Signing into law a change that can prevent thousands of Americans from dying of opioid overdoses should have been met with fanfare. Instead, it not only slid under the media radar but hasn’t been communicated to the people who need to know about it.
Included in the end-of-year appropriations bill that President Biden signed on December 29, 2022 was the bipartisan Mainstreaming Addiction Treatment (MAT) Act of 2023. This act eliminates the so-called X-waiver that physicians had long needed to prescribe buprenorphine, a medication that curbs opioid cravings, reduces drug use, and prevents deaths among people who use opioids.
Before the MAT Act, the U.S. Drug Enforcement Agency required clinicians who wanted to prescribe buprenorphine for the treatment of opioid use disorder to undergo an extensive training and registration process for the “X-waiver,” so named because, upon completion, an “X” was added to the clinician’s DEA registration number. This time-consuming process erected a barrier that discouraged doctors from prescribing buprenorphine for opioid use disorder. The waiver also contributed to the ongoing stigma around both opioid use disorder and buprenorphine, because while any physician can prescribe buprenorphine for chronic pain without a special waiver, the specter of “abusers” who might sell or in some way misuse this pharmaceutical meant that only specially trained experts could be trusted to prescribe buprenorphine for opioid use disorder.
As a result, just 5% of medical providers have been licensed to prescribe buprenorphine, and in large portions of the country none are licensed to prescribe it. In the United States today, only 27% of people who would benefit from taking medication to treat opioid use disorder — buprenorphine, methadone, or naltrexone — is currently on treatment.
As researchers who study opioid use disorder, this astonishes us, because every study of these medications shows they prevent death, decrease the time people use opioids, reduce criminal activity, and their delivery provides an appealing return on investment.
The X-waiver represented a massive barrier to the treatment and care for people with opioid use disorder. Eliminating it will expand access to treatment for opioid use disorder, provide additional resources to first responders, and direct the federal government to raise public awareness on the potency and dangers of fentanyl and other synthetic opioids.
The MAT Act advances basic reforms that addiction specialists and people who use drugs have been seeking for decades, and it takes major steps to advance President Biden’s National Drug Control Strategy of ensuring universal access to medication for opioid use disorder by 2025. The time for the act is certainly right: Although as many as 7 million Americans are currently living with opioid use disorder, only about one-quarter of them are receiving treatment for it. Imagine if only 25% of Americans with cancer, another common and potentially fatal disease, received the appropriate therapy for it.
The MAT Act’s potential to truly bend the curve of overdose death has not been matched by its roll-out. The appropriate agencies made their announcements, and addiction-focused advocacy groups have tried to amplify the message. But there is no major effort to reach beyond the small pool of existing addiction medicine and psychiatry providers who are already prescribing buprenorphine, nor is there a clear plan to support providers to expand the scope of their practices. Further, the MAT Act does nothing to dismantle varying state-level regulations that also erect barriers to treatment.
Vigorously communicating the MAT Act’s historic changes and investing in ancillary supports that prescribers need to effectively manage patients on buprenorphine would increase the number of providers who prescribe this medication, which in turn would reduce fatal drug overdoses. In France, removing regulations limiting buprenorphine prescribing was followed by a 79% decline in deaths from opioid overdoses over the next three years. Extrapolated to the United States, that would translate to more than 30,000 fewer deaths each year from opioid overdoses.
Removal of the X-waiver will also help historically underserved communities gain access to treatment for opioid use disorder. Research shows that rural populations and communities of color have difficulty accessing and receiving buprenorphine because there are few or no X-waivered providers available in their region. The MAT Act will let health care providers prescribe buprenorphine as they would any other medicine, which may help normalize its essential role in treating opioid use disorder. Although the act does direct the Substance Abuse and Mental Health Services Administration to conduct national awareness campaigns that encourage providers to incorporate medication treatment and addiction services into their practices, there has been little action and few plans beyond that high-level commitment.
Communicating major public health milestones is a prerequisite to seeing changes in public health. Local media, national media, advocacy organizations, departments of health, and medical and scientific societies should be working in concert now to raise awareness about better access to buprenorphine. People with opioid use disorder need to know they can now ask their current health care providers for buprenorphine treatment — and gently educate them, if needed, that an X-waiver is no longer required to provide that.
Removing the X-waiver is a historic step forward in treating people with opioid use disorder. But it will do little good if clinicians and people who use opioids aren’t made aware of it.
Beth S. Linas is an infectious disease epidemiologist with RTI International. Benjamin P. Linas, her brother, is a professor of medicine at the Boston University School of Medicine and director of the Syndemics Lab at Boston Medical Center. The views expressed here are the authors’ alone and do not necessarily represent the views or policies of the institutions they work for.
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