The extinct X-waiver: What every DO should know about the future of opioid use disorder management

In December of 2022, as a last act of the 117th Congress, the Consolidated Appropriations Act (Omnibus bill) was passed and ultimately signed into law by President Biden. Fortunately for physicians and other practitioners who care for patients with opioid use disorder (OUD), this included the removal of the federal requirement to have an “X-waiver.”

About the X-waiver

The X-waiver was an addition to a practitioner’s Drug Enforcement Administration (DEA) license to prescribe medications such as buprenorphine for Medication Assisted Treatment (MAT) for OUD outside of controlled rehabilitation facilities. The X-waiver required practitioners to complete a training course and submit a notice of intent to the DEA and Substance Abuse and Mental Health Services Administration (SAMHSA). Upon approval, an “X” was added to the practitioner’s DEA license, and subsequently they were allowed to treat a limited number of patients depending on how long they had had the waiver.

This was thought to be an important step in the treatment of patients with OUD as MAT, particularly as agonist therapy is known to be an excellent tool for treatment, in addition to counseling and care management interventions. In addition, to being a cost-effective management tool, medications such as buprenorphine can lead to improved patient outcomes, including decreased risk of fatal overdose and decreased sequelae of drug misuse. However, some might say the X-waiver itself was prohibitive. The extra time and training necessary to obtain the X-waiver was not realistic for many busy physicians and other practitioners. Many were also bound by some of the regulations of office-based interventions including patient caps.

What is next in OUD education and management?

The elimination of the X-waiver will allow practitioners to prescribe buprenorphine for patients outside of the previous constraints, increasing access to MAT with the hope of decreasing misuse of opioids and the clinical sequelae that may result.

Fortunately, practitioners will not be left in the dark on how to safely manage OUD patients with MAT.  Though there are several specialties that train specifically in the management of these patients, any physician or other practitioner with a DEA license will need to complete an eight-hour course on opioid and substance use disorder management.  This is in lieu of obtaining an X-waiver, and only needs to be completed once. If a practitioner has already completed the previously offered X-waiver training, then this will not be required. Through the Omnibus bill and the incorporated MATE Act, this requirement will take effect in June 2023. States may choose to individually require additional training, and professional schools may choose to utilize addiction medicine education across their curriculum.

As a physician who incorporates addiction medicine in my practice within emergency medicine and medical toxicology, I am thrilled to encourage all physicians and other practitioners to learn safe pharmacologic management of OUD and provide this necessary resource to our patients who have suffered from this debilitating disease.

For years, several professional societies have released statements encouraging the government to do away with the X-waiver requirements. This is considered to be a legislative win for many practitioners looking to safely expand care to patients with OUD and will likely save many lives.

Additional information from SAMHSA regarding the X-waiver removal can be found here, and information on requirements within the DEA can be found here.