Elimination of X-Waiver Removes Major Barrier to Opioid Use Disorder Treatment

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Feb. 10, 2023 (ACP) — Thanks in part to advocacy efforts by the American College of Physicians, the X-waiver requirement is history. Under the prior federal requirement, only doctors who received specialized training and federal permissions could prescribe buprenorphine to treat opioid addiction, which was a significant barrier to the treatment.

Language was included in the Consolidated Appropriations Act 2023, which became law on Dec. 29, that eliminated the requirement for health care practitioners registered to dispense controlled substances to apply for a separate waiver through the Drug Enforcement Administration (DEA) to dispense buprenorphine for opioid use disorder treatment, known as the X-waiver.

On Jan. 12, the Substance Abuse and Mental Health Services Administration and the DEA formally announced the elimination of the X-waiver. Now, any clinician with a current DEA registration that includes Schedule III authority can prescribe buprenorphine for opioid use disorder.

“This is a big step in the right direction to reduce barriers to clinicians prescribing buprenorphine with the hope that more patients who would benefit from this medication will be prescribed it,” said Dr. Eileen Barrett, chair-elect of the ACP Board of Regents. She is also a physician in New Mexico who has firsthand experience with prescribing buprenorphine.

Many patients with opioid use disorder are not offered treatment because of the false belief that using buprenorphine or other medications for addiction treatment (MAT) substitutes one drug for another, she explained.

MAT reduces overdose deaths and improves a person's quality of life. “Gaining updated knowledge about MAT was limited [because] until recently, federal law required extra training and registration with the DEA to get an X-waiver to prescribe buprenorphine,” Barrett said.

Now that this additional training requirement is lifted, one hurdle to starting or continuing treatment for patients with evidence-based addiction care is gone, she explained.

However, there is still more work to be done to make sure people receive evidence-based addiction care, including reducing stigma and increasing availability and access to care. “For example, one study showed that just over half of hospitals statewide carried buprenorphine/naloxone on their formularies, meaning hospitalized patients could not get this medication,” Barrett said. “Another showed extensive barriers to admission to skilled nursing facilities for people on MAT.”

Prior authorization requirements may be another barrier. Several states have already taken action to eliminate or reduce prior authorization requirements for MAT. “Generally, however, in my experience and from my read of the literature, the challenge isn't prior authorization as much as it is clinicians not broaching the topic and patients not having access to care,” Barrett said.

When clinicians receive training and support for caring for people with a substance use disorder (including prescribing MAT), they welcome adding it to their treatment armamentarium, and it can decrease their feelings of helplessness and burnout, Barrett explained. Mentor programs, shadowing experienced clinicians and greater use of telemedicine can help improve education and support efforts around substance use treatment, ACP states.

“I appreciate that ACP is among the organizations that called for lifting the X-waiver and provides Continuing Medical Education on treating opioid use disorder and addiction and specifically on buprenorphine,” Barrett said.

ACP members are encouraged to learn more about MAT and start to prescribe it. ACP also urges members to advocate for MAT availability in their hospitals, skilled nursing facilities and other post-acute care settings.

They can also consider inviting grand rounds speakers, hosting journal clubs and speaking in community settings about the effectiveness of this therapy, Barrett suggested.

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Back to the February 10, 2023 issue of ACP Advocate