After Taking a Step Back, The Administration Takes Two Steps Forward on the “X Waiver”

Jeffrey A. Singer

In the closing days of the Trump Administration, the Department of Health and Human Services announced that it was relaxing the so‐​called “X waiver” for physicians wishing to prescribe buprenorphine as Medication Assisted Treatment (MAT) for substance use disorder, as an emergency action to address the worsening drug overdose rate. The action only applied to physicians and limited them to 30 patients at any given time. I lauded this as a step in the right direction, though not large enough. Unfortunately, in February, the Biden Administration rescinded the order.

Yesterday the Secretary of HHS announced new guidelines that will again suspend the “X waiver” requirement for physicians treating up to 30 patients within their states. It goes a step further by also permitting physicians assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives to use buprenorphine for MAT as well, without having to go through the ordeal of qualifying for an “X waiver” on their narcotics prescribing license from the Drug Enforcement Administration.

Providers who wish to take on more than 30 patients must go through the onerous waiver process.

This improves upon the January 2021 Trump Administration action by extending the exemption beyond physicians to include other health care practitioners.

A 2020 study by Harvard researchers showed MAT with either buprenorphine (provided in its abuse‐​deterrent form Suboxone) or methadone as the only treatments for opioid use disorder that are associated with reduced overdoses or “opioid‐​related morbidity.” The study compared the effectiveness buprenorphine and methadone with naltrexone, inpatient treatment programs, and intensive outpatient treatment programs.

The American Medical Association, the National Academy of Science, Engineering and Medicine, and many addiction specialists have called for eliminating the X waiver program entirely.

There was bipartisan support in the last Congress for legislation that would eliminate the X waiver requirement for health care practitioners prescribing buprenorphine for MAT. Hopefully this Congress will seize the momentum from the new HHS guidance and end the “X waiver” program for good.