counseling staff available. Counseling staff may include licensed clinical social workers (LCSWs), licensed professional counselors (LPCs), psychologists, Licensed Clinical Alcohol & Drug Abuse Counselors (LCADACs), or another title or occupation. The National Alliance on Mental Illness describes different types of mental health professionals and different roles they may play.

Provider Training

Programs may need to train providers and staff about MOUD. Trainings should also address that OUD treatment is typically a long-term process that benefits from coordination and collaboration across multiple workforce roles and responsibilities. Training may address stigma among healthcare providers and staff.

Resources to Learn More

How to Receive Medications for Opioid Use Disorder (MOUD) Training
Provides information and resources regarding clinician training for medication-assisted treatment (MAT) to prevent, identify, and treat opioid use disorder (OUD). Identifies how clinicians working to address OUD may be eligible for free training and free mentoring services.
Organization(s): Health Resources & Services Administration (HRSA)

Providers Clinical Support System (PCSS)
Provides training to health professionals to support medication for opioid use disorder in various medical settings.
Organization(s): Substance Abuse and Mental Health Services Administration (SAMHSA)