Providers still hesitate to prescribe buprenorphine for addiction, despite ‘X-waiver’ removal

Significant challenges remain before most American clinicians feel comfortable treating patients with buprenorphine, according to a new study.

While the federal government’s recent moves to deregulate buprenorphine have led to a bump in new prescribers, it didn’t lead to a significant bump in overall prescribing volume. Many health care providers still see prescribing buprenorphine as difficult, or simply have little interest in using the medication, according to the study.

The research, published Friday in JAMA Health Forum, underscores two major challenges: allowing U.S. health care providers to provide addiction medications, and then convincing them to actually use the medications to treat patients.

“The number of people getting the modified waiver was going up, but the number of people getting buprenorphine prescriptions really wasn’t changing,” said Chris Jones, the study’s lead author and a longtime federal addiction policy official currently serving as director of the Center for Disease Control and Prevention’s injury prevention division. “This survey allowed us to dig into: All right, so you’ve taken the step to get the modified waiver. What are the other challenges that you’re finding with why you’re not prescribing?”

The new research comes on the heels of several government actions that have made it significantly easier to provide buprenorphine, the only medication available outside a specialized clinic that treats opioid addiction by helping to reduce cravings and withdrawal symptoms.

As of late 2020, however, prescribers needed to undergo special training to obtain a so-called “X-waiver” or “DATA-waiver,” a special license just to prescribe buprenorphine. The license required eight hours of additional training for doctors, and 24 hours for nurse practitioners and physician assistants.

The Trump administration effectively eliminated the requirement during its final days in power, allowing providers to treat up to 30 patients with buprenorphine with no additional training. Upon taking office, the Biden administration temporarily put the regulation on hold, but implemented a nearly identical policy in April 2021.

More recently, Congress eliminated the training requirement outright, meaning health care providers are effectively free to treat buprenorphine the way they treat any other medication. Prescribers certified by the Drug Enforcement Administration, however, still must undergo education to maintain their license.

The relaxed restrictions, however, have not fully solved the problem. Despite the increased number of buprenorphine providers, overall prescribing volumes have not climbed significantly, according to recent research.

The new survey helps to explain why. Clinicians reported a laundry list of other obstacles that kept them from prescribing buprenorphine, ranging from concerns about DEA overreach, insurance approval processes, lack of institutional support, concerns about buprenorphine misuse, and concerns about treating patients with opioid use disorder. Additionally, a large number of physician assistant and nurse practitioner prescribers reported they were unable to find a supervising physician to oversee their practice, which several states still require.

“The findings suggest that as implementation of legislation removing the DATA waiver begins, addressing these barriers could be essential to increasing buprenorphine access,” the paper’s authors, including top officials at the Substance Abuse and Mental Health Services Administration and other government agencies, wrote.

Public health experts and the Biden administration have long identified increasing access to addiction medications as a key pillar of the country’s opioid crisis response. Currently, only two drugs are approved to treat opioid addiction: methadone and buprenorphine. Methadone, however, is only available at specialized clinics, leaving buprenorphine as the only weapon in many American providers’ anti-addiction arsenal.

Even as the federal government eliminates restrictions surrounding buprenorphine, however, the drug has become more difficult to use. The prevalence of fentanyl, in particular, has left clinicians scrambling to help patients avoid a condition known as precipitated withdrawal — essentially, withdrawal symptoms that stem from buprenorphine’s relative weakness in the face of fentanyl’s immense potency.

But buprenorphine remains an essential tool for treating opioid use disorder, Jones stressed. While the elimination of the X-waiver didn’t immediately lead to a substantial increase in the number of prescribers or overall prescribing volumes, he added, such an increase is possible if the medical community, and the country more broadly, can continue to change the culture around addiction treatment.

“We also need to do education and engagement around how to manage patients with opioid use disorder so that providers feel more comfortable,” Jones said, “and raise greater awareness about the very real benefits, the lifesaving benefits, of buprenorphine and medications for opioid use disorder. Not only among clinicians, but among patients.”

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