On Jan. 15, the Department of Health and Human Services took the first important step towards expanding access to evidence-based treatment for opioid use disorder by announcing that it would eliminate the need for physicians to earn an x-waiver before prescribing buprenorphine. While there is now some controversy about if the Biden administration will legally implement this change, we believe any changes to prescribing buprenorphine must include all healthcare providers, not just physicians.
The x-waiver is a certificate that eligible clinicians can obtain after the completion of mandatory training in order to prescribe buprenorphine — an evidence-based medication for opioid use disorder. The recent change announced by HHS reported that any physician with a license from the U.S. Drug Enforcement Administration would be able to prescribe buprenorphine for up to 30 patients at once without having completed an eight hour education session.
While an important step, this change is not the “x-ing” of the x-waiver which has been called for by countless clinicians, policymakers and harm reduction advocates and on its own is unlikely to ensure that every American who needs and wants treatment for opioid use will receive it.
This is partially because the change does not include advanced practice registered nurses and physician assistants — clinicians vital to the opioid use disorder treatment workforce.
Advanced practice registered nurses (nurse practitioners, clinical nurse specialists, certified nurse midwives and nurse anesthetists) and physician assistants — the clinicians driving x-waiver attainment and buprenorphine prescribing in rural areas — are still required to earn an x-waiver before they can treat opioid use disorder with buprenorphine.
APRNs and PAs were first allowed to prescribe buprenorphine in 2016 when the Comprehensive Addiction and Recovery Act was passed. The importance of this act cannot be understated — in many rural areas of the country, where the need for accessible opioid use disorder treatment is paramount, nurse practitioners and physician assistants provide a bulk of primary care services. However, this act required that APRNs and PAs attend 24 hours of training before being eligible for an x-waiver; compared to the eight hours required of physicians.
Although there is no clear rationale for the 24 hour requirement, we assume it was chosen due to a belief that APRNs and PAs need additional clinical training to safely prescribe buprenorphine, despite it being a safer medication than many others they often prescribe in primary care practice — including opioid pain medications such as oxycodone and other vital but potentially risky medications like insulin.
In addition, many of these additional training hours are focused on nonclinical content such as the epidemiology of substance use disorders and these differing requirements do not take into account previous experience in substance use treatment. A nurse practitioner who has worked in substance use treatment settings for years is still required to spend significantly more hours training to prescribe buprenorphine than a physician with no clinical background in substance use disorders.
Although APRNs and PAs who are motivated to provide this care will likely continue to fulfill the requirements to attain an x-waiver (as the two nurse practitioner authors of this article have) these training hours are a needless barrier to treatment provision and access and could limit the ability of these clinicians to offer a patient treatment in a timely manner.
Under the current requirements, if an APRN or PA without a waiver discovers that one of their patients wants and needs treatment for opioid use disorder, they will not be able to offer medication that day or likely even that week. If there are no other x-waivered clinicians taking new patients in the area, this patient will have to go without lifesaving treatment and is at very high risk of overdose given the toxicity of the street opioid supply in the U.S. This risk is even greater if the patient has a reduced opioid tolerance, if, for instance, they were recently released from prison.
In the face of a worsening overdose death crisis, the x-waiver requirement is a legal, codified manifestation of the stigma and discrimination people with opioid use disorder face daily. It is yet another obstacle to compassionate, evidence-based healthcare access for a condition that very often goes untreated, despite the existence of safe medications that work for many people.
If we truly care about expanding access to buprenorphine in places where it’s needed most, like rural areas, we need to do everything we can to support the clinicians who are already driving this effort by eliminating the x-waiver training requirements for APRNs and PAs.
Shoshana V. Aronowitz, Ph.D, FNP-BC is an associate fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, a National Clinician Scholars Program postdoctoral fellow and a family nurse practitioner. Laurel Hallock-Koppelman, DNP is an assistant professor and family nurse practitioner in the department of Family Medicine at Oregon Health & Sciences University. Kimberly Sue, MD, PhD is medical director at the National Harm Reduction Coalition and instructor in the Program in Addiction Medicine at Yale University School of Medicine.