Can a Psychiatric‑Mental Health Nurse Practitioner (PMH‑NP) work in a medication‑assisted treatment (MAT) clinic and prescribe buprenorphine, methadone, or extended‑release naltrexone?

Can PMHNPs Work in MAT Clinics?

Yes, Psychiatric-Mental Health Nurse Practitioners (PMHNPs) can absolutely work in medication-assisted treatment (MAT) clinics and prescribe buprenorphine and extended-release naltrexone for opioid use disorder, though methadone prescribing remains restricted to federally licensed opioid treatment programs regardless of provider type. 1

Federal Authorization for PMHNP Prescribing

Buprenorphine Prescribing Authority

• Federal law explicitly permits nurse practitioners (including PMHNPs) to obtain waivers to prescribe buprenorphine for opioid use disorder, subject to state-specific scope of practice regulations. 1
• As of late 2022, the federal waiver requirement (X-waiver) was eliminated, removing a significant barrier to MOUD prescribing by all qualified providers including PMHNPs. 2
• Prior to waiver elimination, PMHNPs could obtain federal waivers after completing required training, with the same patient caps as physicians (30 patients in year 1, expandable to 100, and up to 275 with additional qualifications). 1

Naltrexone Prescribing Authority

• PMHNPs can prescribe both oral and extended-release injectable naltrexone (Vivitrol) without any special waiver or federal restriction. 3, 1
• Naltrexone is FDA-approved for opioid use disorder and can be prescribed from office-based practices, making it particularly accessible for PMHNP practice. 4

Methadone Restrictions Apply to All Providers

• Methadone for opioid use disorder can only be dispensed through federally licensed opioid treatment programs—this restriction applies equally to physicians, PMHNPs, and all other prescribers. 3, 1
• The only exception is emergency administration (not prescription) for up to 72 hours while arranging referral, which any DEA-licensed provider can do. 1

State-Level Scope of Practice Considerations

Critical Regulatory Variability

• State scope of practice regulations remain the primary barrier to PMHNP MOUD prescribing, even after federal waiver elimination. 2
• States with full practice authority for nurse practitioners (such as New Mexico and West Virginia) allow PMHNPs to prescribe MOUD independently. 2
• States requiring physician supervision or collaboration (such as Ohio and Michigan) impose additional practice restrictions that may limit PMHNP autonomy in MAT clinics. 2

Practical Implementation Barriers

• Beyond formal scope of practice laws, PMHNPs face institutional barriers including lack of institutional support, insufficient mental health and psychosocial support services, time constraints, and resistance from physician practice partners. 3, 2
• Stigma surrounding MOUD treatment affects all provider types but may disproportionately impact advanced practice nurses seeking to establish MOUD practices. 2

Unique Contributions of PMHNPs in MAT Settings

Psychiatric Expertise and Dual Diagnosis Management

• PMHNPs bring specialized psychiatric training that is particularly valuable in MAT clinics, where co-occurring mental health disorders are extremely common. 5
• The nursing model of care, which emphasizes holistic patient assessment and therapeutic relationships, aligns well with the comprehensive needs of individuals with substance use disorders. 2
• PMHNPs are specifically trained to assess, diagnose, and treat psychiatric conditions while managing MOUD, addressing the frequent comorbidity of depression, anxiety, and other mental health conditions in this population. 5

Expanding Access to Underserved Areas

• PMHNPs significantly increase access to MOUD treatment, particularly in rural and underserved areas where physician prescribers are scarce. 2
• As of 2016, only 7 physicians with buprenorphine waivers existed per 100,000 residents in California, highlighting the critical need for expanding the prescriber workforce to include PMHNPs. 3
• The PMHNP workforce has capacity to address mental health professional shortages and increase access to the full scope of mental health services including MOUD. 5

Evidence-Based Treatment Protocols PMHNPs Should Follow

Medication Selection Algorithm

• Offer buprenorphine or methadone as first-line medication-assisted treatment for opioid use disorder, with extended-release naltrexone reserved for highly motivated patients who prefer opioid-free treatment or cannot access agonist therapy. 3, 4
• Buprenorphine demonstrates 80% reduction in illicit opioid use along with significant increases in employment and other recovery indices. 3
• Extended-release naltrexone shows noninferiority to buprenorphine-naloxone in maintaining short-term abstinence but requires complete opioid detoxification before initiation. 6

Mandatory Combination with Behavioral Therapies

• All MOUD must be combined with behavioral therapies—medication alone is insufficient for optimal outcomes. 3, 7
• Team-based care models that link PMHNPs to specialists and other healthcare professionals experienced in substance use disorder treatment improve confidence and treatment outcomes. 3
• Combined pharmacotherapy with cognitive-behavioral therapy shows greater efficacy than pharmacotherapy alone. 7

Critical Safety Protocols

• Screen for opioid use disorder using DSM-5 criteria (requiring at least 2 criteria within 12 months). 3
• Before initiating naltrexone, patients must be completely opioid-free to avoid precipitating severe withdrawal syndrome. 4, 8
• Monitor liver function tests at baseline and every 3-6 months for patients on naltrexone due to hepatotoxicity risk. 4
• Provide naloxone for overdose prevention to all patients with opioid use disorder. 7

Common Pitfalls and How to Avoid Them

Regulatory Confusion

• Do not assume that federal waiver elimination automatically grants full prescribing authority—always verify your specific state's scope of practice regulations before prescribing MOUD. 2
• Do not conflate the ability to prescribe buprenorphine and naltrexone with methadone prescribing, which remains restricted to federally licensed treatment programs for all provider types. 3, 1

Clinical Management Errors

• Never initiate naltrexone without confirming complete opioid abstinence (7-10 days for short-acting opioids, 10-14 days for long-acting opioids including buprenorphine) to prevent precipitated withdrawal. 4, 8
• Do not use naltrexone in pregnant women—offer buprenorphine (without naloxone) or methadone instead. 3, 4
• Avoid "cold referrals" to other clinicians who have not agreed to accept the patient, as this contributes to treatment dropout. 4

Underutilization of Team-Based Resources

• Leverage professional support resources such as the Providers' Clinical Support System and Project ECHO (Extension for Community Healthcare Outcomes) to improve confidence and facilitate team-based MOUD care. 3
• Incorporate peer support specialists with MOUD experience, as peers are frequently identified as trusted sources of information for individuals seeking treatment. 9

Insurance and Access Barriers

• Be aware that some Medicaid programs restrict buprenorphine access due to cost concerns, though evidence shows buprenorphine has similar mortality rates to methadone with lower mean annual spending. 3
• Advocate for removal of prior authorization requirements that create unnecessary barriers to timely MOUD initiation. 3