Suboxone is a medication-assisted treatment (MAT) that combines buprenorphine and naloxone, designed to treat Opioid Use Disorder (OUD). Buprenorphine is a partial opioid agonist that reduces cravings and withdrawal symptoms without producing the full euphoric effects of other opioids; naloxone is added to discourage misuse. Expanding access to this treatment is a health priority. Nurse Practitioners (NPs) are advanced practice registered nurses who often serve as primary care or mental health providers, making them crucial in delivering this treatment. The ability of NPs to prescribe Suboxone is governed by a layered set of federal and state regulations.
Federal Authorization for Buprenorphine Prescribing
The federal government has streamlined the process for all practitioners, including NPs, to prescribe buprenorphine for OUD. Historically, the Drug Addiction Treatment Act of 2000 (DATA 2000) required prescribers to obtain a special federal waiver, known as the X-Waiver, to prescribe buprenorphine outside of a dedicated treatment program. This requirement also imposed limits, or patient caps, on the number of people a prescriber could treat.
The Consolidated Appropriations Act of 2023 eliminated this X-Waiver requirement entirely, effective January 2023. Any practitioner who possesses a standard Drug Enforcement Administration (DEA) registration that allows them to prescribe controlled substances, such as buprenorphine, may now do so for OUD treatment. This legislative change removed the major federal barrier that once restricted the number of NPs who could offer this medication.
This federal policy shift established a national baseline that an NP has the authority to prescribe buprenorphine, provided they hold an active DEA license. The removal of the X-Waiver means there are no longer any federal limits on the number of patients an NP can treat. The goal of this change was to increase access to OUD treatment by integrating it into mainstream medical practice.
State-Level Variations in NP Prescriptive Authority
Despite the federal elimination of the X-Waiver, an NP’s ability to prescribe Suboxone remains dependent on the laws of the specific state where they practice. Buprenorphine is classified as a Schedule III controlled substance, and state laws dictate the scope of practice for NPs regarding these medications. These state regulations fall into three primary categories: Full, Reduced, and Restricted Practice Authority.
In states with Full Practice Authority, NPs can evaluate patients, diagnose conditions, order tests, and prescribe medications, including controlled substances like Suboxone, without physician supervision or collaborative agreements. This model allows NPs to operate autonomously and manage OUD treatment independently. Conversely, states with Restricted Practice Authority require NPs to maintain career-long supervision or delegation by a physician for their prescriptive authority.
Reduced Practice Authority is the middle ground, where NPs can engage in some elements of practice independently but must have a supervisory or collaborative agreement with a physician for other elements, often including the prescribing of controlled substances. In these reduced or restricted states, the NP must still comply with state-mandated physician oversight to legally prescribe a Schedule III drug like Suboxone. The need for a collaborative agreement can still act as a practical barrier to treatment expansion, particularly in rural areas where physician oversight may be difficult to secure.
The Administrative Process for NPs to Begin Prescribing
After meeting the federal and state requirements for prescriptive authority, an NP must complete specific bureaucratic steps to begin prescribing Suboxone. The primary administrative requirement is maintaining an active DEA registration that authorizes the NP to prescribe controlled substances. Since buprenorphine is a Schedule III drug, the NP’s DEA registration must specifically include authority for this schedule.
If an NP was not previously authorized to prescribe controlled substances, or if their registration did not include Schedule III, they must update or apply for this authority through the DEA. The Consolidated Appropriations Act of 2023 also introduced a new, one-time federal training requirement for all practitioners who apply for or renew their DEA license. This mandates eight hours of training on the treatment and management of patients with substance use disorders, which applies to all DEA-registered NPs.
Beyond the federal DEA and training requirements, NPs must also adhere to any remaining state-specific administrative mandates. Some states require NPs to register with the state board of nursing or the state controlled substance authority to confirm their prescriptive authority for controlled substances. The NP must ensure their practice aligns with all state-level protocols, collaborative agreements, and any continuing education requirements related to addiction or pain management.