Dr. Emily Uebbing and I teamed up to cover the new HHS guidelines for the X-Waiver requirement when prescribing buprenorphine for opioid use disorder. Here’s what Dr. Uebbing uncovered…
It has been just over a year since the COVID-19 pandemic reached the United States (U.S.), however, the U.S. has been facing a deadly epidemic far longer than that. The opioid epidemic has been plaguing the U.S. since the 1990s and has significantly worsened in the last 12-months as the COVID-19 pandemic led to stress, isolation, and, ultimately, drug use for some people. The past year has accounted for the most drug overdose deaths ever recorded in a 12-month period. Overdose deaths from synthetic opioids, such as fentalogues, account for the majority of the deaths and increased by 38.4% in the 12-month period from May 2019-May 2020 compared to the prior 12-month period.1
The CDC endeavors to combat the opioid pandemic with the release of a multiyear Overdose Data to Action plan that began in September 2019. A large part of this plan includes increasing access to treatment for opioid use disorder. A barrier to which has long been the stringent X-waiver registration required by primary care providers.2
The Drug Addiction Treatment Act of 2000 (DATA 2000) established the X-waiver as an additional registration, separate from Drug Enforcement Administration (DEA) registration. It was required by any provider in order to prescribe schedule III-V medications for outpatient OUD treatment not in sync with a treatment program. The intended purpose of the X-waiver was to allow primary care providers to have a role in opioid use disorder treatment, as prior to this, medications for opioid use disorder treatment could only be prescribed through treatment programs.3 In order to obtain an X-waiver, a practitioner previously had to either be a physician who holds a board certification in addiction medicine or addiction psychiatry, or be a physician extender holding a DEA license (i.e. NP or PA) who provides medication-assisted treatment in a “qualified practice setting. This was in addition to paperwork, fees, and an 8-hour training for physicians or a 24-hour training for other practitioners.4 (https://www.samhsa.gov/medication-assisted-treatment/become-buprenorphine-waivered-practitioner) X-waiver application, audits, and trainings deterred many providers from obtaining an X-waiver and ultimately limited patient access to treatment.3
The X-waiver has faced scrutiny since its conception, especially in relation to use of buprenorphine. Buprenorphine has been used for chronic pain longer than it has been used for OUD; the difference is that the X-waiver is not required for use of buprenorphine in chronic pain but it is for treatment of OUD. And unfortunately, some prescribers and even dispensing pharmacists didn’t know the difference. In regards to chronic pain, buprenorphine is hailed as a safer option compared to traditional opioids for patients as it uniquely reaches a plateau on carbon dioxide accumulation and related respiratory depression.5 One article simply inquired why the X-waiver applies for buprenorphine when it is used to treat OUD but not for chronic pain and other opioid medications that are responsible for causing the opioid epidemic itself.3
The Department of Health and Human Services (HHS) announced on January 12, 2021, the elimination of the requirement of an X-waiver for buprenorphine through releasing Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder. The guidelines exempt physicians ONLY that are already registered with the DEA. Other providers such as nurse practitioners, physician assistance, and clinical nurse specialists, can still apply for an X-waiver and prescribe buprenorphine for OUD with an active X-waiver registration. Additionally, the guidelines released by the HHS limits physicians to treating no more than 30 patients at one time for OUD with buprenorphine.6, 7
The recent news from the HHS regarding the removal of the X-waiver requirement for physicians to prescribed buprenorphine is applauded as a valiant effort to removing barriers to treatment of opioid use disorder (OUD) at a time when access to OUD treatment is needed most. The question remains, why such a small step? Allowing physicians but no other providers may create more stress and stigma for physicians. Are other practitioners less capable or qualified?
An interesting sidebar is how recent politics has played into the desire for pharmacists to distribute and administer COVID-19 vaccines nationwide in an effort to combat a deadly pandemic; but community pharmacists are overlooked as key healthcare clinicians when it comes to the opioid epidemic and increasing access for medication assisted treatments by the most accessible community-based clinicians within both largely populated areas as well as rural communities.
In conclusion, this may be the first small step towards fostering increased access to medications for opioid use disorder to mitigate the opioid morbidity and mortality. In a perfect world, to meet the real intent of X-waiver elimination, pharmacists too would be included among those healthcare clinicians that can provide buprenorphine maintenance for OUD. The hope is that this small step will be followed by other measures to benefit patients with diagnosed opioid use disorder. In conclusion, this change should foster buprenorphine prescribers and supporting staff to engage in this important role an an effort to the increase buprenorphine access.
As always, comments are welcomed with enthusiasm!
About the Author: Dr. Emily Uebbing graduated with her PharmD from University of Rhode Island College of Pharmacy in 2020. She currently is a PGY1 Pharmacy Resident Stratton VA Medical Center Albany, New York and has accepted a position commencing June/July 2021 at Stratton VA as the incoming PGY2 Pharmacy Pain and Palliative Care Resident.
- Centers for Disease Control and Prevention. Overdose Deaths Accelerating During COVID-19, (December 2020). Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/media/releases/2020/p1218-overdose-deaths-covid-19.html
- Centers for Disease Control and Prevention. Understanding the epidemic, (March 2020). Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/drugoverdose/epidemic/index.html
- Fiscella K, Wakeman SE, Beletsky L. Buprenorphine Deregulation and Mainstreaming Treatment for Opioid Use Disorder: X the X Waiver. JAMA Psychiatry. 2019;76(3):229–230. doi:10.1001/jamapsychiatry.2018.3685
- Substance Abuse and Mental Health Services Administration. Become a buprenorphine waivered practitioner. January 21, 2021. Accessed January 25, 2021. Available at: https://www.samhsa.gov/medication-assisted-treatment/become-buprenorphine-waivered-practitioner
- Fudin J, Opioid Agonists, Partial Agonists, Antagonists: Oh My!. Pharmacy & Healthcare Communications, LLC; 2018. Available at: https://www.pharmacytimes.com/contributor/jeffrey-fudin/2018/01/opioid-agonists-partial-agonists-antagonists-oh-my
- Department of Health and Human Services. Announcement of practice guidelines for the administration of buprenorphine for treating opioid use disorder. January 12, 2021. Accessed January 18, 2021. Available at: https://www.hhs.gov/sites/default/files/mat-physician-practice-guidelines.pdf
- Kuntz L. Dropping the X-waiver for buprenorphine. Psychiatric Times. 2021;38:1. Available at: https://www.psychiatrictimes.com/view/improving-care-teens-with-opioid-use-disorder
9 thoughts on “HHS Waves Goodbye to Physician X-Waiver for Buprenorphine”
I have given up on any politician having compassion for anyone suffering with continuous severe total loss of quality of life. They don’t care if I commit suicide because I can’t live with spinal stenosis and facet joint neuropathy severe pain that has me suffering my insurance will not pay for surgery and I’m forced to take generic medications that are not bioequivilent to name brand medications very little relief at all .Are they all so stupid to know the difference between dependence and addiction they don’t care because they enjoy the under the table kick backs they get from health insurance company’s lobbyists. Politics are gonna be the end of all normalcy for us all unfortunately. Humanity is gone compassion is as well so they view people eating bullets to be cheaper than medications and cuts cost on the Healthcare system also .If anyone of the ones behind the cruel inhumane treatment they are causing had to live 10 minute in the pain I indure than maybe there attituudes would change wake up you heartless bastards im human and I suffer and can’t commit to the ultimate sin so give it some thought what your doing to mankind and stop enjoying your greed!!!!!!!
Your story is an all too frequent one. You are a victim of the systemic corruption in the government/industry Power Elite who run this country. You are correct that they don’t give a s*** about you, except to perhaps criminalize you or any doctor with enough training, wisdom and compassion to treat you. The tools of fascist and spying government agencies (The DEA is a spy agency, not a healthcare agency and they have iron-fisted control), intent on hiding their failures at interdiction and diverting your attention to the 99.9% innocent doctors and patients. (All nations know that all criminalizing interdiction fails because human behavior always finds a way. Remember Prohibition failure? No different here).
It is much worse. There is such (completely justified) fear that, not only will doctors not treat you, they have largely forgot the science and medical ethics that allowed them to treat you effectively in the past (with proper training and careful management). History teaches us that it won’t change without massive disruption by those harmed. Remember, Parliament turned a deaf ear to Americans for 25 years until they threw the tea into Boston Harbor. “No change occurs without conflict” – Fredrick Douglass. call your Congress person. Go to their office. Then do it again. And again. Tell everyone you know who has been harmed to do the same.
Within days of the original post above, news was released that the aforementioned guidelines “cannot be issued at this time.”2 It has been decided that the X-waiver, that was established by the Drug Addiction Treatment Act of 2000 (DATA 2000) over 20 years ago cannot be changed or eliminated simply with an announcement by the HHS.3 This Act, mandated by Congress, will require submission of a bill to Congress in order to make any alterations.4 According to the statement that is posted to the Substance Abuse and Mental Health Services Administration (SAMSHA) webpage, the announcement of the X-waiver elimination for physicians was announced “prematurely.”2 This leads to the assumption that the removal of the X-waiver for physicians will occur; but when?
The statement regarding the X-waiver posted on the SAMHSA webpage means that the X-waiver will continue to be a thorn in the sides of physicians who want to utilize buprenorphine to treat patients with OUD and ultimately decrease access to treatment for patients with OUD. As discussed the original post, the announcement from the HHS on January 12th has been praised as a step toward increasing access to treatment for OUD. However, the guidelines were criticized for allowing exemption for physicians and no other qualifying providers which could lead to more stress and stigma for primary care physicians.5
Perhaps the HHS announcement was revoked so that a new plan, without the shortcomings of the previous one, can be released. One way to improve upon the short-lived guidelines would be to remove the X-waiver’s demanding and inflexible requirements for all providers, not just physicians. Additionally, recognizing and utilizing pharmacists as a qualifying provider to increase access treatment for those patients who don’t have a primary care doctor and patients residing in rural areas of the country where primary care doctors are far and few between.
In conclusion, elimination of the X-waiver for physicians for treatment of OUD with buprenorphine, however fleeting it was, accomplished a very important goal. It sparked a discussion amongst medical and political communities of the worsening of the opioid epidemic in the COVID-19 pandemic environment and the lack of effort to combat it. One can hope that there will soon be an announcement of more actions to combat the opioid epidemic that involves increasing access to treatment for OUD.
1. Department of Health and Human Services. Announcement of practice guidelines for the administration of buprenorphine for treating opioid use disorder. January 12, 2021. Accessed January 18, 2021. Available at: https://www.hhs.gov/sites/default/files/mat-physician-practice-guidelines.pdf
2. Substance Abuse and Mental Health Services Administration. Statement Regarding X-Waiver. Available at: https://www.samhsa.gov/sites/default/files/statement-regarding-xwaiver.pdf
3. Fiscella K, Wakeman SE, Beletsky L. Buprenorphine Deregulation and Mainstreaming Treatment for Opioid Use Disorder: X the X Waiver. JAMA Psychiatry. 2019;76(3):229–230. doi:10.1001/jamapsychiatry.2018.3685
4. Diamond D. Biden kills Trump plan on opioid-treatment prescriptions. The Washington Post. January 27, 2021. Available at: https://www.washingtonpost.com/health/2021/01/27/biden-kills-buprenorphine-waiver/
5. Fiscella K, Wakeman SE, Beletsky L. Buprenorphine Deregulation and Mainstreaming Treatment for Opioid Use Disorder: X the X Waiver. JAMA Psychiatry. 2019;76(3):229–230. doi:10.1001/jamapsychiatry.2018.3685
Dr. Uebbing, Thank you for this timely and exciting clarification!
All well and good. But a simple change needs to be made. And it won’t. Too many gun and badge-carrying federal employees ( on your tax dollar), completely and willfully ignorant of the science, have their careers staked on this convoluted and perverted x-waiver. the science and clinical experience of the past 40+ years speaks to this.
Why do we have this convoluted, fear- inducing and criminalizing enforcement of an X-waiver for ONE drug and for ONE indication for that drug (x-waiver is not needed for buprenorphine for pain, but try to get that through to a pharmacist quaking in their boots from the last DEA visit). Especially when it is an often very effective pain medication, Schedule 3, with a markedly better safety profile than the dozens of drugs in Schedule 2 that do not need an X-waiver. The entire regulation of buprenorphine is based on bureaucracy and misdirection, in the complicity between regulators and profit of the Power Elite. It is so systemic and labyrinthine, that those operating the system don’t even understand the science, while the fear generated have caused professionals (doctors, pharmacists, others) to forget the very science underlying this medication.
Simple, obvious solution: Drop x-waiver entirely. This has been obvious since it was implemented. But the healthcare profession is the wimpiest of all. They won’t stand up for what is factual and appropriate, in the face of the slightest intimidation. What mice we have all become.
This was the single only good thing the trump administration did in 4 years and the Biden administration just reversed it. Ugh!
Thank you Dr. Uebbing for mentioning that buprenorphine is also a good choice for pain due to its safety profile vs respiratory depression.
Very true Anne, but some argue it will be problematic to have physicians treating with bupe without proper OUD training. See Washington Post, https://www.washingtonpost.com/health/2021/01/25/biden-buprenorphine-waiver/
Biden reversed all of Trump’s policies. Have you seen the caravans? Their suboxone will be free. I don’t have insurance and make $16,800?a year. 60 ( 1 months supply cost me $99 for the doctor and 36 1.00 with a discount card at cvs. I don’t know qualify for Medicaid
I have been on bupren. for about 9 mos now because I have had Dr’s call me an addict. I was hurt in a big truck accident Aug / “97, cutting off ejbow,knee cap & Back problems.
It took about 2 mos. / neck & back to act up. Knee-cap & elbow were re-paired, not so lucky on back It has been 20 yrs of nothing but B.S. / Insurance Dr.s with other>s really trying.
I am a layman when it comes to medical Diag. Funny if it was not so tragic…. The major policy / DEA seems to ” throw out Baby w / water” REALLY STUPID for the patient w / pain. I have never used pain killers or any other drug on my life.
The pain is so intentance now, I am getting near my wits end w / pain.
I have had MRI’s,CT scans. x-rays.; over10-20 epideralls.
L am a Veteran and thank God I served,W/O their help I would have stamped my ticket. Even so they have their faults also.
I moved to Florida after accident for the heat which L needed,( no more cold w/snow) Can nor count the Dr’s I have had I started out w / morphine (30mg) not bad except when read about some using 100mg / pain WOW!!,
I was finally put on Dilaudid 30mg which gave “Quality of Life” for almost 3-5 yrs until those ASS….. had to play God. Night mare begins w / every Dr having the Pharmacist now overriding the Dr’s advise on which pain meds fit their patients needs.
I moved to Denver w / my daughter & wife just to see if I could handle the cold, could not.!!! The one thing I praise is their VA.& the approach they take in helping u.
After all the Mri’s cts & all , at which time most doctors either believe me about my pain or called me an addict. Had one DR (real winner) tell me he was a Harvard Grad & believed I was Dr shopping / pain meds calling me an addict!!! Thank God my wife was with me that day. I came so close to grabbing that SOB & beating the F… out of him. I was using a Pain clinic for my meds & the VA for film rehab.
The pain had worked its way between my shoulder blades causing a life ending sernero.
One time I was hurting so bad & they were ignoring me with my wife crying & beginning them to help me with their calling me an addict looking for pills. I finally had a shift change in drs. I was laying in a crowed emer room on the ground in the corner shaking–only if i had a gun @ this time glade I did”nt.
I was put on a dilodia drip and told to go back & get new MRI & CT.
God bless that surgan. He had decided to do a lateral view showing I had nerve damage / spinal cord that was black / 7 vertebrae of which 3 were fused and 4 repacked. I finally had proof of my truth telling. I still have my naysayers though
I was good for about 5 yrs w . Hydro & morphine to control pain level. Unfortunately the nerve damage came back w/vengeance.
I had remember reading an article from a veteran w / similar problems.
After using a very small amount of buprenorphine for the nerves only when I needed it.
Since the med is not prescribed my Nev. Dr decided I was an addict & weaned me off my Narcotics, After my new surgeon and I talked about best remedy, the nerve damage was most important w a 6 mos recovery ,so we decided to do nerve surgery so I had to use 20mg / to ween of my narcotics so I could the surgery
I just had surgery , that was dangerous but I am still here. My med.records are have about 4-5 inches thick but here we go again OMG I just don’t know WTD! I am hurting from lower back now. I cannot even stand up straight w/no pain meds
I am leaving Las Vegas in Oct…. back to Fla. for me with animals and a beautiful Mediterranean w awesome beaches to walk..
Being an older person & moving to Fla. w/ hopes of getting my pain meds back& having lower back surgery w / approx 6 mos. to recover
The may be great for weaning off narcotics but I do hear what an awful drug to come off of. Damn I hate pills…. I know this, the Buprenorphine does nothing for pain.
They did not have to take such drastic measures. I am 75 yrs old, hurt in 1996
I have never taken drugs, except aspirin….. I hate pills!!!